In recent years, the field of donor heart preservation has rapidly expanded to incorporate several new technologies aimed at increasing the available donor pool. Traditional ice cold storage, although effective, allows for limited preservation time and also subjects the organ to cold-induced injury. Controlled hypothermia systems improve temperature stability and reduce cold injury, while normothermic ex vivo perfusion platforms enable continuous metabolic support while also incorporating functional assessment, allowing for the utilization of extended-criteria and donation after circulatory death donors. Hypothermic oxygenated perfusion represents a hybrid approach combining the benefit of hypothermia with continuous oxygen delivery, allowing for enhanced preservation and extended preservation times. Emerging techniques such as rapid recovery and intermediate-temperature (10°C) storage further aim to enhance myocardial protection while offering to reduce costs and logistical complexities. Altogether, these technologies represent various strategies that have the potential to expand donor utilization, improve graft preservation, and increase access to heart transplantation.

Objective In patients with moderate ischemic mitral regurgitation (IMR), the impact of concomitant mitral valve intervention at the time of revascularization on late survival remains unclear. The purpose of this study was to compare the lifetime survival of patients with moderate IMR who underwent revascularization alone versus concomitant mitral valve repair or replacement. Methods Retrospective review was performed for 776 consecutive patients, 65 years of age and over with coronary artery disease and moderate IMR who underwent isolated CABG (n = 372), CABG with mitral valve repair (n = 131, CABG+MV repair), or CABG with mitral valve replacement (n = 273, CABG+MV replacement) from 1976 to 2005. Propensity score matching, Kaplan-Meier survival analysis, and Cox-regression were used to compare perioperative and long-term survival. Cross-sectional follow up utilized the CDC National Death Index as well as government and genealogical internet sites, publicly available on-line obituaries, and death notices. Follow up was 98% complete. Results The mean age of the cohort was 74.1±5.8 years with 42.4% female patients. Preoperatively, 54.5% had prior myocardial infarction, 47.7% had a history of congestive heart failure, and 69.1% had an abnormal ejection fraction. Matched patients undergoing CABG or CABG+MV repair had similar incidence of major perioperative morbidity (29.0% vs. 22.1% p = .202) and operative mortality (8.4% vs. 6.1%, p = .475). Late survival was similar between groups (p = .630). Among matched patients undergoing CABG vs. CABG+MV replacement, those undergoing concomitant replacement had significantly increased perioperative major morbidity (35.2% vs. 20.9%, p < .001) and operative mortality (16.9% vs. 7.7%, p < .001). CABG+MV replacement patients experienced an increased risk of late mortality (HR 1.23, 95% CI 1.01-1.49, p = .035), compared to those undergoing isolated CABG. Conclusions In patients with moderate IMR undergoing surgical revascularization, concomitant mitral valve repair did not demonstrate a clear late survival benefit over isolated CABG, while concomitant mitral valve replacement was associated with increased early and late mortality risk.

OBJECTIVE:Minimally invasive mitral valve (MIMV) surgery has increased in prevalence due to reduced postoperative pain, length of stay, and improved cosmesis. However, there is a lack of data describing the risk and impact of postoperative diaphragm dysfunction (DD) after MIMV. METHODS:Consecutive patients at a single institution undergoing isolated mitral valve surgery either via full sternotomy (FS) or MIMV (right thoracotomy) between 2015 and 2024 were included. The diagnosis of DD was based on postoperative diaphragm elevation on chest X-ray and confirmation via ultrasound Sniff test. Factors associated with postoperative DD were identified, and postoperative outcomes were compared between groups. RESULTS:The incidence of postoperative DD was 3.0% (n = 35) among the 1,155 patients undergoing MV surgery. The incidence of DD was 1.8% after FS and 9.3% after MIMV (P < 0.001). Among MIMV patients, all suffered from right DD. After controlling for age, body mass index, and pulmonary comorbidities, MIMV was independently associated with postoperative DD compared with FS (odds ratio = 5.1, 95% CI: 2.4 to 11.0, P < 0.001). Although patients with and without DD had similar postoperative outcomes, those patients older than 70 years with DD had longer postoperative ventilation times (P = 0.03) and hospital length of stay (P = 0.02). CONCLUSIONS:MIMV via right thoracotomy is associated with increased risk of postoperative DD and increased ventilation times and hospital length of stay for elderly patients. Further studies are needed to elucidate the causes for diaphragm injury to minimize this complication.

