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Eight patients with severe systemic pathologies and refractory angina unsuitable for angioplasty were submitted to palliative surgical revascularization without the use of cardiopulmonary bypass and limited to the culprit vessels. Complete relief from angina was achieved in all patients without postoperative mortality and morbidity. [ABSTRACT FROM AUTHOR]

Background: Recent evidence has suggested use of the right internal mammary artery (RIMA) is associated with worse clinical outcomes in patients undergoing coronary artery bypass grafting (CABG) surgery. Therefore, we compared the clinical consequences of secondary conduit selection (RIMA vs radial artery vs saphenous vein) after CABG., Methods: A post-hoc analysis of the CABG Off or On Pump Revascularization Study, involving 3913 patients from 79 centers in 19 countries who underwent CABG surgery and received arterial grafting with at least 2 grafts. Outcomes of interest were all-cause mortality, myocardial infarction, stroke, and revascularization., Results: A total of 3913 patients received veins (3210; 68%), radial arteries (549; 12%), or RIMAs (154; 3%) to supplement left internal mammary artery to left anterior descending artery grafts. The risk of all-cause mortality was reduced in patients who received secondary radial arteries compared with veins (weighted hazard ratio [HR], 0.79; 95% CI, 0.64-0.98) and increased in patients who received RIMA compared with veins (weighted HR, 1.37; 95% CI, 1.13-1.68) after 4.8 years of follow-up. Multiple and single arterial grafting had a similar mortality risk (weighted HR, 0.87; 95% CI, 0.73-1.03)., Conclusions: Supplementing left internal mammary artery to left anterior descending artery grafting using radial arteries led to better clinical outcomes than veins, and too few RIMA were available to draw definitive conclusions. A randomized trial is needed to clarify the role of the RIMA in multiple arterial grafting CABG surgery., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: There is concern that left internal thoracic artery (LITA)-to diagonal (D)-to left anterior descending artery (LAD) grafts may be more susceptible to failure compared with single LITA-LAD grafts., Methods: Pooled individual patient data from 8 clinical trials with systematic graft imaging were analyzed to assess the incidence of sequential LITA-D-LAD vs single LITA-LAD grafts. Mixed-effects multivariable logistic regression, adjusting for patient characteristics and clustering within trials, was used., Results: Of 3969 patients with LITA-LAD grafts, 283 patients (7.1%) received sequential LITA-D-LAD grafts. Patients with sequential LITA-D-LAD grafts were older (66 vs 65 years, P = .009) and more often men (88% vs 83%, P = .03). Overall, graft failure occurred in 9.3% of patients with LITA-LAD grafts, with more graft failure occurring in single (9.5%) than in sequential LITA-D-LAD grafts (6.4%, P = .08) at a median time to imaging of 1.0 years (interquartile range, 1.0-1.1 years). After multivariable adjustment, sequential LITA-D-LAD grafting was not associated with graft failure (adjusted odds ratio, 1.22; 95% CI, 0.68-2.18; P = .55). There was no difference between groups in mortality (2.8% vs 5.3%, P = .06), myocardial infarction (1.4% vs 1.6%, P = .90), revascularization (4.5% vs 7.3%, P = .08), or stroke (1.7% vs 1.2%, P = .40)., Conclusions: In selected patients, LITA-D-LAD grafting was not associated with higher risk of graft failure or adverse clinical events at 1 year., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The role of sex in choosing between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for unprotected left main coronary artery (ULMCA) disease has gained interest., Methods: Randomized controlled trials and adjusted observational studies comparing PCI versus CABG in ULMCA patients with outcomes by sex were included. The primary endpoint was major adverse cardiovascular events (MACE), with secondary endpoints being all-cause mortality and repeated revascularization., Results: Ten studies (3 randomized, 7 observational) involving 22,141 ULMCA disease patients (13,411 PCI, 8730 CABG) with a median 5-year follow-up were included. Among males, PCI was associated with a higher risk of MACE (HR 1.18, 95% CI 1.01-1.38), while no significant difference was seen in females. However, moderator analysis showed no significant interaction between sex and revascularization strategy for MACE (p for interaction .422). No differences in all-cause mortality were observed between PCI and CABG for either sex. Repeated revascularization risk was significantly higher with PCI for both sexes (HR 3.51, 95% CI 2.21-5.59 in males and HR 4.20, 95% CI 2.57-6.87 in females)., Conclusions: In males with ULMCA disease, CABG was associated with a lower risk of MACE compared to PCI, while no significant differences were seen in females. The lack of a significant interaction between sex and revascularization strategy suggests that these findings may not reflect true sex-based effect modification. PCI was linked to a higher risk of repeated revascularization in both sexes compared to CABG., Trial Registration: The protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (ID: CRD42024537726)., (© 2024 The Author(s). European Journal of Clinical Investigation published by John Wiley & Sons Ltd on behalf of Stichting European Society for Clinical Investigation Journal Foundation.)

Competing Interests: None.

Background: Coronary artery disease is a common cause of ischemic left ventricular systolic dysfunction (LVSD), for which the optimal revascularisation strategy remains unclear. We aimed to determine whether percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) results in greater survival advantage in patients with LVSD., Methods: Study-level (SLMA) and reconstructed individual patient data (rIPDMA) meta-analyses from Kaplan-Meier (KM) survival curves were performed. A systematic search of Medline, Embase, and Cochrane Library was conducted for observational and randomised studies published after 2010 that compared PCI and CABG in patients with left ventricular ejection fraction ≤ 40%. The primary outcome was all-cause mortality at longest follow-up. The secondary outcomes were myocardial infarction (MI), stroke, repeated revascularisation, cardiovascular mortality, and major adverse cardiovascular and cerebrovascular events (MACCE) at longest follow-up., Results: Fourteen studies (11 observational, 3 randomised, 13,063 patients) were eligible for the SLMA. Seven contained digitisable KM curves from which individual patient data could be reconstructed. Study-level analysis found PCI to be associated with increased all-cause mortality (hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.18-1.69), MI (HR 2.10, 95% CI 1.62-2.72), repeated revascularisation (HR 2.39, 95% CI 1.37-4.17), and MACCE (HR 1.58, 95% CI 1.23-2.03), without significant differences in stroke (HR 0.86, 95% CI 0.39-1.92) or cardiovascular mortality (HR 1.42, 95% CI 0.78-2.59). In the rIPDMA, PCI resulted in increased all-cause mortality (HR 1.57, 95% CI 1.34-1.87) and repeated revascularisation (HR 3.63, 95% CI 3.12-4.21) but overall lower risk of stroke (HR 0.62, 95% CI 0.39-0.99) owing to fewer events during initial follow-up., Conclusions: In patients with ischemic LVSD, PCI was associated with higher risk of all-cause mortality and repeated revascularisation than CABG, but lower risk of short-term stroke. (PROSPERO: CRD42021291408)., (Copyright © 2024 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: We compared the outcomes of aortic root replacement by composite valve grafts (CVG) and valve-sparing root replacement (VSRR) operations, with an emphasis on postoperative conduction block and the need for permanent pacemaker implantation (PPM)., Methods: From 1997 to 2023, 1712 consecutive patients underwent ARR by VSRR (501 [29%]) or CVG (1211 [71%]) at a high-volume aortic center., Results: Patients undergoing CVG were older (59 ± 14 vs 49 ± 14 years, P < .001), with more cardiovascular comorbidities. Compared with CVG, there were more women undergoing VSRR (17% vs. 13%, P = .042) and more patients with connective tissue disease (22% vs 7.3%, P < .001). Multivariable analysis found that the risk for PPM was higher after CVG compared with VSRR (6.5% vs 1.2%; odds ratio [OR], 2.83; 95% CI, 1.23-7.69; P = .024). Other variables associated with PPM include older age (OR, 1.03; 95% CI, 1.01-1.05; P = .006) preoperative renal impairment (OR, 2.69; 95% CI, 1.24-5.6; P = .010), previous operation (OR, 2.76; 95% CI, 1.29-5.62; P = .007), and bicuspid aortic valve (OR, 3.63; 95% CI, 2.13-6.33; P < .001). Among the CVG population, patients who are at increased risk are especially those with some degree of aortic stenosis (OR, 2.06; 95% CI, 1.18-3.61; P = .011). Patients who required PPM had no additive risk for long-term mortality (hazard ratio, 1.01; 95% CI, 0.47-2.17; P = .986); however, they were more likely to have reduced ejection fraction (29.3% vs 16%, P = .014)., Conclusions: The incidence