Surgery and transcatheter intervention for degenerative mitral regurgitation in the United States.

OBJECTIVES: We evaluated practice trends and 3-year outcomes of transcatheter edge-to-edge repair (TEER) and surgical repair for degenerative mitral regurgitation in the United States. METHODS: From the Centers for Medicare and Medicaid Services data (2012-2019), 53,117 mitral valve interventions (surgery or TEER) were performed for degenerative mitral regurgitation, identified by excluding rheumatic and congenital disease, endocarditis, myocardial infarction, cardiomyopathy, and concomitant or prior coronary revascularizations. Median follow-up was 2.9 years (interquartile range, 1.2-5.1 years). End points were 3-year survival, stroke, mitral reinterventions, and heart failure readmissions. RESULTS: Volume of total annual mitral interventions did not significantly change (P = .18) between 2012 and 2019. However, surgical cases decreased by one-third, whereas TEER increased. Among 27,170 patients (52.5% men; mean age, 73.5 years) who underwent TEER (n = 7755) or surgical repair (n = 19,415), surgical patients were younger (71.8 vs 80.8 years; P < .001), with less comorbidity and frailty. In 4532 patient pairs matched for age, frailty, and comorbidity, 3-year survival after TEER was 65.9% (95% CI, 64.3%-67.6%) and 85.7% (95% CI, 84.5%-86.9%) after surgery (P < .001). Three years after TEER or surgery, stroke rates were 1.8% (95% CI, 1.5%-2.2%) and 2.0% (95% CI, 1.6%-2.4%) (P = .49); heart failure readmission rates were 17.8% (95% CI, 16.7%-18.9%) and 11.2% (95% CI, 10.3%-12.2%) (P < .001); and mitral reintervention rates were 6.1% (95% CI, 5.5%-6.9%) and 1.3% (95% CI, 1.0%-1.7%) (P < .001), respectively. CONCLUSIONS: Among Medicare beneficiaries with degenerative mitral regurgitation, an increase in TEER utilization was associated with worse survival, increased heart failure readmissions, and more mitral reinterventions. Randomized trials are needed to better inform treatment choice.

Descending Thoracic and Thoracoabdominal Aortic Aneurysm Repairs - The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis.

BACKGROUND: Contemporary national outcomes of open and endovascular aortic repair for descending thoracic (DTAA) and thoracoabdominal aortic aneurysms (TAAA) are unclear. We evaluated this using the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD). METHODS: From 07/01/2017 to 6/30/2022, we identified 3522 adults undergoing planned DTAA repair (open 328, endovascular 1895) or TAAA repair (open 870, endovascular 429), after excluding ascending aorta or aortic arch aneurysms (zone 0, 1, or 2), interventions with a proximal extent in zone 0 or zone 1, juxtarenal/infrarenal aortic interventions, hybrid procedures, aortic trauma, and aortic infection. RESULTS: Most DTAA interventions (85.2%) were endovascular repairs, while most TAAA interventions were open repairs (66.9%). For DTAA, the operative mortality, permanent stroke rate, and rate of spinal cord injury were 4.2%, 3.8%, and 2.4% for endovascular repair and 9.2%, 8.5%, and 4.6% for open repair, respectively (all p<0.05). For TAAA, the operative mortality, permanent stroke rate, and rate of spinal cord injury were 6.5%, 2.1%, and 3.0% for endovascular repair and 11.7%, 6.0%, and 12.2% for open repair (all p<0.05). Increasing annual open TAAA repair volume was associated with lower odds of experiencing the composite of operative mortality, permanent stroke, or spinal cord injury. CONCLUSIONS: Based on STS-ACSD data, endovascular repair was the predominant approach for treating DTAA, while most patients undergoing TAAA interventions had an open surgical repair. Outcome differences between open and endovascular approaches may be related to patient selection. Increasing center experience with open TAAA repair is associated with improved outcomes.

Limited cumulative experience with ex vivo lung perfusion is associated with inferior outcomes after lung transplantation.

