The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) is one of the largest and most comprehensive clinical databases, containing data from >8.6 million cardiac operations performed in the United States. The ACSD provides a platform for quality through risk modeling and performance metrics, scientific inquiry through robust outcomes research, and health policy through broad hospital participation. The ACSD is a dynamic, continuously evolving tool for the specialty, with recent initiatives including linkage to longitudinal health data as well as refinement and expansion of existing risk models. This report summarizes the current status of the ACSD and major trends in the specialty. Specifically, data on procedural volumes, surgical practices, and outcomes as well as ACSD research are discussed.

OBJECTIVES:Arrhythmic mitral valve prolapse (AMVP) is associated with malignant ventricular arrhythmias, yet the impact of surgical repair versus transcatheter edge-to-edge repair (TEER) on arrhythmic outcomes remains unclear. We evaluated ventricular arrhythmia occurrence and premature ventricular contraction (PVC) burden following mitral repair in patients with and without AMVP. METHODS:We conducted a retrospective cohort study of 1911 patients who underwent surgical mitral valve repair or TEER between 2004 and 2024 at a single institution. AMVP was defined per EHRA/ESC criteria, requiring mitral valve prolapse with frequent (≥5% PVC burden) or complex ventricular arrhythmias and no alternative arrhythmic substrate. Outcomes included non-sustained ventricular tachycardia (NSVT), ventricular tachycardia (VT), implantable cardioverter-defibrillator (ICD) implantation, mortality, and changes in PVC burden in patients with pre- and post-procedural rhythm monitoring. RESULTS:Among 154 patients with AMVP, 109 (71%) underwent surgical repair and 45 (29%) underwent TEER. Following surgical repair, patients with AMVP had similar rates of NSVT (18% vs 13%), VT (3.7% vs 3.6%), and ICD implantation (3.7% vs 3.7%) compared with non-AMVP patients. In contrast, after TEER, patients with AMVP experienced significantly higher NSVT (33% vs 7%, P < 0.01), VT (12% vs 2.6%, P = 0.01), and ICD implantation (4.7% vs 0%, P = 0.02). PVC burden decreased after surgical repair (1.1% to 0.5%, P < 0.001) but remained unchanged after TEER. Mortality was higher in AMVP but not statistically significant. CONCLUSIONS:Surgical mitral repair is associated with reduced arrhythmic burden in AMVP, whereas TEER is associated with persistently elevated ventricular arrhythmias. These findings support phenotype-guided repair strategies and underscore the need for prospective studies comparing arrhythmic outcomes across repair modalities.

BACKGROUND:Despite increasing radial artery use in multivessel coronary artery bypass grafting (CABG), the optimal harvesting technique remains uncertain. We compared short- and long-term outcomes after multivessel CABG using endoscopic vs open radial artery harvesting at the population level. METHODS:In the Centers for Medicare and Medicaid Services database, 6840 adults underwent isolated, first-time, multivessel, nonemergent CABG with radial artery use between 2015 and 2022: 3938 (57.6%) underwent endoscopic and 2902 (42.4%) underwent open radial harvest. The primary outcome was a composite of major adverse cardiac events defined as death, myocardial infarction, or repeat revascularization at 5 years, compared after propensity matching on 26 variables in a Cox proportional hazards model. Secondary outcomes included length of stay, 30-day mortality, and 1-year wound and vascular complications. RESULTS:Endoscopic patients were younger (median, 69 [interquartile range-IQR, 66-73] years vs 70 [IQR, 66-74] years, P = .002), less likely female (16.8% vs 19.3%, P = .008), and had lower prevalence of heart failure (27% vs 30.6%, P = .001). Propensity matching yielded 2776 well-balanced pairs. Endoscopic patients had shorter hospital stays (6 [IQR, 5-9] days vs 7 [IQR, 5-9] days, P = .02), similar 30-day mortality (1.4% vs 1.2%, P = .35), and similar 1-year wound (4.0% vs 4.8%, P = .12) and vascular complications (0.3% vs 0.4%, P = .65) compared to open harvest. Five-year freedom from major adverse cardiac events was equal between groups (81.1% vs 80.8%, hazard ratio, 1.02; 95% CI, 0.88-1.18; P = .83). CONCLUSIONS:There were no differences in late major adverse cardiac events with endoscopic compared to open radial artery harvesting in patients undergoing multivessel CABG.

