BACKGROUND The transition from the Lung Allocation Score (LAS) to the Composite Allocation Score (CAS) in March 2023 marked a major shift in organ allocation, incorporating age into post-transplant survival modeling. This study evaluated the effect of CAS on waitlist duration and post-transplant outcomes among elderly lung transplant candidates (≥70 years). METHODS A retrospective cohort study using the United Network for Organ Sharing registry data. Recipients aged ≥70 years transplanted March 2022–March 2023 (LAS era, n=358) were compared with recipients in the CAS era (March 2023–March 2024, n=288). Primary outcomes included waitlist duration, procurement logistics, and 6-month survival. RESULTS CAS recipients experienced significantly longer median waitlist duration (28 vs. 20 days, p=0.005), greater donor travel distance (478.5 vs. 194.5 miles, p<0.001), and prolonged cold ischemic time (6.6 vs. 5.6 hours, p<0.001). Despite these logistical differences, in-hospital (3.1% vs. 3.7%, p=0.74), 30-day (4.1% vs. 4.9%, p=0.68), and 6-month mortality (3.8% vs. 7.5%, p=0.67) were similar. Treated acute rejection within 1 year was significantly lower in CAS recipients (0% vs. 10.1%, p<0.001). In multivariable Cox regression adjusting for donor characteristics and procedural factors, the allocation system was not independently associated with 6-month mortality (hazard ratio 0.69; 95% confidence interval 0.25–1.87, p=0.461). CONCLUSIONS Among recipients aged 70 years or older, CAS was associated with longer waitlist duration but not with worse early post-transplant outcomes. A longer follow-up is needed to assess the full effect of this allocation change in elderly lung transplant recipients.
Mitral valve prolapse is a common valvular abnormality, and an arrhythmic subtype is associated with life-threatening arrhythmia that can cause cardiac arrest. We present a case of ventricular tachycardia (VT) accompanying severe mitral regurgitation (MR) and an extremely elongated, scarred lateral papillary muscle that was treated with papillary muscle resection and novel mitral valve repair. At two year follow up, the echocardiogram shows no MR, and no arrhythmia is identified during 10-day rhythm monitoring, suggesting that the scarred papillary muscle may have been integral to the patient’s VT as well as the MR.
PURPOSE The purpose of this new technology is to compute dynamic arterial elastance (Eadyn), Eadyn=pulsepressurevariationstrokevolumevariationwhich reflects ventricular–arterial coupling and is indicative of vasoplegia but remains underused in translational cardiac surgery research. DESCRIPTION We developed an open-source program that computes Eadyn from any arterial pressure waveform for cardiac surgery research. The framework includes: (1) heart rate detection; (2) systolic/diastolic assignment; (3) stroke-volume estimation using the Liljestrand–Zander model; (4) calibration of derived stroke volume with echocardiography; (5) respiratory-cycle identification; (6) computation of Eadyn. EVALUATION Feasibility was evaluated in a translational large animal model.The algorithm consistently detected physiologic heart rate, pressures, and respiratory rate. Average echo-calibrated stroke volume closely matched echocardiographic measurements. Post-bypass Eadyn decreased (pre-bypass median ∼0.86 vs post-bypass median ∼0.37), consistent with vasodilatory physiology and decoupling. CONCLUSIONS This program provides a feasible method to quantify Eadyn from arterial waveforms. The device-agnostic approach enables reproducible ventricular-arterial coupling assessment for cardiac surgery research and may have future clinical applications.
BACKGROUND The clinical use of video-assisted thoracoscopic surgery (VATS) for the treatment of rib fractures remains limited. This study aimed to assess the clinical utility of surgical stabilization of rib fractures (SSRF) combined with VATS performed by thoracic surgeons. METHODS This retrospective study included 30 consecutive patients with multiple traumatic rib fractures who underwent SSRF at Fukuchiyama City Hospital from June 2022 to April 2025. Concomitant intrathoracic organ injuries were assessed thoracoscopically during SSRF using MatrixRIBTM system. Patient characteristics, surgical details, and postoperative outcomes were analyzed. RESULTS The median patient age was 70 years, and 19 patients were male. The median number of rib fractures was 7, with flail chest in 11 cases. We thoracoscopically performed simultaneous lung injury repair in three patients, partial lung resection for traumatic lung pseudocysts in one, and diaphragmatic injury repair in one. Postoperative complications of Clavien–Dindo grade ≥II occurred in eight patients, with pneumonia observed in three. At 6 months post-surgery, the median Glasgow Outcome Scale-Extended was 8, and the return-to-society rate was 90.9%. CONCLUSIONS SSRF combined with VATS facilitates effective management of associated intrathoracic injuries, with favorable postoperative outcomes.
