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Introduction: Patients with metastatic melanoma to the lung typically have poor outcomes. Although a pulmonary metastasectomy for selected patients has been shown to improve survival, the role of surgical resection following the introduction of immunotherapy for metastatic melanoma is unknown. The objective of this study was to determine predictors of survival for patients with melanoma metastatic to the lung in the era of immunotherapy., Methods: In this retrospective study, data from the National Cancer Database were abstracted for patients with melanoma lung metastases. The overall survival was evaluated using Kaplan-Meier and Cox proportional hazard analysis, adjusting for previously described risk factors for mortality. Patients with concomitant metastases to organs other than the lung were excluded from the study., Results: A total of 625 patients with lung metastases at the time of a skin melanoma diagnosis were identified. A total of 280 patients underwent a pulmonary metastasectomy, 267 received immunotherapy, and 78 were treated with both a metastasectomy and immunotherapy. During a median follow-up time of 34.6 months [IQR: 14.2, 75.9], a metastasectomy was found to offer significantly improved survival compared to immunotherapy alone. No difference was noted between a metastasectomy and a combination of a metastasectomy and immunotherapy in the adjusted Cox proportional hazard model., Conclusions: When statistical models were adjusted for risk factors, a metastasectomy maintained a significant survival advantage compared to immunotherapy. The addition of immunotherapy to the treatment of patients treated with a pulmonary metastasectomy did not improve survival. Our findings support the role of surgery for patients with pulmonary metastatic melanoma.

Background:  Rapid and accurate diagnosis of infective endocarditis (IE) allows timely management of this life-threatening disease and improves outcome. The Duke criteria have traditionally been the clinical method for diagnosing IE. These criteria were reformulated at different timepoints. We aimed to evaluate the real accuracy of the modified Duke criteria based on several studies that concluded the diagnosis of IE., Methods:  Three databases were assessed. Studies were considered for inclusion if they reported the use of modified Duke criteria as the initial approach and the confirmation of the diagnosis with the gold standard methods. The meta-analysis of diagnostic test accuracy was performed after fitting the hierarchical summary receiver operating characteristic model (HSROC) with bivariate model and displaying the summarized measures of sensitivity and specificity, and positive and negative likelihood ratios., Results:  A total of 11 studies were included. Accuracy in the included studies ranged from 62.3 to 92.2%, sensitivity ranged from 58.3 to 84.0%, and specificity ranged from 50.0 to 100%. The combined overall sensitivity and specificity were 85% (95% CI: 0.77-0.90) and 98% (95% CI: 0.89-0.99), respectively. The positive likelihood ratio was 40.2 (95% CI: 7.26-220.74) and the negative likelihood ratio was 0.15 (95% CI: 0.01-0.23)., Conclusion:  The analysis reveals that the modified Duke criteria have a high positive likelihood ratio, suggesting a robust correlation between a positive test result and the existence of IE, and a very good overall specificity at 98%. The latter aspect holds significant importance in order to prevent unnecessary overtreatment, given the intricacies involved in managing IE., Competing Interests: None declared., (Thieme. All rights reserved.)

Background:  Coronary artery disease (CAD) limits life expectancy compared to the general population. Myocardial infarctions (MIs) are the primary cause of death. The incidence of MI increases progressively with age and most MI deaths occur in the population older than 70 years. Coronary artery bypass grafting (CABG) may prevent the occurrence of new MIs by bypassing most CAD lesions, providing downstream "collateralization" to the diseased vessel, and consequently prolonging survival. We systematically assessed the survival-improving potential of CABG by comparing elderly CABG patients to the age-matched general population., Methods:  Three databases were assessed. The primary and single outcome was long-term all-cause mortality. Time-to-event data of the individual studies were extracted and reconstructed in an overall survival curve. As a sensitivity analysis, summary hazard ratios (HRs) and 95% confidence intervals (CIs) for all individual studies were pooled and meta-analytically addressed. The control group was based on the age-matched general population of each individual study., Results:  From 1,352 records, 4 studies (4,045 patients) were included in the analysis. Elderly patients (>70 years) who underwent CABG had a significantly lower risk of death in the follow-up compared to the general age-matched population in the overall survival analysis (HR: 0.88; 95% CI: 0.83, 0.94; p  < 0.001: mean follow-up was 7 years)., Conclusion:  Elderly patients who undergo CABG appear to have significantly better long-term survival compared to the age-matched general population. This advantage becomes visible after the first year and underscores the life-prolonging effect of bypass surgery, which may eliminate the expected reduction in life expectancy through CAD., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Emerging evidence indicates a frequent occurrence of atrial fibrillation (AF) detection among patients with established causes of ischemic stroke unrelated to AF. This systematic review and meta-analysis aimed to evaluate AF detection rates in stroke patients with large or small vessel disease, considering the AF detection modality and duration of cardiac rhythm monitoring., Aims: We conducted a comprehensive search of PubMed and Scopus databases up to 2 March 2024, to identify randomized controlled trials, non-randomized prospective studies, and retrospective studies assessing the frequency of AF detection in stroke patients with large or small vessel disease. The primary outcome of interest was the rate of AF detection. We utilized inverse-variance weights to produce the pooled prevalence (effect size (ES)) and 95% confidence interval (CI) of patients diagnosed with post-stroke AF., Summary of Review: In the analysis of 14 eligible studies encompassing 4334 patients, AF was identified in 154 out of 2082 patients with strokes attributed to small or large vessel disease, yielding a pooled prevalence of 6.27% (ES; 95% confidence interval (CI): 3.18-10.17, I 2  = 87.83%). Among patients with large vessel disease strokes, AF was diagnosed in 79 out of 1042 patients, accounting for a pooled prevalence of 5.07% (ES; 95% CI: 1.30-10.33, I 2  = 77.05%). Similarly, among those with small vessel disease strokes, AF was detected in 75 out of 1040 patients, with a pooled prevalence of 5.03% (ES; 95% CI: 1.96-9.06, I 2  = 78.05%)., Conclusions: AF is often found in ischemic stroke patients with large or small vessel disease. Detection rates increase with longer cardiac rhythm monitoring. The safety and benefits of oral anticoagulation for these AF episodes are uncertain., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Liver dysfunction is a known risk factor in the cardiovascular field. It specifically increases perioperative risk in patients undergoing coronary bypass surgery. Since percutaneous coronary intervention (PCI) is the much less invasive procedure for the treatment of coronary artery disease, we aimed to assess the relationship of liver dysfunction with outcomes in patients undergoing PCI., Methods: Three libraries were searched (MEDLINE, Web of Science and The Cochrane Library). We performed a meta-analysis of all studies in patients who underwent PCI that provided information on the presence or absence of liver dysfunction. Primary outcome was short-term mortality. Secondary outcomes were major adverse cardio- and cerebrovascular events (MACCE), bleeding and acute kidney injury. Random-effects model was applied., Results: Five studies were selected and the data from 10,710,317 patients were included in the final analysis. In comparison with the absence of liver dysfunction, patients with liver dysfunction were associated with higher short-term mortality (OR 2.97, 95%CI 1.23-7.18, p = 0.02), higher MACCE (OR 1.42, 95%CI 1.08-1.87, p = 0.01), and higher bleeding (OR 2.23, 95%CI 1.65-3.00, p < 0.01). There was no significant difference regarding acute kidney injury (OR 1.20, 95%CI 0.50-2.87, p = 0.69)., Conclusions: The analysis suggests that liver dysfunction in patients undergoing PCI is independently associated with higher risk of short-term mortality and increased occurrence of MACCE and bleeding. However, there appears to be no association to acute kidney injury., (© 2024. The Author(s).)

Myocardial infarction (MI) is a leading cause of mortality globally and is predominantly attributed to coronary artery disease (CAD). MI is categorized as ST-elevation MI (STEMI) or non-ST-elevation MI (NSTEMI), each with distinct etiologies and treatment pathways. The goal in treatment for both is restoring blood flow back to the myocardium. STEMI, characterized by complete occlusion of a coronary artery, is managed urgently with reperfusion therapy, typically percutaneous coronary intervention (PCI). In contrast, NSTEMI involves a partial occlusion of a coronary artery and is treated with medical management, PCI, or coronary artery bypass grafting (CABG) depending on risk scores and clinical judgment. The Heart Team approach can assist in deciding which reperfusion technique would provide the greatest benefit to the patient and is especially useful in complicated cases. Despite advances in treatment, complications such as cardiogenic shock (CS) and ischemic heart failure (HF) remain significant. While percutaneous coronary intervention (PCI) is considered the primary treatment for MI, it is important to recognize the significance of cardiac surgery in treatment, especially when there is complex disease or MI-related complications. This comprehensive review analyzes the role of cardiac surgery in MI management, recognizing when it is useful, or not.