BACKGROUND Key indicators of the quality of mitral valve (MV) repair for degenerative mitral regurgitation (DMR) are the presence and degree of recurrent (mitral regurgitation (MR) during follow-up, but few studies have provided longitudinal echocardiographic core laboratory-adjudicated data. OBJECTIVES The purpose of this study was to evaluate 2-year survival and MR recurrence in patients who underwent MV repair for DMR with concomitant tricuspid valve (TV) disease between 2016 and 2018. METHODS This is a post hoc analysis of outcomes from a randomized trial (N = 401; 39 sites) evaluating the effects of TV repair during MV surgery for patients with DMR and moderate or less tricuspid regurgitation. Eighty-seven patients (21.7%) were excluded because they underwent MV replacement (32 planned and 9 conversions) or did not have isolated DMR or evaluable echocardiographic data during 2 years. The primary endpoint was a composite of the incidence of all-cause mortality, recurrent severe MR, or MV reoperation (ie, treatment failure) during 2 years. Multivariable modeling identified risk factors for recurrent MR. RESULTS Among 314 eligible patients (median age: 67.4; female: 24.2%), 1.0% (3 of 307) had moderate MR and 0.7% (2 of 307) had severe MR at discharge. Thirty-day all-cause mortality rate was 1.0%. At 2 years, 3.5% (11 of 314) had died, and 2.2% (7 of 314) had MV reoperation. Among 295 survivors free of MV reoperation with evaluable echocardiograms, 9.2% (27 of 295) had moderate MR, 1.4% (4 of 295) had severe MR, and 2.5% (7 of 275) had a mean MV gradient >5 mm Hg. The incidence of death, MV reoperation, or severe MR during 2 years was 8.0% (25 of 313). Patients with anterior or bileaflet MV pathology were at higher risk for treatment failure compared with patients with posterior leaflet pathology (OR: 2.48; 95% CI: 1.09-5.68; P = 0.03). CONCLUSIONS In this international trial with echocardiographic core laboratory adjudication, the rate of survival free from MV reoperation or any episode of severe MR during 2 years was 92% in patients with DMR and concomitant TV disease. These outcomes show that surgical repair achieves high success and durability during 2 years in these patients, providing a contemporary benchmark for clinical decision-making and future trials. (Evaluating the Benefit of Concurrent Tricuspid Valve Repair During Mitral Surgery; NCT02675244) (JACC. 2026;87:3436-3448) (c) 2026 the American College of Cardiology Foundation. Published by Elsevier. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

BACKGROUND:Recent evidence supports early intervention in patients with asymptomatic aortic stenosis (AS) and normal ejection fraction. The study objective was to compare longitudinal surgical aortic valve replacement (SAVR) outcomes in asymptomatic vs symptomatic patients with normal left ventricular ejection fraction (LVEF). METHODS:The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was leveraged to identify patients who underwent isolated SAVR for asymptomatic or symptomatic severe AS with LVEF ≥50% between July 2011 and December 2022. The cohort was linked to Centers for Medicare & Medicaid Services data. The primary outcome was risk-adjusted 10-year survival. Subgroup analysis evaluated long-term survival stratified by age, LVEF, and STS predicted risk of mortality (PROM). RESULTS:A total of 17,683 patients with LVEF ≥50% underwent isolated SAVR; 16,284 (92.1%) were symptomatic and 1399 (7.9%) were asymptomatic. Compared with symptomatic patients, asymptomatic patients were younger (mean age, 74.2 vs 75.0 years; P < .001) and had lower STS PROM (1.9% ± 1.4% vs 2.5% ± 2.0%; P < .001). After risk adjustment, asymptomatic patients demonstrated superior 10-year survival compared with symptomatic patients (adjusted hazard ratio [aHR], 1.19 [95% CI, 1.09-1.29]). In subgroup analyses, long-term survival benefit was more pronounced in asymptomatic vs symptomatic patients aged ≥75 years (aHR, 1.24 [95% CI, 1.11-1.39]), LVEF ≥60% (aHR, 1.20 [95% CI, 1.08-1.34]), and STS PROM <2% (aHR, 1.17 [95% CI, 1.01-1.34]). CONCLUSIONS:In patients with severe AS and preserved LVEF, SAVR before symptom onset shows superior long-term survival. This study supports early SAVR in carefully selected patients with asymptomatic severe AS.

