Objective:Staged single-lung transplantation (SSLT) has been proposed as a strategy for high-risk patients amid donor organ shortages. We aimed to compare modern SSLT versus bilateral lung transplantation (BLT) outcomes and identify factors associated with SSLT long-term survival. Methods:We retrospectively analyzed the United Network for Organ Sharing registry for all adult lung transplants from 2005 to 2021. Propensity-matched outcomes of SSLT (2 sequential, contralateral single-lung transplants) were compared with BLT. Kaplan-Meier methods were used to assess survival, and multivariable analysis identified independent predictors of mortality after SSLT. Results:Among 188 recipients of SSLT and 2948 recipients of BLT, recipients of SSLT were older and more likely to have interstitial lung disease. Despite greater 1-year survival among recipients of SSLT (92.0% vs 87.5%), median overall survival was significantly shorter compared with the BLT cohort (5.8 vs 7.1 years), and both 5-year (54.8% vs 63.8%) and 10-year (27.4% vs 43.6%) survival estimates were lower (P < .001). Thirty-day mortality after the second transplant was also greater in SSLT (4.7% vs 2.7%, P = .04). On multivariable analysis, SSLT was associated with greater 3-year mortality (hazard ratio, 1.72; 95% CI, 1.03-2.84), although on subgroup analysis, those with a diagnosis of interstitial lung disease, age ≥65 years, or body mass index ≥30 and duration between staged lung transplantation ≥5 years at time of listing showed similar outcomes. Conclusions:In the modern era, BLT is associated with superior long-term survival compared with SSLT. SSLT can achieve acceptable early outcomes in select patients or donor-scarce situations, but BLT should remain the preferred approach when feasible.

Objective: The purpose of this study was to examine the longitudinal safety and efficacy of hybrid coronary revascularization (HCR) in a large cohort of patients with multivessel coronary artery disease (CAD). Methods: From 2009 to 2020, 561 consecutive patients (median age 64.0 years, predicted risk of mortality 1.3% ± 1.8%, 403 with 2-vessel disease and 158 with 3-vessel disease) underwent a planned HCR procedure with a robot-assisted off-pump left internal mammary artery to left anterior descending (LIMA-LAD) coronary artery bypass graft (CABG) combined with percutaneous coronary intervention (PCI) of non–LAD vessels. Multivariable regression analysis was used to identify risk factors for short-term and longer-term outcomes. Results: Operative mortality and stroke occurred in 4 (0.7%) and 5 patients (0.9%), respectively. Postoperative angiography revealed LIMA patency in 415 of 425 patients (98%). Median follow-up was 4.5 years and was 93% complete. Repeat revascularization occurred in 44 patients (8%) at a median of 2.7 years. Freedom from repeat revascularization and survival at 5 years was similar between patients with 2-vessel and 3-vessel disease ( P = 0.73 and P = 0.19, respectively). Completely revascularized patients had 5-year survival of 91% versus 64% for incompletely revascularized patients (hazard ratio = 3.8, P < 0.001). Age ( P = 0.03), renal failure ( P < 0.001), and history of myocardial infarction ( P = 0.01) were risk factors for late adverse events. Conclusions: HCR is a safe and effective minimally invasive alternative to conventional CABG or multivessel PCI with a low incidence of late repeat revascularization and mortality. HCR can be safely applied to carefully selected patients with either 2-vessel or 3-vessel CAD; however, incomplete revascularization may result in lower long-term survival.

Background The current recommended intervention for significant left main (LM) stenosis, especially in patients with complex and high SYNTAX score disease, is coronary artery bypass grafting (CABG). Hybrid coronary revascularization (HCR) combines robotic coronary artery bypass and percutaneous coronary intervention, offering a less invasive approach for patients with LM disease. Objectives We compare clinical outcomes between HCR and CABG in patients with LM disease. Methods We retrospectively screened all patients treated for LM disease between 2019 and 2023 at a single institution. Propensity matching was used for baseline characteristics. The primary outcome was major adverse cardiovascular events (MACE) at 30 days, 6 months and 1 year. Secondary outcomes included death, myocardial infarction, repeat revascularization and stroke. Results Out of a total of 761 patients treated for LM disease, 59 HCR patients were propensity matched to 59 CABG patients and were included in the final analysis. SYNTAX score was >33 for 49.1 % of HCR patients and 67.3 % of CABG patients (p = 0.15). Hospital length of stay was significantly shorter for HCR patients compared to CABG (4.07 days vs. 7.58 days, p < 0.001). MACE were significantly lower in the HCR group at 30 days (0 % vs 10.2 %; p = 0.01), 6 months (0 % vs 17 %; p = 0.002) and 1 year (2.4 % vs 20.5 %; p = 0.01) compared to CABG group. Additionally, there was a lower rate of repeat revascularization at 6 months in the HCR group (0 % vs 10.9 %; p = 0.02). Conclusions This retrospective study demonstrates that HCR is a safe and viable alternative to CABG in patients with LM disease. Randomized clinical trials comparing the two treatment modalities are needed to confirm these findings.