Background: Complete removal of cardiac implantable electronic devices (CIEDs) is recommended in patients with CIED infections, including both systemic and localized pocket infection. The aim of the study was to provide an up-to-date and comprehensive assessment of evidence relating to the effect of complete CIED extraction in patients with a CIED infection., Methods: We performed a systematic review and meta-analysis of studies reporting short- and mid-term outcomes in patients who had a device infection or infective endocarditis (IE) and underwent complete removal of the cardiac device (generator and leads) compared to those who received conservative therapy (no removal, partial removal, local antibiotic infiltration or isolated antibiotic therapy). The primary outcome was reinfection/relapse. Secondary outcomes were short-term (30-day/in-hospital) and mid-term (mean follow-up: 43.0 months) mortality. Random effects model was performed., Results: Thirty-two studies met the criteria for inclusion in the final analysis. Patients with complete CIED extraction (n = 905) exhibited a lower rate of relapse/re-infection compared to patients (n = 195) with a conservative treatment approach (n = 195, OR 0.02, 95%CI 0.01-0.06, p < 0.0001, mean-follow-up: 16.1 months). Additionally, these patients displayed a lower short- (OR 0.40, 95%CI 0.23-0.69, p = 0.01) and mid-term (OR 0.52, 95%CI 0.34-0.78, p = 0.002) mortality., Conclusions: The analysis indicates that patients with a CIED infection who undergo complete CIED extraction exhibit a lower rate of relapse/re-infection. Additionally, a lower short- and mid-term mortality is observed, although it is acknowledged that this outcome may be influenced by treatment allocation bias., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

The degree of both mitral (MR) and tricuspid valve regurgitation (TR) correlates with mortality. A vicious cycle has been proposed consisting of increasing regurgitation and decreasing ventricular function. Restoration of valve competence should break this vicious cycle and improve life expectancy. However, a "pop-off" mechanism keeps being entertained, presumably allowing poorly pumping ventricles to relieve volume into the low-pressure atrium through an incomplete repair, avoiding pump failure. We reasoned that if such a mechanism exists, it should offset the relationship between mortality and valve regurgitation after an invasive procedure. In this context, we meta-analytically compared valve regurgitation degree and survival before or after atrio-ventricular valve treatment. The results show significant relationships between valve regurgitation and mortality under all conditions (i.e., before and after surgery or intervention) and irrespective of the underlying pathology (i.e., functional or structural). In summary, the ubiquitously present relationship between valve regurgitation and mortality suggests that generating a tight and durable repair of the affected valve is key to long-term exploitation of a symptom-reducing and life-prologing mechanism, independent of the underlying valve pathology. This recognition may explain current controversies in the treatment effects of MR and TR., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Recent randomized controlled trials (RCTs) have demonstrated similar outcomes in terms of ischemic stroke incidence after carotid endarterectomy (CEA) or carotid artery stenting (CAS) in asymptomatic carotid disease, while CEA seems to be the first option for symptomatic carotid disease. The aim of this meta-analysis is to assess the incidence of silent cerebral microembolization detected by magnetic resonance imaging (MRI) following these procedures., Methods: A systematic search was conducted using PubMed, Scopus, and Cochrane databases, including comparative studies involving symptomatic or asymptomatic patients undergoing either CEA or CAS and reporting on new cerebral ischemic lesions in postoperative MRI. The primary outcome was the newly detected cerebral ischemic lesions. Pooled effect estimates for all outcomes were calculated using the random-effects model. Prespecified random effects metaregression and subgroup analysis were conducted to examine the impact of moderator variables on the presence of new cerebral ischemic lesions., Results: 25 studies reporting on a total of 1827 CEA and 1500 CAS interventions fulfilled the eligibility criteria. The incidence of new cerebral ischemic lesions was significantly lower after CEA compared to CAS, regardless of the time of MRI assessment (first 24 hours; OR: 0.33, 95% CI: 0.17-0.64, P < 0.001), (the first 72 hours, OR: 0.25, 95% CI 0.18-0.36, P < 0.001), (generally within a week after the operation; OR: 0.24, 95% CI: 0.17-0.34, P < 0.001). Also, the rate of stroke (OR: 0.38, 95% CI: 0.23-0.63, P < 0.001) and the presence of contralateral new cerebral ischemic lesions (OR: 0.16, 95% CI 0.08-0.32, P < 0.001) were less frequent after CEA. Subgroup analysis based on the study design and the use of embolic protection device during CAS showed consistently lower rates of new lesions after CEA., Conclusions: CEA demonstrates significant lower rates of new silent cerebral microembolization, as detected by MRI in postoperative period compared with CAS., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: Surgical resection remains the primary treatment for early-stage non-small cell lung cancer (NSCLC), with lobectomy considered the standard approach. However, recent evidence suggests that sublobar resection may be an alternative option for select patients., Materials and Methods: A systematic review and meta-analysis were conducted following PRISMA guidelines. Randomized controlled trials (RCTs) and propensity-score matched (PSM) cohort studies comparing lobectomy and sublobar resection in NSCLC patients were included. The primary outcome was overall survival (OS), and secondary outcomes included disease-free survival (DFS), 30-day mortality, and cancer recurrence rates. Individual patient data (IPD) were reconstructed from Kaplan-Meier curves, and one-stage and two-stage meta-analyses were performed., Results: A total of 18 studies involving 6,075 NSCLC patients (3,119 undergoing lobectomy, 2,956 undergoing sublobar resection) were included. Lobectomy was associated with significantly better OS compared to sublobar resection (hazard ratio [HR]: 0.78, 95 % confidence interval [CI]: 0.68-0.89, p < 0.001). However, when sublobar resection was further divided into segmentectomy and wedge resection, no significant difference in OS was observed between lobectomy and segmentectomy (HR:0.92, 95 %CI: 0.75-1.14, p = 0.464) whereas lobar resection was associated with better OS compared to wedge resection (HR:0.52, 95 %CI: 0.41-0.67, p < 0.001). DFS outcomes were similar between lobectomy and sublobar resection (HR:0.98, 95 %CI: 0.84-1.14, p = 0.778)., Conclusion: Lobectomy is associated with better overall survival compared to sublobar resection in NSCLC patients. However, when sublobar resection is subdivided, segmentectomy shows comparable outcomes to lobectomy, while wedge resection is inferior. These findings support the consideration of segmentectomy as the surgical option of choice for Stage IA NSCLC patients., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Postoperative bleeding requiring re-exploration is a serious complication that occurs in 2.8-4.6% of patients undergoing cardiac surgery. Re-exploration has previously been associated with a higher risk of short-term mortality. However, a comprehensive analysis of long-term outcomes after re-exploration for bleeding has not been published., Materials and Methods: The authors performed a systematic, three databases search to identify studies reporting long-term outcomes in patients who required re-exploration for bleeding after cardiac surgery compared to patients who did not, with at least 1-year of follow-up. Long-term survival was the primary outcome. Secondary outcomes were operative mortality, myocardial infarction, stroke, renal and respiratory complications, and hospital length of stay. Random-effects models was used. Individual patient survival data was extracted from available survival curves and reconstructed using restricted mean survival time., Results: Six studies totaling 135 456 patients were included. The average follow-up was 5.5 years. In the individual patient data, patients who required re-exploration had a significantly higher risk of death compared with patients who did not [hazard ratio (HR): 1.21; 95% CI: 1.14-1.27; P <0.001], which was confirmed by the study-level survival analysis (HR: 1.32; 95% CI: 1.12-1.56; P <0.01). Re-exploration was also associated with a higher risk of operative mortality [odds ratio (OR): 5.25, 95% CI: 4.74-5.82, P <0.0001], stroke (OR: 2.05, 95% CI: 1.72-2.43, P <0.0001), renal (OR: 4.13, 95% CI: 3.43-4.39 P <0.0001) respiratory complications (OR: 3.91, 95% CI: 2.96-5.17, P <0.0001), longer hospital length of stay (mean difference: 2.69, 95% CI: 1.68-3.69, P <0.0001), and myocardial infarction (OR: 1.85, 95% CI: 1.30-2.65, P =0.0007)., Conclusion: Postoperative bleeding requiring re-exploration is associated with lower long-term survival and increased risk of short-term adverse events including operative mortality, stroke, renal and respiratory complications, and longer hospital length of stay. To improve both short-term and long-term outcomes, strategies to prevent the need for re-exploration are necessary., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: To assess survival outcomes for patients with stage IIIA (T1N2M0) non-small cell lung cancer (NSCLC) using the National Cancer Database (NCDB)., Methods: Patients with T1N2M0 NSCLC undergoing lobectomy or segmentectomy were identified in the NCDB from 2004 to 2019. Patient characteristics were compared using χ 2 and Fisher exact tests. Overall survival was evaluated using the Kaplan-Meier method and the Cox proportional hazard analysis adjusting for type of resection, age, sex, and margin positivity, Charlson comorbidity index, number of lymph nodes examined, number of positive lymph nodes, and tumor size., Results: In total, 2883 patients with T1N2 NSCLC undergoing segmentectomy or lobectomy were identified. The majority (96.5%) of patients received lobectomy and 100 (3.5%) patients received segmentectomy. Patients undergoing segmentectomy were older ( P  = .001) and had tumors in the lower lobe of the lung ( P  = .001) versus patients undergoing lobectomy. Fewer patients who received segmentectomy underwent radiation ( P  = .015) and neoadjuvant chemotherapy ( P  = .041). Fewer patients undergoing segmentectomy had >10 lymph nodes examined and >5 positive nodes compared with patients receiving lobectomy (both P  < .001). Although 30-day readmission rates were similar ( P  = .27), 30-day mortality was lower in the segmentectomy cohort ( P  = .047). There was a significantly lower risk of death among patients undergoing lobectomy versus segmentectomy (hazard ratio, 0.96; 95% confidence interval, 0.94-0.98; P  = .001)., Conclusions: In this NCDB analysis, lobectomy was more commonly performed for T1N2 NSCLC compared with segmentectomy. Lobectomy offered a significant survival advantage over segmentectomy, even when adjusting for risk factors. Thus, these findings suggest that lobectomy may be a superior resection of choice for patients with T1N2 disease., Competing Interests: The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (© 2024 The Author(s).)