of PPM after ARR is low, but rates were higher after CVG compared with VSRR., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Aims: Diabetes and obesity are common conditions which can influence outcomes after coronary artery bypass graft (CABG) surgery. The aim of this study was to evaluate the influence of diabetes and obesity, and their interactions, on ten-year outcomes following CABG., Methods and Results: Patients enrolled in the Arterial Revascularisation Trial (ART) were stratified by diabetes and obesity at baseline. Diabetes was further stratified into insulin and non-insulin dependent. The primary outcome was all-cause mortality at 10 years of follow-up. Secondary outcomes were the composite of all-cause mortality, myocardial infarction or stroke at 10 years, and sternal wound complications at 6 months follow-up. A total of 3096 patients were included in the analysis (24% with diabetes, 30% with obesity). Patients in the "diabetes/no obesity" group had a higher risk of all-cause mortality following CABG (adjusted hazard ratio [aHR] 1.33, 95% confidence interval [CI] 1.08-1.64, p = 0.01) compared to the reference group of "no diabetes/no obesity". No excess risk was observed in the "no diabetes/obesity" or "diabetes/obesity" groups. Patients with insulin dependent diabetes had a significantly higher ten-year mortality risk compared to no diabetes (aHR 1.85, 95% CI 1.41-2.44, p = 0.00). Patients in the "diabetes/no obesity" and "diabetes/obesity groups" had a higher risk of sternal wound complications (HR 2.29, 95% CI 1.39-3.79, p < 0.001 and HR 3.21, 95% CI 1.89-5.45, p < 0.001 respectively). The composite outcome results were consistent with the mortality results., Conclusion: Diabetes, especially insulin dependent diabetes, is associated with a higher ten-year mortality risk after CABG, in contrast to obesity which does not appear to increase long term mortality compared to non-obese. The interaction between diabetes and obesity shows an apparent "protective" effect of obesity irrespective of diabetes on mortality. Both conditions are associated with a higher risk of post-operative sternal wound infections., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

The structural and functional integrity of conduits used for coronary artery bypass grafting is critical for graft patency. Disruption of endothelial integrity and endothelial dysfunction are incurred during conduit harvesting subsequent to mechanical or thermal injury and during conduit storage prior to grafting, leading to acute thrombosis and early graft failure. Late graft failure, in particular that of vein grafts, is precipitated by progressive atherogenesis. Intra-operative management includes appropriate selection of conduit-specific harvesting techniques and storage solutions. Arterial grafts are prone to vasospasm subsequent to surgical manipulation, and application of intra-operative vasodilatory protocols is critical. Post-operative management includes continuation of oral vasodilator therapy and selection of antithrombotic and lipid-lowering agents to attenuate atherosclerotic disease progression in conduits. In this review, the scientific evidence underlying the key aspects of intra- and post-operative management of conduits for coronary artery bypass grafting is examined. Clinical consensus statements for best clinical practice are provided, and areas requiring further research are highlighted., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Introduction: The escalating trend of academic article retractions over the last decades raises concerns about scientific integrity, but heterogeneity in retractions and reasons for them pose a major challenge. We aimed to comprehensively overview systematic reviews focusing on retractions in the biomedical literature., Evidence Acquisition: We abstracted salient features and bibliometric details from shortlisted articles. The Joanna Briggs Institute (JBI) Checklist for Systematic Reviews and Research Syntheses was used for validity appraisal., Evidence Synthesis: A total of 11 reviews were included, published between 2016 and 2023, and reporting on a total of 1851 retracted studies. Several major reasons for retractions were identified, spanning both misconduct (e.g., falsification, duplication, plagiarism) and non-misconduct issues (e.g., unreliable data, publishing problems). Correlates include author-related factors (number of authors, nationality) and journal-related factors (impact factor), with repeat offenders contributing significantly. Impacts of retractions is profound, affecting scholarly credibility, public trust, and resource utilization., Conclusions: In order to prevent retractions and amend their adverse effects, rigorous and transparent reporting standards, enhanced training in research ethics, strengthened peer review processes, and the establishment of collaborative and integrated research integrity offices are proposed.

Background: This study evaluated the association between bypass grafting with multiarterial grafts (MAG) and single arterial grafts (SAG) and all-cause mortality and major adverse cardiovascular and cerebrovascular events (MACCE), overall and across different patient subgroups from a Middle Eastern nation., Methods: This single-center retrospective cohort study included 23,798 patients. MAG and SAG groups were balanced using inverse probability weighting (IPW). Associations between MAG and outcomes were assessed using Cox regression. A series of covariate-adjusted Cox models were conducted to evaluate the effect of MAG on outcomes at different levels of independent variables, including age, sex, and cardiovascular risk factors., Results: In the study population (73.9% were men, 65.11 ± 9.94 years), 986 patients (4.1%) underwent MAG. Compared with the SAG group, MAG had lower crude mortality (14.1% vs 21.6%) and MACCE (28.8% vs 34.7%) rates during a median follow-up of 9.23 years (quartile 1-quartile 3, 9.13-9.33 years). Although MAG was significantly associated with reduced risk of study outcomes at the univariate level, these associations disappeared after matching (all-cause mortality (IPW hazard ratio, 0.90; 95% CI, 0.67-1.22) and MACCEs (IPW hazard ratio, 0.94; 95% CI, 0.76-1.15). However, covariate-adjusted models indicated that MAG was associated with a significantly reduced risk of adverse events, particularly MACCEs, in men, younger patients, and those without risk factors., Conclusions: MAG was not associated with improved postsurgery outcomes among the total coronary artery bypass graft population. Our findings, however, should be interpreted in the context of a relatively low total institutional MAG burden. Choosing a second arterial conduit over saphenous vein grafts in specific patient subgroups might be reasonable. This hypothesis-generating finding should be investigated in future clinical trials in these patients., Competing Interests: Disclosures Mario Gaudino is on The Annals of Thoracic Surgery Editorial Board. The other authors have no conflicts of interest to disclose., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Total aortic arch replacement (TAR) after previous cardiovascular surgery is technically challenging and is becoming more frequent as outcomes for primary arch repair have improved. primary. We analyzed outcomes of reoperative compared with first-time TAR., Methods: The institutional aortic database was queried to identify consecutive patients undergoing TAR between 1997 and 2022. In total, 426 patients underwent TAR, of whom 150 (35%) had previous cardiovascular surgery (reop TAR) and 276 (65%) underwent their first cardiovascular operation., Results: The reop TAR group was younger (61 ± 13 vs 71 ± 11, P < .001) with more comorbidities such as ischemic heart disease (12% vs 4.3%, P = .006), previous stroke (36% vs 14.5%, P < .001), and renal impairment (24% vs 12.7%, P = .004). Reop TAR had longer cardiac ischemic times (119.3 ± 45.5 minutes vs 98 ± 31.9 minutes, P < .001), a greater operative mortality (3.3% vs 0.4%, P = .040), and incurred a 4-fold increased risk of major adverse event (95% confidence interval [CI], 1.41-11.49, P = .009). Ten-year survival was also lower in the reop TAR cohort (76% vs 82.2%; hazard ratio, 1.79; 95% CI, 1.12-2.86, P = .015) and there was greater need for late reinterventions, mainly on the downstream aorta (hazard ratio, 1.29; 95% CI, 1.03-1.62, P = .024)., Conclusions: Reop TAR is a technically challenging operation and is associated with increased operative mortality and adverse events. Gratifying results can be obtained with meticulous surgical planning and focused attention on end-organ protection. Late reinterventions occur in a significantly greater percentage of patients undergoing reop TAR, and future studies should focus attention on identifying those at-risk groups who may benefit from a more aggressive index procedure., Competing Interests: Conflict of Interest Statement 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., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. 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.)

