Pub Date : 2026-03-02DOI: 10.1016/j.jtcvs.2026.02.027
Jacob Y Cao, Alexander C Egbe, C Charles Jain, Christopher Francois, Patrick S Kamath, Yves D'Udekem, David Celermajer, Rachael Cordina, William R Miranda
Objectives: The Fontan pathway (inferior vena cava [IVC]-pulmonary artery [PA] connection) regulates forward flow and backward pressure, but its optimal size remains uncertain. This study aimed to evaluate the relationship between Fontan pathway diameter, hemodynamics, exercise capacity, and liver disease markers.
Methods: A retrospective review of 67 adults with extracardiac conduit (EC) or lateral tunnel (LT) Fontan procedures who underwent exercise cardiac catheterization was conducted. Minimal pathway diameter was measured via angiography or computed tomography. Exercise capacity was assessed by % predicted peak VO2. Liver disease markers included aspartate aminotransferase-to-platelet ratio, Fibrosis-4, and Model for End-Stage Liver Disease Excluding INR scores.
Results: The mean age at catheterization was 30.4±7.9 years. Minimal pathway diameter was 17.5±6.0 mm. Larger diameter was associated with reduced augmentation of pulmonary and systemic blood flow during exercise (pulmonary flow -2.3% per mm, 95% confidence interval [CI] -3.9; -0.7; p=0.005; systemic flow -2.2% per mm, 95% CI -4.1; -0.2; p=0.03), and lower % predicted peak VO2 (-0.8% per mm, 95% CI -1.4; -0.2; p=0.009), independent of exercise mean PA and PA wedge pressures, and peak heart rate. No consistent association was observed between pathway diameter and markers of liver disease. Notably, the pressure gradient on the liver imposed by the pathway contributed minimally to IVC pressure at rest (0% [interquartile range 0-7.1]) or during exercise (6.4% [interquartile range 0.5-14.3]).
Conclusions: Larger Fontan pathway diameter was paradoxically associated with impaired flow augmentation during exercise, which may contribute to reduced exercise capacity.
目的：Fontan通路（下腔静脉[IVC]-肺动脉[PA]连接）调节前向血流和后向压力，但其最佳尺寸仍不确定。本研究旨在评估Fontan通路直径、血流动力学、运动能力和肝脏疾病标志物之间的关系。方法：回顾性分析67例接受心外导管（EC）或外侧隧道（LT） Fontan手术的成人，并进行运动性心导管置入术。通过血管造影或计算机断层扫描测量最小路径直径。以预测峰值VO2百分比评估运动能力。肝病标志物包括天冬氨酸转氨酶与血小板比值、纤维化-4和终末期肝病模型（不包括INR评分）。结果：患者平均置管年龄30.4±7.9岁。最小通路直径为17.5±6.0 mm。较大的直径与运动期间肺和全身血流量增加减少相关（肺流量-2.3% / mm， 95%可信区间[CI] -3.9; -0.7; p=0.005；全身血流-2.2% / mm, 95% CI -4.1; -0.2; p=0.03），较低的预测VO2峰值（-0.8% / mm, 95% CI -1.4; -0.2; p=0.009），与运动平均PA和PA楔压和峰值心率无关。未观察到通路直径与肝脏疾病标志物之间的一致关联。值得注意的是，该途径对肝脏施加的压力梯度对静息时（0%[四分位数范围0-7.1]）或运动时（6.4%[四分位数范围0.5-14.3]）下腔静脉压力的影响最小。结论：更大的Fontan通路直径与运动过程中血流增强受损有关，这可能导致运动能力下降。
{"title":"Fontan Pathway Diameter in Adults Undergoing Exercise Catheterization: Association with Hemodynamics, Exercise Capacity, and Liver Scores.","authors":"Jacob Y Cao, Alexander C Egbe, C Charles Jain, Christopher Francois, Patrick S Kamath, Yves D'Udekem, David Celermajer, Rachael Cordina, William R Miranda","doi":"10.1016/j.jtcvs.2026.02.027","DOIUrl":"https://doi.org/10.1016/j.jtcvs.2026.02.027","url":null,"abstract":"<p><strong>Objectives: </strong>The Fontan pathway (inferior vena cava [IVC]-pulmonary artery [PA] connection) regulates forward flow and backward pressure, but its optimal size remains uncertain. This study aimed to evaluate the relationship between Fontan pathway diameter, hemodynamics, exercise capacity, and liver disease markers.