BACKGROUND:Management of atrial fibrillation (AF) at the time of coronary artery bypass grafting (CABG) is a class 1 recommendation. This study evaluated trends in AF management and their association with long-term survival. METHODS:Patients with paroxysmal or persistent AF who underwent isolated CABG were identified from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2022) with linkage to Medicare claims for long-term outcomes. Patients were stratified by AF treatment: none, left atrial appendage occlusion (LAAO) only, epicardial ablation (EA), or intracardiac ablation (IA). The primary end point was all-cause mortality; secondary end points included permanent pacemaker placement, stroke, and readmission for AF, bleeding, or heart failure. Long-term mortality was assessed using Kaplan-Meier methods and Cox regression. Nonfatal outcomes were assessed using competing-risk regression with death as the competing event. RESULTS:Among 59,331 patients, 71.0% had paroxysmal AF, increasing from 56.6% (2011) to 79.6% (2022). AF treatment included none (51.0%), LAAO only (15.3%), EA (25.4%), and IA (8.2%). AF treatment increased from 31.8% to 68.8%, driven by LAAO (1.2%-30.8%). Patients with persistent AF had higher mortality than patients with paroxysmal AF (P < .001). EA showed lower mortality compared with no treatment. IA was associated with higher pacemaker implantation (6.0% vs 3.2%-3.4% in other groups; P < .001). Compared with no treatment, all treatment groups had lower stroke risk (subdistribution hazard ratio, 0.64-0.79; P < .001) and lower AF readmission (subdistribution hazard ratio, 0.85-0.89; P < .05). CONCLUSIONS:Nearly one-half of patients with AF who underwent CABG receive no treatment. Epicardial ablation was associated with superior long-term survival, and all strategies with were associated lower stroke risk.

Background: High-volume centers report acceptable outcomes for robotic mitral repair, yet population-level data are limited. This study compared late mortality and reintervention rates for robotic vs nonrobotic mitral repair in the United States. Methods: The Centers for Medicare & Medicaid Services database validated against clinical records was used to identify 26,524 patients with isolated first-time nonemergency mitral repairs with or without tricuspid repairs or ablations without other concomitant procedures. Of these patients, 2227 (8.3%) underwent robotic repair and 24,297 (91.7%) underwent nonrobotic repairs. Propensity score matching was performed on 30 baseline characteristics. The primary end point was a composite of death or mitral reintervention, and the secondary end point was all-cause mortality. Both were compared in a Cox proportional hazards model. Falsification end point analysis assessed for potential unmeasured confounders with death as a competing risk. Results: Matching yielded 2226 patient pairs (mean age, 72 years; 44% female; 9% with concomitant tricuspid repair; 7% ablation). Thirty-day mortality did not differ between the groups (1.3% robotic vs 1.3% nonrobotic; P = .90). Robotic repair was associated with lower postoperative atrial fibrillation (19.1% vs 23.2%; P = .001) and a shorter hospital stay (median 5 days [interquartile range, 4-7 days] vs 7 days [interquartile range, 5-9 days]; P < .001). At 5 years, the composite of death or mitral reintervention (17.8% vs 18.6%; hazard ratio, 0.93; 95% CI, 0.79-1.09; P = .37) and all-cause mortality (14.9% vs 15.6%; hazard ratio, 0.93; 95% CI, 0.77-1.11; P = .40) were similar, with falsification testing confirming minimal confounding (P = .20). Conclusions: Robotic mitral repair in the United States is safe, yielding outcomes comparable to those of nonrobotic repair.