Purpose of Review: To describe methods to improve representation of women in cardiac surgery clinical trials., Recent Findings: Cardiovascular disease risk among women is high. Historically, women have been excluded from cardiac surgery trials, in part due to restrictive inclusion criteria. Surgical outcomes, specifically after coronary artery bypass grafting, are consistently worse among female patients, and these outcomes have not improved over the last decade. Addressing treatment effects and clinical benefit among women requires accurate representation in cardiovascular surgery trials. ROMA:Women, is the first cardiac surgery trial to focus solely on women, with the goal of addressing underrepresentation. Through utilizing specific strategies, ROMA:Women is a promising first step in advancing health equity., Summary: Strategies to ensure effective recruitment and representation among women in cardiac surgery clinical trials, such as tailored eligibility criteria and comprehensive strategies to improve communication and increase trust, are two of many potential approaches to address the structural barriers to female representation in cardiac surgery clinical trials. To date, ROMA:Women is an example of a trial that has shown extraordinary preliminary success enrolling women. Designing trials exclusively for women is one strategy to improve the diversity of clinical trial participation., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To compare outcomes in women undergoing percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery., Design: This retrospective, propensity-score matched cohort study from the New York State cardiac registry (2012-2018) included all women with multivessel coronary artery disease undergoing PCI with everolimus-eluting stents (EES) and CABG surgery. The primary outcome was all-cause mortality. The key secondary outcome was major adverse cardiac events, defined as the composite of all-cause mortality, myocardial infarction, and stroke., Results: PCI with EES was associated with a higher 6-year risk of mortality (25.75% vs 23.57%; adjusted hazard ratio [AHR], 1.29; 95% confidence interval [CI], 1.14-1.45). PCI also was associated with a higher rate of the composite outcome of death, myocardial infarction, and stroke (36.58% vs 32.89%; AHR, 1.28; 95% CI, 1.17-1.41), as well as myocardial infarction (14.94% vs 9.12%; AHR, 1.84; 95% CI, 1.56-2.17), but not stroke (7.07% vs 7.62%; AHR, 0.83; 95% CI, 0.67-1.03). Repeat revascularization rates also were higher for women undergoing PCI (21.53% vs 11.57%; AHR, 1.88; 95% CI, 1.63-2.17). There was no difference in mortality between the 2 interventions when PCI patients received complete revascularization or had noncomplex lesions and for women without diabetes., Conclusions: For women with multivessel coronary artery disease, CABG surgery is associated with lower 6-year mortality, myocardial infarction, and repeat revascularization rates compared to PCI with EES., Competing Interests: Conflict of Interest Statement 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., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The goal of this study was to evaluate the long-term outcomes of valve-sparing root replacement in patients with connective tissue disease (CTD) and compare them with patients without CTD who underwent valve-sparing root replacement for root aneurysm., Methods: Of 487 patients, 380 (78%) did not have CTD and 107 (22%) had CTD; 97 (91%) with Marfan syndrome, 8 (7%) with Loeys-Dietz syndrome, and 2 (2%) with Vascular Ehlers-Danlos syndrome. Operative and long-term outcomes were compared., Results: The CTD group was younger (36 ± 14 years vs 53 ± 12 years; P < .001), had more women (41% vs 10%; P < .001) and had less hypertension (28% vs 78%; P < .001) and bicuspid aortic valve (8% vs 28%; P < .001). Other baseline characteristics did not differ between the groups. Overall operative mortality was nil (P = 1.000); the incidence of major postoperative complications was 1.2% (0.9% vs 1.3%; P = 1.000) and did not differ between groups. Residual mild aortic insufficiency (AI) was more frequent in the CTD group (9.3% vs 1.3%, P < .001) with no difference in moderate or greater AI. Ten-year survival was 97.3% (97.2% vs 97.4%; log-rank P = .801). Of the 15 patients with residual AI, 1 had none, 11 remained mild, 2 had moderate, and 1 had severe AI on follow-up. Ten-year freedom from moderate/severe AI was 89.6% (hazard ratio, 1.05; 95% CI, 0.8-1.37; P = .750) and 10-year freedom from valve reoperation was 94.9% (hazard ratio, 1.21; 95% CI, 0.43-3.39; P = .717)., Conclusions: The operative outcomes as well as long-term durability of valve-sparing root replacement is excellent in patients with or without CTD. Valve function and durability are not influenced by CTD., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: This study investigated the impact of complete revascularization (CR) and incomplete revascularization (IR) on long-term survival in patients undergoing isolated coronary artery bypass grafting (CABG) using multiple arterial graft (MAGs) or a single artery with saphenous vein grafts (SAGs)., Methods: Between January 2006 and December 2020, 12,625 patients underwent CABG and were divided into 4 groups: MAG CR (n = 1066), MAG IR (n = 286), SAG CR (n = 8360), and SAG IR (n = 2913). Inverse probability of treatment weighting based on the generalized propensity score was used to minimize imbalance between the groups., Results: In the weighted cohort, median follow-up time was 8.35 years (interquartile range, 5.01-11.6 years). MAG CR was associated with similar long-term survival compared with MAG IR (hazard ratio [HR], 0.79; 95% CI, 0.60-1.03; P = .084). SAG CR was associated with improved long-term survival compared with SAG IR (HR, 0.67; 95% CI, 0.52-0.84; P = .01). MAG CR was associated with better long-term survival compared with SAG CR (HR, 0.45; 95% CI, 0.35-0.57; P < .001). Moreover, MAG IR was protective compared with SAG IR (HR, 0.62; 95% CI, 0.45-0.85; P = .033). Additional analysis was performed comparing perfect CR vs imperfect CR vs IR in MAG and SAG patients, separately. In the weighted sample of MAG, there were no differences in the long-term survival between perfect CR, imperfect CR, and IR. However, in the weighted sample of the SAG cohort, SAG perfect CR was associated with improved survival compared with SAG imperfect CR (HR, 0.81; 95% CI, 0.0.72-0.92; P = .001). Whereas, SAG perfect and imperfect CR were both associated with improved survival compared with SAG IR (HR, 0.51; 95% CI, 0.0.35-0.87; P = .006 and HR, 0.72; 95% CI, 0.64-0.82; P < .001), respectively., Conclusions: MAG CR is associated with better survival compared with SAG CR. If IR is inevitable, patients with MAG IR had better long-term survival compared with patients receiving SAG IR. Moreover, similar long-term survival is observed whether perfect CR, imperfect CR, or IR is achieved in the MAG population but not in SAG patients., Competing Interests: Disclosures Sleiman Sebastian