</p><p><strong>Methods: </strong>A retrospective review of 67 adults with extracardiac conduit (EC) or lateral tunnel (LT) Fontan procedures who underwent exercise cardiac catheterization was conducted. Minimal pathway diameter was measured via angiography or computed tomography. Exercise capacity was assessed by % predicted peak VO<sub>2</sub>. Liver disease markers included aspartate aminotransferase-to-platelet ratio, Fibrosis-4, and Model for End-Stage Liver Disease Excluding INR scores.</p><p><strong>Results: </strong>The mean age at catheterization was 30.4±7.9 years. Minimal pathway diameter was 17.5±6.0 mm. Larger diameter was associated with reduced augmentation of pulmonary and systemic blood flow during exercise (pulmonary flow -2.3% per mm, 95% confidence interval [CI] -3.9; -0.7; p=0.005; systemic flow -2.2% per mm, 95% CI -4.1; -0.2; p=0.03), and lower % predicted peak VO<sub>2</sub> (-0.8% per mm, 95% CI -1.4; -0.2; p=0.009), independent of exercise mean PA and PA wedge pressures, and peak heart rate. No consistent association was observed between pathway diameter and markers of liver disease. Notably, the pressure gradient on the liver imposed by the pathway contributed minimally to IVC pressure at rest (0% [interquartile range 0-7.1]) or during exercise (6.4% [interquartile range 0.5-14.3]).</p><p><strong>Conclusions: </strong>Larger Fontan pathway diameter was paradoxically associated with impaired flow augmentation during exercise, which may contribute to reduced exercise capacity.</p>","PeriodicalId":49975,"journal":{"name":"Journal of Thoracic and Cardiovascular Surgery","volume":" ","pages":""},"PeriodicalIF":4.4,"publicationDate":"2026-03-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147357382","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-03-02DOI: 10.1016/j.jtcvs.2026.01.020
Furui Fu, Dezhi Tang
{"title":"A methodologic perspective on validating treatment algorithms and prophylactic recommendations in aortic dissection management during pregnancy.","authors":"Furui Fu, Dezhi Tang","doi":"10.1016/j.jtcvs.2026.01.020","DOIUrl":"https://doi.org/10.1016/j.jtcvs.2026.01.020","url":null,"abstract":"","PeriodicalId":49975,"journal":{"name":"Journal of Thoracic and Cardiovascular Surgery","volume":" ","pages":""},"PeriodicalIF":4.4,"publicationDate":"2026-03-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147345695","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-03-02DOI: 10.1016/j.jtcvs.2026.02.028
Justin T Tretter, Lama Dakik, Iqbal El-Assaad, Munir Ahmad, Hani K Najm
Objective: Postoperative high-grade atrioventricular block is prevalent following congenital aortic valve, root and left ventricular outflow tract (LVOT) surgery. We aimed to evaluate the application of presurgical cardiac computed tomography (CT) estimation of the conduction axis in mitigating this issue.
Methods: Patients with congenital aortic valve, root and LVOT disease evaluated and operated in our center from February 2022 to August 2025 who underwent presurgical CT with intact central fibrous body were included. Anatomical landmarks were used to estimate the atrioventricular node (point A), His bundle course (point B), and left bundle branch origin (point C) relative to the aortic virtual basal ring plane, and guide avoidance during cardiac surgery.
