← Back to Journals

Annals of Cardiothoracic Surgery

Publisher:
—
ISSN:
2225-319X
Category:
SURGERY
Impact factor:
3.3
Official website ↗Official RSS source ↗

Feed status

23 parsed articles

Last update: 2026-10-23

Latest articles

Surgery that looks like transcatheter aortic valve implantation: the transaxillary concept for minimally invasive aortic valve replacement in 1,848 consecutive patients

2026-09-29

Sebastian Arzt, Konstantin Alexiou, Ali Taghizadeh-Waghefi, Asen Petrov, Klaus Matschke, Utz Kappert, Manuel Wilbring

Background: The transaxillary (TxA) concept for minimally invasive aortic valve replacement (MICS-AVR) is a sternum-sparing access technique combining surgical valve replacement with virtually absent visible scarring. This study reports the institutional outcomes of the first 1,848 consecutive TxA MICS-AVR procedures. Methods: This retrospective single-center observational cohort analysis included all consecutive patients undergoing isolated TxA MICS-AVR between January 2019 and June 2026. Exclusion criteria were active endocarditis, redo surgery and concomitant procedures. Thirty-day mortality and major adverse cardiac and cerebrovascular events (MACCEs) served as primary endpoints. Univariable and multivariable logistic regression identified exploratory associations with adverse outcomes. Results: Mean age was 67.7±8.1 years, Society of Thoracic Surgeons Predicted Risk of Operative Mortality (STS-PROM) 1.39%±2.90% and European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) 1.65%±1.12%. The proportion of TxA access among surgical treatments for isolated aortic valve disease increased from 18.8% [2019] to 99.2% [2025]. Mean operative, cardiopulmonary bypass and cross-clamp times were 132±34, 69±23 and 43±16 minutes, respectively. No intraoperative death occurred; conversion to sternotomy was required in 1.6%. Thirty-day mortality was 0.5% and the composite MACCE rate was 1.6%, including stroke in 0.9% and myocardial infarction in 0.5%. Multivariable exploratory associations of mortality were diabetes on insulin [odds ratio (OR) 8.56; 95% confidence interval (CI): 2.10–34.93; P=0.002], left ventricular ejection fraction (LVEF) Conclusions: TxA MICS-AVR demonstrates excellent reproducibility and safety across 1,848 consecutive procedures. Against emerging long-term evidence favoring surgical valve replacement in patients with extended life expectancy, the TxA approach uniquely combines durable surgical therapy with a cosmetic outcome comparable to transcatheter procedures—representing a strategically relevant and scalable platform for the contemporary management of aortic valve disease.

Transaxillary valve surgery: innovation through simplicity in minimally invasive cardiac surgery

2026-09-29

Marco Di Eusanio

Mnimally invasive cardiac surgery (MICS) is widely recognized as an essential component of contemporary cardiac surgical practice, offering reduced surgical trauma, faster recovery, and improved patient satisfaction while maintaining excellent clinical outcomes. Nevertheless, despite decades of technological progress and growing clinical evidence, its adoption remains limited. One of the principal barriers to wider dissemination is the procedural complexity associated with many minimally invasive platforms. Reduced operative exposure, indirect visualization, and dependence on dedicated technology frequently result in demanding workflows, prolonged learning curves, and limited reproducibility. The right transaxillary mini-thoracotomy direct vision approach was developed according to a different philosophy. Rather than relying on additional technology to compensate for the constraints of minimally invasive access, it simplifies the operative platform by preserving the natural interaction between the surgeon and the operative field. By combining favorable surgical geometry, direct visualization, and a standardized operative platform, the transaxillary approach facilitates procedural efficiency, reproducibility and potential applicability across a broad spectrum of minimally invasive valve surgery while relying primarily on conventional surgical instrumentation. More broadly, the transaxillary concept suggests that the future dissemination of MICS may depend not only on technological innovation, but also on the ability to simplify procedural execution, facilitate reproducibility and lower the barriers to adoption.

