Cardiothoracic Surgery

Two-decade experience supports frozen elephant trunk plus total arch in acute type A dissection

In 850 acute type A dissection patients (mean age 46.5 years), frozen elephant trunk plus total arch replacement had 8.4% operative mortality. Major complications included spinal cord injury 2.5%, stroke 3.5%, re-exploration for bleeding 5.6%, and acute kidney injury 8.7%. At 20 years, survival was 70.0% and freedom from reoperation 85.4%, with 99.2% follow-up completeness over a mean 12.5 years. Compared with propensity-matched hemiarch repair, frozen elephant trunk showed similar operative mortality but fewer late adverse events and distal aortic dilatation. Freedom from late adverse events at 20 years was substantially higher with frozen elephant trunk than hemiarch, supporting a more extensive primary repair strategy. 1

REUP allows DCD heart transplantation without reanimation across older donors and long ischemic times

This single-center case series reports 24 adult DCD heart transplants using rapid recovery with extended ultraoxygenated preservation (REUP) without preimplant reanimation or machine perfusion. Donors had a mean age of 32 years, with 38% older than 40 years, and 60% of grafts exceeded 4 hours total ischemic time. Despite these profiles, 30-day survival was 96%, with only 4% severe primary graft dysfunction and 4% secondary graft dysfunction. Acute cellular rejection grade 2R occurred in 4% of patients, with no antibody-mediated rejection on first biopsy. These data support REUP as a feasible, potentially cost-saving DCD procurement approach that may safely expand donor pools and simplify logistics. 2

Public reporting linked to lower-risk case selection, not improved risk-adjusted mortality, in congenital surgery

Among 16,401 congenital heart surgeries at 18 centers, unadjusted in-hospital mortality fell from 3.4% to 2.5% after adoption of public reporting. After adjustment for case complexity, this mortality reduction was no longer statistically significant, suggesting stable risk-standardized outcomes. Predicted probability of mortality decreased by 0.5 percentage points immediately after reporting adoption, indicating a shift toward lower-risk case selection. Observed-to-expected mortality was highest early in the study and improved before public reporting, reflecting ongoing quality gains independent of transparency requirements. These findings imply public reporting may incentivize risk avoidance rather than directly improving risk-adjusted surgical performance. 3

Early rib fixation improves resource use and pulmonary complications in older trauma patients

This National Trauma Data Bank study included 5,129 patients aged 65 years or older undergoing surgical stabilization of rib fractures. Early fixation (<72 hours) was performed in 59.8% and was associated with shorter hospital stay, ICU stay, and mechanical ventilation duration than later fixation. Early surgery also reduced unplanned intubation, tracheostomy, acute respiratory distress syndrome, and pneumonia rates. Mortality did not differ significantly between early and late fixation groups. Multivariable analysis confirmed late fixation independently increased hospital and ICU length of stay and ventilation duration, supporting early stabilization when feasible. 4