Annals of Thoracic Surgery最新文献

Background: Optimal management of ventricular septal defect (VSD) with mild aortic coarctation (isthmus velocity ≥1.50 m/s below intervention thresholds) remains contentious due to limited evidence on post-VSD-closure aortic remodeling.

Methods: This retrospective cohort study analyzed 231 children with mild Aortic coarctation undergoing isolated VSD closure. Primary interests included survival, Aortic coarctation reintervention, longitudinal evolution of isthmic velocity and Z-scores, and predictors of persistent obstruction (velocity ≥1.50 m/s at 3-year follow-up).

Results: At median 5.5 (4.3-6.4) years follow-up, survival was 99.6% (95% CI 96.9-99.9) at 7 years, while only 5 patients (2.2%) required aortic coarctation reintervention within 3.7 year. Isthmic velocity showed a triphasic trajectory: transient postoperative rise, rapid decline through 3 years (71.4% of total reduction), and subsequent stabilization. Anatomically, Z-scores demonstrated parallel catch-up growth, with the steepest improvement also within the first 3 years. Patients with a concomitant patent ductus arteriosus had lower preoperative velocity and greater early rise, but long-term outcomes matched those without patent ductus arteriosus. By 3-year follow-up, 76.1% of patients achieved normalized velocity (<1.50 m/s). Multivariable analysis identified elevated preoperative aortic valve velocity (OR 6.82, 95% CI 1.56-36.28; P=0.032) and a smaller preoperative isthmus Z-score (OR 0.77, 95% CI 0.63-0.94; P=0.028) as independent predictors of persistent obstruction.

Conclusions: Isolated VSD closure achieves coupled hemodynamic and anatomical aortic remodeling in most children with mild aortic coarctation, yielding excellent long-term survival and low reintervention rates. Elevated preoperative aortic valve velocity and a smaller isthmus Z-score identify high-risk patients who may benefit from intensified surveillance, supporting a physiology-guided, deferred-intervention strategy.

Background: Transcatheter mitral valve replacement (TMVR) is a preferred interventional option for high-risk patients with severe mitral regurgitation who are ineligible for transcatheter edge-to-edge repair. However, the role of annular dimensions in risk stratification has been marginally explored in this distinct anatomical setting with preserved native leaflets in patients with varying degree of myocardial damage.

Methods: This subanalysis of the multicenter TENDER registry (NCT04898335) included 145 TMVR patients. Preprocedural 4D-CT-derived annular dimensions were evaluated for associations with cardiac and all-cause mortality.

Results: At one year, all-cause mortality was 24.8% (n=36/145) and cardiac mortality was 5.5% (n=8/145). Cardiac deaths were associated with significantly larger annular parameters, including systolic and diastolic anteroposterior diameter (32.8±2.3 mm vs. 29.9±3.5 mm, p = 0.023; 33.2±2.5 mm vs. 30.3±3.4 mm, p = 0.018), systolic and diastolic annular perimeter (126.1±9.5 mm vs. 115.8±10.5 mm, p = 0.008; 125.6±10.4 mm vs. 115.8±12.7 mm, p = 0.034), and annular area (1271.7±193.2 mm² vs. 1076.2±193.6 mm², p = 0.006; 1262.7±209.9 mm² vs. 1087.2±194.7 mm², p = 0.015). Annular Area Loss, calculated as the difference between native diastolic mitral annular area and the geometric EOA of the implanted valve, was significantly greater in patients who died for cardiac reasons (999.72±225.72 mm²) compared to survivors (826.68±189.45 mm²; p = 0.022; OR=1.005, p = 0.030).

Conclusions: Larger annular dimensions and greater Annular Area Loss may predict one-year cardiac death. Possible mechanisms include impaired LV filling, artificial inflow-related outflow tract obstruction, and limited reverse remodeling. Comprehensive annular assessment may also enhance patient selection for future transseptal TMVR systems.

Background: Cardiothoracic surgery requires prolonged training and offers among the highest compensation in medicine. However, the long-term financial implications across cardiothoracic subspecialties remain incompletely characterized. This study evaluated the lifetime net present value (NPV) of earnings for cardiothoracic surgeons, accounting for variation by subspecialty, training pathway, income percentile, and career trajectory.

Methods: We developed an NPV model using salary data from the 2024 Society of Thoracic Surgeons Cardiothoracic Surgery Compensation Report, stratified by years of post-training experience. Integrated and traditional training pathways were modeled for thoracic surgery, adult cardiac surgery, and congenital heart surgery across income percentiles. Scenario analyses evaluated leadership roles, career length, and discount rate sensitivity. A Monte Carlo simulation incorporated uncertainty across key model parameters.

Results: Modeled lifetime NPV ranked among the highest in medicine, with estimates of $19.3 million for adult cardiac surgeons, $19.1 million for congenital heart surgeons, and $14.1 million for thoracic surgeons at the 50th income percentile. Thoracic surgeons demonstrated consistently lower earnings across scenarios. Congenital heart surgeons exhibited greater variability, reflecting delayed entry into the workforce and the potential for substantially higher compensation later in their careers. At the 90th income percentile with prolonged careers and leadership roles, discounted lifetime earnings for congenital heart surgeons exceeded $40 million.

Conclusions: Despite prolonged training and delayed earnings, cardiothoracic surgeons achieve substantial lifetime income. Thoracic surgeons earn less than their peers, whereas adult cardiac and congenital heart surgeons achieve higher lifetime NPV, with congenital heart surgery exhibiting the greatest variability and potential upside.

