A recent Cardiothoracic Surgery digest,
as sent to subscribers

Study Type: Narrative expert review with a proposed decision algorithm (not a systematic review; no formal search methodology or quantitative synthesis described).

Key Question: How should operative strategy for mitral valve surgery be selected and executed in patients with mitral annular calcification (MAC)?

Key Findings:

• A four-category, severity-based decision matrix guides planning, with management spanning "respect the MAC" (work around calcium) to "resect the MAC" (full resection with atrioventricular groove reconstruction).
• Mild MAC: repair remains feasible and preferred. Moderate MAC: individualised; repair is reasonable if leaflet mobility is preserved and decalcification allows secure annuloplasty, otherwise replacement.
• Severe or circumferential MAC warrants tailored approaches, including transcatheter or hybrid strategies. Decalcification extent should reflect patient risk and operator expertise.

Clinical Relevance: MAC is increasingly encountered in an older, comorbid UK surgical population, and the framework may support MDT discussion of repair, replacement, or transcatheter options.

Limitations: The algorithm is expert-derived, not validated against outcomes, and the abstract provides no quantitative data on complication rates or comparative durability.

Study Type: Retrospective registry cohort study (STS ACSD linked to CMS claims, 2012–2022)

Key Question: Do high-risk features in isolated CABG patients (≥65 years, STS PROM >4%) carry different prognostic weight for perioperative versus one-year mortality?

Key Findings:

• Of 75,385 patients, 89.4% survived 30 days; 13.4% of those 30-day survivors died by one year.
• Liver disease and home oxygen predicted mortality at both 30 days and one year.
• Unresponsive state, prior CABG, PCI within 6 hours, cardiogenic shock and temporary mechanical support predicted early mortality only. Cancer, dialysis and Medicaid coverage were neutral at 30 days but independently predicted one-year mortality.

Clinical Relevance: Supports a more nuanced risk discussion in heart team and consent settings, as PROM-type scores may not distinguish early-hazard from late-hazard phenotypes, though this US Medicare-aged cohort may not map directly onto UK practice.

Limitations: Observational design with no effect sizes in the abstract, and Medicaid status is a US-specific variable of limited transferability to the NHS.

Study Type: Narrative expert review with consensus recommendations (Italian Cardiac Surgery Working Group); not a systematic review, with no stated search strategy or risk-of-bias assessment.

Key Question: How should the 2025 ESC/EACTS Class I recommendation for transfemoral TAVI in patients aged ≥70 years be applied to patients with long life expectancy, considering durability and future reintervention?

Key Findings:

• TAVI's early non-inferiority to SAVR may attenuate with longer follow-up, particularly in patients with substantial life expectancy.
• Randomised durability data are limited; propensity-matched registries suggest possible higher late mortality after TAVI in younger, lower-risk patients.
• Reintervention after TAVI-first strategies may carry increasing technical complexity and procedural risk.

Clinical Relevance: Supports Heart Team discussions of lifetime management as UK practice adopts the 2025 guidelines, favouring SAVR as a reference strategy in long-survival patients and TAVI where life expectancy is limited or surgical risk is high.

Limitations: Conclusions rest on a non-systematic synthesis, with the late-mortality signal drawn from observational registries vulnerable to residual confounding.

Study Type: Single-centre retrospective intention-to-treat case series (n=21, consecutive).

Key Question: Is transcatheter electrosurgical septotomy feasible and safe across the full spectrum of descending aortic dissection, including as stand-alone treatment for malperfusion?

Key Findings:

• Technical success 95% (20/21). Indications: landing-zone preparation (57%), malperfusion (33%), preparation for open repair, true-lumen collapse.
• Malperfusion resolved in all 7 treated patients; median perfused-lumen index rose from 0.16 to 0.98 (n=18, P<0.001).
• No stroke, spinal cord ischaemia or retrograde type A dissection. Mortality: 10% at 30 days, 14% in-hospital, 19% overall (one fatal delayed rupture); 3 unplanned reinterventions at median 5.1 months.

Clinical Relevance: Offers a possible alternative or adjunct to fenestration or stenting for dissection malperfusion using standard electrosurgical equipment, though UK practice would need formal evaluation before adoption.