Bovine jugular vein (BJV) valves are widely used in congenital heart surgery but are limited in durability due to structural valve degeneration (SVD). Here, we examine mechanisms of BJV prosthesis failure and test BJV modification with poly-2-methyl-2-oxazoline (POZ), a polymer shown to inhibit protein and advanced glycation end-product (AGE) absorption. Clinical BJV valve explants (Melody valve, N = 13) underwent Von Kossa staining and immunohistochemistry (IHC) for AGE, carboxymethyllysine (CML), and serum albumin (SA). Collagen structure was analyzed using second-harmonic generation (SHG) imaging. Unmodified and POZ-modified BJV valved conduits underwent 5-week in vitro glycation incubation. Effective orifice area (EOA) and mean pressure gradient (MPG) were recorded weekly using a heart pulse duplicator system. Following incubation, leaflet thickness, IHC, and SHG analyses were performed. In vivo 28-day subcutaneous BJV leaflet implantations were performed in juvenile rats for IHC. Clinical BJV explants demonstrated AGE, CML, and SA infiltration. In vitro glycation induced leaflet thickening (control, 0.03 ± 0.01 vs non-modified, 0.23 ± 0.07 mm, p < 0.001), CML and SA infiltration, and collagen disruption (alignment coefficient: control, 0.76 ± 0.03 vs non-modified, 0.50 ± 0.19, p < 0.01). POZ-modified leaflets remained similar in thickness to unglycated controls. POZ modification reduced CML and SA accumulation and mitigated collagen malalignment. BJV conduits did not reveal clinically significant changes in MPG or EOA. In vivo studies verified POZ modification protected against microcalcification as well as AGE, CML, and SA deposition. BJV valves are subject to SVD-related mechanisms of AGE accumulation, serum protein infiltration, and collagen misalignment. POZ modification mitigates BJV leaflet thickening, AGE and protein infiltration, and collagen disruption.

OBJECTIVE:Permanent pacemaker implantation (PPI) after aortic valve replacement is associated with long-term mortality. However, data regarding PPI after aortic root replacement (ARR) is lacking. Herein we describe the incidence, risk factors, and long-term outcomes of PPI after ARR. METHODS:Consecutive patients undergoing ARR from 2005 to 2020 were selected after excluding those with endocarditis, type A dissection, or preoperative PPI. Patients requiring PPI after ARR were identified, along with the indication and timing. Independent factors associated with PPI after ARR were identified and long-term survival was assessed. RESULTS:The incidence of PPI was 3.8% (n = 85) among 2240 patients undergoing ARR. PPI was performed a median of 7 days (interquartile range, 5-12 days) after ARR most commonly for complete heart block (73%). Bicuspid aortic valve (odds ratio [OR], 1.89; P = .02), female sex (OR, 1.74; P = .04), preoperative heart block (OR, 2.70; P = .02), and prior aortic valve replacement (OR, 2.18; P = .01) were independently associated with PPI while preoperative aortic insufficiency (OR, 0.52; P = .01) and valve-sparing root replacement procedure compared with bio-Bentall (OR, 0.40; P = .01) were protective. Patients requiring PPI after ARR were not at increased risk of operative or long-term mortality compared with patients not requiring PPI (P = .26); however, those undergoing PPI experienced significantly longer hospital length of stay (13 vs 7 days; P < .001). CONCLUSIONS:The incidence of PPI after ARR remains low, particularly after VSRR. Preoperative conduction disturbance, prior AVR, and bicuspid aortic valve are all associated with increased risk of PPI. Although PPI is associated with longer length of stay, it is not associated with early or late mortality.

