Transcatheter aortic valve implantation (TAVI) has significantly expanded the access to aortic valve replacement in numerous populations as well as increased the overall volume of aortic valve replacement since its approval. Beyond its use for symptomatic, severe aortic stenosis, the emergence of new data regarding the importance of cardiac damage has led to exploration of the use of TAVI in patients with asymptomatic, severe aortic stenosis and those with moderate aortic stenosis. Data have demonstrated a potential benefit of TAVI in patients, with asymptomatic, severe aortic stenosis, particularly with respect to rehospitalization, however the data are less complete for patients with moderate aortic stenosis, which is the subject of multiple ongoing randomized trials. This review will provide a current overview of the data surrounding the use of TAVI in these 2 populations as well as explore the future directions of TAVI use in these patients.
Post-operative challenges, including reduced respiratory function and slower overall recovery, are often associated with thoracic surgeries. Rehabilitation strategies have been important over the years for their potential to support patient recovery and improve post-surgical outcomes. Studies published up to March 2025 across the databases, including Google Scholar, PubMed, and ProQuest, were retrieved and analyzed for this systematic review. Out of the initially selected 29 studies systematically reviewed, 8 fulfilled the final inclusion criteria and were included in the analysis. Postoperative rehabilitation strategies such as physiotherapy-based programs, nurse-led initiatives, and technology-assisted interventions have been included in the systematic review and found to influence the recovery following thoracic surgery. Interventions like these improve pulmonary function, better pain management, enhanced functional capacity, reduced complication rates, and shorter recovery periods. The findings suggest that rehabilitative approaches may contribute to better postoperative outcomes. However, further clinical research is still needed to develop more standardized rehabilitation protocols.
Management of acute esophageal perforation varies significantly. Data are particularly limited regarding optimal management of patients with Boerhaave's syndrome (BS). We aimed to compare operative to endoscopic management for patients with acute esophageal injury at a high-volume tertiary referral center. This retrospective cohort study included adult patients presenting to a tertiary referral center with acute esophageal perforation from January 2002 to January 2023. Patients with esophageal cancer or prior esophagectomy were excluded. Our primary variable of interest was endoscopic (EM) versus operative management (OM) and our outcomes of interest included incidence of major postoperative morbidity and 30-day mortality. Additional covariates included demographic characteristics and preoperative clinical factors. Among 117 patients, 65 (56%) met criteria for BS, and 52 (44%) had other etiologies. Mean age was 57 ± 18 years, and 36 patients (31%) were female. Overall, 95 patients (81%) received OM. Twenty-two patients (19%) had EM with stenting; of these, 5 patients (23%) also had endoluminal vac therapy. Median ICU length of stay was 6 days (IQR 8), 30 patients (26%) required readmission, and 30-day mortality was 2.6% (3 patients, 1 with EM). Among patients with BS, 13 (20%) had EM and 52 (80%) had OM. Between BS patients managed endoscopically versus operatively, there were no significant differences in use of enteral feeding access, leaks, strictures, length of stay, readmission, or 30-day mortality (P > 0.05). At a high-volume center, endoscopic management with stenting and/or endoluminal therapy can be safely employed for well-selected patients, including those with BS.
The comparative clinical outcomes of the modified Konno procedure (MKP) and transaortic septal myectomy (TSM) for severe left ventricular outflow tract (LVOT) obstruction in children remain unclear. A total of 177 consecutive patients (age <14 years old) underwent surgical treatments, categorized by MKP or TSM technique (MKP n = 45, TSM n = 132). After propensity-score matching, 45 MKP patients were matched 1:1 with TSM patients. At discharge, the MKP group demonstrated a significantly lower LVOT peak gradient compared to the TSM group (median, 3.2 vs 11.6 mmHg, P = 0.011), which persisted at follow-up (median, 4.8 vs 11.6 mmHg, P = 0.01) in matched data. Although postoperative atrioventricular block was more frequent in the MKP group, no significant difference was observed in permanent pacemaker implantation rate between groups (P = 0.108). During follow-up (median, 1.08 years, 0.25-2.5), the incidence of recurrent LVOT obstruction was higher in the TSM group (17.8% vs 0%). Recurrent LVOT obstruction was associated with aortic annulus size (hazard ratio [HR] = 0.811; 95% confidence interval [CI], 0.675-0.974; P = 0.025) and preoperative LVOT peak gradient (HR = 1.030, 95% CI: 1.010-1.050, P = 0.003). The smaller aortic annulus size (<12.5 mm) or severe LVOT obstruction (>82.5 mmHg) significantly decreased the risk of survival free from recurrent LVOT obstruction (P = 0.01, P < 0.001). The MKP can provide better relief of LVOT obstruction than TSM in young children, particularly with a small aortic annulus or severe obstruction. MKP may not increase the risk of permanent pacemaker implantation and mortality.