Primary graft dysfunction (PGD) is a leading cause of morbidity and mortality following orthotopic heart transplantation (OHT), yet its biology remains unclear, and metabolomics research is limited. A single-center study was conducted on 62 OHT recipients. Preoperative plasma samples underwent metabolomics analysis via liquid chromatography-mass spectrometry. Metabolic signatures of severe PGD were identified using partial least squares discriminant analysis and pathway enrichment analysis of untargeted data, with additional analysis of annotated and identified metabolites. Partial least squares discriminant analysis of combined mass spectral signals from preoperative plasma showed clustering of patients who developed severe PGD. Pathway enrichment highlighted alterations in arachidonic acid, tryptophan, tyrosine, and branched-chain amino acid metabolism as key preoperative predictors of severe PGD. Preoperative blood levels of 75 metabolites, spanning inflammatory lipids, amino acids, and redox-active species, differed (P < .05) between patients who developed severe PGD and those who did not, although only 3 remained significantly different after correction for multiple comparisons (q < .05). Taken together, these exploratory findings demonstrate that distinct preoperative metabolic profiles exist in OHT recipients who develop severe PGD and support hypothesis generation on candidate metabolic signatures to identify patients at high risk. They suggest that the plasma metabolome may be a powerful tool for studying PGD biology.

Background: Left ventricular assist device (LVAD) explantation at the time of orthotopic heart transplantation (OHT) carries increased perioperative risks. This study examined whether institutional operative volume influences outcomes following LVAD explant-OHT in a contemporary national cohort. Methods: Adult patients who underwent LVAD explantation with OHT between 2011 and 2024 were identified in the Organ Procurement and Transportation Network/United Network for Organ Sharing registry. Using a rank-order method based on surgical volume, centers were stratified as either high volume or low volume. The primary outcome was 1-year survival; secondary outcomes included graft failure, ischemic time, dialysis, stroke, and hospital length of stay. Kaplan-Meier and Cox regression analyses were performed to assess survival and predictors of mortality. Results: A total of 2863 patients across 121 centers were analyzed. Eight high-volume centers performed 31.3% (897 cases) of all LVAD explant-OHTs. Baseline characteristics, including heart failure etiology and LVAD device type, were similar in the 2 groups. High-volume centers demonstrated decreased ischemic time (mean, 3.1 ± 1.3 hours vs 3.5 ± 1.4 hours; P < .001), a lower rate of postoperative dialysis (12.7% vs 15.4%; P = .023), and shorter length of stay (mean, 22.8 ± 26.6 days vs 25.9 ± 31.3 days; P = .006) compared to low-volume centers. Graft failure was less common at high-volume centers (24.2% vs 28.8%; P = .011). One-year survival rate (81.6% vs 76.1%; P = .001) and median survival (4.93 years vs 4.00 years; P = .018) were greater at high-volume centers. Multivariable analysis identified low-volume center status as an independent predictor of higher mortality (hazard ratio, 1.28; 95% confidence interval, 1.10-1.50; P = .002). Conclusions: High-volume centers were associated with superior survival and improved perioperative outcomes following LVAD explant-OHT.