Objective: Reoperation after aortic root replacement (ARR) is associated with increased operative risk and complexity. This study evaluated clinical outcomes and reoperation rates in patients undergoing ARR. Methods: From 2004 to 2021, 2700 adult patients underwent an ARR in a 2-institution database. Among 2542 surviving patients, 705 patients who had a history of previous cardiac surgery as well as 11 patients who underwent transcatheter aortic valve replacement after index ARR were excluded. Among the finalized cohort of 1826 patients, 88 (4.8%) underwent a reoperation (REDO) on the aortic valve or proximal aorta (root/ascending) a mean of 3.1 years after index ARR whereas 1738 (95%) did not undergo reoperation (no-REDO). A subgroup analysis was performed among those undergoing reoperation by indication including valve dysfunction (48%), endocarditis/graft infection (33%), and aortic aneurysm/dissection/rupture (12%). Reoperative indication was unknown in 6 patients (7%). Results: The REDO group was younger at time of index ARR (52 vs 58 years, P < .0001) and had more bicuspid aortic valves (56% vs 37%, P = .0003). Most patients underwent modified Bentall ARR (61%), whereas 38% underwent a valve-sparing root replacement. Index root operations were similar between groups. At time of reoperation, 53% underwent aortic valve replacement and 35% underwent redo root replacement. Long-term survival was similar between REDO and no-REDO groups (80% vs 85%, P = .26) and reoperation was not a risk factor for late mortality (hazard ratio, 1.31; P = .26); however, REDO ARR was a risk factor for late mortality (hazard ratio, 2.41; P = .02). Conclusions: The incidence of aortic valve and/or proximal aorta reoperation after index ARR is relatively low at 4.8%; however, root reoperation is a risk factor for late mortality.

OBJECTIVES: This study sought to demonstrate outcomes of veno-arterial extracorporeal life support (VA-ECLS) in non-intubated ('awake') patients with cardiogenic shock, as very few studies have investigated safety and feasibility in this population. METHODS: This was a retrospective review of 394 consecutive VA-ECLS patients at our institution from 2017 to 2021. We excluded patients cannulated for indications definitively associated with intubation. Patients were stratified by intubation status at time of cannulation and baseline differences were balanced by inverse probability of treatment weighting. The primary outcome was in-hospital mortality while secondary outcomes included adverse events during ECLS and destination at discharge. RESULTS: Out of 135 patients in the final cohort, 79 were intubated and 56 were awake at time of cannulation. All awake patients underwent percutaneous femoral cannulation with technical success of 100% without intubation. Indications for VA-ECLS in awake patients included acute decompensated heart failure (64.3%), pulmonary hypertension or massive pulmonary embolism (12.5%), myocarditis (8.9%) and acute myocardial infarction (5.4%). After adjustment, awake and intubated patients had similar ECLS duration (7 vs 6 days, P = 0.19), in-hospital mortality (39.6% vs 51.7%, P = 0.28), and rates of various adverse events. Intubation status was not a significant risk factor for 90-day mortality (hazard ratio [95% confidence interval]: 1.26 [0.64, 2.45], P = 0.51) in multivariable analysis. Heart transplantation (15.1% vs 4.9%) and ventricular assist device (17.4% vs 2.2%) were more common destinations at discharge in awake patients than intubated patients (P = 0.02). CONCLUSIONS: Awake VA-ECLS is safe and feasible with comparable outcomes as intubated counterparts in select cardiogenic shock patients.

Background:Systolic anterior motion (SAM) of the mitral valve can result in mitral regurgitation (MR) and adverse outcomes in patients with obstructive hypertrophic cardiomyopathy (HCM). However, the mechanism and characteristics of MR severity mediated by SAM are unresolved. This study aimed to elucidate the anatomic and hemodynamic associations of MR and the impact of septal myectomy on changes in MR severity in patients with HCM.Methods:We retrospectively reviewed patients who underwent septal myectomy with SAM and interpretable imaging between 2017-2022. Significant MR was defined as moderate or more MR. The mitral valve, papillary muscle, and left ventricular geometry were quantitatively evaluated via echocardiography and cardiac computed tomography.Results:Out of 34 patients, two groups were identified: those with preoperative significant MR (n=16) and those without significant MR (n=18). Patients with significant preoperative MR exhibited worse heart failure symptoms at baseline than those without. Following myectomy, these patients showed higher residual left ventricular outflow tract (LVOT) gradients at rest and with provocative measures than those without preoperative MR. Multivariate regression analysis revealed a significant association between the tenting area and MR severity. Additionally, the chordal cutting procedure alleviated the tenting area [2.1 (1.8-2.6) vs. 1.4 (1.2-1.6) cm2] compared to those without it.Conclusions:Our preliminary data suggested that chordal cutting with septal myectomy was associated with an improvement in the tenting area, contributing to MR severity. This procedure may serve as an effective therapy for patients with SAM and significant MR.