Aboul-Hassan reports a relationship with Getinge that includes: speaking and lecture fees and travel reimbursement. Michel Pompeu Sa reports a relationship with The Society of Thoracic Surgeons that includes: funding grants. Mario Gaudino reports a relationship with National Institutes of Health that includes: funding grants. The other authors have no conflicts of interest to disclose., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Reoperative aortic root replacement (ARR) is a technically challenging procedure. This study assesses the influence of reoperation on outcomes following ARR, particularly after prior acute type A aortic dissection repair., Methods: Of the 1823 patients in this study, 1592 (87.3%) underwent primary ARR, and 231 (12.7%) underwent reoperative ARR. Within the reoperative ARR group, 69 patients (29.9%) had previous acute type A aortic dissection repair, and 162 patients (70.1%) underwent reoperative ARR for other indications., Results: Reoperative ARR patients exhibited higher rates of ischemic heart disease (13.9% vs 3%; P < .001), diabetes (10% vs 5.3%; P = .009), chronic pulmonary disease (9.1% vs 5%; P = .018), renal impairment (17.7% vs 5.3%; P < .001), and had lower ejection fraction (45.5% ± 8.1% vs 47.6% ± 7.9%; P < .001) compared with primary ARR. The overall operative mortality was 0.4%, with no significant difference between groups (0.9% vs 0.3%; P = .485). At multivariable analysis, previous operation was the most powerful predictor for major adverse events (odds ratio, 3.20; 95% CI, 2.12-4.79; P < .001). Reoperative ARR had a lower 10-year survival compared with primary ARR (67.4% vs 85.9%; log-rank P < .001). Multivariable analysis further confirmed that reoperation was significantly associated with 10-year mortality (hazard ratio, 1.76; 95% CI, 1.01-3.06; P = .044). Among the reoperative ARR group, operative mortality after previous acute type A aortic dissection repair was similar to that for other etiologies (0% vs 1.2%; P = .880)., Conclusions: Patients undergoing reoperative ARR have more comorbidities and extensive aortic disease compared with those undergoing primary surgery. They face a 3.5-fold increased risk of major adverse events but no difference in operative mortality compared with primary ARR., Competing Interests: Conflict of Interest Statement 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., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: We sought to evaluate outcomes of valve-sparing root replacement (VSRR) in patients with bicuspid aortopathy (BAV) versus other connective tissue disorder (CTD)., Methods: This was a single-center cohort study of consecutive patients undergoing VSRR via reimplantation from 2000 to 2023 with BAV or CTD. Operative outcomes, Kaplan-Meier survival estimates, and cumulative risk of reoperation and recurrent aortic insufficiency (AI) with the competing risk of death were assessed., Results: Of 516 patients who underwent VSRR, 109 (51.9%) had BAV and 101 (48.1%) had CTD. Patients with BAV were older (46.9 ± 10.4 vs 38.4 ± 14 years, P < .001) and more likely male (89.0% vs 56.4%, P < .001) and hypertensive (66.1% vs 28.7%, P < .001). Preoperative AI was similar (P = .57) between groups (30.3% mild, 18.3% moderate, 11.1% severe). Most patients had no/trivial immediate postoperative residual AI (96.3% vs 93.1%). Operative mortality was zero; postoperative adverse events were minimal. Mean clinical follow-up was 5.2 ± 4.4 years; 10-year survival was 95.6% versus 95.7% (P = .70). Echocardiographic follow-up was 3.9 ± 4.1 years; incidence of >2+ AI (9.7% vs 10.1%, P = 1.0) was similar between groups, whereas the incidence of moderate or greater aortic stenosis was greater with BAV (7.5% vs 0%, P = .02). Reoperation was low in both groups (3.7% vs 5.9%, P = .65). Competing risk analysis found no difference in reoperation hazard between BAV and CTD groups (hazard ratio, 0.36; 95% confidence interval, 0.07-1.81, P = .21)., Conclusions: Patients with BAV and CTD have excellent operative outcomes, no mortality, and minimal residual AI after VSRR. Although the incidence of recurrent AI was similar, patients with BAV are at risk for AS., Competing Interests: Conflict of Interest Statement 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., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Women have worse outcomes after coronary artery bypass surgery (CABG) than men., Objectives: This study aimed to determine the incidence of CABG graft failure in women, its association with cardiac events, and whether it contributes to sex-related differences in outcomes., Methods: A pooled analysis of individual patient data from randomized clinical trials with systematic imaging follow-up was performed. Multivariable logistic regression models were used to assess the association of graft failure with myocardial infarction and repeat revascularization between CABG and imaging (primary outcome) and death after imaging (secondary outcome). Mediation analysis was performed to evaluate the effect of graft failure on the association between female sex and risk of death., Results: Seven randomized clinical trials (N = 4,413, 777 women) were included. At a median imaging follow-up of 1.03 years, graft failure was significantly more frequent among women than men (37.3% vs 32.9% at the patient-level and 20.5% vs 15.8% at the graft level; P = 0.02 and P < 0.001, respectively). In women, graft failure was associated with an increased risk of myocardial infarction and repeat revascularization (OR: 3.94; 95% CI: 1.79-8.67) and death (OR: 3.18; 95% CI: 1.73-5.85). Female sex was independently associated with the risk of death (direct effect, HR: 1.84; 95% CI: 1.35-2.50) but the association was not mediated by graft failure (indirect effect, HR: 1.04; 95% CI: 0.86-1.26)., Conclusions: Graft failure is more frequent in women and is associated with adverse cardiac events. The excess mortality risk associated with female sex among CABG patients is not mediated by graft failure., Competing Interests: Funding Support and Author Disclosures Dr Di Franco has consulted for Novo Nordisk and Servier; and has served as an Advisory Board Member for Novo Nordisk and Scharper. Dr Fremes has received institutional support from Medtronic, Boston, and Amgen for clinical trial participation. Dr Hare has received research grants, educational grants, honoraria, or consultation fees from Abbott Pharmaceuticals, Abbott Structural Heart, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, CSL-Seqiris, Kaneka (Japan), Lundbeck (Denmark), Menarini (Italy), Merk KA (Germany), Merck, Novartis, Pfizer, Sanofi, Servier, and Vifor; and has received fellowship and research funding from the National Health and Medical Research Council of Australia, the Heart Foundation of Australia, the Austin Medical Research Foundation, and Diabetes Australia. Dr ten Berg has received institutional funding of the POPular CABG trial by AstraZeneca. Dr Bhatt has served on the Advisory Board of Angiowave, Bayer, Boehringer