The valved Sano (VS) right ventricle-to-pulmonary artery (RV-PA) shunt was developed to eliminate conduit regurgitation and thereby decrease volume load on the single right ventricle (RV) after the Norwood procedure. By reducing diastolic backflow, VS may limit tricuspid regurgitation and preserve RV function. Additional theoretical advantages include facilitated postoperative recovery and improved pulmonary artery (PA) growth. Despite compelling physiology, available evidence remains limited and largely retrospective. We describe the postoperative course of a low-weight neonate with hypoplastic left heart syndrome who underwent a Norwood procedure using a VS, and we review published literature addressing early outcomes, reintervention burden, late survival, and PA growth. Use of a VS can be associated with improved early physiologic recovery, lower postoperative lactate, faster diuresis and enteral advancement, and better early RV function. Short-term survival appears equivalent to the non-valved Sano. Interstage reinterventions remain frequent (40%-60% before stage II). Late survival beyond stage II is comparable to non-valved Sano. Femoral vein homograft-based conduits may promote greater PA growth and reduce the need for PA augmentation, but findings vary across centers. Valve competence commonly decays within 3-6 months, resulting in conduit regurgitation. VS conduits may facilitate early recovery and potentially favor PA growth when constructed with competent Femoral vein homograft segments, yet they have not demonstrated superior late survival or reduced reintervention burden. Larger multicenter studies are required to clarify optimal patient selection and long-term impact.
Post-operative hemothorax (PH) is one of the most critical complications in thoracic surgery, which requires prompt treatment. The aim of the study is to review the consecutive series of patients with PH undergoing re-operation in Uniportal Video-Assisted Thoracic Surgery (U-VATS) or Thoracotomy, analyzing the outcomes and costs. Out of 1663 patients undergone Thoracic operations (pulmonary resections, esophagectomies, or pleural/chest wall lesions) between 2016 and 2024, 52 (3.12%) developed a PH and underwent surgical treatment. Data of patients were collected and retrospectively analyzed. Thirty-six patients were male (69.23%), with a mean age of 62.54 ± 16.46 years. Active bleeding was intraoperatively discovered in a total of 35 patients (67.30%). Most of the patients who developed PH had undergone a previous wedge resection (20, 38.46%) and in 15 cases (28.84%), the cause was pleural/parenchyma bleeding. Post-operative complications were significantly higher in the group of patients who underwent treatment of PH by thoracotomy (10 (34.48%) vs 2 (8.69%), P:0.028), and 14 patients (48.27%) required ICU admission(P:0.020). Patients with post-operative complications had a significantly longer hospital-stay (9.33 ± 5.02 vs 4.83 ± 2.09 days: <0.001). In general, post-operative hospital-stay was also longer in the thoracotomy group (7.07 ± 3.83 vs 4.35 ± 2.44 days, P:0.005). Total costs, including operating room expenses, hospital-stay, and ICU admission, were higher in the open group compared to U-VATS(6708.94 ± 2738.74 vs 5238.79 ± 2527.92€, P:0.052). Multivariable analysis identified the open approach as the only independent risk factor for complications (OR = 5.53, 95%CI [1.072-28.49], P:0.041). Open approach exposes to higher post-operative complications and costs, with longer hospital stay in case of reoperation for PH. U-VATS technique seems to be safe and effective and with lower costs, although the instruments are more expensive.