BACKGROUND:Although the unique risks of implanting a prosthetic valve after aortic valve (AV) surgery in young patients are well established, studies of aortic root replacement (ARR) are lacking. We investigated long-term outcomes after valve-sparing root replacement (VSRR) versus the use of a composite valve graft with bioprosthesis (b-CVG) in patients age <50 years. METHODS:A total of 543 patients age <50 years underwent VSRR (n = 335) or b-CVG (n = 208) between 2004 and 2021 from 2 aortic centers, excluding those with dissection or endocarditis. Endpoints included mortality over time, reoperative aortic valve replacement (AVR), and development of greater than moderate aortic insufficiency (AI) or aortic stenosis (AS). Fine and Gray competing risk regression was used to compare the risk of reintervention. Propensity score matching (PSM) balanced patient comorbidities, and landmark analysis isolated outcomes beginning 4 years postoperatively. RESULTS:Compared with VSRR, b-CVG was associated with lower 12-year survival (88.6% vs 92.9%; P = .036) and a higher rate of AV reintervention (37.6% vs 12.0%; P = .018). After PSM, survival was similar in the 2 arms (93.4% for b-CVG vs 93.0% for VSRR; P = .72). However, both Fine and Gray multivariable risk regression and PSM showed that b-CVG was independently associated with AV reintervention at >4 years postoperatively (Fine and Gray: subdistribution hazard ratio, 4.3 [95% confidence interval, 1.8-10.2; P = .001]; PSM: 35.7% for b-CVG versus 14.3% for VSRR; P = .024]). PSM rates of greater than moderate AI/AS at 10 years were more than 2-fold greater in the b-CVG arm compared with the VSRR arm (37.1% vs 15.9%; P = .571). CONCLUSIONS:b-CVG in young patients is associated with early valvular degeneration, with increasing rates of reoperative AVR occurring even within 10 years. In contrast, VSRR is durable with excellent survival. In eligible young patients, every effort should be made to retain the native AV.

BACKGROUND:Autograft durability and remodeling are thought to be superior in younger pediatric patients after the Ross operation. We sought to delineate the fate of autografts across the pediatric age spectrum in patients with primary aortic stenosis (AS). METHODS:We retrospectively reviewed patients age ≤18 years with primary AS who underwent the Ross operation between 1993 and 2020. Patients were categorized by age. The primary endpoint was autograft dimensional change, and secondary endpoints were severe neo-aortic insufficiency (AI) and autograft reintervention. RESULTS:A total of 119 patients underwent the Ross operation, including 37 (31.1%) in group I (age <18 months), 24 (20.2%) in group II (age 18 months-8 years), and 58 (48.7%) in group III (age 8-18 years). All groups exhibited similar annular growth rates within the first 5 postoperative years, followed by a collective decrease in annulus growth rates from year 5 to year 10. Group III experienced rapid sinus dilation in the first 5 years, followed by stabilization of the sinus z-score from year 5 to year 10, whereas groups I and II demonstrated stable sinus z-scores over 10 years. There were 4 early deaths (3.4%) and 2 late deaths (1.7%) at a median follow-up of 8.1 years (range, 0.01-26.3 years). At 15 years, the incidences of severe neo-AI (0.0 ± 0.0% vs 0.0 ± 0.0% vs 3.9 ± 3.9%; P = .52) and autograft reintervention (8.4 ± 6.0% vs 0.0 ± 0.0% vs 2.4 ± 2.4%; P = .47) were similar in the 3 groups. CONCLUSIONS:Age at the time of Ross operation for primary AS does not influence long-term autograft remodeling or durability. Other physiologic or technical factors are likely greater determinants of autograft fate.