Ingelheim, CellProthera, Cereno Scientific, Elsevier Practice Update Cardiology, High Enroll, Janssen, Level Ex, McKinsey, Medscape Cardiology, Merck, MyoKardia, NirvaMed, Novo Nordisk, PhaseBio, PLx Pharma, and Stasys; has served on the Board of Directors of American Heart Association New York City, Angiowave (stock options), Bristol Myers Squibb (stock), DRS.LINQ (stock options), and High Enroll (stock); has served as a consultant for Broadview Ventures, Hims, SFJ, and Youngene; has served on Data Monitoring Committees for Acesion Pharma, Assistance Publique-Hôpitaux de Paris, Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Boston Scientific (Chair, PEITHO trial), Cleveland Clinic, Contego Medical (Chair, PERFORMANCE 2), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo; for the ABILITY-DM trial, funded by Concept Medical; for ALLAY-HF, funded by Alleviant Medical), Novartis, Population Health Research Institute, and Rutgers University (for the National Institutes of Health-funded MINT Trial); has received honoraria from American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org; Chair, ACC Accreditation Oversight Committee), Arnold and Porter law firm (work related to Sanofi/Bristol Myers Squibb clopidogrel litigation), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim; AEGIS-II executive committee funded by CSL Behring), Belvoir Publications (Editor-in-Chief, Harvard Heart Letter), Canadian Medical and Surgical Knowledge Translation Research Group (clinical trial steering committees), CSL Behring (AHA lecture), Cowen and Company, Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (Editor-in-Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), K2P (Co-Chair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Oakstone CME (Course Director, Comprehensive Review of Interventional Cardiology), Piper Sandler, Population Health Research Institute (for the COMPASS operations committee, publications committee, steering committee, and USA national co-leader, funded by Bayer), WebMD (CME steering committees), and Wiley (steering committee); served as Deputy Editor for Clinical Cardiology; is named on a patent for sotagliflozin assigned to Brigham and Women's Hospital who assigned to Lexicon (neither he nor Brigham and Women's Hospital receive any income from this patent); has received research funding from Abbott, Acesion Pharma, Afimmune, Aker Biomarine, Alnylam, Amarin, Amgen, AstraZeneca, Bayer, Beren, Boehringer Ingelheim, Boston Scientific, Bristol Myers Squibb, Cardax, CellProthera, Cereno Scientific, Chiesi, CinCor, Cleerly, CSL Behring, Eisai, Ethicon, Faraday Pharmaceuticals, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Garmin, HLS Therapeutics, Idorsia, Ironwood, Ischemix, Janssen, Javelin, Lexicon, Lilly, Medtronic, Merck, Moderna, MyoKardia, NirvaMed, Novartis, Novo Nordisk, Otsuka, Owkin, Pfizer, PhaseBio, PLx Pharma, Recardio, Regeneron, Reid Hoffman Foundation, Roche, Sanofi, Stasys, Synaptic, The Medicines Company, Youngene, and 89Bio; receives royalties from Elsevier (Editor, Braunwald’s Heart Disease); has served as Site Co-Investigator for Abbott, Biotronik, Boston Scientific, CSI, Endotronix, St. Jude Medical (now Abbott), Philips, SpectraWAVE, Svelte, and Vascular Solutions; is a Trustee of the American College of Cardiology; and has performed unfunded research for FlowCo. Dr Alexander has research support through Duke University from Artivion, Bayer, Bristol Myers Squibb, CSL Behring, Ferring, the U.S. Food and Drug Administration, Humacyte, the U.S. National Institutes of Health, and XaTek; and has received consulting payments or honoraria from AbbVie, Akros, Artivion, AtriCure, Bayer, Bristol Myers Squibb, Ferring, GlaxoSmithKline, Janssen, Novostia, Pfizer, Portola, Quantum Genomics, Teikoku, Theravance, and Veralox. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine the association of intraoperative pulmonary artery catheter (PAC) use with in-hospital outcomes in cardiac surgical patients., Methods: MEDLINE, Embase, and Cochrane Library (Wiley) databases were screened for studies that compared cardiac surgical patients receiving intraoperative PAC with controls and reporting in-hospital mortality. Secondary outcomes included intensive care unit length of stay, cost of hospitalization, fluid volume administered, intubation time, inotropes use, acute kidney injury (AKI), stroke, myocardial infarction (MI), and infections., Results: Seven studies (25 853 patients, 88.6% undergoing coronary artery bypass graft surgery) were included. In-hospital mortality was significantly increased with PAC use [odds ratio (OR) 1.57; 95% confidence interval (CI) 1.12-2.20, P = 0.04]; PAC use was also associated with greater intraoperative inotrope use (OR 2.61; 95% CI 1.54-4.41) and costs [standardized mean difference (SMD) = 0.20; 95% CI 0.16-0.23], longer intensive care unit stay (SMD = 0.29; 95% CI 0.25-0.33), and longer intubation time (SMD = 0.44; 95% CI 0.12-0.76)., Conclusions: PAC use is associated with significantly increased odds of in-hospital mortality, but the amount and quality of the available evidence is limited. Prospective randomized trials testing the effect of PAC on the outcomes of cardiac surgical patients are urgently needed., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

The transition from the second to the third millennium happened to be a turning point in the history of myocardial revascularization on a beating heart, which moved from technical development to critical evaluation. This article describes how the initial acceptance and spread of off-pump coronary artery bypass grafting (OPCABG) was followed by the general perception that the technique could not fulfill the expectations placed in it and provides some insight on what should we do with the know-how of OPCABG in the present and the future of coronary surgical revascularization., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: This article identifies minimal clinically important differences (MCIDs) in quality of life (QoL) measures among patients who had coronary artery bypass grafting (CABG) and were enrolled in the arterial revascularization trial (ART)., Methods and Results: The European Quality of Life-5 Dimensions (EQ-5D) and the Short Form Health Survey 36-Item (SF-36) physical component (PC) and mental component (MC) scores were recorded at baseline, 5 years and 10 years in ART. The MCIDs were calculated as changes in QoL scores anchored to 1-class improvement in the New York Heart Association functional class and Canadian Cardiovascular Society scale at 5 years. Cox proportional hazard models were used to evaluate associations between MCIDs and mortality. Patient cohorts were examined for the SF-36 PC (N = 2671), SF-36 MC (N = 2815) and EQ-5D (N = 2943) measures, respectively. All QoL scores significantly improved after CABG compared to baseline. When anchored to the New York Heart Association, the MCID at 5 years was 17 (95% confidence interval: 17-20) for SF-36 PC, 14 (14-17) for the SF-36 MC and 0.12 (0.12-0.15) for