Transaxillary minimally invasive mitral valve surgery: early and mid-term outcomes in 763 patients

2026-09-24

Pietro Giorgio Malvindi, Francesca Spagnolo, Sara Pierdicca, Olimpia Bifulco, Jacopo Alfonsi, Mariano Cefarelli, Filippo Capestro, Alessandro D’Alfonso, Carlo Zingaro, Paolo Berretta, Marco Di Eusanio

Background: The transaxillary (TAxA) approach has been developed as a simplified direct-vision minimally invasive access for heart valve surgery. We report a large single-center cohort of patients undergoing TAxA minimally invasive mitral valve surgery and evaluate early safety, procedural efficacy, recovery and mid-term outcomes. Methods: Consecutive patients who underwent TAxA mitral valve surgery at the University Hospital of Marche, Ancona, Italy, between January 2017 and April 2026 were included. Mitral repair or replacement procedures were considered with or without concomitant tricuspid valve repair, atrial fibrillation ablation or left atrial appendage occlusion. Early outcomes were analyzed in the overall cohort. Mid-term survival and reoperation were assessed in patients undergoing repair for degenerative mitral regurgitation. Results: The study included 763 patients. Mitral valve repair was performed in 640 patients and replacement in 123. The repair rate was 89% in patients with mitral regurgitation and 92% in patients with degenerative mitral regurgitation. Concomitant tricuspid repair, atrial fibrillation ablation and left atrial appendage occlusion were performed in 17%, 5% and 10% of patients, respectively. Mean cardiopulmonary bypass and cross-clamp times were 103 and 63 minutes. Thirty-day mortality was 0.4%, stroke or transient ischemic attack occurred in 0.7%, and conversion to sternotomy was required in 0.7%; no conversion was due to poor exposure. Median ventilation time was 2 [interquartile range (IQR), 0–6] hours, 54% of patients were extubated in theatre and 80% were extubated within 6 hours. Median intensive care unit and hospital stays were 24 (IQR, 22–48) hours and 7 (IQR, 6–9) days. In the degenerative repair cohort, Kaplan-Meier survival was 97.0% at 5 years, and cumulative incidence of reoperation was 4.3% at 5 years. Conclusions: In this large contemporary experience, TAxA minimally invasive mitral valve surgery was associated with low early mortality and morbidity, reasonable operative times, frequent ultra fast-track extubation, and satisfactory mid-term results.

Transaxillary access for ascending aortic and root surgery: a single-center comparison with full and partial sternotomy

2026-09-24

Daniel-Sebastian Dohle, Philipp Pfeiffer, Christian Keller, Edoardo Zancanaro, Ahmed Ghazy, Franz Masseli, Chris Probst, Hendrik Treede

Background: Minimally invasive approaches for ascending aortic and root surgery remain controversial regarding operative complexity and safety. The transaxillary (TAX) approach avoids sternotomy entirely but has not been compared with both full sternotomy (FS) and partial upper sternotomy [minimally invasive cardiac surgery (MIC)]. This study evaluates perioperative outcomes across these three access strategies. Methods: Between January 2022 and December 2025, 194 consecutive patients undergoing elective isolated ascending aortic or root surgery were retrospectively analyzed. Surgical access was FS (n=52), MIC (n=106), or TAX (n=36). TAX suitability was assessed by team consensus on electrocardiogram (ECG)-gated computed tomography (CT). Primary endpoints were in-hospital mortality, major complications [Society of Thoracic Surgeons (STS) composite], and hospital length of stay. TAX was compared with MIC after 1:2 propensity score matching. FS served as descriptive reference. Results: FS patients had higher EuroSCORE II (median 2.7 vs. MIC 2.2 vs. TAX 2.3%, P=0.006). Cardiopulmonary bypass time was longer in TAX {196 [interquartile range (IQR): 175–239] vs. MIC 160 [138–192] vs. FS 172 [140–198] min, P vs. 68 MIC), bypass time remained longer in TAX (196 [175–240] vs. 160 [139–190] min, P vs. 11.8%), AKI (2.9% vs. 10.3%), atrial fibrillation, and wound complications did not differ significantly. Conclusions: TAX ascending aortic and root surgery was feasible in carefully selected patients, with no in-hospital mortality, no stroke, and no wound complications. In a propensity-matched comparison with partial upper sternotomy, early outcomes did not differ significantly despite longer bypass time. TAX extends the sternal-sparing concept to the aortic root and ascending aorta and warrants prospective evaluation.