Chemotherapy-induced cardiotoxicity with subsequent heart failure (HF) is a major cause of morbidity and mortality in cancer survivors worldwide. Chemotherapy-induced HF is exceptionally challenging as it generally manifests in patients who are typically not eligible for left ventricular device implantation or heart transplantation. To explore alternative treatment strategies for cancer survivors suffering from chemotherapy-induced HF, we developed a minimally invasive infusible cardiac stromal cell secretomes adhesive (MISA) that could be delivered locally through an endoscope-guided intrapericardial injection. To mimic the typical clinical presentation of chemotherapy-induced HF in elder patients, we established an aged rat model in which restrictive cardiomyopathy with sequential HF was induced via consecutive doxorubicin injections. In vitro, we prove that MISA not only enhanced cardiomyocytes proliferation potency and viability, but also inhibited their apoptosis. In vivo, we prove that MISA improved the ventricular contractility indexes and led to beneficial effects on histological and structural features of restrictive cardiomyopathy via promoting cardiomyocyte proliferation, angiogenesis, and mitochondrial respiration. Additionally, we also evaluated the safety and feasibility of MISA intrapericardial delivery in a healthy porcine model with an intact immune system. In general, our data indicates that MISA has a strong potential for translation into large animal models and ultimately clinical applications for chemotherapy-induced HF prior to the final option of heart transplantation., Competing Interests: The authors have no conflicts of interest to declare., (© 2024 The Authors.)

Background: The current National Comprehensive Cancer Network advises neoadjuvant chemoradiotherapy followed by surgery for locally advanced cases of esophageal cancer. The role of immunotherapy in this context is under heavy investigation., Methods: Patients with esophageal adenocarcinoma were identified in the National Cancer Database (NCDB) from 2004 to 2019. Three groups were generated as follows: (a) no immunotherapy, (b) neoadjuvant immunotherapy, and (c) adjuvant immunotherapy. Overall survival was evaluated using the Kaplan-Meier method and Cox proportional hazard analysis, adjusting for previously described risk factors for mortality., Results: Of the total 14,244 patients diagnosed with esophageal adenocarcinoma who received neoadjuvant chemoradiation, 14,065 patients did not receive immunotherapy, 110 received neoadjuvant immunotherapy, and 69 received adjuvant immunotherapy. When adjusting for established risk factors, adjuvant immunotherapy was associated with significantly improved survival compared to no immunotherapy and neoadjuvant immunotherapy during a median follow-up period of 35.2 months. No difference was noted among patients who received no immunotherapy vs. neoadjuvant immunotherapy in the same model., Conclusions: In this retrospective analysis of the NCDB, receiving adjuvant immunotherapy offered a significant survival advantage compared to no immunotherapy and neoadjuvant immunotherapy in the treatment of esophageal adenocarcinoma. The addition of neoadjuvant immunotherapy to patients treated with neoadjuvant chemoradiation did not improve survival in this cohort. Further studies are warranted to investigate the long-term outcomes of immunotherapy in esophageal cancer.

Objectives:  Mechanisms of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) differ as CABG provides surgical collateralization and may prolong life by preventing future myocardial infarctions (MIs). However, evidence for CABG in patients with chronic total occlusion (CTO) has not been fully elucidated and the impact of PCI is discussed controversially., Methods:  We performed a meta-analysis of studies comparing outcomes in patients with/without multivessel disease undergoing CABG or PCI for CTO. The primary outcome was long-term all-cause mortality (≥5 years). Secondary outcomes were MIs, repeat revascularization, cardiac mortality, major adverse cardiovascular events, and stroke, as well as short-term mortality (30 days/in-hospital) and stroke. A pooled Kaplan-Meier survival curve after reconstruction analysis was generated. Random-effects models were used., Results:  Six studies totaling 12,504 patients were included. In the pooled Kaplan-Meier analysis, PCI showed a significantly higher risk of death in the follow-up compared with CABG (hazard ratio [HR]: 2.12, 95% confidence interval [CI]: 1.88-2.38, p  < 0.01). During the observation period, PCI was also associated with higher rates of MI (odds ratio [OR]: 2.86, 95% CI: 1.82-4.48, p  < 0.01) and more repeat revascularization (OR: 4.88, 95% CI: 1.99-11.91, p  = 0.0005). The other outcomes did not show significant differences., Conclusion:  CABG is associated with superior survival to PCI over time in patients with CTO who are eligible for both PCI and CABG. This survival advantage is associated with fewer events of MI and repeat revascularization., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: Minimally invasive cardiac surgery (MICS) is increasing worldwide. In most cases, the surgical technique includes cannulation of the groin for the establishment of cardiopulmonary bypass, requiring a second surgical incision (SC) for exposure and cannulation of the femoral vessels. With the introduction of arterial closure devices, percutaneous cannulation (PC) of the groin has become a possible alternative. We performed a meta-analysis and systematic review to compare clinical endpoints between the patients who underwent PC and SC for MICS., Methods: Three databases were assessed. The primary outcome was any access site complication. Secondary outcomes were perioperative mortality, any wound complication, any vascular complication, lymphatic complications, femoral/iliac stenosis, stroke, procedural duration, and hospital length of stay (LOS). A random effects model was performed., Results: A total of 5 studies with 2,038 patients were included. When compared with PC, patients who underwent SC showed a higher incidence of any access site complication (odds ratio [OR] = 3.09, 95% confidence interval [CI]: 1.87 to 5.10, P < 0.01), any wound complication (OR = 10.10, 95% CI: 3.31 to 30.85, P < 0.01), lymphatic complication (OR = 9.37, 95% CI: 2.15 to 40.81, P < 0.01), and longer procedural duration (standardized mean difference = 0.31, 95% CI: 0.12 to 0.51, P < 0.01). There was no significant difference between the 2 groups regarding perioperative mortality, any vascular complication, femoral/iliac stenosis, stroke, or hospital LOS., Conclusions: The analysis suggests that surgical groin cannulation in MICS is associated with a higher incidence of any access site complication (especially wound complication and lymphatic fistula) and with a longer procedural time compared with PC. There was no difference in perioperative mortality., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Infective endocarditis represents a life-threatening disease with high mortality rates. A fraction of patients receives exclusively conservative antibiotic treatment due to their comorbidities and high operative risk, despite fulfilling criteria for surgical therapy. The aim of the present study is to compare outcomes in patients with infective endocarditis and indication for surgical therapy in those who underwent or did not undergo valve surgery., Methods and Results: Three databases were systematically assessed. A pooled analysis of Kaplan-Meier-derived reconstructed time-to-event data from studies with longer follow-up comparing conservative and surgical treatment was performed. A landmark analysis to further elucidate the effect of surgical intervention on mortality was carried out. Four studies with 3003 patients and median follow-up time of 7.6 months were included. Overall, patients with an indication for surgery who were surgically treated had a significantly lower risk of mortality compared with patients who received conservative treatment (hazard ratio [HR], 0.27 [95% CI, 0.24-0.31], P <0.001). The survival analysis in the first year showed superior survival for patients who underwent surgery when compared with those who did not at 1 month (87.6% versus 57.6%; HR, 0.31 [95% CI, 0.26-0.37], P <0.01), at 6 months (74.7% versus 34.6%) and at 12 months (73.3% versus 32.7%)., Conclusions: Based on the findings of this study-level meta-analysis, patients with infective endocarditis and formal indication for surgical intervention who underwent surgery are associated with a lower risk of short- and long-term mortality when compared with conservative treatment.

