August 2022

In this prospective, multicenter, randomized controlled trial, patients with primary degenerative mitral regurgitation (MR) and less-than severe tricuspid regurgitation (TR) who underwent mitral valve intervention were found to have a lower incidence of the composite two-year endpoint of progression of TR, reoperation for TR, or death if they underwent concomitant tricuspid annuloplasty (TA) than if the tricuspid valve was not intervened on, a difference that was primarily driven by rate of progression of TR. However, patients undergoing TA had a significantly higher rate of permanent pacemaker requirement than those undergoing isolated mitral valve intervention. Long-term follow-up data will allow us to weigh the risk of pacemaker requirement against a potential symptomatic and survival advantage of reduced severity of TR.

Summary: Patients undergoing surgical intervention for left-sided valvular heart disease often suffer from some degree of TR. While it is common practice to intervene on severe TR during a surgical mitral or aortic valve repair or replacement, little data exists on the risks and benefits of intervening on lesser degrees of TR. Physiologically, repairing a left-sided valvular defect alone should reduce right-sided filling pressures, contribute to positive right ventricular remodeling, and ultimately improve the degree of TR. However, TR does not always improve following left-sided valve surgery, and progression of TR in this patient population has been shown to be associated with increased risk of long-term mortality and poor functional outcomes. Surgeons, therefore, must weigh the potential benefit of reducing TR against the risks associated with tricuspid valve repair – conduction disturbances requiring permanent pacemaker placement, prolonged cardiopulmonary bypass times, and the risk of iatrogenic valve injury requiring valve replacement. The aim of this study was to assess the risks and benefits of concomitant tricuspid valve annuloplasty during mitral valve surgery in patients with moderate or less-than moderate TR. 

The study assessed 401 patients across 39 centers in the United States, Canada, and Germany who required surgery for primary degenerative MR who also had either moderate TR or less-than moderate TR with annular dilatation ≥40mm. Exclusion criteria included presence of any degree of secondary MR, primary tricuspid valve disease, and non-optimized medical management preoperatively. Patients were randomized to undergo isolated mitral valve intervention (either repair or replacement), or concomitant mitral valve intervention and tricuspid annuloplasty (TA). The primary endpoint assessed was a composite of two-year reoperation for TR, progression of TR by at least two grades or progression to severe TR, or death. Key secondary endpoints assessed included permanent pacemaker placement, major adverse cardiac and cerebrovascular events (MACCE), length of stay, rehospitalization, NYHA classification, quality of life, and measures of functional status. Outcomes were assessed in the intention-to-treat population. 

Of the 401 patients included in the study population, 203 were randomized to mitral valve surgery alone, and 198 were randomized to mitral valve surgery plus TA. Baseline preoperative characteristics, including demographic and clinical factors, were similar between the two groups. Moderate TR was present in 37.3% of patients; less-than moderate TR with annular dilatation was present in 62.7% of patients. The majority of patients across both study groups underwent mitral valve repair (89.8%); 10.2% of patients underwent mitral valve replacement. Patients undergoing TA in addition to mitral valve intervention had longer cardiopulmonary bypass times (mean increase of 33.5 minutes). The composite primary endpoint was reached in significantly more patients in the mitral valve intervention alone group than in those undergoing TA – 10.2% versus 3.9% (relative risk 0.37, 95% confidence interval 0.16 to 0.86, p = 0.02). This difference was driven by significantly higher rates of progression of TR in the mitral valve intervention alone group (6.1% versus 0.6%); there was no significant difference in two-year mortality (4.5% versus 3.2%) or tricuspid valve reintervention (zero patients in each group). Importantly, patients undergoing TA had a significantly higher rate of permanent pacemaker requirement – 14.1% versus 2.5% (rate ratio 5.75, 95% CI 2.27 to 14.60). There was no significant difference in other secondary endpoints, including readmissions, heart failure symptoms, quality of life, functional status, or frailty at two years.

The results of this study shed light on the risks and benefits of conducting concomitant TA during mitral valve surgery in patients with moderate or less-than moderate TR – patients undergoing TA experience lower rates of progression of TR without short-term differences in mortality or symptom burden, but they face significantly increased risk of permanent pacemaker requirement. Of note, the key limitation of this study is the two-year follow-up period – prior studies have highlighted that moderate or severe TR is an independent predictor of long-term mortality, an impact that may not be clinically significant at two years. The longer-term consequences of these differences in TR, as well as the clinical consequences and potential complications of permanent pacemaker placement, should reveal themselves as the study population is followed out to five years.

