BACKGROUND:Recent changes to society-specific guidelines for the management of stable coronary artery disease (CAD) have challenged decades of data comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). We sought to compare index and longitudinal outcomes in these populations using a large contemporary real-world cohort. METHODS:Using the United States Centers for Medicare and Medicaid Services database, we evaluated longitudinal outcomes of all beneficiaries aged ≥65 years undergoing multivessel CABG (n = 105,729) vs multivessel PCI (n = 13,192) for stable CAD (2018-2023). A predicted risk of index CABG mortality model, inclusive of frailty, was fit to simulate The Society of Thoracic Surgeons mortality model (area under the curve, 0.807). Doubly robust risk adjustment was performed with multivariable time-to-event analyses conducted in matched groups. RESULTS:Propensity score matching yielded well-balanced groups (n = 9206 per group) with a median age of 74 years, 71.2% men, and predicted mortality risk of 1.2%. Over the 6-year study period in this well-matched cohort, CABG was associated with superior longitudinal survival (hazard ratio [HR], 0.44; 95% CI, 0.40-0.49; P < .001) and freedom from myocardial infarction (HR, 0.40; 95% CI, 0.36-0.44; P < .001), coronary reintervention (HR, 0.10; 95% CI, 0.08-0.14; P < .001), and the composite outcome of myocardial infarction, coronary reintervention, or death (89.2% vs 71.1%; HR, 0.38; 95% CI, 0.35-0.41; P < .001). CONCLUSIONS:In Medicare beneficiaries with stable multivessel disease, CABG was associated with lower hospital mortality, superior longitudinal survival, and freedom from myocardial infarction and coronary reintervention. These contemporary real-world data support prior trials highlighting the benefits of CABG in stable multivessel CAD, urging a reevaluation of recent guidelines.

BACKGROUND:Lung volume reduction surgery (LVRS) and endobronchial valve (EBV) placement are therapeutic options in patients with advanced emphysema. This study sought to compare the 2 approaches by using a national data set. METHODS:Using the US Centers for Medicare & Medicaid Services Inpatient Claims Database, the study evaluated beneficiaries with severe emphysema who were undergoing either LVRS or an EBV procedure in accordance with Medicare reimbursement criteria. Doubly robust risk adjustment was performed using inverse probability weighting and multilevel regression models and competing-risk time-to-event analysis. RESULTS:Lung volume reduction therapy was performed in 3219 patients: LVRS was performed in 2378 patients, and an EBV procedure was performed in 841. Before risk adjustment, patients undergoing an EBV procedure had lower Elixhauser comorbidity scores (3.37 vs 3.86; P < .001), shorter length of stay (4 days vs 7 days; P < .0001), and lower hospital charges ($124,540 vs $146,221; P < .0001) compared with patients who underwent LVRS. Most surgical procedures were minimally invasive (1897 video-assisted thoracoscopic surgery or robotic vs 481 open). After doubly-robust risk adjustment, the EBV procedure was associated with higher 30-day mortality (odds ratio [OR], 2.68, 95% CI, 1.88-3.87; P < .001), higher 30-day readmission rate (adjusted OR, 1.4; 95% CI, 1.21-1.63; P < .001), higher reintervention rate (adjusted OR, 17.2; 95% CI, 8.42-42.2; P < .001), and higher all-cause mortality at 1 year (adjusted OR, 1.75; 95% CI, 1.49-2.07; P < .001). CONCLUSIONS:Medicare beneficiaries who undergo EBV procedures have higher risk-adjusted mortality and procedure-related morbidity despite fewer comorbidities than patients undergoing LVRS. These results suggest the need to revisit multidisciplinary decision making regarding the role of surgery in the management of advanced emphysema.

This case report describes a rare incidence of innominate artery compression syndrome in a 5-month-old infant, presenting with severe respiratory symptoms. It highlights the diagnostic challenges, the detailed imaging techniques used, and the surgical intervention that resulted in a successful resolution of symptoms, emphasising the importance of early recognition and intervention in paediatric vascular anomalies.

Background Approval of transcatheter aortic valve replacement (TAVR) for all risk profiles has extended TAVR use in patients not otherwise examined in clinical trials. We sought to evaluate contemporary real-world outcomes of surgical aortic valve replacement (SAVR) vs TAVR in Medicare beneficiaries by risk strata. Methods Using the US Centers for Medicare Services database, all patients aged 65-85 years undergoing isolated first-time SAVR (n = 34,215) or TAVR (n = 124,897) were evaluated (2018-2022). Predicted patient risk accounting for comorbidities simulating The Society of Thoracic Surgeons predicted risk of surgical mortality, but including frailty, were stratified by low (<4%, n = 36,297 TAVR; n = 14,693 SAVR), intermediate (4%-8%, n = 44,026 TAVR; n = 9693 SAVR), or high (>8%, n = 44,574 TAVR; n = 9841 SAVR) risk. Doubly robust risk adjustment with inverse probability weighting and multilevel regression with competing-risk time-to-event analyses compared outcomes. Results SAVR was associated with higher risk-adjusted in-hospital mortality, acute kidney injury, and bleeding but lower pacemaker rate compared with TAVR across all risk strata (all P < .05). Longitudinal 5-year analysis highlighted that, compared with TAVR, SAVR was associated with superior freedom from composite death, stroke, or valve reintervention in low- and intermediate-risk patients (hazard ratio [HR] 0.85, P = .044, and HR 0.86, P = .039, respectively) as well as lower overall readmission for stroke in low- (HR 0.72, P = .038) and intermediate- (HR 0.78, P = .042) risk patients. Conclusions In low- and intermediate-risk Medicare beneficiaries, SAVR was associated with higher in-hospital mortality but superior 5-year longitudinal freedom from death, stroke, or valve reintervention compared to TAVR. These data may further enhance heart team decision-making and patient counseling.

We report a 5-year-old girl with transient complete atrioventricular (AV) block following surgical closure of a symptomatic conoventricular ventricular septal defect (VSD) which recovered on post-operative day 9. She later presented with exertional dizziness and fatigue. While congenital cardiac defect repairs are occasionally complicated by complete heart block, this patient was found to have intra-Hisian Wenckebach which is rare in the pediatric population and can be very difficult to discern from surface electrocardiograms and by Holter monitoring. Mechanisms of post-surgical AV block, including intra-Hisian Wenckebach, are not well characterized in the pediatric population.