Results: Fifty-three patients were included (mean age, 32 years [range, 2-68 years]; 72% male). The most common diagnoses were bileaflet (70%) and unileaflet (10%) aortic valves, and LVOT obstruction (7%). Points A, B, and C were located at a mean depth of +11.8 ± 4.8 mm, +3.3 ± 3.2 mm, and +1.5 ± 2.7 mm inferior to the aortic virtual basal ring plane, respectively. Some form of aortic valve repair was performed in 38 patients (72%). The remaining 15 patients (28%) underwent some form of aortic valve replacement. One patient (1.9%) developed high-grade atrioventricular block with permanent pacemaker insertion, with subsequent spontaneous resolution. This incidence compared favorably to our prior report of 10% in a similar cohort without pre-surgical CT conduction system estimation.
Conclusions: This CT-based conduction axis estimation may mitigate conduction damage risk during congenital LVOT, aortic valve, and root surgery. Further prospective multisurgeon, multicenter studies are necessary to validate this approach.
{"title":"Using preoperative cardiac computed tomographic conduction axis prediction to avoid damage in congenital left ventricular outflow tract and aortic valve surgery.","authors":"Justin T Tretter, Lama Dakik, Iqbal El-Assaad, Munir Ahmad, Hani K Najm","doi":"10.1016/j.jtcvs.2026.02.028","DOIUrl":"10.1016/j.jtcvs.2026.02.028","url":null,"abstract":"<p><strong>Objective: </strong>Postoperative high-grade atrioventricular block is prevalent following congenital aortic valve, root and left ventricular outflow tract (LVOT) surgery. We aimed to evaluate the application of presurgical cardiac computed tomography (CT) estimation of the conduction axis in mitigating this issue.</p><p><strong>Methods: </strong>Patients with congenital aortic valve, root and LVOT disease evaluated and operated in our center from February 2022 to August 2025 who underwent presurgical CT with intact central fibrous body were included. Anatomical landmarks were used to estimate the atrioventricular node (point A), His bundle course (point B), and left bundle branch origin (point C) relative to the aortic virtual basal ring plane, and guide avoidance during cardiac surgery.</p><p><strong>Results: </strong>Fifty-three patients were included (mean age, 32 years [range, 2-68 years]; 72% male). The most common diagnoses were bileaflet (70%) and unileaflet (10%) aortic valves, and LVOT obstruction (7%). Points A, B, and C were located at a mean depth of +11.8 ± 4.8 mm, +3.3 ± 3.2 mm, and +1.5 ± 2.7 mm inferior to the aortic virtual basal ring plane, respectively. Some form of aortic valve repair was performed in 38 patients (72%). The remaining 15 patients (28%) underwent some form of aortic valve replacement. One patient (1.9%) developed high-grade atrioventricular block with permanent pacemaker insertion, with subsequent spontaneous resolution. This incidence compared favorably to our prior report of 10% in a similar cohort without pre-surgical CT conduction system estimation.</p><p><strong>Conclusions: </strong>This CT-based conduction axis estimation may mitigate conduction damage risk during congenital LVOT, aortic valve, and root surgery. Further prospective multisurgeon, multicenter studies are necessary to validate this approach.</p>","PeriodicalId":49975,"journal":{"name":"Journal of Thoracic and Cardiovascular Surgery","volume":" ","pages":""},"PeriodicalIF":4.4,"publicationDate":"2026-03-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147357309","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-03-01Epub Date: 2026-02-28DOI: 10.1016/S0022-5223(26)00038-3
{"title":"Information for readers","authors":"","doi":"10.1016/S0022-5223(26)00038-3","DOIUrl":"10.1016/S0022-5223(26)00038-3","url":null,"abstract":"","PeriodicalId":49975,"journal":{"name":"Journal of Thoracic and Cardiovascular Surgery","volume":"171 3","pages":"Page A15"},"PeriodicalIF":4.4,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147415053","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-03-01Epub Date: 2025-08-29DOI: 10.1016/j.jtcvs.2025.08.027
Robert B. Hawkins MD, MSc , Carol Ling MSP , Justin Fanning MD , Shelly C. Lall MD , Alessandro Vivacqua MD , Andrew L. Pruitt MD , Francis D. Pagani MD, PhD , Donald S. Likosky PhD , Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative
Background
Failure to rescue (FTR), defined as death after a surgical complication, is strongly impacted by systems-level care processes. The purpose of this study was to optimize the definition of FTR by developing the methodology for, and evaluating the subsequent impact of, adding complications to the Society of Thoracic Surgeons (STS) definition.
