The adoption of neoadjuvant immune checkpoint inhibitor (ICI)-based chemoimmunotherapy has fundamentally transformed the operative landscape of resectable non-small cell lung cancer (NSCLC). Surgeons are now routinely confronted with ICI-altered tissue planes characterized by hilar fibrosis, vascular friability, and disrupted lymph node architecture. Simultaneously, robotic-assisted thoracic surgery (RATS) has consolidated its position as the dominant minimally invasive platform for pulmonary resection, accounting for the majority of lobectomies and segmentectomies performed at high-volume centers in 2023. Whether RATS confers specific technical advantages in this increasingly complex operative context remains incompletely characterized. We conducted a structured narrative review of published evidence, synthesizing data from randomized controlled trials, prospective cohorts, national registry analyses, and emerging technology reports addressing RATS in the setting of neoadjuvant ICI-based therapy for NSCLC. A systematic literature search was conducted across PubMed and EMBASE using predefined search terms. Available evidence, though largely retrospective and limited by small sample sizes, consistently demonstrates that RATS after neoadjuvant chemoimmunotherapy is technically feasible and oncologically sound, with R0 resection achievable in virtually all cases. The enhanced three-dimensional visualization, tremor filtration, and instrument degrees of freedom afforded by robotic platforms appear particularly advantageous in the setting of dense hilar adhesions and fragile pulmonary vasculature. Lymph node yield, a recognized robotic advantage, is preserved or enhanced despite post-ICI fibrosis. Pooled conversion rates to thoracotomy, derived from post hoc surgical analyses of ICI trial populations rather than trials designed to measure conversion, are higher than for upfront resection; available retrospective single-center data, including one direct RATS-versus-VATS comparison, suggest lower conversion rates with RATS in experienced hands, though this conclusion requires prospective validation. Emerging platform integrations, including combined robotic bronchoscopy and thoracoscopic surgery, single-port systems, and artificial intelligence-assisted anatomical navigation, are poised to further extend the reach of minimally invasive surgery in this challenging clinical scenario. In experienced centers, RATS appears to offer a technically favorable minimally invasive platform for pulmonary resection after neoadjuvant ICI-based therapy, with potential advantages over VATS in managing immunotherapy-altered anatomy; however, this conclusion is derived from retrospective series and should be interpreted cautiously pending prospective comparative data. Prospective multicenter trials with standardized surgical endpoints are urgently needed.

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have rapidly evolved from glucose-lowering agents to central players in cardiovascular risk reduction. Evidence from landmark randomized controlled trials has established their capacity to reduce major adverse cardiovascular events, promote anti-inflammatory signaling, attenuate ischemia–reperfusion injury, and improve myocardial metabolic efficiency. As the prevalence of obesity, type 2 diabetes mellitus, and heart failure in the cardiac surgical population grows, GLP-1 RAs are increasingly encountered in the perioperative setting. Yet the cardiac surgery literature has yet to synthesize their emergent role coherently. This is a narrative review; no systematic review or meta-analysis was performed. This narrative review integrates mechanistic, clinical, and translational evidence to reframe GLP-1 RAs as potential perioperative cardioprotective agents in patients undergoing cardiac surgery. We examine receptor-level biology, evidence from the GLOBE randomized trial, observational data linking GLP-1 RA use to reduced postoperative atrial fibrillation after coronary artery bypass grafting, the rationale for the forthcoming REVERSE-TAVR trial, and evolving perioperative management guidelines. Key evidence gaps are identified, including the absence of prospective data in open cardiac surgery, aortic surgery, and high-acuity populations. We propose a research agenda and conceptual framework to guide future investigation into GLP-1 RAs as a new dimension of perioperative cardioprotection. The current evidence is hypothesis-generating; a definitive perioperative cardioprotective benefit has not yet been demonstrated in cardiac surgery populations, and these agents are presented here as potential rather than proven cardioprotective tools.

Background: Minimally invasive cardiac valve surgery has emerged as a preferred approach in selected patients, yet optimal postoperative extubation timing remains debated. This systematic review and meta-analysis examined clinical outcomes associated with extubation in the operating room (OR) versus the intensive care unit (ICU) among adult patients undergoing minimally invasive cardiac valve surgery. Methods: The study was conducted according to PRISMA guidelines. A single unit of analysis was applied throughout. Pooled odds ratios were computed with the Mantel–Haenszel random-effects method; where a study reported only a matched or covariate-adjusted estimate, that estimate was reserved for a prespecified sensitivity analysis using the generic inverse-variance method. Results: Five observational studies (2023–2025) including 1101 OR-extubated and 899 ICU-extubated patients from high-volume centers with fast-track or enhanced recovery pathways were included. OR extubation was associated with lower odds of reintubation (OR 0.40; 95% CI 0.24–0.69; I² = 0%), postoperative delirium (OR 0.47; 95% CI 0.31–0.72; I² = 0%), and pneumonia (OR 0.30; 95% CI 0.16–0.53; I² = 0%). No significant differences were observed for new-onset atrial fibrillation, stroke, or reoperation for bleeding. Thirty-day mortality was reported by four of the five studies and comprised few events (5 of 1043 ORE versus 17 of 645 ICE across the four studies reporting this outcome); given the small number of events, the concentration of deaths in the higher-risk ICU-extubated patients, and the reliance of the pooled estimate on two confounded cohorts, this difference is not interpretable as a treatment effect, and no pooled odds ratio is reported here. Length of stay was consistently shorter after OR extubation but was not pooled because of extreme heterogeneity (I² = 96–100%). Sensitivity analyses using adjusted estimates attenuated the associations for reintubation and pneumonia, consistent with substantial confounding by indication. Conclusions: In appropriately selected patients undergoing minimally invasive valve surgery, OR extubation is feasible and is associated with a recovery profile at least comparable to that of ICU extubation. Because extubation location was determined largely by intraoperative and early postoperative stability, these associations should be read as reflecting patient selection rather than a causal benefit of the strategy. The findings support the feasibility of OR extubation in appropriately selected patients at experienced centers and motivate prospective, ideally randomized, evaluation.