BACKGROUND Detailed data on how mentorship influences career-specialty decisions are lacking. This study explores the role of mentorship in the career choices of cardiothoracic surgery trainees and practicing surgeons by identifying factors that contribute to its impact. METHODS A survey was distributed electronically to members of the Thoracic Surgery Directors Association and through social media platforms from December 2023 to February 2025. Descriptive statistics, univariate, and multivariate logistic regression analyses were conducted. The primary outcome was mentorship impact on respondent career decisions, and secondary outcome was the perceived strength of the impact. RESULTS Overall, 255 attendings and trainees responded, with 189 females (74%) and 66 males (26%). Trainees accounted for 132(52%) of the participants. Notably, 154 participants (154/255,60%) reported having a mentor (53 attendings (53/123=43%) and 101 trainees (101/132=76%)). Among those with mentors, 73 trainees (73/101=72%) and 31 attendings (31/53=58%) were influenced by their mentors regarding career decision-making, and 51(51/154=30%) reported the influence as highly significant. Weekly mentorship interaction or receiving career guidance significantly increased the odds of mentor influence. Among attendings, mentorship beginning in general surgery residency or medical school was associated with greater influence. Among influenced trainees, mentors from academic institutions were associated with stronger perceived impact on career choice. CONCLUSIONS Most participants had a mentor, and mentorship influenced career decisions. Influence was higher with weekly interaction, when discussions focused on career guidance, and with mentors from academic institutions among trainees. Among attendings, the impact was more significant when mentorship started during general surgery residency or medical school.
Currently, both (modified) single-patch and two-patch techniques are commonly used for repairing complete atrioventricular septal defects. However, long-term concerns related to left atrioventricular valve regurgitation and/or left ventricular outflow tract obstruction remain. We present a modified two-patch technique that reconstructs the left atrioventricular valve into a functional mitral valve and ensures clearance of the left ventricular outflow tract. Early outcomes are promising, showing no reoperations, no evidence of left ventricular outflow tract gradient, and at most mild residual left atrioventricular valve regurgitation. This approach has the potential to improve long-term valve competence and reduce the need for future reoperation.
Transcatheter valve-in-valve replacement is an established option for degenerated surgical bioprostheses, particularly in high-risk or redo settings. However, a surgical dilemma arises when concomitant procedures are required and bioprosthetic explantation is technically hazardous, exposing the patient to excess risk. We report the use of a balloon-expandable transcatheter aortic valve in an open surgical setting as a valve-in-valve implantation within a degenerated rapid-deployment aortic bioprosthesis, in a patient who also required mitral valve replacement. This open valve-in-valve strategy avoided high-risk explantation while allowing definitive treatment of both aortic and mitral valve pathology in a single operation.
A 50-year-old female was incidentally found to have a 33×26 mm cystic-solid space-occupying lesion in the atrial septum on physical examination. She underwent complete resection via right intercostal video-assisted thoracoscopy, with endotracheal tube removal in the operating room. Postoperative pathology verified a foregut cyst. The patient recovered well and was discharged on postoperative day 5. This case proves such lesions can be radically resected thoracoscopically instead of receiving simple decompression and drainage.
Complete proximal mobilization of the left internal thoracic artery (LITA) is often limited by the pleural cupula, which narrows the working space beneath the left innominate vein (LIV). Herein, we describe a stepwise technique for pleural cupula release during skeletonized LITA harvesting. The LIV–LITA crossover served as an intraoperative endpoint of dissection; progressive caudal descent of the thicker proximal segment indicated ongoing mobilization. These landmarks made proximal LITA harvesting more reproducible and helped deliver the largest-caliber segment to the target coronary anastomosis.
BACKGROUND Given the increasing utilization of robotic approaches in cardiac surgery, there remains considerable interest in developing easily reproducible techniques for LAA exclusion through a robotic approach. The objective of the present study was to describe a simple, reproducible method for LAA patch exclusion at time of robotic mitral valve surgery. METHODS Data was retrospectively collected for consecutive patients (n=3) who underwent robotic mitral valve surgery utilizing the described LAA exclusion technique between December 2025 and March 2026. Categorical variables are reported as counts and percentages, while continuous data are reported as medians and interquartile ranges. RESULTS Median age was 67 years (±12). All patients had a history of AF. In all patients, post-intervention transesophageal echocardiography demonstrated successful exclusion of the LAA, with no residual flow observed by color flow doppler. Median ICU stay was 4 days (3.5-4) and hospital duration was 8 days (7-8). Each patient experienced a transient episode of atrial fibrillation in the postoperative period, converting to sinus rhythm prior to discharge. There were no other complications. Pre-discharge computed tomography heart imaging showed an adequately excluded LAA in each case. There were no 30-day mortalities. CONCLUSIONS Endocardial patch exclusion of the LAA with confirmatory methylene blue contrasted dye injection offers a simple and reproducible technique to confirm LAA exclusion in patients with atrial fibrillation undergoing robotic mitral valve surgery.