Cardiovascular surgery has substantially improved survival and quality of life for patients with cardiovascular disease, yet contemporary surgical populations are increasingly older, multimorbid, and affected by advanced disease, rendering procedures and perioperative care more complex. Patients often experience severe physical symptoms, psychological distress, and difficult decisions, which in cases of complications also include escalation, limitation, or withdrawal of life-sustaining treatment. In this article, we argue that palliative care offers a framework to address these complex needs throughout the entire cardiovascular surgery pathway, rather than only at the end of life. Preoperatively, structured shared decision-making, goals-of-care discussions, and advance care planning can help align surgical strategies with patients' values and prepare patients and families for potential complications. Postoperatively, routine assessment and management of physical symptoms, psychological distress, social needs, and spiritual concerns could prevent and alleviate suffering during the hospitalization. In the setting of serious complications, interdisciplinary team support, regular family meetings, and professional communication can support decision-making and reduce distress for patients, families, and clinicians. Most palliative care needs can be addressed by surgical and intensive care teams as primary palliative care, while specialty palliative care should be involved for complex symptoms, decisional conflict, or challenging psychosocial or existential distress. Further research, education, and guideline development are needed to change professional culture and establish palliative care as a routine, complementary component of cardiovascular surgical care.
Pulmonary metastasectomy (PM) is a surgical procedure to remove lung metastases. Although it indicates advanced-stage disease, it is considered a therapeutic option to prolong survival in selected patients with oligometastatic disease, where lesions can be controlled locally. This systematic review synthesized the available evidence from reviews and retrospective studies on survival outcomes and prognostic factors associated with pulmonary metastasectomy (PM). A literature search was conducted in Ovid Medline, EMBASE, and the Cochrane Central Register of Controlled Trials covering the last 30 years up to January 2025, using the term "pulmonary metastasectomy." Studies involving human subjects and published in English were included. Eighty two articles were reviewed. PM offers significant survival benefits across various tumor types, with 5-year survival rates varying widely (e.g., 35% to 72% for breast cancer and 40% to over 70% for colorectal cancer). Key favorable prognostic factors include: control of the primary tumor, absence or control of extrapulmonary metastases, complete resectability (R0), a long disease-free interval (DFI), and a limited number or size of metastases. However, most data comes from retrospective studies with potential selection bias. PM is considered a valid and potentially curative component of multimodal treatment strategies for resectable lung metastases. It requires rigorous patient selection and a multidisciplinary approach. Current limitations of the evidence (lack of randomized controlled trials, selection bias, high recurrence rates) highlight the need for further prospective research to optimize selection criteria and integrate PM with emerging systemic therapies.
Tracheoesophageal fistula (TEF) is a challenging, complex condition with a wide spectrum of underlying causes and clinical manifestations. TEF management requires a deep understanding of anatomical characteristics, underlying conditions, and a multidisciplinary approach to optimize the diagnostic pathways and treatment allocations. The management of benign and malignant TEF has shown progress in its effective treatment; however, surgical techniques remain a challenge and are often complemented by innovative stent deployment strategies. Concurrently, new techniques are being added to the treatment landscape; however, the evidence remains largely limited to case reports. Nevertheless, despite the substantial advancements in the management of TEF, there remains a lack of consensus or established guidelines for this condition in the adult population, and the treatment approach remains highly individualized. The aim of this article is to summarize the current treatment strategies for this complex disease.
The widespread and ever-expanding use of computed tomography for disease, trauma, cardiac imaging, and lung cancer screening has led to increased incidental detection of indeterminate thymic nodules and masses on computed tomography. Chest magnetic resonance imaging provides increased diagnostic specificity and delineation of disease extent and should therefore both reduce unnecessary thymectomy and improve clinical management of thymic masses.
The bronchial sleeve represents a pivotal advancement in thoracic surgery, allowing for oncological radicality while preserving respiratory function. We present 29 cases of telescopic monofilament continuous suture bronchial sleeves out of a total of 43 bronchial sleeve resections performed by us. There were no mortalities, no bronchial positive margins, no local recurrences, and only one anastomotic fistula requiring pneumonectomy with open window thoracostomy, which closed after a few months (Fig. 2). The telescopic intussusception technique avoids the significant problem of caliber discrepancy, and this type of suture consolidates with the physiological increases in airway pressure due to Valsalva maneuver or coughing, because the internal "endobronchial" pressure generated is applied radially on the smaller caliber bronchus, pushing it and causing it to adhere to the larger caliber external bronchus.
