BACKGROUND:Thymic cancers are exceedingly rare, with an incidence of one to two cases per 100 000 person-years with exceptionally diverse presentations. There is limited literature characterising prognostic factors, surgical management strategies and outcomes in Australian patients with thymic tumours. METHODS:We performed a retrospective analysis of all patients that underwent surgical resection of a thymic tumour from 2013 to 2022 within the two major cardiothoracic surgical units in Western Australia. RESULTS:There were 120 patients included in this study, 60 patients with thymoma. There was a higher rate of recurrence in patients with thymoma and concurrent myasthenia gravis. Thoracoscopic surgery was associated with a reduced hospital length of stay (p = 0.04). Of the 40 patients with myasthenia gravis that underwent thymectomy, 30 (75%) had an improvement in their MG symptoms. CONCLUSIONS:We describe the referral patterns, diagnostic methods, clinical management and outcomes for 120 patients who underwent resection of a thymic tumour. Our study affirmed that thymic surgery is well tolerated, supports its application in the management of myasthenia gravis and this research may help to further develop guidelines for best management of these tumours in Australian patients.

Aims:Bioprosthetic valves are increasingly used for surgical aortic valve replacement (SAVR) in patients ≤ 70 years though the relative benefits compared to mechanical valve replacement remain uncertain. This study aims to compare mortality and other outcomes by prosthesis type for patients aged 50-70 years who received SAVR in a well-characterized Australian cohort. Methods and results:Data were prospectively collected at the time of heart valve surgery and linked administrative outcome data. This analysis includes all patients aged 50-70 years who had SAVR in Western Australian public hospitals between 2010 and 2020. The primary endpoint was all-cause mortality. Secondary endpoints were cardiovascular mortality, separately and combined with admission for either non-fatal myocardial infarction or for non-fatal stroke (MACE), major bleeding, and days alive and out of hospital (DAOH). Outcomes, categorized by prosthesis type (mechanical or bioprosthetic), were compared using propensity matching. Within the initial cohort of 706 patients undergoing SAVR (mean age 62.5 years, SD 6), propensity score matching identified 149 patients each with mechanical or bioprosthetic valves. After adjustment, patients who received mechanical valves had lower all-cause mortality [adjusted hazard ratio (aHR) 0.51; 95% confidence interval (CI) 0.27-0.98; P = 0.04] and MACE (aHR 0.53; 95% CI 0.30-0.95; P = 0.03) during median follow-up of 3.6 years. Mechanical valves were associated with increased risk of major bleeding (aHR3.40; 95% CI 1.32-8.77; P = 0.01). There was no difference in risk of cardiovascular mortality, admissions for non-fatal MI, non-fatal stroke, or DAOH by prosthesis type. Conclusion:Patients aged 50-70 years who underwent mechanical valve SAVR had lower risk of all-cause mortality and MACE compared with those who received a bioprosthesis, despite higher bleeding risk. Randomized comparisons are necessary to confirm these findings.

BACKGROUND: Myocardial infarction (MI) is a leading cause of death worldwide and can eliminate up to a third of the cardiomyocytes within the human heart. Although cardiomyocytes undergo mitosis during early development, most cardiomyocytes cease cell cycling soon after birth. In contrast, rodent MI models have shown that cardiomyocytes increase mitosis in response to ischemia; however, this has not been shown in humans. METHODS: Using a unique premortem post-MI human heart, immunostaining, bulk RNA sequencing, proteomics, metabolomics, single-nucleus RNA sequencing and a novel post-MI human biopsy method, we investigated human cardiomyocyte mitosis post-MI. RESULTS: We show that adult human cardiomyocytes exhibit increased mitosis and cytokinesis in response to ischemia. CONCLUSIONS: Future development of therapeutics to enhance this intrinsic mitotic potential could lead to new treatments that reverse heart failure via cardiac regeneration.

This clinical case describes a subacute presentation of decompensated heart failure secondary to an iatrogenic left ventricle–to–coronary sinus fistula after sequential mitral valve surgical procedures. Computed tomography was used to select an unconventional hybrid transapical access approach and facilitate successful closure using a vascular plug.

