The introduction of transcatheter aortic valve replacement (TAVR) over two decades ago has fundamentally reshaped the management and treatment landscape for the treatment of severe aortic stenosis by introducing a less invasive approach compared to a surgical aortic valve replacement (SAVR). The field continues to rapidly evolve as clinical studies expand the indications for TAVR across all surgical risk strata. However, it is unclear whether TAVR can be safely applied to patients with complex aortic valve and root pathologies as well as match the long-term durability demonstrated by SAVR. Thus, optimizing patient selection to maximize net clinical benefit, by defining the indications and limitations of TAVR, continue to be areas of active research and discourse. To this end, the annual ‘Beyond the Guidelines’ session at the 2026 Cardiovascular Research Technologies (CRT) convened an expert panel to highlight the current state of evidence, summarize the accumulated evidence in current domains of clinical equipoise where investigative efforts are focused, and identify key areas of clinical unmet need. This article summarizes the expert panel discussions of current evidence supporting the latest societal guidelines on management of severe aortic stenosis, the accumulation of investigative evidence in established clinical domains of equipoise including TAVR for aortic stenosis in asymptomatic patients; those with bicuspid aortic valves, treatment of transcatheter aortic valve failure, and expert opinions on emerging areas of unmet need where future investigative efforts may need to be focused.

Objective The training pathways in cardiothoracic surgery have evolved so that there are currently several viable options to this career. The purpose of this review is to give insight to medical students and mentors regarding the 4 different pathways. Methods The evolution of cardiothoracic surgery training and 4 current pathways are briefly reviewed. The main differences between these 4 pathways are then discussed in detail. Results Key differences between training pathways include time to completion, opportunities for dedicated academic development or research time, family planning considerations, board certification options, opportunities to change programs, competitiveness, and unique considerations for military personnel. Conclusions This detailed comparison of the training pathways can serve as a resource to help students make informed decisions about the pathway that is best suited to each individual.

OBJECTIVE:Data remain limited on factors influencing the selection of redo-transcatheter aortic valve replacement (TAVR) versus surgical explant in patients with failing transcatheter heart valves. This study aimed to identify clinical and procedural factors guiding treatment decisions. METHODS:This single-center, retrospective study included all patients who underwent aortic valve reintervention following prior TAVR at a U.S. tertiary referral center between January 2015 and June 2024. Clinical records, imaging, and Heart Team notes were reviewed to determine rationale for treatment selection. Procedural details and major adverse cardiac events (MACE: death, rehospitalization, or stroke) were collected. RESULTS:Among 47 patients, 24 (51 %) underwent surgical explant and 23 (49 %) redo-TAVR. The explant group was significantly younger (75 vs. 79 years; p = 0.018), with similar gender distribution (31.9 % female). Time to reintervention was comparable (27.8 vs. 34.2 months; p = 0.75). Common indications for explant included endocarditis (33.3 %), patient-prosthesis mismatch (16.7 %), prior valve-in-valve (16.7 %), annular rupture risk (12.5 %), need for concomitant surgery (8.3 %), and coronary obstruction risk (8.3 %). Thirty-day and one-year MACE rates were significantly higher with explant (30.4 % vs. 0 %, p = 0.029; 59.1 % vs. 21.4 %, p = 0.041). Mortality was numerically higher but not statistically significant. Patients undergoing explant often had more comorbidities and required complex procedures. CONCLUSION:Among patients undergoing reintervention after TAVR, treatment was evenly split between redo-TAVR and explant, underscoring the importance of lifetime planning at initial TAVR. This analysis shows the two groups represent inherently different patient populations and highlights the need for randomized trials to define optimal treatment pathways.

Background Although many options exist for multivessel coronary revascularization, controversy persists over whether multiarterial grafting (MAG) confers a survival advantage over single-arterial grafting (SAG) with saphenous vein in coronary artery bypass grafting (CABG). This study sought to compare longitudinal survival between patients undergoing MAG and those undergoing SAG. Methods All patients undergoing isolated CABG with ≥2 bypass grafts in The Society of Thoracic Surgeons Adult Cardiac Surgery Database (2008-2019) were linked to the National Death Index. Risk adjustment was performed using inverse probability weighting and multivariable modeling. The primary end point was longitudinal survival. Subpopulation analyses were performed and volume thresholds were analyzed to determine optimal benefit. Results A total of 1,021,632 patients underwent isolated CABG at 1108 programs (100,419 MAG [9.83%]; 920,943 SAG [90.17%]). Median follow-up was 5.30 years (range, 0-12 years). After risk adjustment, all characteristics were well balanced. At 10 years, MAG was associated with improved unadjusted (hazard ratio, 0.59; 95% CI 0.58-0.61) and adjusted (hazard ratio, 0.86; 95% CI, 0.85-0.88) 10-year survival. Center volume of ≥10 MAG cases/year was associated with benefit. MAG was associated with an overall survival advantage over SAG in all subgroups, including stable coronary disease, acute coronary syndrome, and acute infarction. Survival was equivalent to that with SAG for patients age ≥80 years and those with severe heart failure, renal failure, peripheral vascular disease, or obesity. Only patients with a body mass index ≥40 kg/m2 had superior survival with SAG. Conclusions Multiarterial CABG is associated with superior long-term survival and should be the surgical multivessel revascularization strategy of choice for patients with a body mass index of less than 40 kg/m2.