Limitations: Small, heterogeneous, retrospective cohort with short follow-up and no comparator, so feasibility is shown but durability and comparative safety are not.

Study Type: Single case report.

Key Question: Can a novel low-radial-force partial elephant trunk (PET) fail to expand adequately in chronic aortic dissection, and how should this be managed?

Key Findings:

• After total arch replacement with a PET for chronic dissection, lower-to-upper limb blood pressure ratio fell to 90% post-bypass, with incomplete stent expansion on intraoperative TOE.
• By postoperative day 1 the ratio had worsened to 70%, attributed to PET stenosis at a steeply angulated arch.
• Emergency TEVAR within the PET fully resolved the pressure gradient.

Clinical Relevance: Surgeons adopting newer frozen elephant trunk devices designed to reduce distal stent graft-induced new entry should anticipate possible under-expansion in chronic dissection, particularly with steep arch angulation, and maintain a low threshold for limb pressure monitoring and bailout TEVAR.

Limitations: A single case provides no incidence data, and the proposed mechanism (thinner nitinol wire, lower radial force, arch angulation) is inferred rather than demonstrated.

Study Type: Small single-centre case series (n=5) describing a technique.

Key Question: Can short-duration VV-ECMO be established and managed entirely in the operating room, without repositioning, to support thoracoscopic surgery in patients who cannot tolerate one-lung ventilation?

Key Findings:

• Semi-supine positioning with femoral cannulation (purse-string closure) and table rotation allowed VATS without turning the patient while circuit-dependent.
• Five of 548 thoracoscopic procedures (Oct 2022–Jun 2025) used the approach; operative time 124–172 min, ECMO support 27–69 min.
• All patients were weaned in theatre. No thromboembolic or haemorrhagic complications occurred despite no systemic or prime heparin (heparin-bonded circuit, 2.5–3.5 L/min flow).

Clinical Relevance: May offer a simpler, safer option for high-risk patients needing brief VATS, though UK practice and ECMO governance would need local consideration.

Limitations: Only five cases with no comparator group, so safety and generalisability, particularly of the heparin-free strategy, cannot be established.

Study Type: Single-centre retrospective cohort study (n=44).

Key Question: Does preoperative aortic morphology predict fenestration-related leak after fenestrated frozen elephant trunk (FET) in aortic dissection, and does fenestration fixation reduce it?

Key Findings:

• Leak occurred in 12/44 (27.3%): 11.5% with fixation vs 50.0% without (P=0.007).
• Larger aortic diameter was associated with leak (34.5 vs 29.9 mm; AUC 0.80, 95% CI 0.63–0.97). Leak incidence rose across diameter strata (12.5%, 57.1%, 80.0%), most evidently above 36 mm. Flat true lumen morphology was also more frequent in leaks (P=0.025).
• After penalised adjustment, diameter (OR 1.29 per mm) and fixation (OR 0.07) remained independently associated with leak.

Clinical Relevance: Provides tentative anatomical thresholds that could inform selective fenestration fixation in dissection patients undergoing FET, though no UK-specific data are presented.

Limitations: Fixation was chosen intraoperatively and events were few, so confounding by indication is likely and findings are exploratory.

Study Type: Single-patient case report.

Key Question: Can intraoperative temporary occlusion testing safely guide ligation of an aneurysmal sinus node artery feeding a recanalised coronary-to-right atrial fistula?

Key Findings:

• Index repair (intra-atrial pledgeted closure plus extracardiac ligation, sinus node artery preserved) failed: the fistula recanalised at one year, with progressive enlargement of the RCA ostium (10 to 11.8 mm) and sinus node artery aneurysm (13 to 15.6 mm).
• At reoperation, P waves persisted during snaring at 3 and 5 minutes. After definitive ligation and division, P waves were absent from 7 to 19 minutes (rate 70–73 bpm) and returned spontaneously at 20 minutes.
• At 6 months the patient was asymptomatic, in sinus rhythm, with no residual fistula and RCA regression to 7.4 mm.

Clinical Relevance: Provides a technical option for rare coronary fistula involving the sinus node artery, though the early P-wave persistence did not predict the transient post-ligation sinus node dysfunction.

Limitations: Single case with short follow-up (6 months); the occlusion test was limited to 5 minutes and its predictive value cannot be established.