BACKGROUND Current graft materials for congenital heart defect reconstruction lack native tissue properties, contributing to complications and reoperation. Autologous human umbilical cord grafts (UCGs) represent a promising alternative, particularly if pre-endothelialized to enhance integration and function. METHODS Human umbilical cords were processed into UCG patches, and matched human umbilical vein endothelial cells (HUVECs) were isolated, expanded, labeled with CMFDA, and seeded onto patch discs at 30,000 cells/well. Constructs were assessed at 2 hours, 2 days, and 4 days using fluorescence microscopy and quantitative fluorescence assays. Unseeded UCGs and HUVECs cultured on plastic served as controls. RESULTS HUVEC isolation from two biological replicates yielded 0.12 and 0.15 million cells, expanded to 2.7 and 3.2 million cells, respectively. Seeded UCGs demonstrated increased fluorescence qualitatively over time. Quantitative analysis showed an initial decline in signal, followed by recovery and increased signal by day 4, consistent with cell retention and proliferation. CONCLUSIONS Autologous HUVECs can be successfully isolated, expanded, and seeded onto matched UCGs. Pre-endothelialized UCGs represent a feasible strategy to enhance graft integration and warrant further functional evaluation for congenital cardiovascular reconstruction.
Cardiac hydatid cysts are rare manifestations of Echinococcus granulosus infection. Mismanagement can lead to cyst rupture, systemic dissemination, anaphylaxis, or death. We present the case of a 41-year-old man with a hydatid cyst involving the interventricular and interatrial septa, confirmed through imaging and serologic testing. This case highlights key principles for management, including preoperative and postoperative albendazole; meticulous field isolation; cyst evacuation; and adjunctive sterilization techniques, such as hypertonic saline irrigation and cryoablation. Following these practices will allow the safe and effective treatment of these patients.
Background Landmark immunotherapy trials have transformed treatment of non-small cell lung cancer (NSCLC), yet underrepresentation of racial and ethnic minorities threatens the generalizability of trial findings. This study evaluated disparities in receipt of immunotherapy during clinical trial periods preceding regulatory approval. Methods Using the National Cancer Database, we assessed receipt of immunotherapy by patients diagnosed with metastatic NSCLC between 2004 and 2015 and resectable stage II-IIIB NSCLC between 2004 and 2021, corresponding to immunotherapy clinical trial periods for metastatic and resectable disease, respectively. Multivariable adjusted logistic regression was used to evaluate associations between race and ethnicity and receipt of immunotherapy. Additional sensitivity analyses were performed among subgroups of patients with insurance, who reside in high-income areas, received treatment at academic facilities, have no comorbidities, and received chemotherapy. Results In multivariable analyses of patients with metastatic disease, Black (odds ratio [OR], 0.81; 95% CI, 0.76-0.88), Asian (OR, 0.84; 95% CI, 0.74-0.95), and Hispanic (OR, 0.79; 95% CI, 0.71-0.89) patients were significantly less likely than non-Hispanic White patients to receive immunotherapy. Disparities persisted in sensitivity analyses, including of insured patients treated at academic centers in high-income areas. Notably, Black patients residing in the highest income areas remained less likely to receive immunotherapy than White patients residing in the lowest income areas (OR, 0.63; 95% CI, 0.42-0.96). Similar disparities were observed in the neoadjuvant setting. Conclusions Patients from racial and ethnic minorities were significantly less likely to receive immunotherapy during clinical trial periods for NSCLC, even in populations with comparable access to care. These findings emphasize persistent inequities in early access to novel therapies and the need for targeted strategies to improve trial representation.
BACKGROUND Donation after circulatory death (DCD) increases cardiac allograft availability, but patients not passing within the allotted time lead to inefficiency and an emotional toll on parties involved. This study aims to identify predictors of donor death within the allotted time. METHODS A single center, retrospective review of DCD recoveries from 2/2020-9/2023 was performed. Donors were classified as passed if the patient died within the allotted time-limit set at the donor center. A multivariable model identified predictors of the patient not passing. A sensitivity analysis stratified each patient as passing within or beyond 60 minutes. RESULTS There were 206 DCD recoveries attempted, where 24 (11.7%) potential donors did not pass. Multivariate modelling found that increasing age (10-year increments; OR 0.43, 95% CI 0.21–0.86), drug overdose (OR 0.17, 95% CI 0.06–0.48), GCS >3 (OR 0.07, 95% CI 0.01–0.46), decreased pCO2 (increases of 10mmHg; OR 2.12, 95% CI 1.12–4.41), and increased inpatient days (per day increase; OR 0.86, 95% CI 0.79–0.93) were associated with decreased odds of passing within the allotted timeframe. Sensitivity analysis found that drug overdose and increased inpatient days were associated with decreased odds of passing within 60 minutes. CONCLUSIONS Increased patient age, drug overdose, GCS >3, lower pCO2 on ABG, and longer inpatient durations were independently associated with DCD heart donor candidates not passing.