OBJECTIVE:Preoperative aortic insufficiency (AI) is associated with inferior autograft durability after the Ross procedure. However, many patients with aortic stenosis (AS) undergo balloon aortic valvuloplasty (BAV) early and present with longstanding AI before Ross. We studied how BAV and subsequent valvular pathology impacts autograft durability. METHODS:Patients undergoing the Ross operation from 1993 to 2020 were identified. Those who underwent BAV before Ross were compared with patients who did not undergo BAV and underwent Ross for predominant AI (AI group) or AS (AS group). Those who underwent previous open surgical aortic valve intervention were excluded. Primary outcome of interest was autograft failure, defined as a composite of autograft reintervention or severe insufficiency. RESULTS:A total of 198 patients were included. Seventy-nine (39.9%) underwent BAV and subsequently underwent the Ross for predominant AI (45.6%) or AS (54.4%). Of patients who did not undergo BAV, 66 (33.3%) presented with predominant AI and 53 (26.8%) with AS. Freedom from autograft failure at 15 years was 90%, 92%, and 62% in BAV, AS, and AI groups, respectively. The AI group was at significantly increased risk of long-term autograft failure (hazard ratio, 5.6; P = .01), whereas the AS and BAV groups had similar, low risk (hazard ratio, 1.1; P = .91). Autograft durability was similar among patients who received BAV and presented with AS or AI before the Ross (P = .84). CONCLUSIONS:BAV before the Ross procedure is common in patients with AS. These patients have excellent long-term autograft durability regardless of preoperative valvular pathology and should strongly be considered for the Ross operation.

BACKGROUND:This study aimed to describe the use of perioperative mechanical circulatory support (MCS) and its impact on outcomes in patients with ischemic cardiomyopathy who were undergoing surgical revascularization. METHODS:Patients with an ejection fraction <35% who underwent isolated coronary artery bypass grafting (CABG) from 2015 to 2021 were identified (N = 378). Patients were divided into no MCS, preoperative MCS, and postoperative MCS groups on the basis of timing of MCS initiation, which included intraaortic balloon pump, extracorporeal membrane oxygenation, or Impella device (Abiomed) use. The primary outcome of interest was operative mortality. RESULTS:The median Society of Thoracic Surgeons Predicted Risk of Mortality was 2.4%. Sixty-six percent (n = 246) of patients had a previous myocardial infarction, and 61.8% of these patients were within 21 days of CABG. Twenty-one patients (5.6%) presented in cardiogenic shock. The preoperative MCS cohort consisted of 31 patients (8.2%) who underwent CABG a median of 2 days after MCS initiation. Thirty (7.9%) patients required postoperative MCS. Independent risk factors for requiring postoperative MCS included the preoperative ejection fraction (odds ratio, 0.93; P = .01 and the presence of preoperative MCS (odds ratio, 3.06; P = .02). Overall, operative mortality was 3.4%, and 3-year survival was 87.0%. Operative mortality in patients who did and did not receive preoperative MCS was 7.7% and 2.9% (P = .12) with no difference in long-term survival (P = .80), whereas patients requiring postoperative MCS had significantly increased operative (16.7%) and late mortality (63%; P <.01). CONCLUSIONS:CABG can be performed safely in patients with ischemic cardiomyopathy with selective use of perioperative MCS. Despite advanced disease severity, patients requiring preoperative MCS demonstrate acceptable short- and long-term survival. Patients requiring postoperative MCS have increased postoperative morbidity and mortality.