Methods
Patients undergoing coronary artery bypass grafting and/or valve operations from 2011 to 2024 in Michigan were included. Complications were considered for the FTR definition on the basis of the complication's association with mortality, event rate, FTR rate, interhospital variability, and percent of operative deaths accounted for by the FTR definition. Risk-adjusted FTR rates were calculated for 34 hospitals.
Results
Of 92,860 cases, 37,162 (40%) patients developed any of 17 complications and 2066 (2.2%) died. In addition to the STS FTR complications (stroke, renal failure, reoperation, prolonged ventilation), 5 additional complications demonstrated high FTR and interhospital variation (cardiac arrest, sepsis, pneumonia, gastrointestinal events, and anticoagulation bleeding events, ie, “STS+5”). The current STS FTR definition accounted for 70% of mortalities, whereas STS+5 accounted for 82%. After risk adjustment, the STS+5 compared with the STS FTR definition changed hospital FTR rates between −19.2% and 19.1%, yet interhospital variability was similar (range, 3.5-50.7% vs 3.7-47.1%).
Conclusions
Adding 5 complications to the STS FTR definition captures more mortalities while retaining similar interhospital variation. A more comprehensive FTR definition will better account for variation in complication-specific FTR by hospital. Leveraging FTR for quality improvement within cardiac surgery will require further work to identify the optimal FTR definition.
背景：抢救失败（FTR），定义为手术并发症后死亡，受到系统级护理过程的强烈影响。本研究的目的是通过开发胸外科学会（Society of Thoracic Surgeons， STS）定义中增加并发症的方法并评估其后续影响，来优化FTR的定义。方法：纳入2011-2024年在密歇根州接受冠状动脉搭桥术和/或瓣膜手术的患者。根据并发症与死亡率、事件发生率、FTR率、医院间变异性和FTR定义所占手术死亡率百分比的关联，将并发症纳入FTR定义。计算34家医院的经风险调整的FTR率。结果：92,860例患者中，37,162例（40%）出现17种并发症中的任何一种，2,066例（2.2%）死亡。除了STS的FTR并发症（中风、肾衰竭、再手术、延长通气时间）外，还有5个额外的并发症（心脏骤停、败血症、肺炎、胃肠道事件和抗凝出血事件；“STS+5”）显示出高FTR和医院间差异。目前的STS FTR定义占死亡人数的70%，而STS+5占82%。风险调整后，与STS FTR定义相比，STS+5使医院FTR率在-19.2%至19.1%之间变化，但医院间变异性相似（范围3.5-50.7% vs 3.7-47.1%）。结论：在STS FTR定义中增加5种并发症，在保留相似的医院间差异的同时，获得了更多的死亡率。更全面的FTR定义将更好地解释不同医院并发症特异性FTR的差异。利用FTR来提高心脏手术的质量需要进一步的工作来确定最佳的FTR定义。
{"title":"Selection of complications to define failure to rescue as an optimal quality improvement metric","authors":"Robert B. Hawkins MD, MSc , Carol Ling MSP , Justin Fanning MD , Shelly C. Lall MD , Alessandro Vivacqua MD , Andrew L. Pruitt MD , Francis D. Pagani MD, PhD , Donald S. Likosky PhD , Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative","doi":"10.1016/j.jtcvs.2025.08.027","DOIUrl":"10.1016/j.jtcvs.2025.08.027","url":null,"abstract":"<div><h3>Background</h3><div>Failure to rescue (FTR), defined as death after a surgical complication, is strongly impacted by systems-level care processes. The purpose of this study was to optimize the definition of FTR by developing the methodology for, and evaluating the subsequent impact of, adding complications to the Society of Thoracic Surgeons (STS) definition.</div></div><div><h3>Methods</h3><div>Patients undergoing coronary artery bypass grafting and/or valve operations from 2011 to 2024 in Michigan were included. Complications were considered for the FTR definition on the basis of the complication's association with mortality, event rate, FTR rate, interhospital variability, and percent of operative deaths accounted for by the FTR definition. Risk-adjusted FTR rates were calculated for 34 hospitals.