Objective: To evaluate outcomes in the follow up of thoracic endovascular aortic repair (TEVAR) vs. medical therapy in patients with acute type B aortic intramural haematoma (IMH)., Data Sources: The following sources were searched for articles meeting the inclusion criteria and published by July 2023: PubMed/MEDLINE, EMBASE, CENTRAL/CCTR (Cochrane Controlled Trials Register)., Review Methods: This systematic review with pooled meta-analysis of time to event data followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines, and its protocol was registered on the public platform PROSPERO (CRD42023456222). The following were analysed: overall survival (all cause mortality), aortic related mortality, and restricted mean survival time. Certainty of evidence was evaluated through the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool., Results: Eight studies met the eligibility criteria, including 1 015 patients (440 in the TEVAR group and 575 in the medical therapy group). All studies were observational, and the pooled cohort had a median follow up of 5.1 years. Compared with patients who received medical therapy alone, those who underwent TEVAR had a statistically significantly lower risk of all cause death (HR 0.44, 95% CI 0.30 - 0.65; p < .001; GRADE certainty: low), lower risk of aortic related death (HR 0.04, 95% CI 0.01 - 0.31; p = .002; GRADE certainty: low) and lifetime gain (restricted mean survival time was overall 201 days longer with TEVAR; p < .001)., Conclusion: Thoracic endovascular aortic repair may be associated with lower risk of all cause and aortic related death compared with medical therapy in patients with acute type B IMH; however, the underlying data are not strong enough to draw robust clinical conclusions. Randomised controlled trials with large sample sizes and longer follow up are warranted to elucidate this question., (Copyright © 2023 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

This systematic review and meta-analysis compared trans-carotid artery revascularization (TCAR) as an alternative approach to carotid endarterectomy (CEA) in patients with carotid artery disease. An electronic search was conducted using PubMed, Scopus, and Cochrane databases including comparative studies with patients who underwent either TCAR or CEA. This meta-analysis is according to the recommendations of the PRISMA statement. Eight studies met our eligibility criteria, incorporating 7,606 and 7,048 patients in the TCAR and CEA groups, respectively. Thirty-day mortality (odds ratio [OR]: 0.94, 95% confidence interval [CI]: 0.56-1.56, P = .81) and stroke (OR: 0.92, 95%CI 0.70-1.22, P = .57) were similar between the two groups, with low heterogeneity. The odds of myocardial infarction (OR: 1.79, 95% CI: 1.18-2.71, P = .01) and cranial nerve injury were significantly higher in patients undergoing CEA compared with TCAR (OR: 4.11, 95% CI: 2.59-6.51, P < .001). The subgroup analysis according to symptomatic pre-intervention status revealed no statistically significant difference regarding 30-day mortality (symptomatic OR: 0.91, 95% CI: 0.40-2.07, P = .82, asymptomatic OR: 0.93, 95% CI: 0.46-1.86, P = .83) and stroke (symptomatic OR: 0.88, 95% CI:0.47-1.64, P = .68, asymptomatic OR: 0.93, 95% CI: 0.64-1.35, P = .70). TCAR offers an alternative treatment for patients with carotid artery stenosis with comparable to CEA mortality and stroke rates during a 30-day post-operative period., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Thoracic aortic aneurysms (TAAs) associated with Marfan syndrome (MFS) are unique in that extracellular matrix metalloproteinase inducer (EMMPRIN) levels do not behave the way they do in other cardiovascular pathologies. EMMPRIN is shed into the circulation through the secretion of extracellular vesicles. This has been demonstrated to be dependent upon the Membrane Type-1 MMP (MT1-MMP). We investigated this relationship in MFS TAA tissue and plasma to discern why unique profiles may exist. Methods : Protein targets were measured in aortic tissue and plasma from MFS patients with TAAs and were compared to healthy controls. The abundance and location of MT1-MMP was modified in aortic fibroblasts and secreted EMMPRIN was measured in conditioned culture media. Results : EMMPRIN levels were elevated in MFS TAA tissue but reduced in plasma, compared to the controls. Tissue EMMPRIN elevation did not induce MMP-3, MMP-8, or TIMP-1 expression, while MT1-MMP and TIMP-2 were elevated. MMP-2 and MMP-9 were reduced in TAA tissue but increased in plasma. In aortic fibroblasts, EMMPRIN secretion required the internalization of MT1-MMP. Conclusions : In MFS, impaired EMMPRIN secretion likely contributes to higher tissue levels, influenced by MT1-MMP cellular localization. Low EMMPRIN levels, in conjunction with other MMP analytes, distinguished MFS TAAs from controls, suggesting diagnostic potential.

Background: The influence of sex on outcomes of surgery for acute type A aortic dissection remains incompletely characterized. We sought to evaluate post-procedural survival in the follow-up of females versus males., Methods: We carried out a systematic review with meta-analysis of Kaplan-Meier-derived time-to-event data from studies published by June 2023 in the following databases: PubMed/MEDLINE, EMBASE, Web of Science and CENTRAL/CCTR (Cochrane Controlled Trials Register)., Results: Twelve studies met our eligibility criteria, including 11,696 patients (3753 females; 7943 males). The mean age ranged from 41.2 to 72.6 years with low prevalence of bicuspid aortic valve (ranging from 0.0% to 12.0%) and connective tissue disorders (ranging from 0.8% to 7.3%). We found a considerable prevalence of coronary artery disease (ranging from 12.1% to 21.1%) and malperfusion (ranging from 20.0% to 46.3%). At 10 years, females undergoing surgery had a significantly higher risk of all-cause mortality compared with males (HR 1.25, 95%CI 1.14-1.38, P ​< ​0.001)., Conclusion: In the follow-up of patients undergoing surgery for type A aortic dissection, females presented poorer overall survival in comparison with males., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

In the era of lifetime management of aortic valve disease, the Ross procedure emerged as an alternative to prosthetic heart valves for young adults; however, more long-term data are warranted. We performed a meta-analysis of reconstructed time-to-event data to compare long-term outcomes between the Ross procedure and mechanical aortic valve replacement (mAVR) in young adults. PubMed/MEDLINE, EMBASE and GoogleScholar were searched for studies comparing Ross procedure with mAVR that reported mortality/survival rates and/or reoperation rates accompanied by at least one Kaplan-Meier curve for any of the outcomes. Six observational studies (5 with propensity score matching) including 5024 patients (Ross: 1737; mAVR: 3287) met our inclusion criteria. Patients who underwent Ross had a significantly lower risk of mortality in the overall population (HR 0.38, 95%CI 0.30-0.49, P<0.001; median follow-up of 7.2 years) and in the propensity score matched cohorts (HR 0.55, 95%CI 0.42-0.73, P<0.001; median follow-up of 10.2 years); however, the incidence function for the cumulative risk of reoperation was higher for the Ross procedure (HR 1.91, 95%CI 1.36-2.70, P<0.001; median follow-up of 9.3 years). Data from observational studies suggest that the Ross procedure is associated with lower all-cause mortality compared with mAVR; however, there is a higher risk of reoperation. Besides serving as basis to inform patients about benefits and risks involved in this choice, these results call for further randomized clinical trials to determine whether the Ross procedure can achieve its potential benefits in young patients in need of AVR., (Copyright © 2022. Published by Elsevier Inc.)