Liver transplantation (LT) has evolved from a treatment for end-stage benign liver disease into a therapeutic strategy for selected oncological indications, including hepatocellular carcinoma (HCC), unresectable colorectal liver metastases (CRLM), hepatoblastoma, neuroendocrine tumor hepatic metastases, and hepatic epithelioid hemangioendothelioma. As the indications for LT expand and post-transplant survival improves, pulmonary recurrence has emerged as the predominant pattern of extrahepatic relapse across histologies. Yet no standardized surgical guidelines exist for managing lung metastases in the post-transplant patient. This narrative review synthesizes the available evidence on pulmonary metastasectomy following LT, addressing the incidence and tumor-specific patterns of pulmonary recurrence, the influence of immunosuppression on metastatic biology, surgical indications and contraindications, approach and timing considerations, and patient selection across primary histologies. We propose a practical decision-making framework integrating primary tumor biology, disease-free interval, lesion characteristics, immunosuppression regimen, and systemic therapy response. With the recent regulatory recognition of CRLM as a standard transplant indication and the ongoing SECA-III randomized trial, the downstream surgical management of pulmonary recurrence in LT recipients requires urgent evidence-based codification.

Transcatheter Aortic Valve Replacement (TAVR) has transformed aortic stenosis management across the full risk spectrum, but expansion into younger populations makes valve failure and reintervention central to lifetime planning. There are two pathways to follow when TAVR fails: redo transcatheter implantation and surgical explantation with surgical aortic valve replacement (SAVR), termed TAVR-SAVR. This narrative review synthesizes evidence from four studies (35,677 patients, 2011–2024) examining the association between prior valve type and redo SAVR outcomes versus redo SAVR after prior surgical prosthesis (SAVR-SAVR). TAVR-SAVR volume grew at up to 144.6% annually, projected to surpass SAVR-SAVR by approximately 2029 based on linear extrapolation from limited registry and single-center data. Operative mortality was 12.3–17% in TAVR-SAVR versus 1.1–9% in SAVR-SAVR, persisting after propensity matching in both comparative studies (11.3% vs. 6.7%, OR 1.7; and 12.0% vs. 1.1%, OR 12.5). Observed-to-expected mortality ratios exceeded 1.0 across all risk strata, including low-risk patients (O/E up to 5.48), while SAVR-SAVR demonstrated a remarkably low ratio of 0.22–0.33. Renal failure, failure to rescue, and prolonged ventilation were significantly higher following TAVR-SAVR; stroke and pacemaker rates were comparable. Paradoxically, shorter bypass and cross-clamp times in TAVR-SAVR despite worse outcomes are consistent with cumulative organ injury, rather than operative complexity, as a predominant contributor to excess mortality, though this mechanistic explanation remains hypothetical. STS risk models, developed for standard surgical populations, showed limited applicability in this population, with observed mortality consistently exceeding predicted values. These findings raise important considerations regarding TAVR-first strategies in operable patients aged 65–80 years, although causality cannot be established from observational data alone. In the era of expanding TAVR indications, the legacy of the first valve cannot be ignored.

Obesity is a common and potentially modifiable barrier to heart transplant candidacy in patients supported by a durable left ventricular assist device (LVAD). Approximately 15% of LVAD recipients carry a body mass index (BMI) of 35 kg/m² or greater; the 2024 International Society for Heart and Lung Transplantation guideline considers weight loss to a BMI below 35 kg/m² reasonable before listing, within an individualized assessment, and only 18.6% of these patients achieve a 10% weight reduction through supportive care alone. Two interventions can close this gap. Anti-obesity medications, principally glucagon-like peptide-1 receptor agonists (GLP-1 RAs), reduce BMI gradually without a procedural intervention; however, the largest LVAD series reports a BMI reduction from 38.3 to 36.2 kg/m² at one year with 26% of patients who began above 35 kg/m² falling below it, and efficacy depends on continued adherence and insurance coverage. In the FIGHT trial, liraglutide showed a non-significant, numerically unfavorable signal in recently hospitalized patients with advanced heart failure with reduced ejection fraction who were not on mechanical support. Metabolic bariatric surgery, most often laparoscopic sleeve gastrectomy, delivers a BMI reduction of 6 to 10 kg/m² within 6 to 12 months and was associated with a threefold higher probability of subsequent transplantation in an observational Medicare cohort, at the cost of serious 30-day complications in 11.3% of LVAD recipients compared with 2.5% of non-LVAD bariatric patients. This narrative review compares mechanisms, LVAD-specific liabilities, and published outcomes of both strategies, including cardiovascular and arrhythmic outcomes, and reframes the choice as a trade-off between the speed of BMI reduction and the distribution of risk over time. We propose a hypothesis-generating selection framework, based on expert opinion, that considers excess BMI above threshold, expected time on device, bleeding profile, and gastrointestinal tolerance, and we define the evidence gaps that a prospective study should address.