</div></div><div><h3>Results</h3><div>Of 92,860 cases, 37,162 (40%) patients developed any of 17 complications and 2066 (2.2%) died. In addition to the STS FTR complications (stroke, renal failure, reoperation, prolonged ventilation), 5 additional complications demonstrated high FTR and interhospital variation (cardiac arrest, sepsis, pneumonia, gastrointestinal events, and anticoagulation bleeding events, ie, “STS+5”). The current STS FTR definition accounted for 70% of mortalities, whereas STS+5 accounted for 82%. After risk adjustment, the STS+5 compared with the STS FTR definition changed hospital FTR rates between −19.2% and 19.1%, yet interhospital variability was similar (range, 3.5-50.7% vs 3.7-47.1%).</div></div><div><h3>Conclusions</h3><div>Adding 5 complications to the STS FTR definition captures more mortalities while retaining similar interhospital variation. A more comprehensive FTR definition will better account for variation in complication-specific FTR by hospital. Leveraging FTR for quality improvement within cardiac surgery will require further work to identify the optimal FTR definition.</div></div>","PeriodicalId":49975,"journal":{"name":"Journal of Thoracic and Cardiovascular Surgery","volume":"171 3","pages":"Pages 693-700.e3"},"PeriodicalIF":4.4,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144976839","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-03-01Epub Date: 2025-09-19DOI: 10.1016/j.jtcvs.2025.08.029
Dimitrios E. Magouliotis MD, PhD , Serge Sicouri MD , Andrew Xanthopoulos MD, PhD , Basel Ramlawi MD, FACS
{"title":"Surgical judgment in the age of artificial intelligence","authors":"Dimitrios E. Magouliotis MD, PhD , Serge Sicouri MD , Andrew Xanthopoulos MD, PhD , Basel Ramlawi MD, FACS","doi":"10.1016/j.jtcvs.2025.08.029","DOIUrl":"10.1016/j.jtcvs.2025.08.029","url":null,"abstract":"","PeriodicalId":49975,"journal":{"name":"Journal of Thoracic and Cardiovascular Surgery","volume":"171 3","pages":"Pages e83-e84"},"PeriodicalIF":4.4,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145088055","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
We clarified associations between biological valve sizes selected during primary surgical aortic valve replacement (SAVR) and its long-term outcomes.
Methods
In total, 754 consecutive patients with aortic stenosis who underwent primary biological SAVR were classified into 3 groups based on valve size: 19-mm (n = 246), 21-mm (n = 262), and ≥23-mm (n = 246). Severe prosthesis-patient mismatch was defined as measured indexed effective orifice area ≤0.65 cm2/m2 if body mass index is < 30 kg/m2 and ≤ 0.55 cm2/m2 if body mass index is ≥ 30 kg/m2. The mean observation period was 6.6 ± 4.0 years (4996 patient-years).
Results
Patients with 19-mm valves were older (19-mm: 74 ± 7.8 years vs 21-mm: 72 ± 8.0 years vs ≥ 23-mm: 69 ± 10 years), predominantly women (91% vs 55% vs 13%), and had smaller body surface area (1.39 ± 0.12 m2 vs 1.53 ± 0.15 m2 vs 1.67 ± 0.16 m2). The incidence of post-SAVR severe prosthesis-patient mismatch was 15%, 5.8%, and 5.0%, respectively (P < .001 for all). However, a mixed-effects model demonstrated that left ventricular mass index regressed equivalently (interaction effect = 0.189). During follow-up, 142 (19%) mortalities and 41 (5.4%) aortic valve reinterventions (31 redo-SAVR and 10 valve-in-valve) were observed, without difference in 10-year all-cause mortality rate (21% vs 33% vs 27%; P = .438). Fine-Gray regression model identified age at surgery (adjusted hazard ratio, 0.4 per 10-years; P < .001) and use of a 19-mm valve (adjusted hazard ratio, 4.0; P < .001) as independent associates with aortic valve reinterventions.