Background: With the improvement in postoperative complications and long-term survival post LVAD, continuing to improve clinical outcomes will require efforts to decrease long-term complications. The purpose of this study is to describe the incidence of mechanical pump failure requiring surgery, which we define as pump failure secondary to either outflow graft compression, outflow graft obstruction, or pump thrombosis requiring surgical intervention., Methods: 141 consecutive adult patients who underwent HeartMate3 Implantation using the "cut-then-sew" implantation technique between September 2015 and September 2021 were included in our study. The primary outcome measure was mechanical pump complication (outflow graft obstruction and or pump thrombosis) requiring surgical intervention. Secondary outcome measures included incidence of bleeding, stroke, renal failure, length of stay, and overall survival. Median follow up was 27.3 months., Results: Eleven (7.8%) of patients developed mechanical pump complications. Six patients developed outflow graft obstruction. Five patients developed acute pump thrombosis. Median time to a mechanical complication was 828 days. Of the 11 patients who underwent surgery, 10 patients (90%) survived to discharge. Overall survival at 1, 3, and 5 years was 82.9%, 69.1% and 55.2% respectively for the entire cohort., Conclusion: The mechanical pump complication rate of 7.8% which is quite high may be related to duration of follow up, as the median time to mechanical complication was 828 days. This study highlights an important late complication that occurs post LVAD implantation., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The effect of an initial surgical approach (in comparison with initial medical therapy) in acute type A intramural hematoma remains insufficiently explored. We designed a pooled analysis of Kaplan-Meier-derived individual patient data from studies with follow-up for overall survival (all-cause death). Restricted mean survival time was calculated to evaluate lifetime gain or loss. The Risk of Bias in Non-Randomized Studies of Interventions tool (ROBINS-I) was used to assess risk of bias. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to assess certainty of evidence. Eight studies met our eligibility criteria, including a total of 654 patients (311 patients treated with surgery and 343 patients treated with medical therapy alone). All the studies were non-randomized and observational. The median follow-up was 4.6 years (interquartile range 1.0 to 7.7). Patients who underwent surgery had a significantly lower risk of mortality compared with patients receiving medical therapy alone (hazard ratio 0.51, 95% confidence interval 0.35 to 0.74, p <0.001). The restricted mean survival time was overall 1.1 years greater with surgery compared with medical therapy, and this difference was statistically significant (p <0.001), which means that surgery is associated with lifetime gain. The overall risk of bias (ROBINS-I) was considered moderate-to-serious and the certainty of evidence (GRADE) was deemed to be low. In conclusion, in the overall follow-up, surgery as the initial approach was associated with better late survival and lifetime gain in comparison with medical therapy alone in the setting of acute type A aortic intramural hematoma; however, high-quality randomized trials are warranted to establish the efficacy of the surgical strategy., Competing Interests: Declaration of Competing Interest Dr. Sultan receives institutional research support from Abbott, Artivion, Boston Scientific, Edwards, Medtronic, Terumo Aortic. Dr. Chu is proctor and consultant for Sanamedi, Inc. The remaining authors have no competing interests to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Mechanisms of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) differ as CABG provides surgical collateralization and may prolong life by preventing future myocardial infarctions (MI). However, CABG benefits are unclear in octogenarians, where surgical risk is often perceived as higher and PCI is chosen more liberally. We performed a meta-analysis of studies comparing outcomes in octogenarians with left main or multivessel disease who underwent CABG or PCI. Primary outcome was late mortality (> 5 years). Secondary outcomes were perioperative mortality, MI, re-revascularization (R-R), acute renal failure (ARF), and stroke. Fourteen studies with 17,942 patients were included. CABG was associated with lower late mortality (hazard ratio, HR: 1.23, 95% confidence interval: CI 1.05-1.44, p < 0.01). In the pooled Kaplan-Meier analysis CABG showed significantly lower risk of death in the follow-up compared to PCI (HR: 1.08, 95%CI 1.02-1.41, p = 0.005). Landmark analyses confirmed the survival advantage of CABG over PCI after 21.5 months of follow-up (HR: 1.31, 1.19-1.44, p < 0.0001), but suggested advantage of PCI over CABG in the first 30-days (HR: 0.72, 0.64-0.82, p < 0.0001) and comparable survival from 1 to 21.5 months (HR: 0.98, 0.92-1.05, p = 0.652). We found lower risk for MI and R-R after CABG but higher perioperative mortality and no differences in ARF and stroke. CABG appears superior to PCI over time in octogenarians with complex CAD. This survival advantage is associated with fewer events of MI and R-R; however, it comes with an increased risk in perioperative mortality., (© 2023. The Author(s).)

Background: In the beginning of the SARS-CoV-2 pandemic, health care professionals dealing with COVID-19 had to rely exclusively on general supportive measures since specific treatments were unknown. The subsequent waves could be faced with new diagnostic and therapeutic tools ( e.g ., anti-viral medications and vaccines). We performed a meta-analysis and systematic review to compare clinical endpoints between the first and subsequent waves., Methods: Three databases were assessed. The primary outcome was in-hospital mortality. The secondary outcomes were intensive care unit (ICU) mortality, ICU length of stay (LOS), acute renal failure, extracorporeal membrane oxygenation (ECMO) implantation, mechanical ventilation time, hospital LOS, systemic thromboembolism, myocarditis and ventilator associated pneumonia., Results: A total of 25 studies with 126,153 patients were included. There was no significant difference for the primary endpoint (OR=0.94, 95% CI 0.83-1.07, p=0.35). The first wave group presented higher rates of ICU LOS (SMD= 0.23, 95% CI 0.11-0.35, p<0.01), acute renal failure (OR=1.71, 95% CI 1.36-2.15, p<0.01) and ECMO implantation (OR=1.64, 95% CI 1.06-2.52, p=0.03). The other endpoints did not show significant differences., Conclusions: The analysis suggests that the first wave group, when compared with the subsequent waves group, presented higher rates of ICU LOS, acute renal failure and ECMO implantation, without significant difference in in-hospital or ICU mortality, mechanical ventilation time, hospital LOS, systemic thromboembolism, myocarditis or ventilator- associated pneumonia., (Copyright © 2023, the Author(s).)

Importance: The COVID-19 pandemic led to the use of lung transplant as a lifesaving therapy for patients with irreversible lung injury. Limited information is currently available regarding the outcomes associated with this treatment modality., Objective: To describe the outcomes following lung transplant for COVID-19-related acute respiratory distress syndrome or pulmonary fibrosis., Design, Setting, and Participants: In this cohort study, lung transplant recipient and donor characteristics and outcomes following lung transplant for COVID-19-related acute respiratory distress syndrome or pulmonary fibrosis were extracted from the US United Network for Organ Sharing database from March 2020 to August 2022 with a median (IQR) follow-up period of 186 (64-359) days in the acute respiratory distress syndrome group and 181 (40-350) days in the pulmonary fibrosis group. Overall survival was calculated using the Kaplan-Meier method. Cox proportional regression models were used to examine the association of certain variables with overall survival., Exposures: Lung transplant following COVID-19-related acute respiratory distress syndrome or pulmonary fibrosis., Main Outcomes and Measures: Overall survival and graft failure rates., Results: Among 385 included patients undergoing lung transplant, 195 had COVID-19-related acute respiratory distress syndrome (142 male [72.8%]; median [IQR] age, 46 [38-54] years; median [IQR] allocation score, 88.3 [80.5-91.1]) and 190 had COVID-19-related pulmonary fibrosis (150 male [78.9%]; median [IQR] age, 54 [45-62]; median [IQR] allocation score, 78.5 [47.7-88.3]). There were 16 instances of acute rejection (8.7%) in the acute respiratory distress syndrome group and 15 (8.6%) in the pulmonary fibrosis group. The 1-, 6-, and 12- month overall survival rates were 0.99 (95% CI, 0.96-0.99), 0.95 (95% CI, 0.91-0.98), and 0.88 (95% CI, 0.80-0.94) for the acute respiratory distress syndrome cohort and 0.96 (95% CI, 0.92-0.98), 0.92 (95% CI, 0.86-0.96), and 0.84 (95% CI, 0.74-0.90) for the pulmonary fibrosis cohort. Freedom from graft failure rates were 0.98 (95% CI, 0.96-0.99), 0.95 (95% CI, 0.90-0.97), and 0.88 (95% CI, 0.79-0.93) in the 1-, 6-, and 12-month follow-up periods in the acute respiratory distress cohort and 0.96 (95% CI, 0.92-0.98), 0.93 (95% CI, 0.87-0.96), and 0.85 (95% CI, 0.74-0.91) in the pulmonary fibrosis cohort, respectively. Receiving a graft from a donor with a heavy and prolonged history of smoking was associated with worse overall survival in the acute respiratory distress syndrome cohort, whereas the characteristics associated with worse overall survival in the pulmonary fibrosis cohort included female recipient, male donor, and high recipient body mass index., Conclusions and Relevance: In this study, outcomes following lung transplant were similar in patients with irreversible respiratory failure due to COVID-19 and those with other pretransplant etiologies.

Background: The advent of endovascular techniques has revolutionized the care of patients with uncomplicated abdominal aortic aneurysms. This analysis compares the overall survival and the freedom from reintervention rate between open surgical repair (OSR) and endovascular repair (EVAR) in patients undergoing elective abdominal aortic aneurysm (AAA) repair., Methods: PubMed, Scopus, and Cochrane databases were searched for studies including patients who underwent either OSR or EVAR for uncomplicated AAA. All randomized controlled trials and propensity-score-matched cohort studies reporting on the outcomes of interest were considered eligible for inclusion. The systematic search of the literature was performed by 2 independent investigators in accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. We conducted 1-stage and 2-stage meta-analyses with Kaplan-Meier-derived time-to-event data and meta-analysis with a random-effects model., Results: Thirteen studies met our eligibility criteria, incorporating 13 409 and 13 450 patients in the OSR and EVAR arms, respectively. Patients who underwent open repair had improved overall survival rates compared with those who underwent EVAR (hazard ratio [HR]=0.93, 95% confidence interval [CI]=0.88-0.98, p=0.004) during a mean follow-up of 53.8 (SD=29.8) months and this was validated by the 2-stage meta-analysis (HR=0.89, 95% CI=0.8-0.99, p=0.03, I 2 =62.25%). Splitting timepoint analysis suggested that EVAR offers better survival outcome compared with OSR in the first 11 months following elective intervention (HR=1.37, 95% CI=1.22-1.54, p<0.0001), while OSR offers a significant survival advantage after the 11-month timepoint and up to 180 months (HR=0.84, 95% CI=0.8-0.89, p<0.0001). Similarly, freedom from reintervention was found to be significantly better in EVAR patients (HR=1.28, 95% CI=1.14-1.44, p<0.0001) within the first 30 days. After the first month postrepair, however, OSR demonstrated higher freedom-from-reintervention rates compared with EVAR that remained significant for up to 168 months during follow-up (HR=0.73, 95% CI=0.66-0.79, p<0.0001)., Conclusions: Despite the first-year survival advantage of EVAR in patients undergoing elective AAA repair, OSR was associated with a late survival benefit and decreased risk for reintervention in long-term follow-up., Clinical Impact: Open surgical repair for uncomplicated abdominal aortic aneurysm offers better long-term outcomes in terms of survival and freedom from reintervention rate compared to the endovascular approach but in the first year it carries a higher risk of mortality. The novelty of our study lies that instead of comparing study-level effect estimates, we analyzed reconstructed individual patient-level data. This offered us the opportunity to perform our analyses with mathematically robust and flexible survival models, which was proved to be crucial since there was evidence of different hazard over time. Our findings underline the need for additional investigation to clarify the significance of open surgical repair when compared to the latest endovascular devices and techniques within the evolving era of minimally invasive procedures., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