Background/Objectives: Donation after circulatory death (DCD) has emerged to expand the heart-donor pool, but many DCD donors have risk factors such as cocaine or methamphetamine use. Stimulant use can cause coronary vasospasm and premature coronary artery disease, leading to routine donor coronary angiography (left heart catheterization, LHC) for coronary screening. However, performing LHC in DCD donors is challenging. We examined whether omitting LHC in stimulant-exposed DCD donors affects outcomes. Methods: A retrospective analysis was performed using the United Network for Organ Sharing (UNOS) database (2019-2024) to identify adult heart transplant recipients from DCD donors with documented cocaine or amphetamine use. Donors were stratified by whether antemortem LHC was performed. The primary outcome was 1-year recipient survival; secondary outcomes included graft failure and acute rejection. Kaplan-Meier survival curves and Cox regression analyses were performed. Results: A total of 485 DCD heart transplant recipients were identified; 135 (28%) donors underwent LHC and 350 (72%) did not. Recipient characteristics were similar between groups. No significant differences in 30-day (6% vs. 3%; p = 0.11), 90-day (6% vs. 3%; p = 0.21), or 1-year survival (7% vs. 6%; p = 0.48) were observed between the LHC and non-LHC cohorts. Graft failure and complication rates were also similar. However, among stimulant-exposed DCD donors with diabetes, an absence of LHC was associated with higher recipient mortality (HR 5.86, 95% CI: 1.57-21.87; p = 0.008). Conclusions: Routine donor coronary angiography may be unnecessary for stimulant-exposed DCD donors without additional risk factors. Omitting LHC did not compromise transplant outcomes. A selective LHC approach for high-risk DCD donors (e.g., diabetic donors) could safely expand the donor pool.

BACKGROUND:Hybrid revascularization is a less invasive approach to conventional open-chest coronary artery bypass graft surgery for patients with multivessel coronary arterial disease. However, this is infrequently performed because of technical demands, logistical challenges, and concerns for long-term vessel patency. CASE SUMMARY:A 68-year-old man with a history of prostate cancer with bony metastasis presented with accelerated angina. Left heart catheterization revealed multivessel coronary disease. The patient underwent staged hybrid surgical and percutaneous revascularization treatment. Ultimately, the intervention was successful, and the patient had symptomatic relief with successful recovery to baseline function. DISCUSSION:This case provides insight into the efficacy and application of an individualized hybrid approach in a high-risk patient with comorbidities. TAKE-HOME MESSAGE:Hybrid revascularization is safe and can be considered on an individual basis for patients with complex medical comorbidities.

Objective: Hepatorenal dysfunction after lung transplantation is associated with significant morbidity and mortality. The Model for End-stage Liver Disease excluding international normalized ratio (MELD-XI) score may predict outcomes after lung transplantation. Methods: Adult lung transplant recipients from the United Network for Organ Sharing database were identified (2010-2024) and stratified by MELD-XI score: low (≤9), intermediate (>9 to <13), and high (≥13) categories. Multivariate logistic regression and Cox proportional hazard models were applied to determine associations between MELD-XI score and postoperative outcomes. Results: Among 30,148 lung transplant recipients, 90.6% had low, 6.9% intermediate, and 2.5% high MELD-XI scores at time of transplant listing. Greater MELD-XI score was associated with significantly increased mortality at 30-day, 90-day, 1-year, 5-year, and 10-year time points (P < .001). On adjusted analysis, intermediate and high MELD-XI categories had greater mortality risk versus low (HR 1.16 and 1.41, respectively; P < .001). Patients with high MELD-XI also experienced more frequent severe complications, including postoperative dialysis (26.9% vs 6.7% in low MELD-XI), extracorporeal membrane oxygenation support (23.9% vs 7.8%), grade 3 primary graft dysfunction (43.9% vs 30.2%), and prolonged hospital stay >30 days (38.3% vs 23.8%) (all P < .001). Conclusions: Preoperative MELD-XI scores >9 independently predicted greater posttransplant mortality and major complications. Incorporating MELD-XI into lung transplant candidate assessments can improve risk stratification and inform perioperative planning.

Background: Both percutaneous coronary interventions (PCIs) and robotic-assisted coronary artery bypass (CAB) offer viable options for left anterior descending (LAD) chronic total occlusion (CTO) revascularization. Our study aims to compare long-term clinical outcomes associated with these 2 strategies. Methods: In this retrospective study, we analyzed data from 273 patients diagnosed with LAD CTO who underwent either PCI (n = 129) or CAB (n = 144) at a single institution. Long-term follow-up was available for 96 PCI and 125 CAB patients. We employed Kaplan-Meier curves and the log-rank test to conduct cumulative survival analyses free of major adverse cardiovascular events (MACE), cumulative survival, survival free of myocardial infarction, and repeat revascularization. Results: In the study cohort, patients who underwent PCI exhibited a higher prevalence of comorbidities including diabetes (48.9% vs 24.6%; P < .001), lower ejection fraction (44 ± 14 vs 52 ± 10; P < .001), prior heart failure (36.6% vs 22.2%; P = .02), and prior bypass surgery (16% vs 0, P < .001). PCI to non-LAD vessels was performed as part of initial complete revascularization in 40.3% of PCI and 40.6% of CAB patients. Upon a median 3.4 years of follow-up, CAB patients had significantly higher rates of survival free of MACE compared to PCI patients (unadjusted hazard ratio, 2.39; 95% CI, 1.13-5.03). Although PCI patients had similar unadjusted mortality, they experienced higher myocardial infarction and repeat revascularizations compared to CAB. However, the risk of repeat revascularization was attenuated after adjusting for prior bypass, diabetes, and ejection fraction. Conclusions: Among patients with LAD CTO, those undergoing robotic-assisted CAB had a higher 5-year overall survival free of MACE compared to those who underwent PCI. This discrepancy in outcomes can be attributed in part to the greater burden of comorbidities among PCI patients.