Lung transplantation for cancer is controversial. The hesitancy has largely been driven by historical outcomes. However, early-stage lung cancer does not significantly affect the outcome of lung transplant for other end-stage lung diseases. We have also made more donor lungs available and hence can consider transplanting patients where the only curative option is to resect both lungs. With careful patient selection, experienced transplant centers can achieve acceptable long-term lung transplant results in patients with cancer as compared to those with other end-stage lung diseases. Additionally, there are two ongoing trials investigating the role of lung transplant for lung cancer and aim to expand access to lung transplants for cancer patients and potentially change medical opinion. If more than one type of patient can benefit from transplant, is it ethical to only allocate donor allografts to patients with chronic lung disease simply because that is what we have always done? Is one disease process more deserving of treatment than another?
Reoperative total arch replacement (TAR) following prior cardiovascular surgery presents significant technical challenges and is associated with higher risk profiles. With increasing numbers of patients undergoing reoperation as a result of successful outcomes from primary procedures, we sought to compare the clinical outcomes of reoperative TAR with those of first-time TAR. We reviewed 474 patients who underwent TAR at our institution from 1997 to 2024. Of these, 171 patients (36%) had previously undergone cardiovascular surgery, while the remaining 303 (64%) were undergoing TAR for the first time. Demographic, procedural, and outcome data were collected and analyzed. Comparisons between the reoperative and primary groups were made, and multivariable regression was used to identify covariates associated with major postoperative adverse events (MAEs). Patients in the reoperative group were younger on average (61.5 ± 13.5 vs 70.7 ± 10.9 years, P < 0.001), but presented with a higher burden of comorbidities, including ischemic heart disease (15.8% vs 7.3%, P = 0.006), prior strokes (38.6% vs 15.5%, P < 0.001), and renal impairment (24.6% vs 12.5%, P = 0.001). Operative times were significantly longer for reop TAR, with extended circulatory arrest (48.4 ± 12.8 vs 36 ± 10.8 minutes, P < 0.001), cardiac ischemia (118.2 ± 44.2 vs 99 ± 32.1 minutes, P < 0.001), and cardiopulmonary bypass duration (180.7 ± 38.2 vs 146.7 ± 26.3 minutes, P < 0.001). The reoperative group had higher operative mortality (4.1% vs 0.3%, P = 0.007) and a 2.3-fold increased risk of MAEs (OR 2.27, 95% CI 1.01-5.1, P = 0.046). Reoperative TAR is associated with increased operative risk, longer procedural times, and higher rates of operative complications compared to first-time TAR. Despite these challenges, successful outcomes can be achieved with thorough preoperative planning and attention to key technical details.
Transcatheter pulmonary valve replacement (TPVR) has been associated with an increased risk of infective endocarditis. However, there are few reports investigating the risk of endocarditis with the specific prostheses used in TPVR-the Melody valve and SAPIEN valve. Rarely, endocarditis of the pulmonary valve may also extend to adjacent tissue, resulting in the need for more complex surgical management. This article reviews current literature on infective endocarditis following TPVR and compares this to rates following surgical pulmonary valve replacement, with a particular focus on the Melody valve, SAPIEN valve, and Contegra conduit. We will also discuss our experiences with pulmonary valve endocarditis and several reported cases of its extension to the aortic valve and paravalvular area.
Chest wall resection and reconstruction for T4 non-small cell lung cancer (NSCLC) represents a challenging surgical scenario; T4 Pancoast tumors and tumors involving the spine (T4 spine) are the most frequently encountered subsets. Multidisciplinary assessment is performed to select the optimal surgical approach, determine the extent of resection necessary to obtain tumor-free margins, define the geometric characteristics of the chest wall defect, and choose the most appropriate reconstructive materials. Two or 3 incisions, selected on the basis of the individual patient, are recommended to access T4 Pancoast tumors. Depending on the level of involvement of the vertebral structure, the approach to the T4 spine may require a thoracotomy and a midline posterior incision. Chest wall reconstruction is often complicated by sequelae of chemoradiation or chemoimmunotherapy, superimposed infection, or anatomic derangement after previous surgery. Since 2019, the Chest Wall Multidisciplinary Team at Memorial Sloan Kettering Cancer Center has generated several recommendations for chest wall resection and reconstruction for patients with T4 tumors. Anterior defects are generally reconstructed using rigid materials. T4 Pancoast tumors are preferentially reconstructed using semirigid (biologic) materials and a bulky free flap, which provide similar stability as rigid materials and avoid impingement on the thoracic inlet neurovascular bundle. For posterior defects, semirigid resorbable materials are used to avoid pleural fluid extravasation and seromas. The use of free flaps allows more-extensive chest wall resection and promises a high likelihood of R0 resection, with morbidity similar to that with regional flaps. A multidisciplinary approach ensures optimal management of these complex cases.