It is current practice to perform concomitant coronary artery bypass grafting (CABG) in patients with infective endocarditis who have relevant coronary artery disease. However, CABG may add complexity to the operation. We performed a systematic review and a meta-analysis of studies that presented outcomes from patients who underwent valve surgery because of infective endocarditis with or without concomitant CABG. Three databases were assessed. Perioperative mortality was the primary outcome. Long-term mortality and postoperative stroke were the secondary outcomes. Inverse variance method and random model were performed. Five studies with a total of 5,408 patients were included. Mean follow-up was 8.2 years. Just 1 study addressed exclusively patients with documented coronary artery disease. Perioperative mortality did not differ between patients with or without concomitant CABG (odds ratio 1.53, 95% confidence interval 0.52 to 4.48, p = 0.44). Long-term mortality did not differ between patients who received and those who did not receive concomitant CABG (odds ratio 1.79, confidence interval 0.88 to 3.65, p = 0.11). Only 1 study from a multicenter registry reported data on the occurrence of postoperative stroke, which demonstrated that its incidence after adjustment was 26% in patients with concomitant CABG versus 21% in patients without concomitant CABG (p = 0.003). The results suggest that in endocarditis patients, adding CABG to valve surgery does not affect perioperative or long-term mortality. Data available on the impact of concomitant CABG on neurologic outcomes are limited to a retrospective multicenter registry and suggest that concomitant CABG may be associated with higher postoperative stroke., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Based on previous meta-analyses including immediate/1-year results, individuals with bicuspid aortic valve (BAV) stenosis can undergo TAVI with similar outcomes as those with tricuspid aortic valve (TAV), but with higher rates of periprocedural complications. The widespread belief is that BAV patients would have poor results in comparison with TAV patients after TAVI over time. Therefore, we performed a systematic review with meta-analysis with reconstructed time-to-event data of studies published by January 2022 to compare late outcomes of patients with BAV versus TAV who underwent TAVI. This approach reconstructs individual patient data (IPD) based on the published Kaplan-Meier graphs. Ten studies met our eligibility criteria, including 9,071 patients with BAV and 171,070 patients with TAV. Patients with BAV had a significantly lower risk of mortality (HR 0.70, 95%CI 0.65-0.77, P<0.001), however, this result was driven by populations in which the risk score was statistically significantly lower in the BAV group (HR 0.69, 95%CI 0.63-0.76, P<0.001) and by populations in which the BAV group was statistically significantly younger (HR 0.72, 95%CI 0.64-0.81, P<0.001). In patients with selected BAV anatomy deemed favorable for TAVI, we did not find worse survival over time in comparison with patients with TAV; however, the follow-up beyond 1 year remains limited in the studies and we need more investigation for specific bicuspid anatomies with longer follow-up. Most importantly, randomized controlled trials including exclusively BAV patients treated with TAVI versus SAVR are warranted., (Copyright © 2022. Published by Elsevier Inc.)

Background-Aim: Several studies have been published showing conflicting results on the outcome after endovascular aneurysm sealing (EVAS). The aim of the present study is to conduct a systematic review and meta-analysis of published evidence to assess the efficacy of EVAS in the management of patients with abdominal aortic aneurysm (AAA)., Methods: An electronic search of the English medical literature, from 2010 to March 2021, was conducted using MEDLINE, EMBASE, and Cochrane databases to find studies relevant to outcome after EVAS., Results: The final analysis included 12 articles published between 2011 and 2021, including 1440 patients. In total, 79.3% of the included patients underwent aneurysm treatment according to the instructions for use. Technical success was 98.8%. Overall, 30-day mortality was 1.3%. Procedure-related complications were reported in 4% of the cohort. During median follow-up of 28.1 months (range 9-72 months), the pooled estimate of endoleak type I, migration and reinterventions was 16% (95% confidence interval [CI]=7-25), 16% (95% CI=9-23), and 19% (95% CI=11-28), respectively. In a sub-analysis, 7 studies (703 patients) reported outcome with a mean follow-up of more than 2 years (range 24-72 months). In these studies, the pooled estimate of endoleak type I, migration, and reinterventions was 25% (95% CI=13-38), 22% (95% CI=19-26), and 27% (95% CI=21-33), respectively., Conclusion: Patients who have been treated with EVAS are in high risk for reintervention especially beyond 2 years following implantation. Close surveillance for patients treated with EVAS is mandatory.

Background An aspect not so clear in the scenario of aortic surgery is how patients fare after composite aortic valve graft replacement (CAVGR) depending on the type of valve (bioprosthetic versus mechanical). We performed a study to evaluate the long-term outcomes of both strategies comparatively. Methods and Results Pooled meta-analysis of Kaplan-Meier-derived time-to-event data from studies with follow-up for overall survival (all-cause death), event-free survival (composite end point of cardiac death, valve-related complications, stroke, bleeding, embolic events, and/or endocarditis), and freedom from reintervention. Twenty-three studies met our eligibility criteria, including 11 428 patients (3786 patients with mechanical valves and 7642 patients with bioprosthetic valve). The overall population was mostly composed of men (mean age, 45.5-75.6 years). In comparison with patients who underwent CAVGR with bioprosthetic valves, patients undergoing CAVGR with mechanical valves presented no statistically significant difference in the risk of all-cause death in the first 30 days after the procedure (hazard ratio [HR], 1.24 [95% CI, 0.95-1.60]; P =0.109), but they had a significantly lower risk of all-cause mortality after the 30-day time point (HR, 0.89 [95% CI, 0.81-0.99]; P =0.039) and lower risk of reintervention (HR, 0.33 [95% CI, 0.24-0.45]; P <0.001). Despite its increased risk for the composite end point in the first 6 years of follow-up (HR, 1.41 [95% CI, 1.09-1.82]; P =0.009), CAVGR with mechanical valves is associated with a lower risk for the composite end point after the 6-year time point (HR, 0.46 [95% CI, 0.31-0.67]; P <0.001). Conclusions CAVGR with mechanical valves is associated with better long-term outcomes in comparison with CAVGR with bioprosthetic valves.