BACKGROUND:Internal thoracic artery (ITA) use is a benchmark of quality in coronary artery bypass grafting (CABG), yet its value in contemporary practice among octogenarians remains uncertain. We compared mid-term major adverse cardiac events and all-cause mortality among octogenarians undergoing CABG with ITA plus saphenous vein grafts (SVGs) vs SVG-only. METHODS:We identified 13,925 octogenarians who underwent isolated first-time elective CABG with 2-4 grafts from 2015 to 2022 in the US Centers for Medicare and Medicaid database validated against individual clinical records: 12,280 received ITA+SVG and 1105 received SVG-only. The primary outcome was 6-year freedom from major adverse cardiac events (MACE) defined as death, myocardial infarction, or repeated revascularisation. The secondary outcome was 6-year all-cause mortality. Median follow-up time was 4.3 years (interquartile range [IQR] 4.2-4.5 years). Outcomes were compared in a Cox proportional hazards model after propensity matching across 28 covariates with an exact number of grafts. RESULTS:Patients receiving ITA+SVG were of similar age (81 years [IQR 80-83 years] vs 82 years [IQR 80-84 years]; P = 0.13) and less often female (24% vs 31.1%; P < 0.001). Propensity score matching yielded 1101 well matched pairs. Six-year freedom from MACE was 49.7% in the ITA+SVG group vs 48% in the SVG-only group (adjusted hazard ratio [aHR] 0.92, 95% confidence interval [CI] 0.79-1.06; P = 0.23). There was no difference in 6-year all-cause mortality (54.8% vs 52.7%; aHR 0.90, 95% CI 0.78-1.05; P = 0.19). CONCLUSIONS:Among octogenarians undergoing elective multivessel CABG, ITA use was not associated with improved 6-year freedom from MACE or all-cause mortality. These findings suggest that universal ITA-based quality metrics may need reassessment for octogenarians.

BACKGROUND:National data on the durability of surgical mitral repair and outcomes of reintervention are lacking. This study aimed to quantify the national incidence and outcomes of mitral reintervention after surgical repair. METHODS:The US Centers for Medicare & Medicaid Services claims identified patients aged ≥65 years who underwent surgical mitral repair followed by reintervention (replacement, repeat repair, or transcatheter edge-to-edge repair [TEER]) between 2012 and 2023. The 30-day and 3-year mortality, stroke, and heart failure readmission after reintervention were assessed using logistic regression and adjusted Cox proportional hazards modeling. Competing risks were used to estimate the probability of reintervention, heart failure, and stroke. RESULTS:Of 45,482 patients undergoing surgical mitral repair, 1560 required reintervention. Of these, 1223 (78.4%) had surgical replacement, 164 (10.5%) underwent surgical repair, and 173 (11.1%) had TEER. The median time to reintervention was 1.9 years (interquartile range, 0.64-4.1 years). The cumulative incidence of reintervention at 9 years was 5%. The adjusted 30-day rate of heart failure readmission was lowest among patients who underwent TEER (4.8% vs 15.9% replacement, vs 14.6% repeat repair; P < .01), whereas 30-day mortality and stroke readmission rates did not differ among the reintervention approaches. At 3 years, there was no significant difference in survival, heart failure readmissions, or stroke readmissions by reintervention approach. CONCLUSIONS:Surgical mitral repair is durable, with a low 9-year risk of reintervention. The reintervention approach does not affect mortality, heart failure, and stroke readmissions at 3 years, a finding suggesting that any of these approaches is appropriate for reintervention.

Objective:Severe graft failure after lung transplantation is a devastating outcome with limited therapeutic options. Mechanical support provides temporary stabilization but may compromise re-transplantation candidacy. This study examined postoperative outcomes and long-term survival of graft failure re-transplants by preoperative mechanical support use. Methods:The UNOS database was queried for adults undergoing early re-transplantation for graft failure (EGF) performed within 1 year of the primary transplant from 2005 to 2025. Primary transplants, multiorgan, and re-transplants from unknown causes were excluded. Patients were stratified by preoperative mechanical support use (ventilation and/or ECMO). The primary outcome was 5-year survival. Results:Among 1453 re-transplants, 140 (9.6%) were for EGF. 85 (61%) required preoperative mechanical support (61%), and 55 did not (39%). Within the mechanical support group, 72 (85%) were ventilated, 44 (52%) received ECMO, and 31 (36%) had both ECMO and ventilation. Supported patients had higher LAS scores (89.3 vs 71.6, p<0.001) and more dialysis use (24% vs 1%, p<0.001). Postoperatively, supported patients experienced more prolonged ventilation (34% vs 16%, p=0.02) and more ECMO support (20% vs 9%, p=0.03). Ninety-day mortality was equivalent (27.1% vs 16.4%, p=0.14). However, mechanical support use of any form was associated with higher 5-year mortality (adjusted HR 1.71 [1.02-2.85], p=0.04). Combined ventilator and ECMO use had the worst long-term survival compared to no mechanical support (aHR 2.13 [1.03-4.40], p=0.04). Conclusion:Preoperative mechanical support was associated with greater postoperative morbidity and worse long-term survival. These findings underscore the need to critically evaluate whether re-transplantation truly benefits this high-risk population.

