Complex bileaflet and Barlow-type degenerative disease remains among the most demanding substrates in reconstructive mitral surgery, and a right mini-thoracotomy amplifies every source of intraoperative variability. Two determinants dominate durability: excessive posterior leaflet height, which displaces the coaptation line anteriorly and drives residual regurgitation and systolic anterior motion; and, in anterior prolapse, neochordal length, where a millimetric error produces residual prolapse, restriction or recurrence. We describe RE-LOCK and TRACK, a two-component, posterior-first protocol designed to control both reproducibly. RE-LOCK relocates the redundant posterior leaflet head towards the annular plane and anchors it to a stable posterior reference, converting a mobile prolapsing edge into a controlled hinge and establishing a low, posteriorised coaptation shelf; posterior neochordae are not used. TRACK then calibrates anterior support: expanded-polytetrafluoroethylene neochordae anchored to the papillary head are advanced against a temporary annular guide kept coplanar with the annulus, so that length is set against an anatomical reference rather than by visual estimation or ventricular loading. Complete ring annuloplasty stabilises the result, and intraoperative transoesophageal echocardiography governs any revision. By fixing the sequence, platform first and calibration second, the protocol converts individually demanding manoeuvres into a repeatable, teachable operation particularly well suited to the minimally invasive field.
OBJECTIVES:Biventricular repair of congenitally corrected transposition of the great arteries (ccTGA) with a nonrestrictive ventricular septal defect (VSD) and left ventricular outflow tract obstruction ("complex ccTGA") provides suboptimal long-term results and carry a high risk of surgical atrioventricular block (AVB). We report outcomes of a restrictive left ventricle-to-pulmonary artery (LV-PA) conduit without VSD closure. METHODS:Retrospective single-centre review (January 1999-January 2024) of complex ccTGA patients receiving a restrictive LV-PA conduit without VSD closure. RESULTS:Nine of 553 ccTGA patients met inclusion criteria (median age 5 years, weight 18 kg). Unfavorable anatomy was mainly due to inlet or remote VSD (n = 5) and/or atrioventricular valves straddling (n = 2). Over a median follow-up of 12.5 years, there were no operative or late deaths and no permanent pacing for AVB. Freedom from reintervention was 62.5% at 10 years. At last follow-up, 8 of 9 patients were in NYHA class I-II and median SpO2 was 95%. Tricuspid regurgitation was basent or mild in 8 cases and moderate in 1 case. 2 patients had decreased morphologic right ventricle function and morphologic left ventricular function was preserved in all. CONCLUSIONS:Restrictive LV-PA conduit placement without VSD closure is a safe biventricular alternative in complex ccTGA unsuitable for anatomic repair or single-ventricle palliation.
OBJECTIVES:To assess the long-term effects of teleprehabilitation on modifiable risk factors and quality of life up to 1 year following elective cardiac surgery. METHODS:This secondary analysis of the Digital Cardiac Counselling trial, a randomized controlled trial, compared multimodal teleprehabilitation with standard care in patients undergoing elective cardiac surgery. The teleprehabilitation programme targeted physical fitness, inspiratory muscle training, psychological support, nutritional optimization, and smoking cessation. Outcomes included trajectories of modifiable risk factors and quality of life measured preoperatively and at 3, 6, and 12 months postoperatively. Generalized linear mixed models assessed differences over time between groups, with exploratory post hoc analyses for individual timepoints. RESULTS:Both groups showed postoperative reductions in all assessed modifiable risk factors and improvements in quality of life over time (P < .001), except for nutritional optimization (P = .173). Teleprehabilitation was associated with more favourable trajectories for smoking behaviour (P = .045) and nutritional risk (P = .011), with consistently lower incidences throughout follow-up. Smoking prevalence remained significantly lower in the teleprehabilitation group at all timepoints (P < .05), while malnutrition prevalence was lower at 3 months postoperatively (P = .012). Quality-of-life scores were consistently higher in the teleprehabilitation group throughout follow-up (P = .002). CONCLUSIONS:Teleprehabilitation in cardiac surgery patients not only reduces postoperative complications, but may also provide additional long-term benefits, particularly in smoking cessation, nutritional optimization, and quality of life. These findings support teleprehabilitation as a valuable addition to standard preoperative care, with possible sustained benefits for long-term lifestyle and quality of life.