Conclusions
Despite a higher incidence of severe prosthesis-patient mismatch and aortic reintervention after primary SAVR, use of a 19-mm biological valve can be justified for elderly patients with small body surface area, as evidenced by equivalent long-term survival and left ventricular mass regression to those with larger valves.
目的：我们阐明了原发性主动脉瓣置换术（SAVR）中选择的生物瓣膜大小与其长期预后之间的关系。方法：共有754例连续主动脉瓣狭窄患者行原发性生物SAVR，根据瓣膜大小分为3组：19mm （n=246）、21mm （n=262）和≥23mm （n=246）。严重假体-患者失配（PPM）定义为：如果体重指数（BMI）为2，测量的指标性有效孔面积≤0.65 cm2/m2，如果BMI≥30 kg/m2，测量的指标性有效孔面积≤0.55 cm2/m2。平均观察时间6.6±4.0年（4996患者年）。结果：19 mm瓣膜患者年龄较大（19 mm: 74±7.8岁vs. 21 mm: 72±8.0岁vs.≥23 mm: 69±10岁），以女性为主（91% vs. 55% vs. 13%），体表面积（BSA）较小（1.39±0.12 m2 vs. 1.53±0.15 m2 vs. 1.67±0.16 m2）。savr后严重PPM的发生率分别为15%、5.8%和5.0%（均p< 0.001）。然而，混合效应模型显示左室（LV）质量指数等效回归（交互效应=0.189）。在随访期间，观察到142例（19%）死亡和41例（5.4%）主动脉瓣再介入（31例复位savr和10例瓣内介入），10年全因死亡率无差异（21% vs. 33% vs. 27%, p=0.438）。细灰色回归模型确定手术年龄（校正风险比0.4 / 10年）。结论：尽管原发性SAVR后严重PPM和主动脉再介入的发生率较高，但对于BSA较小的老年患者，使用19mm生物瓣膜是合理的，其长期生存率和左室质量回归与瓣膜较大的患者相当。
{"title":"Prognostic influence of biological valve size on long-term outcomes of primary surgical aortic valve replacement for aortic stenosis","authors":"Rieko Kutsuzawa MD , Satoshi Kainuma MD, PhD , Naonori Kawamoto MD, PhD , Kota Suzuki MD, PhD , Takashi Kakuta MD, PhD , Ayumi Ikuta MD, PhD , Kohei Tonai MD , Masaya Hirayama MD , Hironobu Sakurai MD, PhD , Shinichi Kurashima MD , Yuki Irie MD , Takahiro Sakamoto MD, PhD , Kenji Moriuchi MD , Masashi Amano MD, PhD , Atsushi Okada MD, PhD , Kensuke Takagi MD, PhD , Makoto Amaki MD, PhD , Hideaki Kanzaki MD, PhD , Takeshi Kitai MD, PhD , Chisato Izumi MD, PhD , Satsuki Fukushima MD, PhD","doi":"10.1016/j.jtcvs.2025.09.035","DOIUrl":"10.1016/j.jtcvs.2025.09.035","url":null,"abstract":"<div><h3>Objectives</h3><div>We clarified associations between biological valve sizes selected during primary surgical aortic valve replacement (SAVR) and its long-term outcomes.</div></div><div><h3>Methods</h3><div>In total, 754 consecutive patients with aortic stenosis who underwent primary biological SAVR were classified into 3 groups based on valve size: 19-mm (n = 246), 21-mm (n = 262), and ≥23-mm (n = 246). Severe prosthesis-patient mismatch was defined as measured indexed effective orifice area ≤0.65 cm<sup>2</sup>/m<sup>2</sup> if body mass index is < 30 kg/m<sup>2</sup> and ≤ 0.55 cm<sup>2</sup>/m<sup>2</sup> if body mass index is ≥ 30 kg/m<sup>2</sup>. The mean observation period was 6.6 ± 4.0 years (4996 patient-years).</div></div><div><h3>Results</h3><div>Patients with 19-mm valves were older (19-mm: 74 ± 7.8 years vs 21-mm: 72 ± 8.0 years vs ≥ 23-mm: 69 ± 10 years), predominantly women (91% vs 55% vs 13%), and had smaller body surface area (1.39 ± 0.12 m<sup>2</sup> vs 1.53 ± 0.15 m<sup>2</sup> vs 1.67 ± 0.16 m<sup>2</sup>). The incidence of post-SAVR severe prosthesis-patient mismatch was 15%, 5.8%, and 5.0%, respectively (<em>P</em> < .001 for all). However, a mixed-effects model demonstrated that left ventricular mass index regressed equivalently (interaction effect = 0.189). During follow-up, 142 (19%) mortalities and 41 (5.4%) aortic valve reinterventions (31 redo-SAVR and 10 valve-in-valve) were observed, without difference in 10-year all-cause mortality rate (21% vs 33% vs 27%; <em>P</em> = .438). Fine-Gray regression model identified age at surgery (adjusted hazard ratio, 0.4 per 10-years; <em>P</em> < .001) and use of a 19-mm valve (adjusted hazard ratio, 4.0; <em>P</em> < .001) as independent associates with aortic valve reinterventions.