Surgical replacement of the ascending aorta and root was first undertaken in the 1950s although methodologies were rudimentary compared to the current era. Advances in brain protection and surgical technique have made complex root procedures relatively low risk in experienced hands. The standard critieria for elective replacement of the root and ascending aorta has been 5.5 cm when there is no connective tissue etiology for the aneurysm. Recent literature has suggested that a more liberal criteria would may be appropriate in healthy patient at low risk, patients with high-risk features including strong family history of adverse aortic events, and in centers whose outcomes are such that the risk of surgery at lower aortic size is far less than the risk of progression of disease or significant adverse event. This manuscript critically evaluates recent literature to suggest in which patients and at what type of centers a more aggressive prophylactic approach should be entertained.
Pulmonary lobectomy via a minimally invasive surgery (MIS) approach represents the current standard of care in early-stage non-small cell lung cancer. However, MIS has mostly relied on intercostal incisions, with the inherent risk of intercostal nerve injury. As a result, several non-intercostal approaches were developed. However, published data on the subject remain scarce. We aim to review existing non-intercostal MIS lobectomy techniques to specifically assess their feasibility and safety. Systematic review from 2010-2025. The outcomes for feasibility and safety were conversion rate and 30-day mortality, respectively. A total of 17 studies were included in the qualitative synthesis. From a combined total of 2376 patients included in the study, 66% (n = 1570) underwent a non-intercostal lobectomy. Among these, 83.5% (n = 1312) were performed via a subxiphoid approach, 15% (n = 236) via subcostal incisions. Among the studies that reported on outcomes, conversion rate and mortality were reported, respectively, as 4.3% (n = 53/1228) and 0.4% (n = 1/259) for subxiphoid approach, 1.4% (n = 2/140) and 0.7% (n = 1/140) for subcostal incisions. There has been growing interest in various non-intercostal approaches to pulmonary lobectomy over the past decade. Notably, recent studies suggest a shift toward higher-quality research and a transition from subxiphoid video-assisted to subcostal robotic-assisted thoracic surgery techniques. Among these, Outside the Cage (OTC) RATS robotic-assisted thoracic surgery emerges as the only fully non-intercostal reproducible robotic approach. Despite encouraging early data, further efforts are required to rigorously evaluate potential benefits. Nonetheless, the evidence to date suggests that it could be both feasible and safe to step "outside the cage."
Thymic epithelial tumors require tailored surgical strategies to optimize outcomes. This review synthesizes current evidence on surgical approaches, emphasizing the critical roles of tumor stage, anatomy, and multidisciplinary planning. For early-stage thymic epithelial tumors (Stage I/II), minimally invasive techniques (video-assisted thoracic surgery, robotic-assisted) demonstrate equivalent oncologic outcomes to open surgery, with reduced morbidity, shorter hospitalization, and faster recovery. Recent propensity-matched studies highlight robotic thymectomy's advantages, including lower blood loss and complication rates, though operative times may be longer. Locally advanced tumors (Stage IIIA-B) demand meticulous R0 resection, often necessitating open approaches for complex resections involving pericardium, phrenic nerves, or great vessels. Induction therapy shows promise in converting borderline resectable tumors and improving R0 rates. For Stage IVA disease, surgery within multimodal regimens may enhance survival, though benefits depend on pleural burden and histology, underscoring the need for individualized management. Emerging debates focus on refining resection extent. Lymphadenectomy gains traction for thymic carcinomas and advanced thymomas due to nodal metastasis risks, while partial thymectomy for early-stage tumors remains controversial, requiring randomized trials to balance oncologic efficacy against long-term immunologic consequences. Thymic surgery continues to evolve, prioritizing R0 resection while integrating minimally invasive advancements and multimodal therapies. Centralized, high-volume centers and international collaboration remain pivotal to addressing these rare malignancies. Future research must clarify lymphadenectomy's role, validate partial thymectomy, and optimize induction strategies through prospective trials.
