Background and Aims: Severe tricuspid regurgitation is associated with increased mortality rates, but benefit of its correction and ideal timing are not clearly determined. This study aimed to identify patient subsets who might benefit from the surgery. Methods: In TRIGISTRY, an international cohort study of consecutive patients with severe isolated functional tricuspid regurgitation (33 centres, 10 countries), survival rates up to 10 years were compared between patients who underwent isolated tricuspid valve surgery (repair or replacement) and those conservatively managed, overall and according to TRI-SCORE category (low: ≤3, intermediate: 4–5, and high: ≥6). Results: One thousand and two hundred seventeen were managed conservatively, and 551 underwent isolated tricuspid valve surgery (200 repairs and 351 replacements). TRI-SCORE distribution was 33% low, 32% intermediate, and 35% high. At 10 years, survival rates were similar between surgical and conservative management [41% vs. 36%; hazard ratio (HR) .97; 95% confidence interval (CI) .88–1.08, P = .57]. Surgery improved survival compared with conservative management in the low TRI-SCORE category (72% vs. 44%; HR .27; 95% CI .20–.37, P < .0001), but not in the intermediate (36% vs. 37%; HR 1.17; 95%CI .98–1.40, P = .09) or high categories (20% vs. 24%; HR 1.06; 95% CI .91–1.25, P = .45). Both repair and replacement improved survival in the low TRI-SCORE category (84% and 61% vs. 44%; HR .11; 95% CI .06–.19, P < .0001, and HR .65; 95% CI .47–.90, P = .009). Repair showed benefit in the intermediate category (59% vs. 37%; HR .49; 95% CI .35–.68, P < .0001) while replacement was possibly harmful (25% vs. 37%; HR 1.43; 95% CI 1.18–1.72, P = .0002). Conclusions: Higher survival rates were observed with repair than replacement and benefit of intervention declined as TRI-SCORE increased with no benefit of any type of surgery in the high TRI-SCORE category. These results emphasize the importance of timely intervention and patient selection to achieve the best outcomes and the need for randomized controlled trials.

Reoperative mitral valve surgery (MVS) through a median sternotomy (ST-MVS) can be particularly challenging due to dense adhesions and is known to carry a substantial risk of injuries to vascular structures. These injuries occur in 7–9% of cases and are associated with increased mortality rates. A valid alternative that could avoid the risks associated with redo ST-MVS is the right anterolateral minithoracotomy (MT-MVS) approach. The aim of this study was to quantify the effects of MT-MVS compared with those of ST-MVS on morbidity and mortality among patients who underwent prior cardiac surgery through a sternotomy. The MEDLINE and EMBASE databases were searched through 1 November 2017. Data regarding mortality, stroke, reoperation for bleeding and length of hospital stay were extracted and submitted to a meta-analysis using random effects modelling and the I²-test for heterogeneity. Six retrospective observational studies were included, enrolling a total of 777 patients. In a pooled analysis, MT-MVS demonstrated reduced mortality rates compared to a standard sternotomy [odds ratio (OR) 0.41, 95% confidence interval (CI) 0.18–0.96; P = 0.04]. MT-MVS was, moreover, associated with reduced length of hospital stay [difference between the means was −3.81, 95% CI −5.53 to −2.08; P < 0.0001) and reoperation for bleeding (OR 0.32, 95% CI 0.10–0.99; P = 0.0488). The incidence of stroke was similar (OR 1.51, 95% CI 0.65–3.54; P = 0.34), all in the absence of heterogeneity. In conclusion, reoperative minimally invasive MVS through a minithoracotomy is a safe alternative to standard sternotomy, with reduced mortality rates, length of hospital stay and reoperations for bleeding and a comparable risk of stroke. However, because the existing literature provided limited, low-quality evidence, more methodologically rigorous randomized controlled trials are needed.

Summary: The integration of artificial intelligence (AI) into surgery raises significant ethical concerns, including the impact on autonomy, human authority and the patient–doctor relationship. This study underscores the need for a multidisciplinary approach to navigate these ethical dilemmas, involving stakeholders from various fields. A comprehensive literature review up to March 2024 was conducted to assess the ethical implications of AI applications in surgery. This included an examination of data privacy, informed consent, algorithmic bias, the role of advanced robotics, and the impact on surgeons’ decision-making. The study also considered the development of autonomous surgical robots and their ethical implications. The review highlights that while AI can enhance surgical precision and improve clinical decision-making, it also poses several ethical challenges. AI’s ability to support decision-making risks undermining surgeons’ autonomy and judgement, raising concerns about over-reliance on technology. Issues such as data privacy, algorithmic bias and equitable access to AI-driven tools were identified as key ethical concerns. Autonomous surgical robots, while promising, introduce complex questions about accountability and liability, particularly when unexpected outcomes occur. Effective integration of AI into surgical practices demands the development of ethical frameworks that respect both the capabilities of AI and the irreplaceable value of human judgement. Balancing technological advancement with ethical integrity is essential to safeguard patient-centred care and ensure equitable access to AI benefits in healthcare.

