Journal of Thoracic and Cardiovascular Surgery最新文献

Objective: The optimal surgical strategy for severe rheumatic mitral stenosis with more than mild regurgitation remains unclear. We aimed to characterize mitral valve pathology in these patients and compare outcomes between repair and replacement.

Methods: This dual-center retrospective study analyzed 870 surgically-treated severe rheumatic mitral stenosis patients with complete imaging. Inverse probability weighting balanced baseline characteristics (SMD<0.1). Quantitative assessment combined echocardiography and computed tomography angiography. Primary endpoint was all-cause mortality.

Results: Of 870 patients, 408 (46.9%) had more than mild regurgitation. Compared to pure stenosis, these patients had larger left atrial diameters (51.0 vs 49.0 mm, P<0.001), higher mean pulmonary artery pressures (42.0 vs 41.0 mmHg, P=0.015), and shorter anterior (33.3 vs 33.7 mm, P=0.026) and posterior (19.2 vs 20.0 mm, P<0.001) leaflets, and a comparable rate of mitral valve repair (65.0% vs 63.0%, P=0.595). Among patients with more than mild regurgitation, early outcomes did not differ between repair (n=265) and replacement (n=143). At 5-year postoperative follow-up, repair was associated with significantly lower mortality (1.4% vs. 7.1%, P=0.009) and comparable reoperation rates (1.4% vs. 1.0%, P=1.000). Survival analysis favored repair (log-rank P=0.005), which independently predicted survival (HR 0.347; P=0.039).

Conclusions: Nearly half of severe rheumatic mitral stenosis patients present with more than mild regurgitation. Mitral repair demonstrates improved 5-year survival without increased reoperations, supporting its consideration as a key candidate strategy when feasible.

Objective: Prolonged asystolic warm ischemic time (AWIT) during donation after circulatory death (DCD) heart transplantation worsens outcomes. Despite American Society of Transplant Surgeons (ASTS) recommendations, declaration of death upon pulseless electrical activity (PEA) instead of asystole remains inconsistent. This study evaluated the association between prolonged PEA WIT (PWIT) and outcomes in adult recipients of cardiac allografts recovered using thoracoabdominal normothermic regional perfusion (TA-NRP).

Methods: Adult heart transplants from DCD allografts recovered with TA-NRP from 01/2020-02/2025 were reviewed, excluding multiorgan transplants and congenital heart disease. PWIT was defined as the time from systolic blood pressure (SBP) <30mmHg to TA-NRP perfusion. Receiver operating characteristic (ROC) curve analysis dichotomized PWIT, and inverse probability of treatment weighting (IPTW) adjusted for confounders when associating prolonged PWIT with outcomes.

Results: 133 patients met inclusion criteria with a median PWIT of 11mins (IQR 9-13), of whom 57 (42.9%) were not declared at PEA. ROC curve analysis identified a PWIT inflection point of 12 mins when predicting 90-day mortality, with 99 (74.4%) patients having PWIT ≤12 mins and 34 (25.6%) with >12 mins. Adjusted outcomes after IPTW found that PWIT >12 mins was associated with increased rates of severe primary graft dysfunction (OR 4.62, p=0.013), 90-day (OR 7.67, p=0.010), and 1-year mortality (OR 5.93, p=0.014).

Conclusions: PWIT >12 minutes is significantly associated with increased mortality and severe PGD in NRP-recovered DCD hearts. Standardization of declaration upon PEA instead of asystole, in addition to other strategies to minimize PWIT, could improve postoperative adult heart transplant recipient outcomes.

Background: Failure to rescue (FTR)-mortality following complications-is an important cardiac surgery quality metric. While risk-adjusted FTR measures account for traditional patient risk, the impact of socioeconomic status (SES) on FTR is less understood.

Methods: This sample included 67,386 Medicare beneficiaries undergoing coronary and/or valve surgery between 2016-2019. The distressed community index (DCI), a measure of neighborhood economic well-being, was linked to beneficiary zip code and stratified into quintiles for univariate analyses. Outcomes included complications, operative mortality, and in-hospital FTR. A composite of complications included renal failure, venous thromboembolism, pneumonia, gastrointestinal bleeding, pulmonary failure, hemorrhage, and surgical site infections. Mixed-effects logistic regression assessed the association between DCI (per 10-point increase) and FTR.

Results: The cohort was 31.6% female, 5.9% Black, and 1.3% Hispanic, with 24.1% in the lowest and 16.4% in the highest distressed quintiles. Beneficiaries in the highest versus lowest distressed quintile were younger as well as more likely female and minorities. The highest versus lowest DCI quintiles were more likely underwent coronary artery bypass grafting. Beneficiaries in the highest distressed quintile had increased rates of composite complications (32.3% vs. 28.9%, p<0.001), mortality (5.3% vs. 4.5%, p<0.001), and FTR (12.0% vs. 10.2%, p<0.05). Adjusted odds of FTR were 2% greater (OR 1.02 CI95% 1.00-1.04) per 10-point increase in DCI.

Conclusion: Residential DCI was predictive of FTR after cardiac surgery. Future work should identify and disseminate strategies to mitigate the disproportionate impact of low SES on FTR.