Objectives: To evaluate the long-term outcomes of valve-sparing aortic root replacement (VSARR) versus composite aortic valve graft replacement (CAVGR) in the treatment of acute type A aortic dissections (ATAAD)., Methods: We performed a pooled meta-analysis of Kaplan-Meier-derived time-to-event data from studies with longer follow-up beyond the immediate postoperative period., Results: Seven studies met our eligibility criteria, comprising a total of 858 patients (367 patients in the VSARR groups and 491 patients in the CAVGR group). We found no statistically significant differences in the overall survival between the groups over time (HR 0.83, 95%CI 0.63-1.10, P = 0.192), but we observed a higher risk of reoperation in the VSARR group when compared with the CAVGR group (HR 9.99, 95% CI 2.23-44.73, P = 0.003). The meta-regression revealed statistically significant positive coefficients for age (P < 0.001) in the analysis of survival, which means that this covariate has a modulating effect on this outcome. The higher the mean age, the higher the HR for overall mortality was found to be with VSARR as compared with CAVGR. Other covariates such as female sex, hypertension, diabetes, connective tissue disorders, bicuspid aortic valve, hemiarch and/or total arch replacement, concomitant coronary bypass surgery did not seem to have any effect on the outcomes., Conclusion: VSARR did not confer a better (or worse) survival over time in patients with ATAAD, but it was associated with higher risk of reoperations in the long run., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Nissen fundoplication is considered the cornerstone surgical treatment for hiatal hernia repair. Belsey Mark IV (BMIV) transthoracic fundoplication is an alternative approach that is rarely utilized in today's minimally invasive era. This study aims to summarize the safety and efficacy of BMIV and to compare it with Nissen fundoplication., Methods: We searched MEDLINE, Scopus, and Cochrane Library databases for single arm and comparative studies published by March 31st, 2022, according to PRISMA statement. Inverse-variance weights were used to estimate the proportion of patients experiencing the studied outcome and random-effects meta-analyses were performed., Results: 17 studies were identified, incorporating 2136 and 638 patients that underwent Belsey Mark IV or Nissen fundoplication, respectively. A total of 13.8% (95% CI: 9.6-18.6) of the patients that underwent fundoplication with the BMIV technique had non-resolution of their symptoms and 3.5% (95% CI: 2.0-5.4) required a reoperation. Overall, 14.8% (95% CI: 9.5-20.1) of the BMIV arm patients experienced post-operative complications, 5.0% (95% CI: 2.0-9.0) experienced chronic postoperative pain and 6.9% (95% CI: 3.1-11.9) had a hernia recurrence. No statistically significant difference was observed between Belsey Mark IV and Nissen fundoplication in terms of post-interventional non-resolution of symptoms (odds ratio [OR]: 1.49 [95% Confidence Interval (95%CI):0.6-4.0]; p = 0.42), post-operative complications (OR:0.83, 95%CI: 0.5-1.5, p = 0.54) and in-hospital mortality (OR:0.69, 95%CI: 0.13-3.80, p = 0.67). Belsey Mark IV arm had significantly lower reoperation rates compared to Nissen arm (OR:0.28, 95%CI: 0.1-0.7, p = 0.01)., Conclusions: BMIV fundoplication is a safe and effective but technically challenging. The BMIV technique may offer benefits to patients compared to the laparoscopic Nissen fundoplication. These benefits, however, are challenged by the increased morbidity of a thoracotomy., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Left ventricular assist devices (LVAD) and extracorporeal membrane oxygenation (ECMO) are well established therapies in heart failure (HF) management. Their use is generally associated with a sudden increase in inflammatory mediators, which are often already elevated in patients with HF prior to device implantation. An exaggerated release of proinflammatory cytokines is associated with organ dysfunction and increased mortality. Hemoadsorption has been shown to reduce inflammatory mediators during cardiopulmonary bypass., Objective: To investigate the role of hemoadsorption during the management of acute or chronic heart failure with mechanical circulatory support and its impact on survival., Methods: We systematically searched MEDLINE selecting all studies comparing the use of hemoadsorption during LVAD implantation or veno-arterial (v.a.) ECMO therapy. Records were screened by two different investigators. Reports without a control group and duplicates were excluded., Results: Our search delivered six studies. One was randomized and five were retrospective studies, of which three were risk-adjusted. During LVAD implantation, one study showed no difference in mortality but higher incidence of respiratory insufficiency in the hemoadsorption group (54% vs 30%, p = 0.024) and the other study found higher mortality in the hemoadsorption group (33% vs 0%, p = 0.01). During ECMO therapy, three of four studies including the randomized one found no difference in survival or major adverse cardiac events between the hemoadsorption and the control groups. Only one study found lower mortality in the hemoadsorption group (20% vs 60%. p = 0.02)., Conclusions: The results of this literature review suggest that the use of hemoadsorption in patients undergoing LVAD implantation might be associated with higher morbidity and mortality. The majority of studies on the use of hemoadsorption during v.a. ECMO therapy showed no effect on mortality or organ dysfunction, while only one small study showed that hemoadsorption was able to reduce mortality. The results are limited by the retrospective nature and the small sample sizes of the majority of the studies included., Competing Interests: The authors declare no conflict of interest., (Copyright: © 2023 The Author(s). Published by IMR Press.)

Background: It remains controversial whether prosthesis-patient mismatch (PPM) (in general considered moderate if indexed effective orifice area is 0.65-0.85 cm 2 /m 2 and severe when <0.65 cm 2 /m 2 ) affects the outcomes after transcatheter aortic valve replacement (TAVR)., Objectives: The purpose of this study is to evaluate the time-varying effects and association of PPM with the risk of overall mortality., Methods: Study-level meta-analysis of reconstructed time-to-event data from Kaplan-Meier curves of studies published by December 30, 2021., Results: In total, 23 studies met our eligibility criteria and included a total of 81,969 patients included in the Kaplan-Meier curves (19,612 with PPM and 62,357 without PPM). Patients with moderate/severe PPM had a significantly higher risk of mortality compared with those without PPM (HR: 1.09 [95% CI: 1.04-1.14]; P < 0.001). In the first 30 months after the procedure, mortality rates were significantly higher in the moderate/severe PPM group (HR: 1.1 [95% CI: 1.05-1.16]; P < 0.001). In contrast, the landmark analysis beyond 30 months yielded a reversal of the HR (0.83 [95% CI: 0.68-1.01]; P = 0.064), but without statistical significance. In the sensitivity analysis, although the authors observed that severe PPM showed higher risk of mortality in comparison with no PPM (HR: 1.25 [95% CI: 1.16-1.36]; P < 0.001), they did not observe a statistically significant difference for mortality between moderate PPM and no PPM (HR: 1.03 [95% CI: 0.96-1.10]; P = 0.398)., Conclusions: Severe PPM, but not moderate PPM, was associated with higher risk of mortality following TAVR. These results provide support to implementation of preventive strategies to avoid severe PPM following TAVR., Competing Interests: Funding Support and Author Disclosures This study was supported by the Sharpe-Strumia Research Foundation (Bryn Mawr Hospital). Dr Sá has received support from The Thoracic Surgery Foundation (charitable arm of The Society of Thoracic Surgeons–STS) through the TSF Every Heartbeat Matters Global Structural Heart Fellowship Award. Dr Clavel has a computed tomography core laboratory contract with Edwards Lifesciences, for which she receives no direct compensation; and she has received a research grant from Medtronic. Dr Pibarot has echocardiography Core Laboratory contracts with Edwards Lifesciences, for which he receives no direct compensation. Dr Ramlawi has received financial support from Medtronic, Corcym, and AtriCure. All other authors have reported that they have no relationships relevant to the contents of this study to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: To evaluate all-cause mortality in ViV-TAVI versus redo SAVR in patients with failed bioprostheses., Methods: Study-level meta-analysis of reconstructed time-to-event data from Kaplan-Meier curves of non-randomized studies published by September 30, 2021., Results: Ten studies met our eligibility criteria and included a total of 3345 patients (1676 patients underwent ViV-TAVI and 1669 patients underwent redo SAVR). Pooling all the studies, ViV-TAVI showed a lower risk of all-cause mortality in the first 44 days [hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.49-0.93, P = 0.017], with an HR reversal after 197 days favoring redo SAVR (HR 1.53; 95% CI 1.22-1.93; P < 0.001). Pooling only the matched populations (1143 pairs), ViV-TAVI showed a lower risk of all-cause mortality in the first 55 days [hazard ratio (HR) 0.63, 95% confidence interval (CI) 0.45-0.89, P < 0.001], with a reversal HR after 212 days favoring redo SAVR (HR 1.57; 95% CI 1.22-2.03; P < 0.001). The Cox regression model showed a statistically significant association of prosthesis-patient mismatch (PPM) with all-cause mortality during follow-up for ViV-TAVI (HR 1.03 per percentage increase in the study- and treatment arm-level proportion of PPM, 95% 1.02-1.05, P < 0.001)., Conclusion: ViV-TAVI is associated with a strong protective effect immediately after the procedure in comparison with redo SAVR, however, this initial advantage reverses over time and redo SAVR seems to be a protective factor for all-cause mortality after 6 months. Considering that these results are the fruit of pooling data from observational studies, they should be interpreted with caution and trials are warranted., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Paravalvular leak (PVL) after transcatheter aortic valve implantation (TAVI) is frequent and the impact of mild PVL on outcomes remains uncertain. Our study aimed to evaluate the impact of PVL on TAVI outcomes., Methods: To analyze late outcomes of patients after TAVI according to the presence and severity of PVL, PubMed/MEDLINE, EMBASE and Google Scholar were searched for studies that reported rates of all-cause mortality/survival and/or rehospitalization and/or cardiovascular mortality accompanied by at least one Kaplan-Meier curve for any of these outcomes. We adopted a 2-stage approach to reconstruct individual patient data based on the published Kaplan-Meier graphs., Results: Thirty-eight studies with Kaplan-Meier curves met our eligibility criteria including over 25,000 patients. Patients with any degree of PVL after TAVI had a significantly higher risk of overall mortality (hazard ratio (HR), 1.52; 95% confidence interval (CI), 1.43-1.61; p < 0.001), rehospitalization (HR, 1.81; 95% CI, 1.54-2.12; p < 0.001), and cardiovascular mortality (HR, 1.52; 95% CI, 1.33-1.75; p < 0.001) over time. These findings remained consistent when we stratified the results for the methods of assessment of PVL (i.e., echocardiography vs. angiography) and PVL severity. Both moderate/severe PVL and mild PVL were associated with increased risk of overall mortality ( p < 0.001), rehospitalization ( p < 0.001), and cardiovascular mortality ( p < 0.001) during follow-up., Conclusions: Patients with PVL, even if mild, experience higher risk of all-cause mortality, rehospitalization, and cardiovascular mortality following TAVI. These findings provide support to the implementation of procedural strategies to prevent any degree of PVL at the time of TAVI., Competing Interests: Philippe Pibarot has echocardiography Core Laboratory contracts with Edwards Lifesciences, for which he receives no direct compensation. Marie-Annick Clavel has a computed tomography Core Laboratory contract with Edwards Lifesciences, for which she receives no direct compensation, and has received a research grant from Medtronic. Basel Ramlawi has received financial support from Medtronic, Corcym, and AtriCure. The other authors had no conflicts to declare., (© 2022 The Author(s).)

