Cardiothoracic Surgery

TAVI vs SAVR in bicuspid AS >60: early gain, worse midterm outcomes

This meta-analysis reconstructed time-to-event data from five comparative studies of 5901 TAVI and 12,427 SAVR patients with bicuspid AS aged ≥60 years. By 48 months, TAVI had higher hazard of death, stroke, or unplanned rehospitalization than SAVR (HR 1.62; 95% CI 1.46–1.79). Landmark analysis showed an initial outcome benefit with TAVI that reversed after 6 months and persisted through 12–48 months. Multiple sensitivity approaches, including frailty Cox and restricted mean survival time, confirmed limited midterm benefit of TAVI in this setting. These data support SAVR as the default for suitable older bicuspid AS patients, reserving TAVI for carefully individualized indications. 1

Sivelestat reduces ARDS and improves 90-day survival after cardiovascular surgery

In this single-center randomized trial, 424 patients undergoing major cardiovascular surgery received postoperative continuous IV sivelestat or placebo for up to 7 days. Among 382 completers, sivelestat lowered ARDS incidence compared with placebo (16.8% vs 31.2%; P<.001). Ninety-day mortality was also reduced with sivelestat (1.1% vs 5.2%; P=.02), without excess monitored adverse events. Neutrophil elastase and interleukin-6 concentrations were significantly lower with sivelestat, supporting a biologically plausible mechanism. These findings suggest neutrophil elastase inhibition may meaningfully attenuate postoperative lung injury, but multicenter confirmation is needed before routine use. 2

Robotic vs VATS lung cancer surgery: incremental benefits, higher costs

This PRISMA-based meta-analysis pooled 25 randomized and cohort studies including 41,417 patients undergoing RATS or VATS for pulmonary tumors. RATS was associated with lower conversion to thoracotomy, less blood loss, more extensive lymphadenectomy, and higher R0 resection rates. Robotic procedures had shorter chest tube duration, ICU stay, and overall hospital stay, with lower pneumonia and atrial fibrillation rates. Overall complications as well as 30- and 90-day mortality were similar between platforms, but hospitalization costs were higher with RATS. Pooled survival suggested a possible long-term advantage of RATS, warranting definitive randomized trials and cost-effectiveness analyses. 3