Abstract Background Opioid analgesia remains a cornerstone of the management of perioperative pain in cardiac surgical patients. Emerging evidence suggests that intermediate and long-term postoperative opioid dependence is underappreciated and associated with adverse patient outcomes. Methadone has emerged in the cardiothoracic and non-cardiothoracic anesthesia literature as an option that may provide lasting analgesic benefit and may be associated with a reduction in overall perioperative opioid requirements. Main body This study was a systematic literature review and meta-analysis that aimed to provide evidence supporting the use of perioperative or intraoperative methadone in adult cardiac surgical patients, particularly with respect to objective measures of postoperative pain and opioid requirements prior to and at discharge from the hospital. Electronic searches of three research databases were performed: PubMed (1972 to October 2023), Ovid MEDLINE (1946 to October 2023), and EMBASE (1978 to October 2023). This search yielded a total of 190 articles, 7 of which met the relevant inclusion and exclusion criteria. This included five randomized controlled trials and two large retrospective cohort studies. Conclusion Preoperative or intraoperative methadone led to reduced pain scores at 24 h postoperatively and reduced opioid requirements at discharge. Methadone may be effective at reducing perioperative pain scores and opioid requirements postoperatively, including at discharge. The literature on this subject has important limitations, and further research in larger randomized controlled trials is needed.

OBJECTIVE:Mitral valve repair (MVr) has become the standard therapy for degenerative mitral regurgitation (DMR), but real-world late mortality, reintervention, and readmission data are lacking. This study estimates MVr outcomes for DMR to 3 years in the Medicare fee-for-service population. METHODS:There were 4,219 DMR patients older than 65 years undergoing MVr within the Medicare 100% standard analytic file from October 2015 to December 2018 who were evaluated. Outcomes were analyzed for isolated MVr patients (n = 2,433) and patients undergoing MVr with certain concomitant procedures: MVr + tricuspid valve surgery (TVS; n = 619), MVr + cardiac ablation (CA; n = 540), and MVr + left atrial appendage closure (n = 627). Outcomes over a 3-year period included all-cause mortality, reintervention, rehospitalization, and common complications. All outcomes were modeled with adjustments for patient demographics and comorbid conditions. RESULTS:The average age for all patients was 71.9 ± 5.2 years. Adjusted all-cause mortality and MV reintervention (surgery or transcatheter) at 3 years for the primary cohort of isolated MVr was 3.5% and 1.6%, respectively. Directionally higher mortality at 3 years was observed in patients with concomitant TVS or CA. All-cause readmission and cardiac readmission for isolated MVr was 37.0% and 14.1%, with the highest rates for those with concomitant TVS or CA. Acute kidney injury and stroke/transient ischemic attack were the most common adverse events over 3 years for all patients. CONCLUSIONS:The 3-year mortality and reintervention rates in Medicare patients undergoing degenerative MVr are low. Those undergoing concomitant TVS or CA had directionally higher mortality and cardiac readmission rates. These results help refine outcome benchmarks as new transcatheter MVr procedures continue to emerge.

INTRODUCTION:The left upper lobe (LUL) has unique hilar anatomy, and LUL multi-segmentectomy (apical trisegmentectomy and lingulectomy) may result in different outcomes than both single anatomical segmentectomy and left upper lobectomy in the management of early-stage primary lung cancer; however no meta-analyses have been performed. The aim of this meta-analysis is to determine if LUL multi-segmentectomy is non-inferior to left upper lobectomy for long-term survival outcomes, or superior for in-hospital outcomes.METHODS:Electronic databases searches were performed on PubMed, Embase, and the Cochrane Library to identify studies comparing outcomes in LUL multi-segmentectomy vs left upper lobectomy in early-stage lung cancer (clinical stage T2 N0 or less). Long-term postoperative overall and disease-free survival were assessed via reconstruction of Kaplan-Meier survival curves. In-hospital complications and length of stay, as well as long term recurrence were analysed via random effects models.RESULTS:Five relevant studies were identified, including 1,196 patients. Overall survival did not differ at 5 years (multi-segmentectomy 92.6% vs lobectomy 89.3%, P=0.188), but patients undergoing LUL multi-segmentectomy had better disease-free survival at 5 years (93.1% vs 88.4%, P=0.041). Patients undergoing LUL multi-segmentectomy had a shorter mean length of hospital stay (mean difference -0.26 days, 95% CI; -0.39 to 0.14, P<0.01, I2=0.00%). There was no difference in combined in-hospital complications (P=0.14), local recurrence (P=0.35), distant recurrence (P=0.23), or overall recurrence (P=0.39).CONCLUSION:LUL multi-segmentectomy is associated with reduced hospital length of stay, but no difference in long-term overall survival compared with left upper lobectomy in the management of early-stage primary lung cancer.