Objective To test for associations between optic disc pallor and two clinical variables: ischaemic stroke subtype (cortical and lacunar) and cerebral small vessel disease (SVD) scores in a cohort of hospital patients admitted with mild stroke (Mild Stroke Study 1).Methods We used previously validated software, PallorMetrics, to quantify optic disc pallor in colour fundus photographs of patients diagnosed as having either cortical (n=92) or lacunar (n=92) stroke. We used logistic regression to assess the relationship between stroke type and disc pallor in several zones and ordinal logistic regression to assess the relationship between disc pallor and total SVD score. The left and right eyes were analysed separately.Results In the right eye, independent of age, sex, disc area, hypertension and diabetes, increased optic disc pallor was significantly associated with lacunar stroke in all zones (for global pallor: OR per SD increase=1.55, 95% CI 1.11 to 2.17, p=0.011) and total SVD score in the temporal superior (standardised β=0.36, SE=0.15, p=0.020) and nasal-inferior zones (standardised β=0.44, SE=0.15, p=0.004) in the right eye. Weaker trends were observed in the left eye; however, these did not reach statistical significance.Conclusion Optic disc pallor may be associated with SVD severity and lacunar stroke, which may reflect vascular damage to the optic nerve or its pathways. Our findings underscore the utility of colour fundus photography to learn more about SVD pathology.

A 59-year-old male with incompletely treated aortic valve endocarditis from complicated methicillin-sensitive Staphylococcus aureus bacteremia presented with acute left lower-extremity osteomyelitis. He was found to have new large infected coronary artery aneurysms, which were confirmed by multimodality imaging. This case highlights key decision-making by the multidisciplinary team.

Abstract Eating a healthy diet is associated with a lower risk of neurodegenerative diseases, such as Alzheimer’s disease (AD). Identifying associations between diet and AD biomarkers is key to understanding and identifying critical periods for interventions. The retina provides a unique, non-invasive, window into brain health. This study explored cross-sectional and longitudinal associations between diet and retinal imaging markers in the PREVENT Dementia cohort (UK/Ireland). We calculated a Mediterranean diet (MedDiet) adherence score (Pyramid) for each participant and tested for associations with measures of retinal vessel morphology (CRAE Hubbard Zone C (HZC) and artery tortuosity) using generalised additive models due to abnormally distributed residuals. Additionally, we tested for associations with dietary intake of manganese. All analyses were completed cross-sectionally and then longitudinally in the participants with follow-up data (data collection ongoing). In a preliminary study, we included 86 participants, mean age 50.87 (5.63) years, majority female (57%), with 31 APOEe4 carriers (36%). Participants had a moderate mean Pyramid score (8.16 (SD = 1.40)), which was comparable to scores in other UK cohorts, and a dietary intake of 4.77 mg (SD = 3.05) manganese. There was evidence of an association between higher dietary manganese intake and lower CRAE HZC density in the right eye. There was no evidence of associations between the Pyramid score in either eye or dietary manganese in the left eye, and no signs of longitudinal associations (n=47). Further research is needed to explore any these analyses in a larger sample, and expand with other variables.

Acute pulmonary embolism is the third leading cause of cardiovascular death, with most pulmonary embolism-related mortality associated with acute right ventricular failure. Although there has recently been increased clinical attention to acute pulmonary embolism with the adoption of multidisciplinary pulmonary embolism response teams, mortality of patients with pulmonary embolism who present with hemodynamic compromise remains high when current guideline-directed therapy is followed. Because historical data and practice patterns affect current consensus treatment recommendations, surgical embolectomy has largely been relegated to patients who have contraindications to other treatments or when other treatment modalities fail. Despite a selection bias toward patients with greater illness, a growing body of literature describes the safety and efficacy of the surgical management of acute pulmonary embolism, especially in the hemodynamically compromised population. The purpose of this document is to describe modern techniques, strategies, and outcomes of surgical embolectomy and venoarterial extracorporeal membrane oxygenation and to suggest strategies to better understand the role of surgery in the management of pulmonary embolisms.

We present a case of post–myocardial infarction free-wall rupture in a critically ill patient presenting to the emergency department. Through our case we highlight the prompt evaluation, diagnosis, and management necessary to improve survival in a patient with this life-threatening condition. (Level of Difficulty: Beginner.)