Prognostic significance of right ventricular-pulmonary artery coupling in patients undergoing tricuspid valve surgery

2026-04-01

Jagdip Kang, Antonio Mutarelli, Svitlana Bielichenko, Abdellaziz Dahou, Jacob P. Dal-Bianco, Michael A. Borger, Nathaniel B. Langer, David D’Alessandro, Judy Hung, Thoralf M. Sundt, Evin Yucel, Serguei Melnitchouk

Background: The accurate evaluation of right ventricular function and its response to correction of tricuspid valve pathology are challenging. This retrospective study evaluated the predictive value of right ventricular-pulmonary arterial (RV-PA) coupling in patients undergoing isolated or combined tricuspid and mitral valve surgery. Methods: Patients at Massachusetts General Hospital who underwent isolated tricuspid or combined tricuspid and mitral valve surgery between January 2013 and June 2024 with available preoperative transthoracic echocardiography images were included. The RV-PA coupling ratio was calculated by dividing the tricuspid annular plane systolic excursion (TAPSE) by PA systolic pressure. The optimal cut-off value for this ratio was determined using the maximal log-rank test. The primary outcome was mid-term survival, while secondary outcomes included in-hospital mortality, intensive care unit (ICU) stay duration, hospital stay, and prolonged postoperative inotrope use. Results: A total of 264 patients were followed for a median of 23 months (interquartile range, 7.0–48.0 months). The optimal RV-PA coupling ratio linked to mortality was 0.339 mm/mmHg. Patients with an RV-PA coupling ratio of ≤0.339 mm/mmHg had significantly higher all-cause mortality (25.5% vs. 10.0%; P<0.002), longer median ICU stay (4.0 vs. 3.0 days; P<0.001), longer median hospital stay (11.5 vs. 9.0 days; P=0.002), increased need for inotropic support (45.7% vs. 21.8%; P<0.001), and higher in-hospital mortality (10.6% vs. 2.9%). In multivariable Cox regression analysis, an RV-PA coupling ratio >0.339 mm/mmHg was linked to a reduced risk of all-cause mortality (hazard ratio 0.09, P=0.003). TAPSE and RV free-wall strain showed no association with mortality. Conclusions: Echocardiography-derived RV-PA coupling is a robust, independent predictor of adverse outcomes in patients undergoing tricuspid valve surgery, particularly in those undergoing combined procedures. It captures a critical dimension of RV physiology not fully appreciated by standard measures and may serve as a powerful tool in surgical risk stratification and patient selection.

Tricuspid transcatheter edge-to-edge repair in patients with cardiac implantable electronic device leads

2026-04-01

Vandan Upadhyaya, Perry Wengrofsky, Sung-Han Yoon, Craig Basman, Ryan Kaple

Cardiac implantable electronic devices (CIEDs) are frequently encountered in patients undergoing transcatheter edge-to-edge repair (TEER) for severe tricuspid regurgitation (TR), with a prevalence exceeding 30%. Transvalvular leads introduce unique anatomic and procedural challenges, including imaging shadowing, leaflet tethering, device-lead interaction, and risk of entanglement during repair. Successful intervention requires careful preprocedural assessment of tricuspid valve anatomy, mechanism of TR, inferior vena cava (IVC) alignment, and the spatial relationship of right atrial, coronary sinus, right ventricular, or leadless systems to the tricuspid apparatus. This manuscript describes a structured intraoperative approach to managing CIED leads during tricuspid TEER (tTEER). The strategy incorporates multi-site femoral venous access, stiff-wire straightening techniques to correct IVC offset, and the use of a steerable sheath to achieve controlled intracardiac lead manipulation. Step-by-step technical considerations are detailed, including lead tethering, commissural repositioning, and controlled release following device deployment. This approach aims to standardize management of CIED-related challenges and provide a reproducible technique for safe and effective tTEER in this complex cohort.