OBJECTIVES:Atrial fibrillation (AF) is associated with stroke, congestive heart failure, and mortality. Treatment has evolved from the cut-and-sew Cox-Maze III procedure to energy-based ablation using cryoablation and radiofrequency ablation, often via minimally invasive approaches. This review aims to establish standardized definitions and reporting practices for rhythm outcomes after surgical AF ablation. METHODS:In this review, we establish a definition for rhythm success that can be used to compare outcomes across various types of catheter and surgical ablation. We examine biatrial versus uniatrial ablation and the lesion sets that should be recomended for paroxysmal versus persistent AF. We discuss ablation performed during coronary artery bypass grafting, aortic valve replacement, and mitral valve replacement. We also review minimally invasive thoracoscopic and hybrid ablation approaches. RESULTS:We suggest standardizing rhythm monitoring and reporting using electrocardiograms, Holter monitors, mobile devices, and implantable loop recorders. We suggest standardizing antiarrhythmic drug use, both within and after the blanking period, and describe how use of these medications should affect reporting of ablation success. Description of a detailed lesion set and the mode of application by type of device and cardiopulmonary bypass status are also warranted. CONCLUSIONS:Standardized reporting of rhythm outcomes is essential in clinical reports of surgical ablation. Detailed description of the mechanism of lesion application is often missing and should be included in research reports as lesion integrity as part of the ablation scheme is a key factor in success. Superior rhythm outcomes with equivalent morbidity and mortality are obtainable with a complete Maze procedure performed via right thoracotomy.
Transcatheter aortic valve implants are increasingly performed in younger and lower-risk patients, shifting attention towards long-term prosthetic valve durability. Although transthoracic echocardiography remains the cornerstone of follow-up, it primarily reflects global haemodynamics and may not detect early structural or geometric abnormalities after the valve is implanted. Hypoattenuated leaflet thickening and reduced leaflet motion, collectively referred to as subclinical leaflet thrombosis, represent dynamic phenomena that may precede overt valve dysfunction. Growing evidence suggests that prosthesis geometry, including underexpansion, ellipticity, commissural misalignment, canting, and implant depth, may alter neo-sinus flow and promote thrombotic substrate formation. Multidetector computed tomography enables integrated assessment of leaflet morphology, perivalvular thrombus, and prosthetic geometry, providing insights into the mechanical determinants of thrombosis. In this state-of-the-art review, we examine the role of multimodality imaging in identifying thrombogenic valve phenotypes and propose a pragmatic imaging framework integrating echocardiography with selective multidetector computed tomography to support the surveillance and management of individualized post-transcatheter aortic valve implants.
Patients with concomitant severe aortic stenosis (AS) and moderate/severe mitral stenosis (MS) pose a complex therapeutic challenge. While double valve surgery (DVS) remains the gold standard, its high operative risks have led to investigating novel strategies, chiefly transcatheter interventions. Due to the lack of commercially available transcatheter devices for MS, numerous high-risk patients undergo isolated transcatheter aortic valve replacement (I-TAVR). The long-term efficacy and durability of this single-valve approach in a multivalvular stenotic setting is not well established. Retrospective analyses of consecutive patients treated for concomitant severe AS and moderate-to-severe MS at a single institution (2015–2025), divided according to treatment strategy (DVS vs I-TAVR). Propensity-score matching accounted for baseline differences, while univariable and multivariable analyses evaluated factors associated with recurrent heart failure (HF) readmissions. Ninety-seven patients underwent DVS and 129 I-TAVR. Both before and after propensity score matching, no differences were observed in short- nor mid-term incidence of all-cause mortality (unmatched, p = 0.078; matched, no events) nor stroke (unmatched, p = 0.783; matched, p = 1.00). However, I-TAVR was found to be associated with greater HF rehospitalizations (unmatched, p = 0.001; matched, p = 0.006). The univariable and multivariable analyses demonstrated I-TAVR to be an independent risk factor for HF rehospitalization, in both the unmatched and matched populations. In patients with high-grade concomitant AS and MS, addressing only AS with I-TAVR is an independent predictor of HF readmissions. While I-TAVR remains a valid therapeutic option in high-risk patients with high-grade multivalvular stenosis, DVS should be considered as the preferred treatment option in any patient that can tolerate surgery. IRB-AAAV5910. Consent was waived owing to the retrospective design of the study.