EQ-5D. Using the Canadian Cardiovascular Society scale as an anchor, the MCID at 5 years was 15 (15-17) for the SF-36 PC, 12 (13-15) for the SF-36 MC and 0.12 (0.11-0.14) for the EQ-5D. The MCIDs for SF-36 PC and EQ-5D at 5 years were associated with a lower risk of mortality at the 10-year follow-up point after surgery., Conclusions: MCIDs for CABG patients have been identified. These thresholds may have direct clinical applications in monitoring patients during follow-up and in designing new trials that include QoL as a primary study outcome., Clinical Trial Registration Number: ISRCTN46552265., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: To assess the effect of different antiplatelet strategies on clinical outcomes after coronary artery bypass grafting., Design: Five year follow-up of randomised Different Antiplatelet Therapy Strategy After Coronary Artery Bypass Grafting (DACAB) trial., Setting: Six tertiary hospitals in China; enrolment between July 2014 and November 2015; completion of five year follow-up from August 2019 to June 2021., Participants: 500 patients aged 18-80 years (including 91 (18.2%) women) who had elective coronary artery bypass grafting surgery and completed the DACAB trial., Interventions: Patients were randomised 1:1:1 to ticagrelor 90 mg twice daily plus aspirin 100 mg once daily (dual antiplatelet therapy; n=168), ticagrelor monotherapy 90 mg twice daily (n=166), or aspirin monotherapy 100 mg once daily (n=166) for one year after surgery. After the first year, antiplatelet therapy was prescribed according to standard of care by treating physicians., Main Outcome Measures: The primary outcome was major adverse cardiovascular events (a composite of all cause death, myocardial infarction, stroke, and coronary revascularisation), analysed using the intention-to-treat principle. Time-to-event analysis was used to compare the risk between treatment groups. Multiple post hoc sensitivity analyses examined the robustness of the findings., Results: Follow-up at five years for major adverse cardiovascular events was completed for 477 (95.4%) of 500 patients; 148 patients had major adverse cardiovascular events, including 39 in the dual antiplatelet therapy group, 54 in the ticagrelor monotherapy group, and 55 in the aspirin monotherapy group. Risk of major adverse cardiovascular events at five years was significantly lower with dual antiplatelet therapy versus aspirin monotherapy (22.6% v 29.9%; hazard ratio 0.65, 95% confidence interval 0.43 to 0.99; P=0.04) and versus ticagrelor monotherapy (22.6% v 32.9%; 0.66, 0.44 to 1.00; P=0.05). Results were consistent in all sensitivity analyses., Conclusions: Treatment with ticagrelor dual antiplatelet therapy for one year after surgery reduced the risk of major adverse cardiovascular events at five years after coronary artery bypass grafting compared with aspirin monotherapy or ticagrelor monotherapy., Trial Registration: NCT03987373ClinicalTrials.gov NCT03987373., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: support from AstraZeneca for the submitted work; YZhu has received personal fees and non-financial support from AstraZeneca, Johnson & Johnson, Medtronic, Novartis, Sanofi, and Chugai and grants from the Science and Technology Commission of Shanghai Municipality and the Shanghai Shenkang Hospital Development Centre; WZ has received personal fees and non-financial support from MSD, Pfizer, Boston Scientific, Cordis, and Becton, Dickinson and Company; LH has received grants from the Science and Technology Commission of Shanghai Municipality. ZC has received personal fees and non-financial support from AstraZeneca, Medtronic, Johnson & Johnson, and Edwards life science and grants from the Science and Technology Commission of Henan Municipality, Henan Provincial Health Commission, Henan Provincial People's Hospital, and Zhengzhou University; JM has received grants from the National Natural Science Foundation of China and the Science and Technology Commission of Shanghai Municipality; XC has received grants from the National Natural Science Foundation of China; XW has received personal fees and non-financial support from AstraZeneca, Johnson & Johnson, and Medtronic and grants from the National Natural Science Foundation of China; QX has received personal fees and non-financial support from Medtronic and Novartis; JH has received personal fees and non-financial support from Medtronic and Johnson & Johnson; MT has received personal fees from Pfizer and grants from the National Natural Science Foundation of China; RW has received personal fees from Novartis. MG has received grants from the National Heart, Lung, and Blood Institute and the Canadian Institutes of Health Research; QZ has received grants, personal fees, and non-financial support from AstraZeneca, personal fees and non-financial support from Medtronic and Johnson & Johnson, and grants from the National Science Foundation of China, Science and Technology Commission of Shanghai Municipality, Shanghai Jiao Tong University, Ruijin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai Shenkang Hospital Development Centre, and Chugai; no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: In the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial, among participants with stable coronary artery disease, the risk of cardiac events was similar between an invasive (INV) strategy of angiography and coronary revascularisation and a conservative (CON) strategy of initial medical therapy alone. Outcomes according to participant sex were not reported., Aims: We aimed to analyse the outcomes of ISCHEMIA by participant sex., Methods: We evaluated 1) the association between participant sex and the likelihood of undergoing revascularisation for participants randomised to the INV arm; 2) the risk of the ISCHEMIA primary composite outcome (cardiovascular death, any myocardial infarction [MI] or rehospitalisation for unstable angina, heart failure or resuscitated cardiac arrest) by participant sex; and 3) the contribution of the individual primary outcome components to the composite outcome by participant sex., Results: Of 5,179 randomised participants, 1,168 (22.6%) were women. Female sex was independently associated with a lower likelihood of revascularisation when assigned to the INV arm (adjusted odds ratio 0.75, 95% confidence interval [CI]: 0.57-0.99; p=0.04). The INV versus CON effect on the primary composite outcome was similar between sexes (women: hazard ratio [HR] 0.96, 95% CI: 0.70-1.33; men: HR 0.90, 95% CI: 0.76-1.07; p interaction =0.71). The contribution of the individual components to the composite outcome was similar between sexes except for procedural MI, which was significantly lower in women (9/151 [5.9%]) than men (67/519 [12.9%]; p=0.01)., Conclusions: In ISCHEMIA, women assigned to the INV arm were less likely to undergo revascularisation than men. The effect of an INV versus CON strategy was consistent by sex, but women had a significantly lower contribution of procedural MI to the primary outcome.