Background The use of transcatheter aortic valve replacement for severe aortic stenosis in low-risk patients necessitates an evaluation of contemporary long-term, real-world outcomes of similar patients undergoing surgical aortic valve replacement (SAVR) in a national cohort. Methods All patients undergoing primary, isolated SAVR in The Society of Thoracic Surgeons (STS) database between 2011 and 2019 were examined. The study population of 42,586 adhered to the inclusion/exclusion criteria of the Placement of Aortic Transcatheter Valves (PARTNER) 3 and Evolut Low Risk randomized trials. Patients were further stratified by STS predicted risk of mortality (PROM), age, and left ventricular ejection fraction. The primary end-point was all-cause National Death Index mortality. Unadjusted survival to 8 years was estimated using the Kaplan-Meier method. Results Mean age was 74.3 ± 5.7 years and mean STS PROM was 1.9% ± 0.8%. The overall Kaplan-Meier time to event analysis for all-cause mortality at 1, 3, 5, and 8 years was 2.6%, 4.5%, 7.1%, and 12.4%, respectively. In subset analyses, survival was significantly better for (1) lower STS PROM (P < .001), (2) younger vs older age (P < .001), and (3) higher vs lower left ventricular ejection fraction (P < .001). When STS PROM was below 1% or the patient age was below age 75 years, the 8-year survival after SAVR was 95%. Conclusions The results of this national study confirm that long-term survival after SAVR remains excellent, at 92.9% at 5 years. These contemporary longitudinal data serve to aid in the balanced interpretation of current and future trials comparing SAVR and transcatheter aortic valve replacement and may assist in the clinical decision-making process for patients of lower surgical risk.

Background:Complex or malignant left-sided heart tumors present a challenge for resection and reconstruction. Cardiac autotransplantation was developed to address this but is a complex technique. Partial autotransplantation was developed to simplify the procedure. This study evaluates the outcomes of partial cardiac autotransplantation compared with those of full cardiac autotransplantation. Methods:We analyzed our prospectively collected cardiac tumor database for cases between 1998 and 2022 requiring full or partial cardiac autotransplantation. The primary end points for the study were morbidities including bleeding, total blood transfusions, renal failure, prolonged ventilation (>48 hours), arrhythmias, total cardiopulmonary bypass time, total aortic clamp time, hospital length of stay, and intensive care unit length of stay. The secondary end point was operative 30-day mortality. Results:We identified 57 consecutive cases of partial or full cardiac autotransplantation. Full autotransplantation was performed in 47 of 57 (82.5%) patients, and partial autotransplantation was performed in 10 of 57 (17.5%) patients. For full vs partial techniques, mean cardiopulmonary bypass time was 191.0 vs 147.5 minutes (P = .01), and median number of blood transfusions was 5.0 vs 2.0 units (P = .04). Mean aortic clamp time was 120.5 vs 103.0 minutes (P = .12), median length of hospital stay was 12.0 vs 8.5 days (P = .23), and intensive care unit stay was 5.0 vs 2.0 days (P = .14); renal failure (9/47 [19%] vs 0) did not differ (P = .34). There was no 30-day mortality in the partial group. Conclusions:Partial cardiac autotransplantation represents a simplification of the full autotransplantation technique and can be performed with a reasonable operative risk.

