William D. T. Kent

Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic disorder characterized by a dynamic left ventricular outflow tract (LVOT) obstruction and an increased risk of sudden cardiac death. For patients with symptoms refractory to medical management, or intolerant to the new selective myosin inhibitor, septal reduction therapy (SRT) with surgical septal myectomy (SM) is indicated. This narrative review provides a contemporary assessment of septal myectomy, integrating its historical development, technical advancements, and comparative long-term outcomes. SM is established as the current reference standard, offering extensive anatomical relief and favorable long-term survival in clinical registries. It consistently achieves residual LVOT gradients 5 years). The disparity in long-term survival and the risk associated with sequential septal reduction procedures underscore the critical need for precise patient selection guided by institutional expertise. Furthermore, advancements like virtual surgical myectomy and transapical beating-heart septal myectomy are expanding the scope of intervention. This review synthesizes comparative contemporary data on HOCM management, highlighting the need for prospective, multicenter studies to address enduring knowledge gaps concerning equitable access, genotype integration, and long-term comparative effectiveness as current evidence remains dominated by retrospective studies.

Background: Comprehensive knowledge of the clinical presentation, contemporary management, and outcomes on "allcomer" patients referred for mitral valve surgery (MVS) are critical to evaluate current practice and adherence to guidelines, understand selection biases, and inform key stakeholders on quality improvement. Methods: MITRACURE is a large international retrospective registry of consecutive adult patients who underwent isolated or combined MVS for mitral regurgitation (MR) in France or Canada in 2019 with in-depth clinical and echocardiographic characterization. Patients operated on for isolated mitral stenosis or who had a prior mitral valve intervention were excluded. Data were obtained from detailed chart abstraction and were site reported. Results: In 2019, 3522 patients underwent MVS (48% combined) across 40 centers (88±46 MVSs/center, median 80, interquartile [51–131]). Mean age was 65±12 years, and 35% were women. The most common MR etiology was myxomatous (61%), followed by functional (9%), infective endocarditis (9%), and rheumatic disease (7%). MR quantification was performed in only 43%. Advanced clinical presentation was common: 43% were in New York Heart Association class III/IV, 30% exhibited congestive heart failure, 47% were on diuretics, 22% had atrial fibrillation/flutter, 35% presented with reduced ejection fraction, and 22% had pulmonary hypertension (≥50 mm Hg). Most patients were symptomatic or presented with class I/IIa indication for intervention, and an early intervention was performed only in 3% of patients. The repair rate was 62% overall and 80% in myxomatous disease. In-hospital mortality was 4.5% overall but 2.3% in patients with myxomatous MR (1.8% isolated, 3.1% combined). Conclusions: MITRACURE provides a contemporary, multicenter, "real-world" picture of the clinical presentation, management, and in-hospital outcomes of MVS for MR in two Western countries. Patients were often referred late in the disease process, with few patients undergoing early intervention. The higher mortality and lower repair rates reported may be more reflective of an unselected MR patient population but have room for improvement. Our results underline the need to develop strategies to improve management and outcomes of patients with MR.

Enhanced Recovery After Surgery (ERAS) is an evidence-based, holistic perioperative recovery protocol intended to improve patient outcomes and decrease postoperative complication rates. While ERAS protocols were first introduced in 1997, specific guidelines for cardiac surgery were not established until 2019. Although the core principles of ERAS remain constant across surgical disciplines, ERAS guidelines for cardiac surgery have remained relatively understudied, likely due to the unique complexities posed by cardiac procedures. Within this comprehensive narrative review, we aimed to explore the current guidelines and evidence for ERAS in both cardiac and non-cardiac surgeries. In non-cardiac surgeries, ERAS has been shown to improve various outcomes, including ICU length of stay, patient satisfaction, and pain management. ERAS for cardiac surgery has also shown encouraging results, including shorter ICU and hospital stays, reduced postoperative opioid use, and faster recovery times. However, there is limited consensus across studies, particularly regarding its impact on morbidity and mortality, with mixed results reported. Furthermore, the limited data on the efficacy of ERAS in minimally invasive cardiac surgeries makes it difficult to establish well-supported guidelines for these procedures. Despite its limitations, the overall outcomes of ERAS for cardiac surgery remain promising. As our understanding and application of ERAS in cardiac surgery continue to evolve, these protocols have the potential to redefine cardiac surgical care standards.

Background: Coronary artery bypass grafting (CABG) has been associated with reduced mortality, myocardial infarction, and repeat revascularization compared with percutaneous coronary intervention (PCI) for patients with 3‐vessel coronary artery disease (CAD) and diabetes. The majority of previous studies have been limited to follow‐up of P =0.003, adjusted hazard ratio [aHR], 0.75 [95% CI, 0.61–0.91]), myocardial infarction (15.6% versus 28.1%, P P P =0.656) and stroke (11.6% versus 12.2%, P =0.794) did not significantly differ between groups. Conclusions: In this study, we describe one of the longest follow‐up periods for patients with diabetes and 3‐vessel coronary artery disease who underwent CABG or PCI and confirmed that the shorter‐term benefits seen in randomized trials do translate into longer‐term reductions in risk of death, myocardial infarction, or repeat revascularization.

By sparing the sternum, the right anterior minithoracotomy (RAMT) approach may facilitate a quicker functional recovery when compared with conventional aortic valve replacement (AVR). In the following review, outcomes after RAMT AVR are compared with full sternotomy AVR. The RAMT approach is described, including suggestions for patient selection. The application of the RAMT approach for other cardiac procedures is also discussed.

Objective: The surgical treatment of aortic stenosis continues to evolve, and sutureless aortic valve replacement (SUAVR) is an emerging technology. With the Perceval S (Corcym, London, UK) as the only true sutureless valve on the market, the objective of this review is to analyze the current literature on Perceval S. Focusing on valve design and deployment as well as applications of the technology for challenging pathology, clinical outcomes are assessed, including a comparison with transcatheter AVR (TAVR). Methods: PubMed and MEDLINE were searched by 3 authors for studies analyzing SUAVR from inception to May 19, 2023. Results: SUAVR facilitates minimally invasive surgery and offers an alternative strategy for patients with small aortic annuli. It also has a time-saving advantage for patients who require complex operations. SUAVR results in excellent long-term morbidity, mortality, durability, and hemodynamic function. In comparison with conventional surgical AVR (SAVR), SUAVR does have a greater risk of postoperative pacemaker implantation; however, increasing user experience and refinements in implantation technique have contributed to reductions in this outcome. SUAVR results in morbidity and mortality that is similar to rapid-deployment AVR. Midterm outcomes are superior to TAVR; however, further robust investigation into all of these comparisons is ultimately necessary. Conclusions: SUAVR bridges the gap in technology between SAVR and TAVR. The application of this exciting technology will undoubtedly grow in the coming years, during which additional investigation is paramount to optimize preoperative planning, valve deployment, and reintervention strategies.

Sternal reentry when the ascending aorta is adherent to the posterior table of the sternum is associated with substantial risk. A minimally invasive right thoracotomy beating heart approach is an alternative when the aorta cannot be cross-clamped. This report details this technique for a complex reoperative mitral valve repair procedure performed in a patient with connective tissue disease who had required multiple aortic operations and presented with heart failure and severe functional mitral regurgitation.