Background: This review aims to systematically evaluate the currently available evidence investigating the use of artificial intelligence (AI) and machine learning (ML) in the field of cardiac transplantation. Furthermore, based on the challenges identified we aim to provide a series of recommendations and a knowledge base for future research in the field of ML and heart transplantation., Methods: A systematic database search was conducted of original articles that explored the use of ML and/or AI in heart transplantation in EMBASE, MEDLINE, Cochrane database, and Google Scholar, from inception to November 2021., Results: Our search yielded 237 articles, of which 13 studies were included in this review, featuring 463 850 patients. Three main areas of application were identified: (1) ML for predictive modeling of heart transplantation mortality outcomes; (2) ML in graft failure outcomes; (3) ML to aid imaging in heart transplantation. The results of the included studies suggest that AI and ML are more accurate in predicting graft failure and mortality than traditional scoring systems and conventional regression analysis. Major predictors of graft failure and mortality identified in ML models were: length of hospital stay, immunosuppressive regimen, recipient's age, congenital heart disease, and organ ischemia time. Other potential benefits include analyzing initial lab investigations and imaging, assisting a patient with medication adherence, and creating positive behavioral changes to minimize further cardiovascular risk., Conclusion: ML demonstrated promising applications for improving heart transplantation outcomes and patient-centered care, nevertheless, there remain important limitations relating to implementing AI into everyday surgical practices., (© 2022 The Authors. Artificial Organs published by International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.)

Background: Permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR) is relatively frequent, and its impact on outcomes during follow-up remains a matter of discussion. Previous meta-analyses have yielded conflicting results., Methods: To compare late outcomes in patients after TAVR with and without PPI, PubMed/MEDLINE, Embase, and Google Scholar were searched for studies that reported rates of mortality/survival, rehospitalization for heart failure (HF), stroke, and/or endocarditis accompanied by at least 1 Kaplan-Meier curve for any of these outcomes. We adopted a 2-stage approach to reconstruct individual patient data on the basis of the published Kaplan-Meier graphs., Results: Twenty-eight studies with Kaplan-Meier curves met our eligibility criteria and included a total of 50,282 patients (7232 who underwent PPI and 42,959 who did not undergo PPI). Patients who underwent PPI after TAVR had a significantly higher risk of mortality (hazard ratio [HR], 1.21; 95% CI, 1.14-1.28; P < .001) and HF-related rehospitalization (HR, 1.30; 95% CI, 1.17-1.45; P < .001) over time. We did not observe statistically significant differences in the incidence of stroke (HR, 1.07; 95% CI, 0.55-2.08; P = .849) and endocarditis (HR, 0.98; 95% CI, 0.61-1.57; P = .925) during follow-up., Conclusions: Patients who undergo PPI after TAVR experience higher risk of mortality and HF-related rehospitalization over time. These findings provide support for the implementation of procedural strategies to prevent heart conduction disorder and, thus, avoid PPI at the time of TAVR., (© 2022 The Author(s).)

Objectives: The present authors aimed to assess the late outcomes of patients undergoing aortic root enlargement (ARE) at the time of surgical aortic valve replacement (SAVR)., Design: Study-level meta-analysis with reconstructed time-to-event data., Setting: Follow-up of patients after surgical procedure., Participants: Adult patients with aortic valve disease requiring surgery., Interventions: SAVR with ARE versus SAVR without ARE., Measurements and Main Results: This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. The following databases were searched for studies meeting the authors' inclusion criteria and published by November 30, 2021: PubMed/MEDLINE, Embase, SciELO, LILACS, CCTR/CENTRAL, and Google Scholar. Nine nonrandomized studies met the authors' eligibility criteria. All studies were nonrandomized. A total of 213,134 patients (SAVR with ARE: 7,556 patients; SAVR without ARE: 205,578 patients) were included from studies published from 1997 to 2021. The total rate of AAE was 3.7%, varying in the studies from 2.9% to 28.1%. The studies consisted of patients whose mean age varied from 63 to 79 years. Patients in the SAVR with ARE group had a significantly better overall survival (hazard ratio [HR] 0.94, 95% confidence interval [CI] 0.90-0.99, p = 0.016) in the unmatched populations, but the matched analysis revealed no difference between SAVR with/without ARE in terms of overall survival (HR, 1.06; 95% CI, 0.90-1.25; p = 0.474)., Conclusions: In the context of patients undergoing SAVR with or without ARE, patients who undergo ARE do not experience worse late outcomes. Further randomized controlled trials are needed to confirm or refute the authors' current findings., Competing Interests: Acknowledgement Michel Pompeu Sá receives support from The Thoracic Surgery Foundation (charitable arm of The Society of Thoracic Surgeons) through the TSF Every Heartbeat Matters Global Structural Heart Fellowship Award for the project “Structural Heart/Minimally Invasive Cardiac Surgery.”, (Copyright © 2022 Elsevier Inc. All rights reserved.)

Atrial fibrillation (AF) is the most common atrial arrhythmia following coronary artery bypass graft (CABG). Its prevalence is 15-45% and is associated with poor long-term prognosis. Risk factors can be patient-related, intraoperative, and/or postoperative. Therapeutic and preventive strategies have been developed to curtail AF burden. Cardioversion is recommended for unstable or symptomatic patients and rate control if asymptomatic. Anticoagulation is challenging with risk of thromboembolism and bleeding. However, patients should be anticoagulated after cardioversion or if AF persists >48 h and risk factors of stroke exist. A minimum of 4 weeks is recommended but longer duration should be considered in patients at high risk of stroke irrespective of recurrence of AF., Competing Interests: Declaration of competing interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: We aimed to investigate the potential beneficial effect of immunomodulation therapy on the thromboembolic risk in hospitalized COVID-19 patients., Methods: We searched PubMed and Scopus for randomized trials reporting the outcomes of venous thromboembolism (VTE), ischemic stroke or systemic embolism, myocardial infarction, any thromboembolic event, and all-cause mortality in COVID-19 patients treated with immunomodulatory agents. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using the Mantel-Haenszel random effects method., Results: Among 8499 patients hospitalized with COVID-19, 4638 were treated with an immunomodulatory agent, 3861-with usual care only. Among the patients prescribed immunomodulatory agents, there were 1.77 VTEs per 100 patient-months compared to 2.30 among those treated with usual care (OR: 0.84, 95% CI: 0.61-1.16; I 2 : 0%). Among the patients who received an interleukin 6 (IL-6) antagonist, VTEs were reported in 12 among the 1075 patients compared to 20 among the 848 receiving the usual care (OR: 0.52, 95% CI: 0.22-1.20; I 2 : 6%). Immunomodulators as an add-on to usual care did not reduce the risk of stroke or systemic embolism (OR: 1.10, 95% CI: 0.50-2.40; I 2 : 0%) or of myocardial infarction (OR: 1.06, 95% CI: 0.47-2.39; I 2 : 0%) and there was a nonsignificant reduction in any thromboembolic event (OR: 0.86, 95% CI: 0.65-1.14; I 2 : 0%)., Conclusions: We did not identify a statistically significant effect of immunomodulation on prevention of thromboembolic events in COVID-19. However, given the large effect estimate for VTE prevention, especially in the patients treated with IL-6 antagonists, we cannot exclude a potential effect of immunomodulation.

Objectives: The aim of this study is to assess any relation between spondylitis and aortic aneurysmal disease by reviewing the current literature., Methods: A systematic search was undertaken using MEDLINE, EMBASE and CENTRAL databases till May 2019, for articles reporting on patients suffering from spondylitis and aortic aneurysm., Results: The most involved aortic segment was infrarenal aorta (56.9%). The lumbar vertebrae were more frequently affected (79.7%). Commonest symptoms were back pain (79.1%), fever (33.7%) and lower limb pain (29.1%). 55.8% of cases were diagnosed using computed tomography. The pathology was attributed to infectious causes in 25.1% of cases. 53.4% of patients were treated only for the aneurysm, 27.9% for both pathologies, while two patients solely for the vertebral disease. Endovascular aneurysm repair was chosen in 12.8% of cases. The 30-day mortality was 8.1% (7/86); mostly from vascular complications., Conclusions: A synchronous spondylitis and aortic aneurysm may share common etiopathology, when an infectious or inflammatory cause is presented. The lumbar vertebrae are more frequently affected. Low quality data do not allow safe conclusion to suggest the best treatment option., (Copyright © 2021. Published by Elsevier Inc.)