Comparison of biplanar- with 3D-vena contracta and vena contracta area for the assessment of tricuspid valve regurgitation by intraoperative transesophageal echocardiography

2026-03-30

Rajni Singh, Massimiliano Meineri, Waseem Zakhary, Sophia Sgouropoulou, Joerg Ender, Anna Flo Forner

Background: Tricuspid regurgitation (TR) is often incidentally detected at intraoperative transesophageal echocardiography (TEE), resulting in possible changes in the surgical plan. The aim of this study was to compare 2D and 3D measurements of TR vena contracta width (VCW) and the degree of TR severity using TEE from the three standard mid-esophageal (ME) views. Methods: In a prospective observational study, we analyzed 3D and 2D TEE datasets from 30 adult patients undergoing elective tricuspid valve (TV) repair. 2D and 3D TEE color flow Doppler (CFD) loops of the TV in the three standard ME views (4Chamber, RV inflow-outflow (inflow) and modified bicaval) were recorded immediately after induction of anesthesia. VCW from single views and the average of the measurement of biplane VCW (2D biplane VCW) from each standard view were compared with the maximum and minimum diameters of the 3D vena contracta area (VCA) and their average (3D average VCW). TR severity classification was compared between 2D biplane VCW and 3D average VCW and VCA. Correlation between measurements was analyzed using Pearson coefficient and agreement assessed using the Bland-Altman method. Cohen’s Kappa correlation was used to assess TR severity concordance. Results: Biplane VCW in all three ME views underestimated 3D average VCW measurement, with VCW from ME inflow view showing the best agreement. VCW measurements in single standard views systematically underestimated the maximum 3D VCA diameter. We detected very good agreement in TR grading between 3D average VCW and 3D VCA, and an underestimation by 2D biplane VCW (moderate agreement for inflow and fair for the other views). Intra- and inter-observer correlation when repeating 2D measurements was more reliable than that for 3D measurements. Conclusions: Our study shows that 2D biplane VCW from the ME inflow view best agrees with 3D average VCW and allows the most accurate classification of TR severity compared to 3D average VCW.

Transcatheter and surgical management of tricuspid valve disease: multidisciplinary lifetime management considerations

2026-03-27

Suzanne de Waha, Thilo Noack, Tobias Kister, Steffen Desch, Mateo Marín-Cuartas, Philipp Kiefer, Michael A. Borger

Tricuspid valve disease (TVD) has long been underrecognized compared with left-sided valvular disorders, yet it represents a major determinant of cardiovascular morbidity and mortality. Tricuspid regurgitation (TR), the predominant manifestation of TVD, is being recognized with increasing frequency as populations age and the burden of left-sided heart disease rises. While mild TR is often physiological, moderate and severe TR are associated with adverse outcomes, independent of left ventricular function or pulmonary pressures. Secondary TR, driven by right atrial or right ventricular remodeling, constitutes the majority of cases, whereas primary TR due to intrinsic valvular pathology is less frequent. Cardiac implantable electronic device (CIED)-related TR represents a distinct and increasingly prevalent mechanism that often requires dedicated management considerations. Historically, management of TVD has often been delayed until the onset of advanced right heart failure or end-organ dysfunction, resulting in poor outcomes. Contemporary evidence emphasizes the importance of early recognition, precise etiologic characterization, and timely intervention within a multidisciplinary framework. Surgical repair, particularly annuloplasty, remains the reference standard in suitable candidates, offering durable results when performed before irreversible right ventricular remodeling develops. Transcatheter tricuspid valve interventions have expanded therapeutic options for high-risk or inoperable patients, demonstrating symptomatic and hemodynamic improvement in early studies. Optimal management of TVD follows a lifetime approach, integrating multimodality imaging, risk stratification, and individualized treatment strategies. General physicians and cardiologists play a key role in early detection, while coordinated collaboration among imaging specialists, electrophysiologists, heart failure experts, interventional cardiologists, cardiac surgeons, and anesthesiologists is essential for comprehensive care. Ultimately, a patient-centered lifetime management strategy initiated early and adapted to disease progression offers the best opportunity to preserve right heart function, improve survival, and maintain quality of life in patients with TVD.