Editors' Choice

Discover the featured content in this month’s The Annals of Thoracic Surgery issue, personally selected by Editor-in-Chief Dr. Joanna Chikwe & Senior Editor Dr. Robbin Cohen, who highlight the authors' important findings, with select illustrations from Dr. Sarah Chen, Associate Editor/CMI. As an additional benefit to your STS Membership and Annals subscription, this monthly newsletter aims to bring expert perspectives on recently published research, straight to your digital doorstep. 

Featured in this issue...

Image

Nayak, Silvestry, and coauthors

The 16th Annual Report from The Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) reports outcomes in 28,029 patients with continuous-flow left ventricular assist devices (LVADs) implanted between 2015 to 2024. One-year survival was 85.9%, and 5-year survival as 60.2% in patients with fully magnetically levitated continuous-flow LVADs. In patients aged over 65 years one-year survival was 80.6% and 5-year survival was 51.1%. At 5 years, freedom from gastrointestinal bleeding was 73.5%, device malfunction 81.8%, and stroke was 87.1%. Nationally, fewer than 3000 devices are implanted each year, with no significant change since 2016.

-Joanna Chikwe, MD
Editor-in-Chief

Reddington, Lou, and coauthors

Emergency conversion from robotic to open thoracotomy occurs in approximately 5% of lung resections and is associated with significantly increased mortality compared with elective conversion, but there are no standard guidelines for emergency management and practice is variable. This consensus guidance on the indications for and conduct of emergency intra-operative conversion from robotic to open lung surgery was developed by 21 robotic thoracic surgeons, using a structured discussion based on multiple rounds of questionnaires.

-Joanna Chikwe, MD
Editor-in-Chief

Chopko, Khan, and Stulak

Median sternotomy is the most common incision in cardiac surgery, and inadequate closure predisposes to sternal infections, mediastinitis, and sternal dehiscence. Despite innovation in sternal closure, with certain studies indicating superiority, wire cerclage predominates due to surgeon familiarity and experience, cost, low complication rate, and speed. This literature review suggests that sternal plating may be associated with lower risk of mortality, mediastinitis, dehiscence, non-union, pain, and improved patient reported outcomes, exercise capacity and cost compared to wire cerclage.

-Joanna Chikwe, MD
Editor-in-Chief

Lamelas, Alnajar

In an expert single-surgeon series, sternal-sparing aortic valve replacement with ascending aorta replacement via a 4-5cm right thoracotomy performed in 172 patients, with or without hemiarch under circulatory arrest (mean time 31 minutes) with retrograde cerebral protection and / or root replacement (44, 26%), was associated with longer operative times but similar in-hospital outcomes compared with isolated aortic valve replacement performed in 624 patients. In the overall cohort there were 2 in-hospital deaths, 1 stroke, and 3 patients required ECMO. At 1 and 2 years, survival was 99.5% after isolated AVR and 98.8% after concomitant ascending aorta replacement, and there were 4 deaths over 60 months follow-up.

-Joanna Chikwe, MD
Editor-in-Chief

Koechlin, Berdajs, and coauthors

In a single-center where all patients undergoing coronary bypass routinely undergo CT angiography to evaluate graft patency on post-operative day 5 to evaluate graft patency, graft occlusion was detected in 45 of 589 patients (7.6%) and was seen significantly more often in female patients compared with male patients (n = 13 [14%] vs n = 32 [6.5%], P = .02), representing 14 of 292 (4.8%) and 35 of 1690 (2.1%) occluded grafts (P < .01), respectively. Female sex was significantly associated with higher odds of graft occlusion (odds ratio, 2.6; 95% CI, 1.1-5.7; P = .02). During the median follow-up of 14.5 months (interquartile range, 13.3-16.5 months) in 292 patients, overall mortality was 3.1% (n = 9), with higher incidence of rehospitalizations (28% vs 4.1%, P = .01) and reinterventions (28% vs 2.6%, P < .01) observed in patients with occluded grafts. 

-Joanna Chikwe, MD
Editor-in-Chief

Ribeiro, Jacobs, and coauthors

In an analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database, including 108,512 patients at 123 centers between 2006 and 2023, prenatal detection rates of congenital heart disease continuously increased, varying by region (43.6%-56.2%) and lesion type—from anomalous pulmonary venous drainage (diagnosed prenatally in 13%), to hypoplastic left heart syndrome (diagnosed prenatally in 77%). Prenatal detection rate increased for lesions primarily visible on outflow tract views views (e.g. double outlet right ventricle, truncus arteriosus and transposition of the great arteries, isolated arch obstruction and tetralogy of Fallot) in comparison to those routinely detected on a 4-chamber view (e.g. hypoplastic left heart syndrome, single ventricle, atrioventricular and ventricular septal defects). The authors conclude that suboptimal prenatal detection rates require ongoing quality improvement efforts.

-Joanna Chikwe, MD
Editor-in-Chief

Image

Onorati, Luciani, and coauthors

This was a prospective multicenter European analysis of 498 patients (median age 60.1 yrs) who underwent SAVR with the Inspiris Resilia bioprosthesis (Edwards Lifesciences) with a mean followup of 4.7 + 1.1 years. Structural valve deterioration (SVD) was staged according to the VARC-3 criteria. Freedom from stage 1 SVD at 1, 3, and 5 years was 98.6%, 96.2%, and 95.7% respectively, with negligible stage 2 and stage 3 SVD. The authors report satisfactory durability and hemodynamics with this “novel” bioprosthesis. However, in his invited commentary, Dr. George Tolis challenges the credibility of 5-year performance reports, citing the failed long-term promise of several other biologic valves that had similarly excellent midterm results.

-Robbin Cohen, MD, MMM
Senior Editor

Burmistrova, Fabian, and coauthors

As competition for fellowship positions in cardiothoracic surgery (CTS) grows, rates of unmatched applicants have stabilized at high levels (41% since 2022), making it difficult for those who did not initially match to be considered in subsequent years. Thirty of 77 program directors (PD) responded to a survey that asked characteristics of those who matched, compared with those who did not initially match, but did so on additional attempts.

• Most PDs interviewed and ranked reapplicants, but only 32% matched 1 or more reapplicants from 2018-2023.

• PD’s who matched reapplicants were more likely to rate their technical skills as equal or superior to first time applicants, possibly due to additional training acquired during gap years.

• For all CTS fellowship applicants, interview performance followed by letters from known CTS faculty, and residency performance were the most important factors.

• For reapplicants, American Board of Surgery in-training examination scores were the most important factor, followed by additional training before reapplying.

-Robbin Cohen, MD, MMM
Senior Editor

Image

Matsushioro, Kitamura, and coauthors

Successful emergency repair of acute type A aortic dissection requires a rapid intraoperative assessment of both anatomic and pathologic findings, with adjustments in technique and myocardial preservation when warranted. The authors describe their experience in the case of type a aortic dissection in the intramural segment of an anomalous right coronary artery originating from the left coronary sinus.

-Robbin Cohen, MD, MMM
Senior Editor