BACKGROUND:Key indicators of the quality of mitral valve (MV) repair for degenerative mitral regurgitation (DMR) are the presence and degree of recurrent (mitral regurgitation (MR) during follow-up, but few studies have provided longitudinal echocardiographic core laboratory-adjudicated data. OBJECTIVES:The purpose of this study was to evaluate 2-year survival and MR recurrence in patients who underwent MV repair for DMR with concomitant tricuspid valve (TV) disease between 2016 and 2018. METHODS:This is a post hoc analysis of outcomes from a randomized trial (N = 401; 39 sites) evaluating the effects of TV repair during MV surgery for patients with DMR and moderate or less tricuspid regurgitation. Eighty-seven patients (21.7%) were excluded because they underwent MV replacement (32 planned and 9 conversions) or did not have isolated DMR or evaluable echocardiographic data during 2 years. The primary endpoint was a composite of the incidence of all-cause mortality, recurrent severe MR, or MV reoperation (ie, treatment failure) during 2 years. Multivariable modeling identified risk factors for recurrent MR. RESULTS:Among 314 eligible patients (median age: 67.4; female: 24.2%), 1.0% (3 of 307) had moderate MR and 0.7% (2 of 307) had severe MR at discharge. Thirty-day all-cause mortality rate was 1.0%. At 2 years, 3.5% (11 of 314) had died, and 2.2% (7 of 314) had MV reoperation. Among 295 survivors free of MV reoperation with evaluable echocardiograms, 9.2% (27 of 295) had moderate MR, 1.4% (4 of 295) had severe MR, and 2.5% (7 of 275) had a mean MV gradient >5 mm Hg. The incidence of death, MV reoperation, or severe MR during 2 years was 8.0% (25 of 313). Patients with anterior or bileaflet MV pathology were at higher risk for treatment failure compared with patients with posterior leaflet pathology (OR: 2.48; 95% CI: 1.09-5.68; P = 0.03). CONCLUSIONS:In this international trial with echocardiographic core laboratory adjudication, the rate of survival free from MV reoperation or any episode of severe MR during 2 years was 92% in patients with DMR and concomitant TV disease. These outcomes show that surgical repair achieves high success and durability during 2 years in these patients, providing a contemporary benchmark for clinical decision-making and future trials. (Evaluating the Benefit of Concurrent Tricuspid Valve Repair During Mitral Surgery; NCT02675244).

Objective: In 2015, restrictive allograft syndrome (RAS) was first definitively associated with poorer outcomes after lung retransplantation compared with bronchiolitis obliterans syndrome (BOS). This study aimed to evaluate how strategies and outcomes of lung retransplantation for RAS have evolved over time. Methods: The United Network for Organ Sharing database was queried to identify adult lung retransplants for RAS between 2005 and 2025. Primary transplants, multiorgan transplants, and retransplants with unknown indications were excluded. Patients were stratified into Era 1 (2005-2015) and Era 2 (2016-2025). The primary outcome was 5-year survival. Results: A total of 293 patients were included, with 141 (48%) in Era 1 and 152 (52%) in Era 2. The proportion of retransplants for restrictive disease was similar across eras (19% vs 22%, P = .16). Compared with Era 1, patients from Era 2 had greater allocation scores, less preoperative ventilator dependence, and similar waitlist times. Retransplants in Era 2 were characterized by longer ischemia times and a significantly greater use of bilateral retransplantation (65% vs 41%, P < .001). Postoperatively, patients in Era 2 required more prolonged mechanical ventilation, inhaled nitric oxide, and extracorporeal membrane oxygenation support. Thirty- and 90-day mortality were similar between eras. On multivariable analysis, era of retransplantation was not associated with improved 5-year survival (adjusted hazard ratio, 0.98; 95% CI, 0.70-1.38, P = .93) Conclusions: Since 2015, lung retransplantation for RAS has increasingly favored bilateral procedures, accompanied by greater perioperative support. Despite these changes, long-term survival remains poor, underscoring the need for improved candidate selection and strategies to prevent recurrent chronic allograft injury.