OBJECTIVE: Ex vivo lung perfusion (EVLP) allows for prolonged preservation and evaluation/resuscitation of donor lungs. We evaluated the influence of center experience with EVLP on lung transplant outcomes. METHODS: We identified 9708 isolated, first-time adult lung transplants from the United Network for Organ Sharing database (March 1, 2018-March 1, 2022), 553 (5.7%) involved using donor lungs after EVLP. Using the total volume of EVLP lung transplants per center during the study period, centers were dichotomized into low- (1-15 cases) and high-volume (>15 cases) EVLP centers. RESULTS: Forty-one centers performed EVLP lung transplants, including 26 low-volume and 15 high-volume centers (median volume, 3 vs 23 cases; P < .001). Recipients at low-volume centers (n = 109) had similar baseline comorbidities compared with high-volume centers (n = 444). Low-volume centers used numerically more donation after circulatory death donors (37.6 vs 28.4%; P = .06) and more donors with Pao2/Fio2 ratio <300 (24.8 vs 9.7%; P < .001). After EVLP lung transplants, low-volume centers had worse 1-year survival (77.8% vs 87.5%; P = .007), with an adjusted hazard ratio of 1.63 (95% CI, 1.06-2.50, adjusting for recipient age, sex, diagnosis, lung allocation score, donation after circulatory death donor, donor Pao2/Fio2 ratio, and total annual lung transplant volume per center). When compared to non-EVLP lung transplants, 1-year survival of EVLP lung transplants was significantly worse at low-volume centers (adjusted hazard ratio, 2.09; 95% CI, 1.47-2.97) but similar at high-volume centers (adjusted hazard ratio, 1.14; 95% CI, 0.82-1.58). CONCLUSIONS: The use of EVLP in lung transplantation remains limited. Increasing cumulative EVLP experience is associated with improved outcomes of lung transplantation using EVLP-perfused allografts.

Impact of minimally invasive lung transplantation on early outcomes and analgesia use: A matched cohort study.

BACKGROUND: Minimally invasive (MI) approaches to lung transplantation (LTx) offer the prospect of faster recovery compared to traditional incisions, however, little data exist describing the impact of surgical technique on early outcomes and analgesia use. METHODS: A prospectively maintained institutional registry identified 170 patients who underwent LTx between January, 2017 and June, 2022. Post-COVID acute respiratory distress syndrome, repeat, and multiorgan transplants were excluded (n = 27) leaving 37 MILTx and 106 traditional LTx patients. Propensity score matching by age, sex, body mass index, diagnosis, lung allocation score, double vs. single lung, hypertension, diabetes, and hospitalization status created 37 pairs. RESULTS: Before matching, MILTx patients were more often male (70% vs 43%) and more likely to receive grafts from younger (31 vs 42 years), circulatory death donors (19% vs 6%) compared with traditional LTx patients (all p < 0.05). After matching, there were no differences in graft warm ischemia or operative duration (both p > 0.05). Postoperatively, MILTx experienced shorter intensive care unit (ICU) (4.3 [IQR 3.1-5.5] vs 8.2 [IQR 3.7-10.8] days) and hospital lengths of stay (LOS) (13 [IQR 11-15] vs 17 [IQR 12-25] days) (both p < 0.05). Among patients surviving to discharge, MILTx patients required fewer opioid prescriptions at discharge (38% vs 66%, p = 0.008) and had improved pulmonary function at 3 months (Forced expiratory volume in 1 second 82 [IQR 72-102] vs 77 [IQR 52-88]% predicted; forced vital capacity 78 [IQR 65-92] vs 70 [IQR 62-80]% predicted] (both p < 0.05). CONCLUSION: Minimally invasive LTx techniques demonstrate potential advantages over traditional approaches, including reduced ICU and hospital LOS, lower opioid use on discharge, and improved early pulmonary function.

Robotic navigational bronchoscopy in a thoracic surgery practice: Leveraging technology in the management of pulmonary nodules.

Objectives: Robotic navigational bronchoscopy is increasingly used to improve diagnostic yield for pulmonary nodules compared with the 50% to 60% obtained by standard bronchoscopy; however, safety and efficacy data are limited to small series. The aim of this study was to evaluate diagnostic yield and clinical outcomes in a large multisurgeon single-center cohort. Methods: All patients who underwent robotic navigational bronchoscopy and biopsy from September 2020 to October 2022 were identified from a prospective institutional registry. The primary outcome was diagnostic yield. The secondary outcome was diagnostic yield for molecular testing. Results: A total of 503 nodules were biopsied during the study period. Median nodule size was 2.1 cm. Overall diagnostic yield was 87.9%. Factors associated with increased diagnostic yield were decreased time from date of planning computed tomography to procedure date (odds ratio, 0.98; 95% CI, 0.96-0.99; P = .04) and greater nodule size (odds ratio, 1.03; 95% CI, 1.01-1.07; P = .02) per 0.1-cm increment. Molecular analysis was sent in 101 patients and was sufficient in 90% of cases. Complications occurred in 22 (5%) patients, including 13 (3.1%) with pneumothoraxes (7 patients requiring a chest drain), and 5 (1.2%) patients had bleeding requiring intraprocedural bronchial intervention. A total of 41 patients were consented for biopsy and resection during a single anesthetic event. Four of these cases were stopped at robotic navigational bronchoscopy due to an alternative diagnosis. Mean length of stay was 3.4 ± 1.1 days. There were no major complications. Conclusions: This study suggests robotic navigational bronchoscopy has a high diagnostic yield and obtains adequate tissue for molecular analysis critical for selection of targeted therapies. With careful patient selection robotic navigational bronchoscopy can be combined with surgery to treat lung cancer as a single procedure with low complication rates.