The frozen elephant trunk (FET) technique has enabled synergy between cardiac and vascular surgery in the operative management of aortic disease in the arch and into the descending thoracic aorta. Its best usage in clinical practice is still being established.

Selection of the type of prosthesis for middle-aged patients undergoing aortic valve replacement (AVR) is complex, where several patient and prosthesis factors must be considered. A large cohort of Western Australian (WA) patients undergoing AVR was studied and long-term survival between patients receiving bioprosthetic valves (BV) and mechanical valves (MV) was compared.

Central MessageIt is imperative for heart teams to evaluate the specific anatomic relationships of the aortic root that may influence the ability to safely undertake a repeat TAVR-in-TAVR or TAVR-in-SAVR procedure.See Article page XXX. It is imperative for heart teams to evaluate the specific anatomic relationships of the aortic root that may influence the ability to safely undertake a repeat TAVR-in-TAVR or TAVR-in-SAVR procedure. See Article page XXX. The surgical explant of transcatheter aortic valve replacement (TAVR) prosthesis will become more common as these devices are implanted more frequently in low- and intermediate-risk patients for the treatment of aortic stenosis (AS). Although growing, the overall experience with TAVR explant remains limited.1Saad A.M. Kassis N. Isogai T. Gad M.M. Ahuja K.R. Abdelfattah O. et al.Trends in outcomes of transcatheter and surgical aortic valve replacement in the United States (2012-2017).Am J Cardiol. 2021; 141: 79-85Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar,2Jawitz O.K. Gulack B.C. Grau-Sepulveda M.V. Matsouaka R.A. Mack M.J. Holmes Jr., D.R. et al.Reoperation after transcatheter aortic valve replacement: an analysis of the Society of Thoracic Surgeons database.JACC Cardiovasc Interv. 2020; 13: 1515-1525Crossref PubMed Scopus (48) Google Scholar Vitanova and colleagues3Vitanova K. Zaid S. Tang G.H.L. et al.Aortic valve versus root surgery after failed transcatheter aortic valve replacement.J Thorac Cardiovasc Surg. 2022; (XX:XX-X)Google Scholar describe the largest experience of surgical TAVR explant comparing surgical aortic valve replacement (SAVR) versus root replacement to date from the multi-institutional EXPLANT-TAVR Registry. The series includes 196 patients, 168 of whom had TAVR explant and SAVR, and 28 who underwent TAVR explant and aortic root replacement. Low-risk patients accounted for 25% of the cohort. This series is small, reflective of the limited experience, but is an important glimpse into the potential need for surgery following TAVR in the future. Because TAVR is performed in younger, low-risk patients, there has been much discussion about the lifetime management of AS. Infective endocarditis, a contraindication for redo-TAVR, was the indication for surgical TAVR explant in only 43% of cases. Of those who did not have endocarditis as the indication for surgery, 31% had “unfavorable anatomy” for TAVR-in-TAVR, and 8.5% had already had TAVR-in-TAVR. Surgical explant of TAVR will need to be included in heart team discussions of the lifetime management of AS when considering TAVR in younger patients. For example, outcomes in terms of hemodynamic status and patient–prosthesis mismatch may be high in those requiring a TAVR-in-TAVR in low-risk patients who are sized for a 20 or 23-mm balloon expandable valve or a 23-mm self-expanding TAVR prosthesis. In these patients, a patient may be best served with an initial surgery of an annular enlargement and implantation of a bioprosthetic valve or an aortic root replacement that can be followed by a TAVR-in-SAVR procedure. Heart teams should also consider the implantation of a mechanical prosthesis in appropriate young patients. The mortality and stroke rate of surgical TAVR explant is high at 9.6% and 8.8% at 30 days, respectively. Mortality was more than double that expected for SAVR (observed to expected ratio, 2.25). One might expect that this rate may decrease because both surgical experience and the proportion of low-risk cases increases, but the Society of Thoracic Surgeons predicted risk of mortality score or the heart team's risk assessment during index TAVR were not predictors of mortality at TAVR explant. Although data for TAVR-in-TAVR remain limited, it has been shown in early outcomes that perioperative outcomes of TAVR-in-TAVR are better than those undergoing redo surgical AVR. Moreover, it is likely that surgical TAVR explant is a higher risk procedure than redo SAVR, in part due to the high-risk nature of TAVR patients.4Malik A.H. Yandrapalli S. Zaid S. Shetty S.S. Aronow W.S. Ahmad H. et al.Valve-in-valve transcatheter implantation versus redo surgical aortic valve replacement.Am J Cardiol. 2020; 125: 1378-1384Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar The gradients achieved after surgical TAVR explant in this series are excellent, and superior to those achieved after series of TAVR valve-in-valve.5Tuzcu E.M. Kapadia S.R. Vemulapalli S. Carroll J.D. Holmes Jr., D.R. Mack M.J. et al.Transcatheter aortic valve replacement of failed surgically implanted bioprostheses: the STS/ACC registry.J Am Coll Cardiol. 2018; 72: 370-382Crossref PubMed Scopus (104) Google Scholar It would be interesting to know if surgeon experience would lead to improved outcomes. Although our experience with 15 patients has not required a root replacement, some patients have required pericardial patch reconstruction of the anterior leaflet of the mitral valve and/or the noncoronary cusp. TAVR explant should ideally be performed by surgeons comfortable with aortic root replacement or with significant experience with high-risk aortic valve surgery because the decision sometimes is made intraoperatively after the aorta has been opened. The importance of heart team assessment of patients with AS is critically important and can not be overemphasized. It remains imperative for interventional cardiologists and cardiac surgeons to evaluate the specific anatomic relationships of the aortic root that may influence the ability to safely undertake a repeat TAVR-in-TAVR or TAVR-in SAVR procedure.