The sex disparity in outcomes of patients with cardiovascular disease is well-described and has persisted across recent decades. While there have been several proposed mechanisms to explain this disparity, there are limited data on female patient-physician sex concordance and its association with outcomes. The authors review the existing literature on the relationship between patient-physician sex concordance and clinical outcomes in patients with cardiovascular disease, the evidence of a benefit in clinical outcomes with female patient-physician sex concordance, and the possible drivers of such a benefit and highlight directions for future study., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Coronary artery aneurysms (CAAs), coronary arteriovenous malformations (CAVMs), and spontaneous coronary artery dissections (SCADs) are rare clinical entities, and much is unknown about their natural history, prognosis, and management., Methods: A systematic search of MEDLINE, Embase, and Cochrane Library databases was performed in March 2023 to identify published papers related to CAAs, CAVMs, and SCADs., Results: CAAs are found in 0.3% to 12% of patients undergoing angiography and are often associated with coronary atherosclerosis. They are usually asymptomatic but can be complicated by thrombosis in up to 4.8% of patients and rarely by rupture (0.2%). CAAs can be managed medically, percutaneously with stents or coil embolization, and surgically. The most common surgical procedure is ligation of the aneurysm, followed by coronary artery bypass grafting. The incidence of CAVMs is 0.1% to 0.2% in patients undergoing angiography, and they are most likely associated with congenital abnormal development of the coronary vessels. The diagnosis of CAVMs is usually incidental. Surgical or percutaneous intervention is indicated for patients with large CAVMs, which carry a potential risk of myocardial infarction. SCADs represent 1% to 4% of all acute coronary syndromes and typically affect young women. SCADs are strongly correlated with pregnancy, suggesting the role of sex hormones in their pathogenesis. Conservative management of SCAD is preferred for stable patients without signs of ischemia as spontaneous resolution is frequently reported. Unstable patients should undergo revascularization either percutaneously or with coronary artery bypass grafting., Conclusions: Further evidence regarding the management of these rare diseases is needed and can ideally be derived from multicenter collaborations., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Basic, translational or clinic, research is a key component of cardiac surgery. Understanding basic cellular and molecular mechanisms is key to improving patient outcomes, and cardiac surgical procedures must be compared with nonsurgical alternatives. However, guidance for early-career investigators interested in cardiac surgery research is limited. This opinion piece aims at providing basic guidance and principles based on the authors' experience., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Anastomotic leak after esophagectomy carries important short- and long-term sequelae. The authors conducted a systematic review and meta-analysis to determine its association with surgical volume., Materials and Methods: A systematic literature review was performed to identify all studies reporting on anastomotic leak after esophagectomy. Studies with less than 100 cases were excluded. The primary outcome was postesophagectomy anastomotic leak, while secondary outcomes were operative mortality overall and after anastomotic leak. Pooled event rates (PER) were calculated, and the association with annual esophagectomy volume by center was investigated., Results: Of the 3932 retrieved articles, 472 were included ( n =177 566 patients). The PER of anastomotic leak was 8.91% [95% CI=8.32; 9.53%]. The PER of early mortality overall and after an anastomotic leak was 2.49% [95% CI=2.27; 2.74] and 11.39% [95% CI=9.66; 13.39], respectively. Centers with less than 37 annual esophagectomies had a higher leak rate compared to those with greater than or equal to 37 annual esophagectomies (9.58% vs. 8.34%; P =0.040). On meta-regression, surgical volume was inversely associated with the PER of esophageal leak and of early mortality., Conclusions: The frequency of anastomotic leaks after esophagectomy, perioperative, and leak associated mortality are inversely associated with esophagectomy volume., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Importance: The overall prevalence of mitral valve replacement (MVR) or MV repair at the time of cardiac surgery in the setting of isolated anterior mitral leaflet degenerative pathologic status in the US population is unknown., Objective: To investigate the prevalence of MVR and MV repair using the Society of Thoracic Surgeons' Adult Cardiac Surgery Database., Design, Setting, and Participants: In a cross-sectional study, all patients diagnosed with isolated anterior mitral leaflet degenerative regurgitation who underwent either surgical MVR or MV repair between July 1, 2011, and June 30, 2022, were identified. Linear regression analysis was used to assess trends over time., Main Outcomes and Measures: Assessment of the trends in MV repair and MVR over time., Results: A total of 16 259 patients (9624 [59.2%] men) were identified, and the median age was 68 (IQR, 58-74) years. A total of 7214 patients (44.4%) had MVR, and 9045 (55.6%) had MV repair. There was a declining trend of MV repair from 58.0% in 2011 to 51.6% in 2022 (P = .05). The MVR group was older (median [IQR] age, 70 [62-77] vs 67 [58-74] years; P < .001) and had more comorbidities. A total of 85.1% of all patients underwent concomitant procedures. In 81.7% of MVR cases, no attempt at MV repair was made. The median (IQR) annual hospital volume was lower with MVR vs MV repair (2.50 [1.50-5.00] vs 4.00 [2.00-7.00]; P < .001). Conventional surgical approaches were most common (91.5%) but with a declining trend (P < .001). Minimally invasive approaches were used in 13.1% (robotic, 4.6%), and with an inclining trend from 5.0% in 2011 to 12.0% in 2022 (P < .001). Annuloplasty was performed in 88.8% of MV repair cases. Its use as a sole mean of MV repair decreased from 48.0% in 2011 to 13.9% in 2022 (P < .001). Repair maneuvers in addition to annuloplasty were neochordae (overall 40.1%, increasing from 22.5% in 2011 to 62.3% in 2022; P < .001), leaflet resection (overall 10.2%, decreasing from 13.1% in 2011 to 7.9% in 2022, P = .002), edge-to-edge MV repair (overall 5.3%, decreasing from 6.9% in 2011 to 4.5% in 2022; P = 0.04), and chordal transfer (overall 2.4%, decreasing from 2.7% in 2011 to 0.7% in 2022; P = .004)., Conclusions and Relevance: In this cross-sectional study, MV repair was the preferred option for degenerative mitral valve disease but was only slightly more commonly performed than MVR for isolated anterior leaflet pathologic status. A large proportion of MVR was performed without an MV repair attempt, suggesting reluctance to repair this pathologic condition.

Individual patient data (IPD) meta-analyses build upon traditional (aggregate data) meta-analyses by collecting IPD from the individual studies rather than using aggregated summary data. Although both traditional and IPD meta-analyses produce a summary effect estimate, IPD meta-analyses allow for the analysis of data to be performed as a single dataset. This allows for standardization of exposure, outcomes, and analytic methods across individual studies. IPD meta-analyses also allow the utilization of statistical methods typically used in cohort studies, such as multivariable regression, survival analysis, propensity score matching, uniform subgroup and sensitivity analyses, better management of missing data, and incorporation of unpublished data. However, they are more time-intensive, costly, and subject to participation bias. A separate issue relates to the meta-analytic challenges when the proportional hazards assumption is violated. In these instances, alternative methods of reporting time-to-event estimates, such as restricted mean survival time should be used. This statistical primer summarizes key concepts in both scenarios and provides pertinent examples., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Latest research has indicated a potential adverse effect on graft patency rates and clinical outcomes with skeletonizing the left internal thoracic artery. We aim to provide a prospective, randomized, multicentre trial to compare skeletonized versus pedicled harvesting technique of left internal thoracic artery concerning graft patency rates and patient survival. A total of 1350 patients will be randomized to either skeletonized or pedicled harvesting technique and undergo surgical revascularization. Follow-up will be performed at 30 days, 1 year, 2 years and 5 years after surgery. The primary outcome will be death or left internal thoracic artery graft occlusion in coronary computed tomography angiography or invasive angiography within 2 years (+/- 3 months) after surgery. The secondary outcome will be major adverse cardiac events (composite outcome of all-cause death, myocardial infarction and repeated revascularization) within 1 year, 2 years and 5 years after surgery. The primary end point will be compared in the modified intention-to-treat population between the two treatment groups using Kaplan-Meier graphs, together with log-rank testing. Hereby, we present the study protocol of the first adequately powered prospective, randomized, multicentre trial which compares skeletonized and pedicled harvesting technique of left internal thoracic artery regarding graft patency rates and patient survival., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: Midline sternotomy is the main surgical access for cardiac surgeries. The most prominent complication of sternotomy is sternal wound infection (SWI). The use of a thorax support vest (TSV) that limits thorax movement and ensures sternal stability has been suggested to prevent postoperative SWI., Methods: We performed a meta-analysis to evaluate differences in clinical outcomes with and without the use of TSV after cardiac surgery in randomized trials. The primary outcome was deep SWI (DSWI). Secondary outcomes were superficial SWI, sternal wound dehiscence, and hospital length of stay (LOS). A trial sequential analysis was performed. Fixed (F) and random effects (R) models were calculated., Results: A total of 4 studies (3820 patients) were included. Patients who wore the TSV had lower incidence of DSWI [odds ratio (OR) = F: 0.24, 95% confidence interval (CI), 0.13-0.43, P < 0.01; R: 0.24, 0.04-1.59, P = 0.08], sternal wound dehiscence (OR = F: 0.08, 95% CI, 0.02-0.27, P < 0.01; R: 0.10, 0.00-2.20, P = 0.08) and shorter hospital LOS (standardized mean difference = F: -0.30, -0.37 to -0.24, P < 0.01; R: -0.63, -1.29 to 0.02, P = 0.15). There was no difference regarding the incidence of superficial SWI (OR = F: 0.71, 95% CI, 0.34-1.47, P = 0.35; R: 0.64, 0.10, 4.26, P = 0.42). The trial sequential analysis, however, showed that the observed decrease in DSWI in the TSV arm cannot be considered conclusive based on the existing evidence., Conclusions: This meta-analysis suggests that the use of a TSV after cardiac surgery could potentially be associated with a reduction in sternal wound complications. However, despite the significant treatment effect in the available studies, the evidence is not solid enough to provide strong practice recommendations., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Coronary artery bypass grafting has evolved considerably since it was introduced approximately 50 years ago, with continuously improved patient outcomes as a result of this growth. The most up-to-date evidence on topics such as graft patency, grafting strategy, approaches to graft harvesting, minimally invasive coronary artery bypass grafting, and postoperative pharmacotherapy may lead to changes in current accepted practice. In addition, several unanswered questions in the field of coronary artery bypass grafting may benefit from further investigation and, if resolved, might advance the field and change practice. Current or upcoming clinical trials seek to answer these unanswered questions and may generate data that yields improved outcomes and quality of life for all patients after coronary artery bypass grafting. In addition, cutting edge clinical trials designed specifically for women and racial and ethnic minorities who have had poorer outcomes and have traditionally been underrepresented in cardiovascular surgery research, have recently been launched that may change the way that a large portion of the coronary artery bypass grafting population is treated in the future.

