Cardiothoracic Surgery

Small-annulus vs large-annulus outcomes after newer-generation balloon-expandable TAVR

This propensity-matched study compared 533 patients with small (≤430 mm²) versus large annuli after newer-generation balloon-expandable TAVR over 5 years. Small-annulus patients had markedly higher rates of mean gradients ≥20 mm Hg and severe prosthesis–patient mismatch. Despite this, all-cause mortality, heart failure rehospitalization, bioprosthetic valve failure, and aortic valve reintervention were similar at 5 years. Both groups achieved sustained improvements in NYHA class and Kansas City Cardiomyopathy Questionnaire scores despite higher gradients in small-annulus patients. 1

Off-label tricuspid TEER/TTVR shows meaningful TR reduction and QoL gains

This STS/ACC TVT registry analysis described 995 commercial off-label tricuspid procedures (238 TTVR, 757 T-TEER) at 142 US sites from 2021–2023. Most centers were very low volume, with 72% performing five or fewer cases, while four centers performed 49–120 procedures each. Among TTVR patients, 97% had ≤ moderate residual TR at 30 days, with substantial KCCQ improvement and 3.9% 30-day mortality and 19% 1-year mortality. Among T-TEER patients, 74% had ≤ moderate residual TR, similar quality-of-life gains, and 3.0% 30-day mortality with 18% 1-year mortality. 2

Pre-Fontan mean PA pressure predicts long-term death or transplant

This multicenter registry included 1,175 children undergoing first-time Fontan with pre-Fontan catheterization between 1982 and 2011. Among 1,111 patients discharged with Fontan physiology, 85 deaths and 49 transplants occurred over a median 20.6-year follow-up. Higher pre-Fontan mean pulmonary arterial pressure was the strongest hemodynamic predictor of death or transplantation with a continuous risk relationship. Twenty-five–year transplant-free survival fell from 83.7% in the lowest mean PA pressure tertile to 73.7% in the highest tertile. Systemic right ventricle and Fontan completion after age four independently increased late death or transplant risk, informing timing and counseling. 3

Conversion from VV ECMO to VA or hybrid is rare but high-risk

In 28,888 adult VV ECMO runs from the ELSO registry, only 702 (2.4%) were converted to VA or hybrid configurations. Conversion was associated with pre-ECMO cardiac disease, bridge-to-lung-transplant indication, vasoactive use, and lower 24-hour PaO2. Configuration change occurred early, at a median of 56 hours after VV initiation, with earlier conversion to hybrid circuits. Converted patients had substantially higher cardiovascular, hemorrhagic, vascular, renal, metabolic, infectious, and circuit-related complications. In-hospital mortality was 60.8% overall and 63.2% for VV-to-VA conversions, highlighting the poor prognosis once escalation is required. 4