This multi-center retrospective study is the first to determine the factors associated with survival in patients undergoing adrenal metastasectomy across all lung cancer pathologic subtypes; ultimately recommending adrenal metastasectomy for patients with isolated, ipsilateral adrenal metastases of non-small cell lung cancer.

Background: The prevalence of adrenal metastasis in lung cancer is about 8%. Those with adrenal metastasis have been shown to have a poorer prognosis, especially when treated non-operatively. Adrenal metastasectomy is associated with increased survival in non-small cell lung cancer (NSCLC) with isolated adrenal metastases and thus the authors of this paper wanted to evaluate the benefit of adrenal metastasectomy for all subtypes of lung cancer. 

Methods: The authors performed a retrospective multi-institutional cohort study using patients undergoing adrenal metastasectomy for metastatic lung cancer between 2001 and 2015. They collected data on time to adrenal metastasis, laterality of the adrenal lesion, lung cancer sub-type, adrenalectomy resection status, operative approach, and adjuvant therapies. The primary outcomes of interest were disease free survival (DFS), defined as time from adrenalectomy to disease recurrence and overall survival (OS), defined as time from adrenalectomy to death. 

Results: 122 patients were included in the study who were undergoing adrenal metastasectomy for metastatic lung cancer. Median time to adrenal metastasis was 11 months (IQR: 0–19 months), with lesions more often being metachronous (59.0%) than synchronous (37.7%). Most patient had non-small cell carcinoma (89.3%). Adrenal metastasectomy was most often performed laparoscopically (60.7%). Median DFS was 40 months (1 year: 64.8%; 5 year: 42.9%) and median OS was 47 months (1 year: 80.2%; 5 year: 35.2%). They found that primary tumor resection (HR: 0.001; p = 0.005), longer time to adrenal metastasis (HR: 0.94; p = 0.005), and ipsilateral metastases (HR: 0.13; p = 0.004) were associated with longer DFS. On the other hand, older age (HR: 1.11; p = 0.01), R1 resection (HR: 8.94; p = 0.01), adjuvant radiation (HR: 9.45; p = 0.02), and open adrenalectomy (HR: 10.0, p = 0.03) were associated with shorter DFS. Additionally, longer OS was associated with ipsilateral metastatic disease (HR: 0.55; p = 0.02) and adjuvant (HR: 0.35; p = 0.02) or primary (HR: 0.29; p = 0.05) chemotherapy while shorter OS was associated with extra-adrenal metastases at adrenalectomy (HR: 3.52; p = 0.007), small cell histology (HR: 15.0; p = 0.04), and a history of lung radiation therapy (HR: 3.37, p = 0.002).

Bottom line: In patients who underwent adrenalectomy for lung cancer metastases, there was longer disease-free survival associated with primary tumor resection, longer time to adrenal metastasis and ipsilateral metastasis while shorter overall survival was associated with extra-adrenal metastases, small cell histology and history of lung radiation therapy. Thus, adrenal metastasectomy provides durable survival in those with isolated adrenal metastases from lung cancer.

Trainees who solicited more frequent feedback via the SIMPL app had higher autonomy and performance scores. This highlights the importance of learner involvement and feedback-seeking behavior in skill acquisition.

Summary: Research in nonmedical domains has demonstrated positive associations between feedback-seeking and performance. SIMPL is a smartphone-based assessment app from the Society for Improving Medical Professional Learning (SIMPL) that allows trainees to request performance ratings and narrative comments from their supervising faculty. The authors set out to explore the relationship between residents’ feedback-seeking behavior and measures of operative autonomy and performance. 

The study population included all categorical US general surgery residents who submitted a SIMPL app evaluation for a general surgery procedure during the 5-year study period. A total of 58,104 SIMPL assessments from 2190 residents in 61 programs were analyzed. The research team built a linear effects model to account for possible confounders including trainee, rater, procedure, program, gender, PGY, month of academic year, and case complexity. 

There was a positive association between the number of evaluation requests and increased autonomy ratings. In addition, there was also a positive association between number of evaluations and increased operative performance ratings. The authors point to the importance of active involvement in the feedback process. They also note that prior research has shown that trainees’ feedback-seeking behavior is in part related to the trainees’ perceived value of the assessments as well as the supportiveness of their supervising faculty.