Myocardial infarction (MI) is a leading cause of death worldwide and can eliminate up to a third of the cardiomyocytes (CMs) within the heart. Several non-human mammalian models and a limited number of human heart studies suggest that CMs can proliferate during early development, but most CMs stop regenerating soon after birth. In contrast, rodent MI models show that CMs increase their regenerative capacity in response to ischemia, however this has not been shown in humans. Using immunostaining, multi-omics and a unique pre-mortem human heart collected 5 days post-MI, we show that adult human CMs exhibit an increased intrinsic regenerative potential in response to ischemia. Furthermore, single nucleus ribonucleic acid sequencing (snRNAseq) reveals the unique gene expression of post-MI proliferative human CMs. Finally, we demonstrate a novel clinical method to safely biopsy peri-ischemic post-MI human heart tissue and provide further evidence of ischemic CM regeneration. Developing a means to enhance this intrinsic CM regenerative potential could lead to novel therapeutics for cardiac injury and heart failure.

Valve-sparing root replacement or aortic valve (AV) repair techniques are an increasing part of our surgical armamentarium to treat younger patients with aortic root aneurysm with or without concomitant aortic insufficiency (AI). This is an attractive biological option that is more viable in patients who are younger or of child-bearing age. Over the past 2 decades, numerous technical modifications have been introduced to improve the long-term durability of these complex patients. These procedures are technically challenging, and most have recommended that they be performed by experienced surgeons.