BackgroundTricuspid valve annuloplasty (TA) during mitral valve repair (MVr) is associated with increased risk of permanent pacemaker (PPM) implantation, but the magnitude of risk and long-term clinical consequences have not been firmly established.ObjectivesThis study assesses the incidence rates of PPM implantation after isolated MVr and following MVr with TA as well as the associated long-term clinical consequences of PPM implantation.MethodsState-mandated hospital discharge databases of New York and California were queried for patients undergoing MVr (isolated or with concomitant TA) between 2004 and 2019. Patients were stratified by whether or not they received a PPM within 90 days of index surgery. After weighting by propensity score, survival, heart failure hospitalizations (HFHs), endocarditis, stroke, and reoperation were compared between patients with or without PPM.ResultsA total of 32,736 patients underwent isolated MVr (n = 28,003) or MVr + TA (n = 4,733). Annual MVr + TA volumes increased throughout the study period (P < 0.001, trend), and PPM rates decreased (P < 0.001, trend). The incidence of PPM implantation <90 days after surgery was 7.7% for MVr and 14.0% for MVr + TA. In 90-day conditional landmark-weighted analyses, PPMs were associated with reduced long-term survival among MVr (HR: 1.96; 95% CI: 1.75-2.19; P < 0.001) and MVr + TA recipients (HR: 1.65; 95% CI: 1.28-2.14; P < 0.001). In both surgical groups, PPMs were also associated with an increased risk of HFH (HR: 1.56; 95% CI: 1.27-1.90; P < 0.001) and endocarditis (HR: 1.95; 95% CI: 1.52-2.51; P < 0.001), but not with stroke or reoperation.ConclusionsCompared to isolated MVr, adding TA to MVr was associated with a higher risk of 90-day PPM implantation. In both surgical groups, PPM implantation was associated with an increase in mortality, HFH, and endocarditis.

PURPOSE OF REVIEW:This review explores recent advancements in robotic cardiac surgery, specifically focusing on its application in diverse mitral valve surgeries. The aim is to provide an overview of current clinical practices and supporting evidence in this evolving field. RECENT FINDINGS:A literature review indicates a 30% surge in robotic mitral valve repair from 2015 to 2021, paralleled by a decline in sternotomy-based repair per the STS database. Robotic mitral valve repair consistently shows effective and safe outcomes, with comparable mortality but lower morbidity risks than sternotomy and thoracotomy. The robotic approach exhibits lower conversion to valve replacement, shorter ICU stays, and reduced 30-day readmissions. For experienced programs, robotic techniques prove versatile in various pathologies, including rheumatic heart valve disease, infective endocarditis, ischemic cardiomyopathy, and mitral annular calcification necessitating valve replacement. Literature supports their selective use in high-risk scenarios, including redo surgeries and elderly patients. SUMMARY:Recent evidence supports the growing use of robotic approaches in mitral valve surgery, highlighting their efficacy with comparable mortality rates but lower morbidity risks. Robotic techniques consistently yield positive outcomes across various pathologies and patient profiles, signaling a potential paradigm shift in mitral valve interventions.

