Isolated tricuspid valve regurgitation secondary to infective endocarditis is most commonly associated with pacemaker infection or intravenous drug abuse,¹ x 1 Baraki, H., Saito, S., Al Ahmad, A., Fleischer, B., Schmitto, J., Haverich, A. et al. Surgical treatment for isolated tricuspid valve endocarditis—long-term follow-up at a single institution. Circ J. 2013; 77: 2032–2037 Crossref | PubMed | Scopus (16) | Google Scholar See all References and the surgical options for treating this pathologic entity are suboptimal. Mechanical and bioprosthetic valves are subject to thrombosis or degenerative calcification, respectively,² x 2 Said, S.M., Burkhart, H.M., Schaff, H.V., Johnson, J.N., Connolly, H.M., and Dearani, J.A. When should a mechanical tricuspid valve replacement be considered?. J Thorac Cardiovasc Surg. 2014; 148: 603–608 Abstract | Full Text | Full Text PDF | PubMed | Scopus (14) | Google Scholar See all References ^{, 3} x 3 Rodriguez-Capitan, J., Gomez-Doblas, J.J., Fernandez-Lopez, L., Lopez-Salguero, R., Ruiz, M., Leruite, I. et al. Short- and long-term outcomes of surgery for severe tricuspid regurgitation. Rev Esp Cardiol (Engl Ed). 2013; 66: 629–635 Crossref | PubMed | Scopus (5) | Google Scholar See all References ^{, 4} x 4 Garatti, A., Nano, G., Bruschi, G., Canziani, A., Colombo, T., Frigiola, A. et al. Twenty-five year outcomes of tricuspid valve replacement comparing mechanical and biologic prostheses. Ann Thorac Surg. 2012; 93: 1146–1153 Abstract | Full Text | Full Text PDF | PubMed | Scopus (33) | Google Scholar See all References and no commercially available valve prostheses are specifically designed for the tricuspid valve's distinct anatomy, in particular, the elliptical shape of the annulus.⁵ x 5 Bateman, M.G., Quill, J.L., Hill, A.J., and Iaizzo, P.A. The clinical anatomy and pathology of the human atrioventricular valves: implications for repair or replacement. J Cardiovasc Transl Res. 2013; 6: 155–165 Crossref | PubMed | Scopus (12) | Google Scholar See all References Prosthetic valves in the tricuspid position are frequently associated with heart block⁶ x 6 Kratz, J.M., Crawford, F.A.J., Stroud, M.R., Appleby, D.C.J., and Hanger, K.H. Trends and results in tricuspid valve surgery. Chest. 1985; 88: 837–840 Crossref | PubMed | Scopus (32) | Google Scholar See all References and are susceptible to residual infection. Furthermore, reinfection has been common in the context of the high recidivism rates among intravenous drug abusers.⁷ x 7 Miro, J.M., Moreno, A., and Mestres, C.A. Infective endocarditis in intravenous drug abusers. Curr Infect Dis Rep. 2003; 5: 307–316 Crossref | PubMed | Scopus (30) | Google Scholar See all References

Geometric ring annuloplasty has shown promise during bicuspid aortic valve repair for aortic insufficiency. This study examined early outcomes of bicuspid aortic valve repair associated with proximal aortic aneurysm replacement. From September 2017 to November, 2021, 127 patients underwent bicuspid aortic valve repair with concomitant proximal aneurysm reconstruction. Patient age was 50.6 ± 12.7 years (mean ± standard deviation), male gender was 83%, New York Heart Association Class was 2 (1-2) (median [interquartile range]), and preoperative aortic insufficiency grade was 3 (2-4). Ascending aortic diameter was 50 (46-54) mm, and all patients had ascending aortic replacement. Forty patients had sinus diameters greater than 45 mm, prompting remodeling root procedures. A total of 105 patients had Sievers type 1 valves, 3 patients had type 0, and 7 patients had type 2. A total of 118 patients had primarily right/left fusion, 8 patients had right/nonfusion, and 1 patient had left/nonfusion. Leaflet reconstruction used central leaflet plication and cleft closure, with limited ultrasonic decalcification in 31 patients. Ring size was 23 (21-23) mm, and 26 of 40 root procedures were selective nonfused sinus replacements. Aortic clamp time was 139 (112-170) minutes, and bypass time was 178 (138-217) minutes. Postrepair aortic insufficiency grade was 0 (0-0) (P < .0001), and mean valve gradient was 10 (7-14) mm Hg. No early and 1 late mortality occurred. Four patients required reoperation for bleeding, and 4 patients required pacemakers. At a mean follow-up of 20 months (maximal 93), there were no valve-related complications, 5 late repair failures prompting valve replacement, and 1 death due to Coronavirus Disease 2019. Geometric ring annuloplasty for bicuspid aortic valve repair with proximal aortic aneurysm reconstruction is safe and associated with good early outcomes. Further experience and follow-up will help inform long-term durability.