</div></div><div><h3>Conclusions</h3><div>Despite a higher incidence of severe prosthesis-patient mismatch and aortic reintervention after primary SAVR, use of a 19-mm biological valve can be justified for elderly patients with small body surface area, as evidenced by equivalent long-term survival and left ventricular mass regression to those with larger valves.</div></div>","PeriodicalId":49975,"journal":{"name":"Journal of Thoracic and Cardiovascular Surgery","volume":"171 3","pages":"Pages 578-589.e2"},"PeriodicalIF":4.4,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145208449","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-03-01Epub Date: 2025-10-15DOI: 10.1016/j.jtcvs.2025.09.054
Vincent Chauvette MD, PhD(c) , Ismail Bouhout MD, PhD , Charles Laurin MD , Maximiliaan L. Notenboom MD , Elbert E. Williams MD , Raymond Cartier MD , Nancy Poirier MD , Philippe Demers MD, MSc , Ismail El-Hamamsy MD, PhD
Background
Contemporary evidence supports use of the Ross procedure (pulmonary autograft) to treat patients with aortic valve disease. No studies have evaluated the impact of autograft repair to correct residual aortic regurgitation at the index Ross procedure on late outcomes.
Methods
This study includes patients undergoing a Ross procedure followed by concomitant autograft valve repair at 2 institutions. Autograft repair was defined as correction of residual aortic regurgitation during the same admission for the Ross procedure.
Results
Between 2011 and 2024, 675 patients underwent a Ross procedure in 2 large-volume institutions. Of them, 22 (3%) underwent autograft repair for postprocedural aortic regurgitation (mean age, 52 years; 23% were female). Fourteen patients had a bicuspid valve (64%), and 5 patients had a unicuspid aortic valve (23%). One patient had a bicuspid autograft. Residual aortic regurgitation was eccentric in 8 patients (36%), commissural in 9 patients (41%), and combined in 5 patients (23%). Aortic regurgitation was corrected using central plication sutures in 13 patients (59%) and commissuroplasty in 14 patients (63%). There were no perioperative deaths. One patient required reintervention and conversion to a Bentall procedure 6 days after the index Ross procedure. All patients but 1 (5%; mild aortic regurgitation) had no or trivial aortic regurgitation on discharge. At a median echocardiographic follow-up of 3 years (Q1-Q3: 2-8), 7 patients have mild aortic regurgitation (32%), and 1 patient developed mild-to-moderate aortic regurgitation after 7 years. All other patients have no or trivial aortic regurgitation. At 5 years, the cumulative incidence of aortic regurgitation greater than 2 is 6% ± 6%.