Background: Perioperative statin therapy can have pleiotropic effects beyond reducing plasma cholesterol level. Whether perioperative statin therapy can reduce surgical infection after cardiac surgery remains unclear. We aimed to assess whether preoperative statin therapy is associated with a reduced risk of surgical site infections and pneumonia after cardiac surgery.Methods: This retrospective cohort study included 1902 adult patients who had cardiac surgery between February 2015 and April 2019 at a major cardiothoracic centre in Western Australia. The primary outcomes were surgical site infections and pneumonia; secondary outcomes were inotrope requirement, duration of mechanical ventilation, intensive care unit (ICU) and hospital stay, and 30-day mortality. We used propensity-score matching to minimise confounding.Results: Following propensity-score matching (N=1098), patients on preoperative statins (n=551) were associated with a reduced risk of postoperative wound infections (0.7% vs 13.9%, adjusted odds ratio [OR] 0.010, 95% confidence interval [CI] 0.001-0.075, P<0.001) and pneumonia (38.3% vs 52.5%, adjusted OR 0.359, 95% CI 0.278-0.464, P<0.001). The length of ICU (40.7 hrs vs 46.0 hrs, P=0.001) and hospital stay (9 days vs 10 days, P=0.016) were both also significantly shorter among those treated with preoperative statin than those without statin therapy. In the subgroup of patients who underwent non-bypass-grafting surgery, preoperative statin was associated with a reduced risk of 30-day mortality (1.5% vs 5.5%, OR 0.106, 95% CI 0.014-0.812, P=0.028).Conclusions: Use of statin before cardiac surgery was associated with a reduced risk of postoperative surgical site infections and pneumonia.

aDepartment of Cardiology, Fiona Stanley Hospital bInternal Medicine, Medical School, The University of Western Australia cDepartment of Cardiothoracic Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia Correspondence to Nick S.R. Lan, Department of Cardiology, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Perth 6150, WA, Australia Tel: +61 0861522222; e-mail: [email protected] Received 18 August, 2022 Accepted 18 September, 2022