OBJECTIVES:To describe the mitral valve (MV) anomalies found in patients with transposition of the great arteries (TGA), the surgical procedures performed, and the fate of the abnormal MV. METHODS:From 1990 to 2020, 52 patients out of 1590 TGA {S, D, D} patients (3.3%) undergoing biventricular repair were identified with abnormal MV. Anomalies were a mitral cleft (n = 46 [88%], ejection/outflow tract in 40 and as atrioventricular septal defect [AVSD]-type in 6) and/or anomalies of the subvalvular apparatus (60%). A ventricular septal defect was present in 88.5% and pulmonary stenosis in 17.3%. RESULTS:The main surgical procedure was an arterial switch operation (90.4%). Overall survival was 92.3% at 1 year and 88.3% at 20 years with a mean follow-up of 11.2 years. Ten patients (19.2%) had a concomitant mitral procedure at initial surgery: cleft/indentation closure alone in 4, isolated subvalvular/annuloplasty repair in 1, and combined cleft closure plus subvalvular procedures in 5; 4 had a preoperative grade ≥2 mitral regurgitation (MR). None of these patients have required subsequent MV surgery during follow-up. Another 6 patients required late MV surgery for MR (n = 4) and/or for left ventricular outflow tract obstruction (LVOTO) due to accessory MV material or a narrowed subaortic pathway. None had undergone a mitral procedure at initial repair. All 6 underwent cleft closure, with LVOTO relief in 3 (abnormal chordae attachments resection in 2 and fibromuscular stenosis without MV subvalvular apparatus' anomalies in 1). One patient required redo MV surgery for MV replacement. Freedom from late MV surgery in the overall cohort was 97.9% at 1 year, 93.7% at 5 years, and 82.8% at 20 years. CONCLUSIONS:The most frequent MV anomalies in TGA are anterior clefts and subvalvular abnormalities. Mortality and reoperation rates are much higher than in the other subtypes of TGA. Mitral repair at initial surgery should be considered only in cases of significant regurgitation or obstruction due to subvalvular apparatus' anomalies. Late MV procedure, for a limited proportion of patients, involves cleft closure and LVOTO relief.
OBJECTIVES:Quantify inter-operator variation in referred coronary artery bypass grafting (CABG) following angiography and evaluate associations with practice patterns and long-term outcomes. METHODS:Observational study using administrative health data in British Columbia, Canada (2010-2024). Interventional cardiologist-level CABG Rate was defined as the proportion of referred CABGs to total angiograms performed. Variation across Interventionalists was correlated with other practice characteristics. Among patients undergoing angiography followed by revascularization, associations between operator CABG Rate and all-cause mortality, major adverse cardiovascular events (MACEs), and repeat revascularization were evaluated using hierarchical Cox regression. RESULTS:Among 252 408 angiograms by 40 Interventionalists, CABG Rate varied 13-fold (2.03%-26.4%) and was not explained by hospital-level factors alone (intraclass correlation coefficient [ICC]: 0.358; 95% confidence interval [CI], 0.054-0.621). Higher CABG Rates were associated with lower percutaneous coronary intervention (PCI) utilization (R = -0.60; P < .001), lower PCI extensiveness (R = -0.52; P < .001), and lower procedural volume (R = -0.36; P = .022). In 73,603 first-time revascularized patients, CABG Rate was associated with reduced repeat revascularization (hazard ratio [HR] = 0.075; P < .001), without differences in mortality or MACE. CONCLUSIONS:Referred CABG varies markedly between Interventionalists and reflects operator practice style. Higher CABG utilization is associated with more durable revascularization without impact on survival or MACE. Broader implementation of multidisciplinary Heart Teams may improve consistency of care.