Immune-checkpoint inhibitors (ICIs) were proven effective in inducing tumor regression. However, its toxicity tends to be fatal. We sought to investigate the hospital volume/outcomes relationship. Databases were searched for studies reporting immune-checkpoint inhibitors adverse events (AEs) in patients with solid-organ malignancies. The outcomes were A) the pooled events rate (PER) of grade 5, grade 3-4, cardiac-related, and pulmonary-related AEs, and B) the assessment of the volume/outcomes relationship. One hundred and forty-seven studies met our inclusion criteria. The PER of grade 5, grade 3-4, and any-grade AEs was 2.75% (95%CI: 2.18-3.47), 26.69% (95%CI: 21.60-32.48), and 77.80% (95%CI: 70.91-83.44), respectively. The PER of pulmonary-related AEs was 4.56% (95%CI: 3.76-5.53). A higher number of annual cases per center was significantly associated with reduced grade 5 ( p = 0.019), grade 3-4 ( p = 0.004), and cardiac-related AEs ( p = 0.035) in the meta-regression. In the current era of cancer immunotherapy, knowledge regarding the early diagnosis and management of immunotherapy-related AEs is essential. Our meta-analysis demonstrates the importance of center volume in improving outcomes and reducing the incidence of severe AEs.

Background: Women undergoing coronary artery bypass grafting (CABG) have higher operative mortality than men., Objectives: The purpose of this study was to evaluate the relationship between intraoperative anemia (nadir intraoperative hematocrit), CABG operative mortality, and sex., Methods: This was a cohort study of 1,434,225 isolated primary CABG patients (344,357 women) from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2022). The primary outcome was operative mortality. The attributable risk (AR) (the risk-adjusted strength of the association of female sex with CABG outcomes) for the primary outcome was calculated. Causal mediation analysis derived the total effect of female sex on operative mortality risk and the proportion of that effect mediated by intraoperative anemia., Results: Women had lower median nadir intraoperative hematocrit (22.0% [Q1-Q3: 20.0%-25.0%] vs 27.0% [Q1-Q3: 24.0%-30.0%], standardized mean difference 97.0%) than men. Women had higher operative mortality than men (2.8% vs 1.7%; P < 0.001; adjusted OR: 1.36; 95% CI: 1.30-1.41). The AR of female sex for operative mortality was 1.21 (95% CI: 1.17-1.24). After adjusting for nadir intraoperative hematocrit, AR was reduced by 43% (1.12; 95% CI: 1.09-1.16). Intraoperative anemia mediated 38.5% of the increased mortality risk associated with female sex (95% CI: 32.3%-44.7%). Spline regression showed a stronger association between operative mortality and nadir intraoperative hematocrit at hematocrit values <22.0% (P < 0.001)., Conclusions: The association of female sex with increased CABG operative mortality is mediated to a large extent by intraoperative anemia. Avoiding nadir intraoperative hematocrit values below 22.0% may reduce sex differences in CABG operative mortality., Competing Interests: Funding Support and Author Disclosures The data for this research were provided by The Society of Thoracic Surgeons’ National Database Participant User File Research Program. Data analysis was performed at the investigators’ institution(s). The views and opinions presented in this paper are solely those of the author(s) and do not represent those of The Society of Thoracic Surgeons. Dr Harik is partially supported by a T-32 Multidisciplinary Research Training Grant in Cardiovascular Disease from the National Heart, Lung, and Blood Institute (1 T32 HL160520-01A1). Dr Rong is supported by a grant from the National Institutes of Health K23 HL153836. Dr Sandner is supported by the Austrian Science Fund KLI1147-B. Dr Bairey-Merz is supported by National Institutes of Health R01HL124649 and U54 AG065141; the Edythe L. Broad and the Constance Austin Women's Heart Research Fellowships, Cedars-Sinai Medical Center; the Barbra Streisand Women's Cardiovascular Research and Education Program, Cedars-Sinai Medical Center; The Society for Women's Health Research; the Linda Joy Pollin Women's Heart Health Program; the Erika Glazer Women's Heart Health Project; and the Adelson Family Foundation, Cedars-Sinai Medical Center. Dr Gaudino receives research grants from the National Institutes of Health, the Canadian Health and Research Institutes, and the Starr Foundation. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

The optimal antiplatelet strategy after coronary artery bypass graft (CABG) surgery in patients with chronic coronary syndromes (CCS) is unclear. Adding the P2Y 12 inhibitor, ticagrelor, to low-dose aspirin for 1 year is associated with a reduction in graft failure, particularly saphenous vein grafts, at the expense of an increased risk of clinically important bleeding. As the risk of thrombotic graft failure and ischaemic events is highest early after CABG surgery, a better risk-to-benefit profile may be attained with short-term dual antiplatelet therapy followed by single antiplatelet therapy. The One Month Dual Antiplatelet Therapy With Ticagrelor in Coronary Artery Bypass Graft Patients (ODIN) trial is a prospective, randomised, double-blind, placebo-controlled, international, multicentre study of 700 subjects that will evaluate the effect of short-term dual antiplatelet therapy with ticagrelor plus low-dose aspirin after CABG in patients with CCS. Patients will be randomised 1:1 to ticagrelor 90 mg twice daily or matching placebo, in addition to aspirin 75-150 mg once daily for 1 month; after the first month, antiplatelet therapy will be continued with aspirin alone. The primary endpoint is a hierarchical composite of all-cause death, stroke, myocardial infarction, revascularisation and graft failure at 1 year. The key secondary endpoint is a hierarchical composite of all-cause death, stroke, myocardial infarction, Bleeding Academic Research Consortium (BARC) type 3 bleeding, revascularisation and graft failure at 1 year (net clinical benefit). ODIN will report whether the addition of ticagrelor to low-dose aspirin for 1 month after CABG reduces ischaemic events and provides a net clinical benefit in patients with CCS. (ClinicalTrials.gov: NCT05997693).