BACKGROUND: The role of left atrial appendage occlusion (LAAO) in patients without previous atrial fibrillation (AF) is not established. This meta-analysis was conducted on patients with normal sinus rhythm who underwent cardiac surgery, with and without concomitant LAAO, to evaluate its effect on the incidence of cerebrovascular accidents (CVAs). METHODS: A systematic review was conducted from inception until December 2023 for randomized and propensity-score studies comparing CVA in patients without AF undergoing cardiac surgery with or without LAAO. RESULTS: Six studies met our inclusion criteria with a total of 4130 patients: 2146 in the LAAO group and 1984 in the no-LAAO group. The risk ratio of postoperative AF was 1.05 (95% CI, 0.86–1.28); P =0.628. The CVA rates at 5 years were 6.8±1.0% in the no-LAAO group and 4.3±0.8% in the LAAO group (log-rank P =0.021). The Cox regression analysis for CVA in patients undergoing LAAO reported a hazard ratio of 0.65 (95% CI, 0.45–0.94); P =0.022. Landmark analysis at 4 years highlighted a significant difference in overall survival between no-LAAO and LAAO groups, 86±12.2% versus 89.6±11.0%; P =0.041. CONCLUSIONS: In this meta-analysis of patients without previous AF undergoing cardiac surgery, LAAO was associated with a decreased risk of CVA, no difference in the incidence of postoperative atrial fibrillation, and a significant overall survival benefit at a 4-year landmark analysis. Although these findings support LAAO, the randomized LeAAPS trial (Left Atrial Appendage Exclusion for Prophylactic Stroke Reduction Trial), LAA-CLOSURE trial (A Randomized Prospective Multicenter Trial for Stroke Prevention by Prophylactic Surgical Closure of the Left Atrial Appendage in Patients Undergoing Bioprosthetic Aortic Valve Surgery), and LAACS-2 trial (Left Atrial Appendage Closure by Surgery-2) will help define the effectiveness of LAAO in patients undergoing cardiac surgery who have risk factors for AF and CVA. REGISTRATION: URL: https://www.crd.york.ac.uk/prospero/ ; Unique identifier: CRD42024496366.

Benefits of concomitant atrial fibrillation (AF) surgical treatment are well established. Cardiac societies support treating AF during cardiac surgery with a class I recommendation. Despite these guidelines, adoption has been inconsistent. We report results of routine performance of concomitant Cox‐Maze IV (CMIV) from participating centers using a standardized, prospective registry. Nine surgeons at four cardiac surgery programs enrolled 807 patients undergoing concomitant CMIV surgery over 12 years. Lesions were created using bipolar radiofrequency clamps and cryoablation probes. Follow‐up occurred at 3‐ and 6‐months, then annually for 3 years. Freedom from AF was defined as no episode >30 s of atrial arrhythmia. Sixty‐four percent of patients were male, mean age 69 years, mean left atrial size 4.6 cm, mean preoperative AF duration 4.0 years, mean EuroSCORE 6.4, and mean CHADS₂ score 3.1. Thirty‐day postoperative mortality and neurologic event rates were 3.3% and 1.3%, respectively. New pacemaker implant rate was 6.3%. Freedom from AF rates at 1‐ and 3‐years stratified by preoperative AF type were: paroxysmal 94.6% and 87.5%, persistent 82.1% and 81.9%, and longstanding persistent 84.1% and 78.1%. At 3‐year follow up, 84% of patients were off antiarrhythmic drugs and 74% of sinus rhythm patients were off oral anticoagulants. Routine CMIV is safe and effective. Acceptable outcomes can be achieved across multiple centers and multiple operators even in a moderate risk patient population undergoing more complex procedures. Surgeons and institutions should be encouraged by all cardiac societies to adopt the CMIV procedure to maximize patient benefit.