Conclusions
Addressing postprocedural aortic regurgitation after autograft implantation is safe and associated with durable outcomes in the first decade. These findings support correction of postprocedural commissural or eccentric jets at the time of index operation.
{"title":"Pulmonary valve repair at the time of the Ross procedure: A safe and durable strategy to address postimplantation aortic regurgitation","authors":"Vincent Chauvette MD, PhD(c) , Ismail Bouhout MD, PhD , Charles Laurin MD , Maximiliaan L. Notenboom MD , Elbert E. Williams MD , Raymond Cartier MD , Nancy Poirier MD , Philippe Demers MD, MSc , Ismail El-Hamamsy MD, PhD","doi":"10.1016/j.jtcvs.2025.09.054","DOIUrl":"10.1016/j.jtcvs.2025.09.054","url":null,"abstract":"<div><h3>Background</h3><div>Contemporary evidence supports use of the Ross procedure (pulmonary autograft) to treat patients with aortic valve disease. No studies have evaluated the impact of autograft repair to correct residual aortic regurgitation at the index Ross procedure on late outcomes.</div></div><div><h3>Methods</h3><div>This study includes patients undergoing a Ross procedure followed by concomitant autograft valve repair at 2 institutions. Autograft repair was defined as correction of residual aortic regurgitation during the same admission for the Ross procedure.</div></div><div><h3>Results</h3><div>Between 2011 and 2024, 675 patients underwent a Ross procedure in 2 large-volume institutions. Of them, 22 (3%) underwent autograft repair for postprocedural aortic regurgitation (mean age, 52 years; 23% were female). Fourteen patients had a bicuspid valve (64%), and 5 patients had a unicuspid aortic valve (23%). One patient had a bicuspid autograft. Residual aortic regurgitation was eccentric in 8 patients (36%), commissural in 9 patients (41%), and combined in 5 patients (23%). Aortic regurgitation was corrected using central plication sutures in 13 patients (59%) and commissuroplasty in 14 patients (63%). There were no perioperative deaths. One patient required reintervention and conversion to a Bentall procedure 6 days after the index Ross procedure. All patients but 1 (5%; mild aortic regurgitation) had no or trivial aortic regurgitation on discharge. At a median echocardiographic follow-up of 3 years (Q1-Q3: 2-8), 7 patients have mild aortic regurgitation (32%), and 1 patient developed mild-to-moderate aortic regurgitation after 7 years. All other patients have no or trivial aortic regurgitation. At 5 years, the cumulative incidence of aortic regurgitation greater than 2 is 6% ± 6%.</div></div><div><h3>Conclusions</h3><div>Addressing postprocedural aortic regurgitation after autograft implantation is safe and associated with durable outcomes in the first decade. These findings support correction of postprocedural commissural or eccentric jets at the time of index operation.</div></div>","PeriodicalId":49975,"journal":{"name":"Journal of Thoracic and Cardiovascular Surgery","volume":"171 3","pages":"Pages 569-576.e1"},"PeriodicalIF":4.4,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145309806","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-03-01Epub Date: 2025-10-30DOI: 10.1016/j.jtcvs.2025.10.030
Charles R. Liu MD, Ruben G. Nava MD
{"title":"Commentary: Ex vivo and normothermic regional perfusion are friends, not foes, in the preservation of donation after circulatory death lungs","authors":"Charles R. Liu MD, Ruben G. Nava MD","doi":"10.1016/j.jtcvs.2025.10.030","DOIUrl":"10.1016/j.jtcvs.2025.10.030","url":null,"abstract":"","PeriodicalId":49975,"journal":{"name":"Journal of Thoracic and Cardiovascular Surgery","volume":"171 3","pages":"Pages 801-802"},"PeriodicalIF":4.4,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145423370","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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