Central MessageReoperative mitral valve replacement can be performed with excellent results in some centers. Additionally, transcatheter mitral valve-in-valve offers high-risk patients an opportunity for treatment.See Article page 1804. Reoperative mitral valve replacement can be performed with excellent results in some centers. Additionally, transcatheter mitral valve-in-valve offers high-risk patients an opportunity for treatment. See Article page 1804. Javadikasgari and colleagues1Javadikasgari H. Chemtob R.A. Gillinov A.M. Pettersson G.B. Lowry A.M. Desai M.Y. et al.Outcomes of mitral valve re-replacement for bioprosthetic structural valve deterioration.J Thorac Cardiovasc Surg. 2022; 163: 1804-1812.e5Google Scholar report the experience of mitral valve re-replacement for structural valve deterioration at the Cleveland Clinic over 27 years. A total of 525 patients with a mean age of 67 years had a second mitral valve replacement (MVR): isolated redo-MVR in 25% and with concomitant procedures in 75%. The results are outstanding, with mortality <0.75% for isolated redo-MVR and 7.1% for those with concomitant procedures. The authors identify New York Heart Association functional class IV symptoms, concomitant coronary artery bypass grafting, prolonged cardiopulmonary bypass time, and transfusion as independent risk factors for mortality. Ten-year survival for isolated redo-MVR and redo-MVR with concomitant procedures was 52% and 48%, respectively. This article raises a number of important points. The ratio of observed mortality to that expected from the Society of Thoracic Surgeons Database was 0.12. This underscores that national estimated percentages cannot always be generalized to high-volume centers that are commonly performing these risky procedures compared with smaller programs in which redo-MVR may be done a couple of times a year. In fact, just looking at US centers performing primary, isolated MV repair, only 13% perform 10 or more procedures per year.2Gammie J.S. Chikwe J. Badhwar V. Thibault D.P. Vemulapalli S. Thourani V.H. et al.Isolated mitral valve surgery: the Society of Thoracic Surgeons Adult Cardiac Surgery Database analysis.Ann Thorac Surg. 2018; 106: 716-727Google Scholar Secondly, the patient cohort in the current series is relatively young and may represent a very select group of patients because no data are available on the proportion of patients either not offered redo-MVR or those who went the way of transcatheter valve therapies. An older cohort of patients (mean age, 78 years) undergoing redo-valvular surgery at another high-volume expert center reported an operative mortality of 10%.3Maganti M. Rao V. Armstrong S. Feindel C.M. Scully H.E. David T.E. Redo valvular surgery in elderly patients.Ann Thorac Surg. 2009; 87: 521-525Google Scholar The experience in transcatheter mitral valve-in-valve (ViV) replacement is early. The procedure is safe, but long-term data are lacking. Furthermore, those patients with a previous mechanical mitral valve prosthesis or those with a narrow postimplant neo-left ventricular outflow tract will be excluded from transcatheter therapeutic options. A comparison of surgical redo-MVR and transcatheter mitral ViV has demonstrated similar early mortality, albeit in groups with different risk profiles.4Kamioka N. Babaliaros V. Morse M.A. Frisoli T. Lerakis S. Iturbe J.M. et al.Comparison of clinical and echocardiographic outcomes after surgical redo mitral valve replacement and transcatheter mitral valve-in-valve therapy.JACC Cardiovasc Interv. 2018; 11: 1131-1138Google Scholar Surgical redo-MVR patients had a lower transvalvular gradient at 1 year. This has mirrored the enormous enthusiasm for transcatheter aortic valve replacement ViV as an alternative for redo-surgical aortic valve replacement in the setting of failed bioprostheses. Recent publications with >5-year follow-up have supported the early safety of this approach but long-term data highlight that not all bioprosthetic structural valve deterioration is best treated with transcatheter aortic valve replacement ViV; especially, those with small failed surgical prostheses.5Deharo P. Bisson A. Herbert J. Lacour T. Etienne C.S. Porto A. et al.Transcatheter valve-in-valve aortic valve replacement as an alternative to surgical re-replacement.J Am Coll Cardiol. 2020; 76: 489-499Google Scholar,6Bleiziffer S. Simonato M. Webb J.G. Rodés-Cabau J. Pibarot P. Kornowski R. et al.Long-term outcomes after transcatheter aortic valve implantation in failed bioprosthetic valves.Eur Heart J. 2020; 41: 2731-2742Google Scholar Until a randomized trial is performed, it is going to be very difficult to determine the relative efficacy of redo-valvular surgery compared with a transcatheter approach. The increasing availability of transcatheter mitral ViV procedures offers those who are high-risk for redo-surgery—or are inoperable—an opportunity for treatment. For patients who are of low or intermediate risk, heart teams must debate the relative efficacies of each approach, acknowledging the excellent outcomes of redo-surgery available at some centers together with the unknown long-term results of ViV procedures. Outcomes of mitral valve re-replacement for bioprosthetic structural valve deteriorationThe Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 5PreviewReoperation for structural valve deterioration (SVD) of bioprosthetic mitral valves carries a presumed high operative risk, and transcatheter mitral valve-in-valve implantation has emerged as an alternative. However, surgical risk and long-term outcome following mitral valve re-replacement in these patients remain ill-defined. Hence, we sought to evaluate outcomes and long-term survival following surgical mitral valve re-replacement and to identify risk factors for mortality. Full-Text PDF

Transcarotid access for transcatheter aortic valve replacement is safe and could be considered the next best access to the transfemoral approach. Comparable Outcomes for Transcarotid and Transfemoral Transcatheter Aortic Valve Replacement at a High Volume US CenterSeminars in Thoracic and Cardiovascular SurgeryVol. 34Issue 2PreviewWith continued growth of transcatheter aortic valve replacement (TAVR), safe alternative access remains important for patients without adequate transfemoral (TF) access. Registry-based outcomes with transcarotid (TC) TAVR are favorable compared to transapical or transaxillary/subclavian, but TC vs TF comparisons have not been made. Our objective was to compare outcomes between TF and TC access routes for TAVR at a high-volume United States center. Methods: We retrospectively evaluated all TF and TC TAVR procedures from June 11, 2014 (first TC case) through December 31, 2019. Full-Text PDF