Background:Survival for heart transplant recipients with type 2 diabetes mellitus is reduced; however, the effect of donor diabetes in this cohort is unknown. We examined the impact of donor diabetes status on long-term outcomes among diabetic heart transplant recipients. Methods:The United Network for Organ Sharing database was queried to identify adult diabetic recipients undergoing single-organ heart transplantation between 2005 and 2025. The primary outcome was 10-year all-cause mortality, assessed after propensity score matching on 26 variables in a Cox proportional hazards model. Secondary outcomes included 30-day mortality, dialysis requirement, stroke, permanent pacemaker implantation, and length of stay. Median follow-up time was 7.05 years (95% CI 7.00-7.18). Results:Of 13,091 heart transplant recipients identified, 540 (4%) received a diabetic donor heart and 12,551 (96%) received a non-diabetic donor heart. Recipients in the diabetic donor group were older (60.0 years [IQR 54.0-65.0] vs 59.0 [52.0-64.0], p < 0.001) and had shorter waitlist times (44.5 days [IQR 14.0-185.5] vs 60.0 [17.0-213.0], p = 0.02). Donors with diabetes were older (41.0 years [IQR 34.0-48.0] vs 32.0 [23.0-41.0], p < 0.001), had a higher prevalence of hypertension (55.9% vs 15.2%, p < 0.001), and were more likely to have donor-recipient sex mismatch (26.9% vs 21.5%, p = 0.003). Propensity score matching produced 539 pairs. In the matched cohort, 10-year survival was lower among recipients of diabetic donor hearts compared with non-diabetic donor hearts (48.5% vs 57.0%, adjusted HR: 1.26, 95% CI: 1.00-1.59, p = 0.04). Secondary outcomes were similar between groups. Conclusion:Diabetic heart transplant recipients experience worse long-term survival when a diabetic donor heart is utilized.

OBJECTIVES:The comparative long-term safety and efficacy of transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR) remains under continued investigation, particularly in patients at low- to intermediate-surgical risk. This study aims to synthesise and update contemporary long-term TAVI versus SAVR data. METHODS:This study comprised a systematic review and meta-analysis and employed a Bayesian hierarchical design. Randomised controlled trials (RCTs) comparing TAVI to SAVR in low-risk to intermediate-risk patients with at least 5-year follow-up were included. The primary outcome was 5-year all-cause mortality; secondary outcomes were the 5-year incidence of stroke and the 5-year incidence of the composite of mortality and stroke. REVIEW METHODS:Time-to-event data were reconstructed. Relative risks (RRs) with 95% credible intervals (CrIs) were estimated from reported 5-year event rates using minimally informative priors. Sensitivity analyses were performed using various meta-analytical models, and using conventional frequentist random-effects and fixed-effects models for sensitivity purposes. RESULTS:A total of six RCTs, enrolling 7249 low- to intermediate-risk patients reported 5-year outcomes (TAVI n=3704, SAVR n=3545). The 5-year all-cause mortality rate was 29.7% (28.2-31.2%, TAVI) and 27.6% (26.1-29.1%, SAVR). The median RR for all-cause mortality was 1.12 (95% CrI 1.02-1.22, heterogeneity τ2=0), with a 99.3% posterior probability that SAVR is superior to TAVI for this endpoint. For stroke, the median RR was 1.13 (95% CrI 0.93-1.39, heterogeneity τ2=0.04), resulting in an 88.0% posterior probability that SAVR outperformed TAVI for this outcome. These results were consistent across conventional frequentist random-effects and fixed-effects models employing p values (RR 1.13, 95% CI 1.05 to 1.22, p=0.001, and RR 1.12, 95% CI 1.03 to 1.23, p=0.011, respectively). There was no evidence for an interaction effect of surgical risk category (p=0.470). CONCLUSION:In this meta-analysis of RCTs, TAVI resulted in a clinically relevant increase in all-cause mortality, and a high probability of an increased risk of stroke, at 5 years of follow-up in low-risk to intermediate-risk patients, when compared to SAVR.