BACKGROUND Given evidence linking hospital volume and weekend intervention with survival after cardiac surgery, we sought to determine whether surgical repair of acute type A aortic dissection(TAAD) performed on Saturday or Sunday was associated with increased short-term mortality and whether any observed “weekend effect” was modified by hospital aortic surgical volume. METHODS We retrospectively analyzed Medicare beneficiaries hospitalized between 1999-2019 with procedural codes indicating aortic surgery. Hospitals were stratified by annual aortic procedural volumes into low-volume(LVAC), intermediate-volume(IVAC), or high-volume(HVAC) centers. CPT codes identified beneficiaries undergoing surgical repair of TAAD. A flexible parametric survival model adjusting for demographics, comorbidities, surgeon/hospital volume, and procedural details was developed to evaluate the association between day of surgery and 30-day mortality. RESULTS Among 15,375 beneficiaries undergoing TAAD repair, median age was 71.9±9.8 years; 55.5% male and 80.1% White. Comorbidity burden was modestly higher among HVAC patients. Overall unadjusted 30-day survival ranged from 78.0-79.2% for weekday operations, compared with 77.1% on Saturday and 73.9% on Sunday. After risk-adjustment, standardized 30-day survival probabilities were higher for weekday versus weekend surgery at HVACs: (85.1% versus 82.6%), IVACs: (78.1% versus 75.5%), and LVACs: (72.3% versus 68.4%). CONCLUSIONS Among Medicare beneficiaries undergoing surgical intervention for TAAD, weekend surgery was associated with significantly higher 30-day mortality across all hospital volume strata. Although higher institutional volume was associated with improved overall survival, it did not eliminate the weekend-associated excess mortality, which was most pronounced at low-volume centers.
Aortic dissection during pregnancy is rare but life-threatening. We report a 37-year-old woman at 31 weeks’ gestation presenting with acute chest pain. Imaging confirmed Stanford type A aortic dissection extending from the aortic valve to the iliac arteries, with innominate involvement. She underwent emergent cesarean delivery, followed by a Bentall procedure with hemiarch replacement and innominate artery reimplantation. The mother recovered; however, the neonate died on day 8. This case highlights the importance of rapid multidisciplinary management, with persistent fetal risk
Background The opioid crisis remains a significant issue, with >55,000 opioid-related deaths in 2023. Overprescription of opioids after surgery contributes to this crisis and is associated with adverse effects, particularly in thoracic surgery patients who undergo painful chest incisions. Our institution implemented a nonopioid pain management protocol as part of an enhanced recovery after surgery (ERAS) initiative for minimally invasive pulmonary lobectomy in 2019. This study evaluated its impact on clinical outcomes and resource utilization. Methods A retrospective review of 376 patients undergoing minimally invasive lobectomy from 2016 to 2022 compared outcomes before and after nonopioid pain regimen introduction. The nonopioid protocol included preoperative education, intraoperative liposomal bupivacaine nerve blocks, and a scheduled multimodal pain regimen. Results Patients in the nonopioid group had lower opioid use during hospitalization (P < .01) and at discharge (29.1% vs 94.2%; P < .01). Pain scores were significantly improved on postoperative days 0 to 7 (P < .01). Intensive care unit admissions (2.0% vs 6.3%; P = .04) and length of stay (3.5 vs 4.9 days; P < .01) decreased, leading to total encounter cost savings of $1129 per patient despite higher medication costs. Conclusions These findings support the adoption of nonopioid pain management strategies as part of ERAS protocols in lung resection, demonstrating improved pain control, reduced opioid use, and significant cost savings. Further multi-institutional studies are needed to optimize ERAS strategies.
Left ventricular–right atrial shunt (Gerbode defect) is a rare but serious complication after aortic valve surgery and may occur after transcatheter aortic valve explantation. We describe an 81-year-old man in whom a delayed-onset Gerbode defect developed after surgical explantation of a transcatheter aortic valve replacement. The shunt progressed to refractory heart failure and was unsuitable for transcatheter closure because of right ventricular involvement. Surgical repair was performed through a right atrial approach. Temporary partial detachment of the septal tricuspid leaflet provided improved exposure, allowing secure double-patch closure entirely from the right atrial side while preserving tricuspid valve function.