Objective: Studies of reintervention after valve-sparing aortic root replacement (VSRR) are limited by sample size and failure to evaluate all types of reinterventions, including distal aorta and transcatheter interventions. In this report, reintervention after VSRR using a large patient cohort was comprehensively analyzed. Methods: In a series involving 2 academic aortic centers, 781 consecutive patients from 2005 to 2020 undergoing David V VSRR for aortic aneurysm (91%) or dissection (9%) were included. Median age was 50 years, and 23% had a bicuspid aortic valve (AV). Median follow-up was 7.0 years. Open or transcatheter reintervention on the AV, proximal, or distal thoracic aorta was identified. Cumulative incidence was calculated, and subdistribution hazard models identified factors associated with reintervention. Time-dependent incidence of reintervention was plotted using risk-hazard functions. Results: Sixty-eight reinterventions (57 open, 11 transcatheter) were performed. Reinterventions were divided by indication into degenerative AV (n = 26, including 1 transcatheter aortic valve replacement), endocarditis (n = 11), proximal aorta (n = 8), and distal aorta (n = 23, including 10 thoracic endovascular aortic repairs). Risk of reintervention for endocarditis peaked 1 to 3 years after VSRR, whereas other indications had stable, low rates of occurrence throughout the follow-up period. The cumulative incidence of reintervention was 12.5% whereas the cumulative incidence of AV reintervention was 7.0% at 10 years and was associated with residual postoperative aortic insufficiency. In-hospital mortality after reintervention was 3%. Conclusions: Reintervention rates after VSRR are relatively low in long-term followup and can be performed with acceptable operative risk. The majority of reinterventions are performed for indications other than AV degeneration, with the timing of reintervention varying by the specific clinical indication. (J Thorac Cardiovasc Surg 2024;167:1229-38)

Postcardiotomy shock (PCS) remains a dreaded complication after cardiac surgery, occurring in up to 5% of cases. 1 Fukuhara S. Takeda K. Garan A.R. et al. Contemporary mechanical circulatory support therapy for postcardiotomy shock. Gen Thorac Cardiovasc Surg. 2016; 64: 183-191https://doi.org/10.1007/s11748-016-0625-4 Crossref PubMed Scopus (47) Google Scholar The institution of venoarterial extracorporeal membrane oxygenation (ECMO) can be lifesaving, although outcomes have remained poor despite increasing use. Understanding the risks and benefits of ECMO in this setting will help us better understand who may benefit most from this costly and resource-intensive therapy. In this issue of The Annals of Thoracic Surgery, Heuts and colleagues 2 Heuts S. Mariani S. van Bussel B.C.T. et al. The relation between obesity and mortality in postcardiotomy venoarterial membrane oxygenation. Ann Thorac Surg. 2023; 116: 147-155https://doi.org/10.1016/j.athoracsur.2023.03.025 Abstract Full Text Full Text PDF Scopus (1) Google Scholar study the relationship between body mass index (BMI) and outcomes in patients requiring venoarterial ECMO for PCS. Through a multicenter, international collaboration, the authors retrospectively examined 2046 patients across 36 centers in 16 countries. Patients were divided into 6 groups based on BMI, ranging from underweight to class III obesity, and in-hospital outcomes were compared by a mixed logistic regression model to control for confounding factors. The results suggest that although there is an increasing trend for death observed in patients with increased BMI, there is no association after controlling for associated comorbidities and intraoperative variables. The Relation Between Obesity and Mortality in Postcardiotomy Venoarterial Membrane OxygenationThe Annals of Thoracic SurgeryVol. 116Issue 1PreviewObesity is an important health problem in cardiac surgery and among patients requiring postcardiotomy venoarterial extracorporeal membrane oxygenation (V-A ECMO). Still, whether these patients are at risk for unfavorable outcomes after postcardiotomy V-A ECMO remains unclear. The current study evaluated the association between body mass index (BMI) and in-hospital outcomes in this setting. Full-Text PDF

Valvular heart disease is an important source of cardiovascular morbidity and mortality. Current prosthetic valve replacement options, such as bioprosthetic and mechanical heart valves are limited by structural valve degeneration requiring reoperation or the need for lifelong anticoagulation. Several new polymer technologies have been developed in recent years in the hope of creating an ideal polymeric heart valve substitute that overcomes these limitations. These compounds and valve devices are in various stages of research and development and have unique strengths and limitations inherent to their properties. This review summarizes the current literature available for the latest polymer heart valve technologies and compares important characteristics necessary for a successful valve replacement therapy, including hydrodynamic performance, thrombogenicity, hemocompatibility, long-term durability, calcification, and transcatheter application. The latter portion of this review summarizes the currently available clinical outcomes data regarding polymeric heart valves and discusses future directions of research.