Patients scheduled for cardiac surgery and procedures often present with modifiable risk factors for adverse perioperative outcomes. Prehabilitation has shown potential to enhance mental and physical fitness however, its effect on clinical cardiovascular endpoints in this population has not been studied. The current trial was designed to evaluate the effect of a personalized multimodal teleprehabilitation on the incidence of composite endpoint on major adverse cardiovascular events (MACE) in patients scheduled for elective cardiac surgery. In a multicentre randomized controlled trial, 394 patients awaiting elective cardiac surgery and procedures were enrolled. Of these, 197 patients were randomized to an online multimodal personalized teleprehabilitation program through shared-decision making by a multidisciplinary team, and 197 were assigned to a control group. The primary outcome was MACE, (i.e., cardiovascular death, myocardial infarction, stroke, hospitalization for heart failure or other life-threatening cardiac events, and earlier or repeated intervention), as measured from the randomization until 1-year postoperatively. All events were adjudicated by a blinded event committee. Secondary outcomes included length of hospital stay, postoperative complications, quality of life, adherence to the program, and effect on the incidence of modifiable risk factors. Sensitivity analyses of the primary outcome were conducted adjusting for baseline characteristics to evaluate the consistency of treatment effects. From randomization until one year postoperatively, the primary endpoint occurred in 33 patients (16.8%) in the teleprehabilitation group and 50 patients (25.5%) in the control group (difference 8.8%; 95% confidence interval (CI) 0.7 to 16.8; P=0.032). This difference was primarily driven by a reduction in hospitalizations and the sensitivity analyses showed that treatment effect was mainly in the patients undergoing a cardiac surgery rather than transcatheter procedures with adjusted odds ratio of 0.54 (95% CI, 0.30-0.96; P = 0.035). Teleprehabilitation also reduced the incidence of active smokers, elevated pulmonary risk scores, and elevated depression scores. There was no significant difference in postoperative length of hospital stay, occurrence of postoperative complications, physical fitness, incidence of obesity, or malnutrition. Multimodal personalized teleprehabilitation resulted in a clinically relevant and statistically significant reduction of the primary endpoint in patients undergoing cardiac surgery. gov (NCT04393636).

OBJECTIVES: Minimally invasive mitral valve surgery (MIMVS) has been performed increasingly for the past 2 decades; however, large comparative studies on short- and long-term outcomes have been lacking. This study aims to compare short- and long-term outcomes of patients undergoing MIMVS versus median sternotomy (MST) based on real-world data, extracted from the Netherlands Heart Registration. METHODS: Patients undergoing mitral valve surgery, with or without tricuspid valve, atrial septal closure and/or rhythm surgery between 2013 and 2018 were included. Primary outcomes were short-term morbidity and mortality and long-term survival. Propensity score matching analyses were performed. RESULTS: In total, 2501 patients were included, 1776 were operated through MST and 725 using an MIMVS approach. After propensity matching, no significant differences in baseline characteristics persisted. There were no between-group differences in 30-day mortality (1.1% vs 0.7%, P = 0.58), 1-year mortality (2.6% vs 2.1%, P = 0.60) or perioperative stroke rate (1.1% vs 0.6%, P = 0.25) between MST and MIMVS, respectively. An increased rate of postoperative arrhythmia was observed in the MST group (31.3% vs 22.4%, P < 0.001). A higher repair rate was found in the MST group (80.9% vs 76.3%, P = 0.04). No difference in 5-year survival was found between the matched groups (95.0% vs 94.3%, P = 0.49). Freedom from mitral reintervention was 97.9% for MST and 96.8% in the MIMVS group (P = 0.01), without a difference in reintervention-free survival (P = 0.30). CONCLUSIONS: The MIMVS approach is as safe as the sternotomy approach for the surgical treatment of mitral valve disease. However, it comes at a cost of a reduced repair rate and more reinterventions in the long term, in the real-world.