Background:CONVERGE was a prospective, multicenter, randomized controlled trial that evaluated the safety of Hybrid Atrial Fibrillation Convergent (HC) and compared its effectiveness to endocardial catheter ablation (CA) for the treatment of persistent atrial fibrillation (PersAF) and longstanding PersAF (LSPAF). In 2020, we reported that CONVERGE met its primary safety and effectiveness endpoints. The primary objective of the present study is to report CONVERGE trial results for quality of life (QOL) and Class I/III anti-arrhythmic drug (AAD) utilization following HC.Methods:Eligible patients had drug-refractory symptomatic PersAF or LSPAF and a left atrium diameter ≤6.0 cm. Enrolled patients were randomized 2:1 to receive HC or CA. Atrial Fibrillation Severity Scale (AFSS) and the 36-Item Short Form Health Survey (SF-36) were assessed at baseline and 12 months; statistical comparison was performed using paired t-tests. AAD utilization at baseline through 12 and 18 months post-procedure was evaluated; statistical comparison was performed using McNemar's tests.Results:A total of 153 patients were treated with either HC (n=102) or CA (n=51). Of the 102 HC patients, 38 had LSPAF. AFSS and SF-36 Mental and Physical Component scores were significantly improved at 12 months versus baseline with HC overall and for the subset of LSPAF patients treated with either HC or CA. The proportion of HC patients (n=102) who used Class I /III AADs at 12 and 18 months was significantly less (33.3% and 36.3%, respectively) than baseline (84.3%; P<0.001). In LSPAF patients who underwent HC (n=38), AADs use was 29.0% through 18 months follow-up versus 71.1% at baseline (P<0.001).Conclusions:HC reduced AF symptoms, significantly improved QOL, and reduced AAD use in patients with PersAF and LSPAF.ClinicalTrialsgov Identifier:NCT01984346.

Background:Valvular heart disease (VHD) management has evolved rapidly in recent decades, but disparities in health care access persist among countries with varying socioeconomic backgrounds. Objectives:The purpose of this study was to investigate global mortality trends from VHD and assess the difference between middle- and high-income countries. Methods:We obtained mortality data from the World Health Organization Mortality Database for VHD and its subgroups (rheumatic valvular disease [RVD], infective endocarditis [IE], aortic stenosis [AS], and mitral regurgitation [MR]) from 2000 to 2019. Age-specific and age-standardized mortality rates per 100,000 persons in middle- and high-income countries were calculated, and trends were analyzed using joinpoint regression. Results:A total of 93 countries (42 middle-income and 51 high-income) were included in the analysis. Both middle- and high-income countries showed an increasing trend in crude VHD mortality rate. In middle-income countries, the age-standardized VHD-related mortality rate was constant (0.0%/year), with decreasing RVD (-2.7%/year) and increasing IE, AS, and MR (0.8%/year, 2.0%/year, and 2.2%/year, respectively). In high-income countries, the age-standardized VHD-related mortality rate was decreasing (-0.6%/year). However, there was a rapid increase in mortality rate from IE in age ≤39 years after 2009 (7.0%/year). Moreover, there was a decreasing mortality rate from AS after 2015 but an increasing rate from MR after 2013, particularly in age ≥80 years. Conclusions:Our study identified a rising burden of VHD-related mortality worldwide. The distribution and trends of VHD mortality differed between middle- and high-income countries. Further investigation is needed to understand the underlying etiology of these varying mortality trends in VHD and its subgroups.

BACKGROUND The purpose of this review is to provide recommendations for cardiac surgeons interested in adopting a robotic platform into their programs. METHODS The recommendations are based on the experience of the authors and cover a diverse array of cardiac surgical procedures that are currently performed with robotic assistance. The focus, as with any innovative surgical approach, is to ensure patient safety, maximize quality and efficacy, and set realistic expectations about what is required to achieve proficiency in robotic cardiac surgery. RESULTS Even though there may be steady growth in robotic cardiac procedures, it is possible that these procedures will be concentrated in higher-volume programs that already offer expertise in mitral valve or coronary surgery. Once success and proficiency with robotic cardiac approaches to coronary or valvular heart disease is achieved, as outlined in this review, surgeons may wish to embark on more complex robotic procedures, such as reoperative mitral valve surgery, totally endoscopic coronary artery bypass, or aortic valve replacement. CONCLUSIONS Maintaining the same principles and techniques for coronary surgery or intracardiac procedures and maintaining the fundamentals of myocardial protection and cardiopulmonary bypass are essential to ensure excellent technical and clinical outcomes and to optimize patient safety.

Robotic-assisted coronary bypass is an attractive option in the management of patients with isolated left anterior descending artery (LAD) disease or multi-vessel coronary disease providing the benefits of the left internal mammary artery (LIMA) to the LAD graft while avoiding the morbidity of a sternotomy. Although the learning curve is significant, both cardiothoracic surgery trainees as well as experienced coronary surgeons can learn this technique. As the prevalence of patients requiring these procedures increases, we must be prepared to respond by increasing our training of robotic coronary surgeons.