Central MessageGiven high mortality of native TAVR explant, lifetime management of aortic stenosis should consist of SAVR-first strategy in low- and intermediate-risk patients with 10 to 15 years of life expectancy.See Article page XXX. Given high mortality of native TAVR explant, lifetime management of aortic stenosis should consist of SAVR-first strategy in low- and intermediate-risk patients with 10 to 15 years of life expectancy. See Article page XXX. Over the last decade, transcatheter aortic valve replacement (TAVR) volumes have surged, with an associated decline in the number of surgical aortic valve replacements (SAVRs) being performed for patients with aortic stenosis.1Kim K.M. Arghami A. Habib R. Daneshmand M.A. Parsons N. Elhalabi Z. et al.The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2022 update on outcomes and research.Ann Thorac Surg. 2023; 115: 566-574Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Several clinical trials have demonstrated the periprocedural safety and short-term efficacy of TAVR for all patient risk groups.2Otto C.M. Otto R.A. Nishimura R.O. Bonow R.O. Carabello B.A. Erwin J.P. et al.2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.J Am Coll Cardiol. 2021; 77: e25-e197Crossref PubMed Scopus (578) Google Scholar Now commercially available, TAVR is the recommended treatment for most older patients and intermediate- or high-risk patients with severe aortic stenosis who have limited predicted long-term survival. Increasingly, younger, low-risk patients are requesting and receiving TAVR. While we await the long-term durability data, is this prudent? Fukuhara and colleagues3Fukuhara S. Kim K.M. Yang B. Romano M. Ailawadi G. Patel H.J. et al.Reoperation following transcatheter aortic valve replacement: insights from 10-year experience.J Thorac Cardiovasc Surg. 2023; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (1) Google Scholar from the University of Michigan have highlighted an alarming observation concerning TAVR explants. Incidence of mortality after native TAVR explant was 14.2%. The majority of the native TAVR explant deaths were in patients considered low- (41%) or intermediate-risk (31%) at the time of TAVR implant. Many of the patients required combined or complex procedures, given the technical challenges of dissecting free the embedded transcatheter valve, but even isolated TAVR explant with SAVR had a mortality of 18.2%. Of "paradoxical" note, in the group of 24 patients undergoing reoperative surgery for valve-in-valve (VIV) TAVR explant, there were no operative (30-day) deaths, even though 62.5% of patients were high-/extreme-risk at the time of TAVR implant. Furthermore, the long-term survival in the native TAVR explant cohort was significantly worse compared with the VIV-TAVR explant cohort. Over the 10-year study period at the University of Michigan, the 8-year cumulative incidence of TAVR explant was 1.9% and 14.1% in the native TAVR and VIV-TAVR cohorts, respectively. Although this incidence seems acceptably low, the true incidence of patients with indications for TAVR explant may be much greater. Of the 1834 patients who underwent TAVR or VIV-TAVR, nearly one half of the patients (n = 882) died without TAVR intervention. Given that the median time to TAVR explant in this study was 1.8 years, it could be that more patients had an indication for TAVR explant, but this was not offered due to perceived high risk. Food and Drug Administration approval for TAVR has occurred incrementally—in high-risk patients in 2012, intermediate-risk patients in 2016, and low-risk patients in 2019—and retrospective analyses and registries only record the procedures we perform and not procedures that we do not offer. The startling data from this study and other corroborating registries4Bapat V.N. Zaid S. Fukuhara S. Saha S. Vitanova K. Kiefer P. et al.Surgical explantation after TAVR failure: mid-term outcomes from the EXPLANT-TAVR international registry.JACC Cardiovasc Interv. 2021; 14: 1978-1991Crossref PubMed Scopus (43) Google Scholar should give us all pause as we consider the lifetime management for patients with aortic stenosis. Most bioprosthetic valves are expected to fail over time. For older and/or higher-risk patients whose life expectancy is limited by comorbid conditions, TAVR should be the procedure of choice because the need for valve reintervention will be unlikely. In younger and healthier patients whose life expectancy is greater than 10 to 15 years, SAVR should be highly recommended by the Heart Team. Should that prosthesis fail over time, redo SAVR or VIV-TAVR can then be more safely performed than TAVR explant. Today's solution should not create tomorrow's problem. Reoperation following transcatheter aortic valve replacement: Insights from 10 years' experienceThe Journal of Thoracic and Cardiovascular SurgeryPreviewUse of transcatheter aortic valve replacement (TAVR) has demonstrated dramatic growth in the past decade. This study aims to investigate implications of post-TAVR reoperation from our 10-year experience. Full-Text PDF

We sought to evaluate whether differences in left ventricular assist device (LVAD) canula alignment are associated with stroke. There is a paucity of clinical data on contribution of LVAD canulae alignment to strokes. We conducted a retrospective analysis of patients who underwent LVAD implantation at Houston Methodist hospital from 2011 to 2016 and included those who had undergone cardiac computed tomography (CT) with contrast. LVAD graft alignment using X-ray, echocardiography, and cardiac CT was evaluated. The primary outcome was stroke within 1 year of LVAD implantation. Of the 101 patients that underwent LVAD Implantation and cardiac CT scan during the study period, 78 met inclusion criteria. The primary outcome occurred in 12 (15.4%) patients with a median time to stroke of 77 days (interquartile range: 42-132 days). Of these, 10 patients had an ischemic and two had hemorrhagic strokes. The predominant device type was Heart Mate II (94.8%). Patients with LVAD outflow cannula to aortic angle lesser than 37.5 degrees and those with outflow graft diameter of anastomosis less than 1.5 cm (assessed by cardiac CT) had significantly higher stroke risk (p < 0.001 and p = 0.01 respectively). In HMII patients, a lower LVAD speed at the time of CT scan was associated with stroke. Further studies are needed to identify optimal outflow graft configuration to mitigate stroke risk.

The risks a patient assumes when undergoing a surgical procedure is of great concern to both the patient and his or her oped, the most common in North America being the Society of Thoracic Surgeons short-term risk calculator, which was last updated during November 2018. Cardiac surgeons have used this risk calculator in conjunction with an estimate based on their prior experience and how the patient appears stenosis carries a high mortality when left untreated, and to improve survival. Until recently, surgical aortic valve