The 2018 heart allocation policy sought to improve risk stratification and reduce waitlist mortality for the sickest patients. This study sought to evaluate changes in wait times for the highest priority patients since policy implementation. All adult single-organ transplant recipients were identified in the United Network for Organ Sharing registry from October 18, 2018, to July 8, 2022, and separated into 4 periods. Outcomes were compared by blood type and UNOS region. Over the study period, 897 of 9,143 patients were listed as status 1 with no significant change in median wait time by blood type or region. More patients were listed as status 2 (4,523/9,143), and each subsequent period postpolicy change was associated with a 4.2-day increase in mean status 2 waitlist time (95% confidence interval 3.0-5.5, p < 0.0001). Wait times were longest for candidates with blood type O and shortest for AB & A. Regional variations continued, however, wait time increased in every region over time.(c) 2023 International Society for Heart and Lung Transplantation. All rights reserved.

Objectives: We examined cases of operative mortality at a single quaternary aca-demic center for patients undergoing relatively lower-risk (Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1-3) procedures, as a means of identifying systemic weaknesses and opportunities for quality improvement.Methods: A retrospective review of all operative mortality events for patients who underwent a Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1, 2, or 3 index procedure (2009-2020) at our institution was performed. After a detailed chart review was performed by 2 independent faculty for each case, factors and system deficiencies that contributed to mortality were identified.Results: A total of 42 mortalities were identified. A total of 37 patients (88%) had at least 1 Society of Thoracic Surgeons-designated risk factor, including prior cardiac operations (48%), extracardiac malformations (43%), and preoperative ventilation (33%). Eight patients (19%) had non-Society of Thoracic Surgeons-designated preoperative patient-level variables considered as at potential risk, including severe ventricular dysfunction, pulmonary hypertension, lung hypoplasia, and undiagnosed severe coronary abnormalities. Four patients (10%) had no identified preoperative risk factors. After detailed chart review, 5 broad categories were identified: patient-related factors (n = 33; 78%), postoperative infection (n = 13; 31%), postoperative residual lesions (n = 7; 17%), Fontan physiology failure (n = 4; 10%), and unex-plained left ventricular failure after tetralogy of Fallot repair (n = 3; 7%). A total of 74% of patients had at least 1 preoperative, intraoperative, or postoperative sys-tem deficiency. A total of 50% of surgeries were urgent or emergency.Conclusions: Operative mortality after Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1 to 3 procedures is related to the presence of multifactorial risk patterns (Society of Thoracic Sur-geons and non-Society of Thoracic Surgeons-designated patient-level risk factors and variables, broad risk categories, system deficiencies, emergency surgery). A multidisciplinary approach to care, with early recognition and treatment of modifi- able additional burdens, could reduce this risk. (J Thorac Cardiovasc Surg 2023;166:325-33)

Objective: Since the heart transplant allocation policy change in 2018, there has been an increase in temporary mechanical circulatory support for Status 2 patients. We sought to examine the temporal pattern of waitlist and posttransplant outcomes for Status 2 patients. Methods: Adult patients in the United Network for Organ Sharing registry who were listed as Status 2 from January 2019 to June 2022 were included. Temporal trends in waitlist time, waitlist events, and posttransplant outcomes were assessed. Probability of transplant or death after being listed was compared over time. Multivariable regression was performed to identify risk factors for mortality after transplant. Results: A total of 6310 patients were included. From 2019 to 2022, the number of Status 2 patients listed increased from 4.2 to 5.9 per day. Microaxial ventricular assist devices at Status 2 listing increased over time (P < .001). During the study period, median waitlist time (18 days vs 23 days, P < .001) as well as Status 2 days (8 days vs 12 days, P < .001) increased. Waitlist mortality remained stable (5.5%); however, probability of transplant within 90 days of Status 2 listing progressively declined (P <.001). Finally, longer waitlist duration was independently associated with 30-day posttransplant mortality (odds ratio, 1.01; 95% confidence interval, 1.00-1.01, P 1/4 .02). Conclusions: Since the allocation policy change there has been a steady rise in the number of patients listed for Status 2. This has led to increasing waitlist times and lower probability of transplantation for Status 2 patients, which may have negative consequences for posttransplant outcomes.