BACKGROUND Robotic resection of left atrial myxomas has emerged as a minimally invasive alternative to sternotomy, but comparative data is limited. We evaluated referral patterns and outcomes following robotic left atrial myxoma at a high-volume robotic cardiac surgery center. METHODS We identified 42 consecutive adults undergoing isolated left atrial myxoma resection between 2011 to 2024 from a prospective institutional registry. Outcomes were compared by operative approach. Our primary outcome was the Society of Thoracic Surgeons risk-adjusted composite morbidity and mortality at 30-days. Our secondary outcome was tumor recurrence. Median follow-up was 2 years (IQR: 0.1-4 years). RESULTS Of 42 patients undergoing surgical myxoma resection, 16 (38%) received sternotomy and 26 (62%) received robotic resection. Myxomas were identified following incidental imaging (n=22, 52%) or symptomatic disease (n=20, 48%). Baseline characteristics between patients undergoing open and robotic tumor resection were similar (67 vs 63 years, p=0.59; female 15% vs 21%, p=0.38; LVEF 63% vs 63%, p=0.84), as were tumor size and cardiopulmonary bypass time.Robotic resection was associated with shorter operative time (161 vs 188 minutes, p=0.007), while sternotomy was associated with greater product transfusion (38% vs 8%, p=0.04) and atrial septal defect repair (63% vs 27%, p=0.02). Composite morbidity and mortality did not differ by approach (7.7% open vs 6.3% robotic, p=1.0). There were no deaths or strokes at 30-days, and no recurrences at 2 years. CONCLUSIONS Robotic left atrial myxoma resection is feasible at an experienced center without compromising short-term outcomes. Longer imaging follow-up is required to assess comparative durability.

Background: When transcatheter aortic valve replacement (TAVR) fails and repeat TAVR is not possible, TAVR explantation remains a viable strategy. However, results from multicenter studies have shown high morbidity and mortality. This study aimed to examine early and late outcomes after TAVR explantation at a high-volume structural heart center. Methods: At a single center performing >600 TAVR procedures annually, the institutional The Society of Thoracic Surgeons registry was queried to identify all patients undergoing surgical aortic valve replacement with a history of TAVR between 2011 and 2024. Institutional trends, operative details, and outcomes at 30-days and 5-years were compared between TAVR explantation with isolated surgical aortic valve replacement (SAVR; n = 14) and TAVR explantation with SAVR plus concomitant procedures (n = 40). Results: TAVR implantations and explantations increased significantly over time (P < .001). The median time to TAVR explantation was 455 days (interquartile range, 145-1094 days), and the median surgeon TAVR explantation experience was 4 cases (interquartile range, 1-11 cases). Overall, 30-day mortality (7.4%) and 30-day morbidity and mortality (25.9%) were relatively low despite high rates of concomitant procedures (74.1%). There were no differences in 30-day mortality (P = .52) or 5-year survival (hazard ratio, 1.78; 95% CI, 0.38-8.40; P = .47) between the isolated SAVR and concomitant procedures groups. Conclusions: The risk of morbidity and mortality was relatively low in patients undergoing TAVR explantation in a single high-volume center, a finding highlighting the potential need to centralize care for this complex procedure.

BACKGROUND:Recent evidence suggests that cardiac surgery after transcatheter aortic valve replacement (TAVR) carries additional risk. Herein we describe validation of a risk model for surgical aortic valve replacement (SAVR) after prior TAVR and risk distribution over time. METHODS:Patients undergoing SAVR (July 2014-March 2025) were extracted from The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Patients were excluded for no prior TAVR, concomitant arch/descending aortic procedures, other major surgery, or missing operative mortality data. Patients undergoing proximal aortic or other valve surgery were included. De novo, parsimonious models were built for all 8 Society of Thoracic Surgeons outcomes. RESULTS:Of 651,398 SAVR patients during the study period, 5708 had SAVR after TAVR, with 2298 (40.3%) isolated SAVR after TAVR and 3410 (59.7%) concomitant procedures. The risk model for SAVR after TAVR had excellent discrimination for operative mortality (area under the curve, 0.82) and morbidity or mortality (area under the curve, 0.73). Calibration was excellent across risk deciles for all demographic and surgical subgroups. Of isolated SAVR after TAVR cases that might qualify for redo TAVR (excluding endocarditis, root enlargement, and emergent cases), 53.3% (753/1334) had predicted risk of mortality <3%, and the operative mortality rate decreased over time from 13.1% to 3.5%. Given improvement over time, era was included as an interaction term in the model for isolated SAVR cases, leading to stable observed to expected ratios. CONCLUSIONS:Mortality rates for SAVR after TAVR have decreased. The risk model has excellent performance and demonstrates that a large cohort of TAVR explantation patients can be classified as low risk. The new risk model allows accurate risk estimates to inform clinical decision-making.