Background: Mechanical mitral valve replacement (MVR) is widely performed for severe rheumatic mitral stenosis (MS) but requires lifelong anticoagulation and carries prosthesis-related risks. Open mitral commissurotomy offers a valve-preserving alternative, yet contemporary long-term data are scarce. We compared long-term outcomes of open mitral commissurotomy and MVR in severe MS.

Methods: We retrospectively analyzed 249 patients undergoing mitral valve surgery for severe rheumatic MS (1995-2021): open mitral commissurotomy (n=58) and MVR (n=191). The primary outcome was a composite of all-cause death, mitral valve reoperation, major bleeding, stroke, heart failure readmission, and infective endocarditis. Propensity score matching adjusted for baseline differences.

Results: Mean follow-up was 11.4±7.0 years. In the matched cohort, 20-year composite outcome incidence was similar between open mitral commissurotomy and MVR (36.9% vs. 44.6%; sHR 0.78; 95% CI 0.42-1.45; P=.429). Major bleeding was lower with open mitral commissurotomy (4.4% vs. 22.5%; sHR 0.22; P=.047), and infective endocarditis occurred only after MVR (0% vs. 2.4%). Mitral valve reoperation tended to be more frequent in the open mitral commissurotomy group (16.7% vs. 5.7%; sHR 3.04; P=.137), but the difference was not statistically significant. In open mitral commissurotomy, mitral valve area increased from 0.90±0.14 cm² preoperatively to 1.56±0.31 cm² at 15 years (P<.001), and transmitral pressure gradient decreased from 11.4±7.3 to 4.6±1.9 mmHg (P<.001).

Conclusions: In patients with severe MS, open mitral commissurotomy provides comparable long-term clinical outcomes to MVR and is associated with fewer bleeding and no infective endocarditis. These findings support open mitral commissurotomy as a reasonable valve-preserving option in selected patients.

A patient with multiple recurrent episodes of endocarditis of both the mitral and aortic valves was treated with a mitral valve homograft procured from a heart transplant recipient's explanted native heart via an auto-transplant approach. This novel source could benefit patients with recurrent prosthetic valve endocarditis.

Background: In patients with tricuspid regurgitation (TR), surgical and transcatheter interventions aim to impact outcomes and symptomatic quality of life. Compared tricuspid transcatheter edge-to-edge repair (T-TEER) to isolated surgical tricuspid valve repair (TVr).

Methods: Assessing United States Medicare data (2018-2022), excluding endocarditis and rheumatic disease, we evaluated all patients undergoing isolated T-TEER (n=1,540) or isolated TVr (n=1,221). International Classification of Diseases 10th revision codes were used to define comorbidities and frailty using validated metrics. Doubly robust risk adjustment was performed with inverse probability weighting, multilevel regression, and competing-risk time-to-event analyses. Outcomes of interest include procedural mortality, pacemaker, and kidney injury as well as three-year freedom from death, valve reintervention and heart failure readmission.

Results: Surgical TVr was associated with higher unadjusted hospital mortality (8.8% vs 2.1%, p<0.001), but lower 3-year mortality (20.8% vs 26.2%, p=0.025) and valve reintervention (0.9% vs 2.1%, p=0.015). After risk adjustment, surgical TVr was associated with higher hospital mortality (OR 2.83, p<0.001) but improved longitudinal survival compared to T-TEER (HR 0.76, p=0.012). Surgical TVr was associated with lower rates of overall readmission (HR 0.87, p=0.040), heart failure-related readmission (HR 0.79, p=0.001), and valve reintervention (HR 0.83, p=0.003) at 3 years compared to T-TEER.

Conclusions: Among Medicare patients with symptomatic TR, surgical TVr was associated with higher perioperative risk, but improved risk-adjusted 3-year survival, heart failure readmission and valve reintervention compared to T-TEER. These contemporary data may inform future trial designs and heart team decision making for patients with severe symptomatic TR.

Background: The surgical management of moderate ischemic mitral regurgitation (IMR) in patients undergoing coronary artery bypass grafting (CABG) remains controversial, with limited real-world evidence, particularly from Asian populations.

Methods: We retrospectively analyzed 650 patients with moderate IMR who underwent isolated CABG (n=493) or CABG with mitral valve repair (n=157) between August 2009 and April 2024. Inverse probability of treatment weighting was applied to adjust for baseline differences. The primary endpoint was all-cause mortality; the secondary endpoint was major adverse cardiovascular and cerebrovascular events.

Results: During a median follow-up of 36.6 months, CABG with mitral valve repair was associated with lower all-cause mortality (multivariable HR, 0.41; 95%CI, 0.22-0.79; weighted log-rank P=0.006) and fewer composite events (weighted log-rank P=0.001), mainly driven by fewer deaths and rehospitalizations for heart failure. Findings were consistent across sensitivity and subgroup analyses. Echocardiographic follow-up (median 11.6 months) showed greater improvement in mitral regurgitation (75.4% vs 50.4%, P<0.001) and a larger reduction in left ventricular end-diastolic diameter (4.0[0, 7.8] vs 3.0[-1.0, 6.0], P = 0.026). CABG with repair was associated with longer postoperative intubation, intensive care unit stay, and an increased risk of acute kidney injury, without increased early mortality.

Conclusions: In one of the largest Asian real-world cohorts, concomitant mitral valve repair during CABG for moderate IMR was associated with lower mortality and fewer major adverse cardiovascular and cerebrovascular events and greater echocardiographic improvement, but at the expense of increased perioperative morbidity.