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Central MessageAn expanded portfolio of AATS publications, including 2 new open access journals, JTCVS Open and JTCVS Techniques, provides additional opportunities to publish an increasing number of high-quality articles. Each article receives a full review by JTCVS and is modified to meet our exacting standards before transfer to one of the new journals. As a result, we anticipate our community will appreciate the quality and value of the articles published in the 2 new journals. An expanded portfolio of AATS publications, including 2 new open access journals, JTCVS Open and JTCVS Techniques, provides additional opportunities to publish an increasing number of high-quality articles. Each article receives a full review by JTCVS and is modified to meet our exacting standards before transfer to one of the new journals. As a result, we anticipate our community will appreciate the quality and value of the articles published in the 2 new journals. Last September, the editors of The Journal of Thoracic and Cardiovascular Surgery (JTCVS) shared several new developments under way with the American Association for Thoracic Surgery (AATS) publications,1Weisel R. McGrath S. New developments for AATS publications.J Thorac Cardiovasc Surg. 2019; 158: 820-821Abstract Full Text Full Text PDF Scopus (1) Google Scholar including the launch of 2 new open access journals: JTCVS Open and JTCVS Techniques. The new journals from the AATS provide additional options to publish high-quality information of importance to thoracic and cardiovascular surgeons. Authors who have submitted to JTCVS are offered transfer to one of our sister journals if their article has insufficient priority for publication in JTCVS. We established this article transfer model more than 5 years ago when we began offering authors the option of publication in Seminars in Thoracic and Cardiovascular Surgery (Seminars). The option of transferring JTCVS submissions to Seminars has been extremely successful. In 2019, the articles of 86 authors were offered transfer to Seminars and 78 authors agreed to publish their article in Seminars, representing more than 90% author approval. The transferred articles are improved by the extensive revisions required by the JTCVS reviewers and JTCVS and Seminars editors. The transferred articles are also reviewed by the JTCVS statistical reviewers and editors so that the conclusions are justified by the results presented. The authors have revised their articles to the Journal’s rigorous standards before publication. Each of these Seminars articles has the same standards of visual display and conclusive analytics required for the JTCVS. In the past 5 years, there has been a progressive increase in readership and citations to Seminars as our community has embraced the value offered. Seminars articles are now highly downloaded and frequently cited in articles published in other high-impact journals. As a result, Seminars will now become indexed in the Science Citation Index Expanded and will be awarded an Impact Factor in June 2020! On the basis of the citation rate in 2018, we calculated a projected Impact Factor of 1.6, and we are expecting Seminars to debut a similar Impact Factor later this year. Please join us in congratulating the editors of JTCVS and Seminars on achieving this prestigious milestone! The editors have now expanded this model to JTCVS Open and JTCVS Techniques, and we expect similar success over the next 3 to 5 years with both JTCVS Open and JTCVS Techniques. Each article receives a full review by JTCVS and is modified to meet our exacting standards before transfer to one of the new journals. As a result, we anticipate our community will appreciate the quality and value of the articles published in the 2 new journals. With the increasing impact factor of the JTCVS, we have seen a progressive increase in the number of manuscripts submitted (Figure 1). We anticipate that we will be able to facilitate the publication of an increasing number of high-quality articles in our new journals. As with many new journals recently, JTCVS Open and JTCVS Techniques are open access, and authors are requested to pay an article processing charge for publication after an article has been accepted. The advantage of the open access model is that all articles are immediately available to all readers worldwide without restrictions. In our initial experience with the new journals, authors have responded positively and agreed to transfer articles. As of January 2020, JTCVS Open has 5 articles in press and JTCVS Techniques has more than 30 Brief Reports in various stages of publication. The early success of these journals will facilitate a timely application to PubMed. Our aim is for both journals to be indexed in PubMed in the next 12 months, at which time PubMed will index all articles retroactively to the first article. Readers of JTCVS will notice many of the valuable aspects of JTCVS carried over to JTCVS Open and JTCVS Techniques. Each article transferred to JTCVS Open or JTCVS Techniques is published with at least 1 Commentary from an expert in the field. In addition, leading experts have contributed articles originally presented at the AATS 99th Annual Meeting in Toronto, which will be published early in 2020, and we plan to receive more contributions from the 100th Annual Meeting in New York. We want our readers to discover this important information published across all AATS journals with as few barriers as possible. Readers of JTCVS will be given single-click, immediate access to all the high-quality articles published in JTCVS Open and JTCVS Techniques from the online version or print version (using the QR code) of the Journal—look for the “Recent Papers in AATS Journals” page published at the beginning of each subspecialty section of the Journal. Also, we have begun to provide readers access to featured material in each subspecialty through AATS Journals Alerts, a monthly email containing featured in-press articles for adult cardiac, congenital, or thoracic surgery. Readers can receive all the latest information published in their respective subspecialty through one AATS Journals Alert. We are excited by the support that AATS members and all our authors and readers have given the new publications. Together, we can provide valuable information to surgeons through a strong, diverse portfolio of AATS publications.

Central MessageOur journal authors are vital to the success of the portfolio, and we aim to reduce the burden for authors during the submission and peer review process. Our journal authors are vital to the success of the portfolio, and we aim to reduce the burden for authors during the submission and peer review process. The American Association for Thoracic Surgery (AATS) journals program is strong, and the AATS is actively building out the portfolio in a forward-looking manner. We believe the AATS journals program is a robust example of a field-leading society portfolio. The Journal of Thoracic and Cardiovascular Surgery (JTCVS) continues to be the top journal in the field in terms of impact and citation activity of our articles. The AATS has taken a progressive approach by launching JTCVS Open and JTCVS Techniques to expand and enhance the portfolio. Both titles are now indexed in PubMed Central, and we expect each to receive an Impact Factor in the next year or two. The other journals in the AATS portfolio, Seminars in Cardiothoracic Surgery, Operative Techniques, and Pediatric Annual, have continued their strong performance and appreciation by the readership. In the past few months, JTCVS and associated journals have embarked on a comprehensive strategic planning process to help guide journal direction in the coming years. Generally, the scientific and medical journal publishing landscape is transitioning to open access publication and an article-based economy, and away from the traditional subscription model. The announcement earlier this year from the US Office of Science and Technology Policy1Memorandum for the heads of executive departments and agencies. Office of Science and Technology Policy. Accessed August 30, 2022. https://www.whitehouse.gov/wp-content/uploads/2022/08/08-2022-OSTP-Public-Access-Memo.pdf.Google Scholar outlines a major policy shift. Key points of the new policy include the following:•Sets forth the expectation of immediate public access of research articles resulting from federal funding upon publication (elimination the 12-month postpublication embargo currently in place at the National Institutes of Health)•Applies to all authors on an article, not just the corresponding author•Includes public availability of the scientific data underlying peer-reviewed publications resulting from federally funded research The National Institutes of Health and other federal agencies will establish new policy requirements, which must be in place by January 2026. Most likely, the new policy requirements will result in accelerated erosion of journal subscriptions in favor of open access publication models. In response to this shifting landscape, we aim to position the AATS journals to take advantage of opportunities presented by open access publication. We are working to develop a portfolio strategy that uses the strengths of the journal program as a whole and increases the amount of high-quality surgical information published across the AATS journals. We strive to offer a robust publishing program with editorial policies that support our authors and ensure a high-quality author experience. In my first year as Editor-in-Chief, we have focused on initiatives to improve the author experience of submitting to and publishing in JTCVS. Our journal authors are vital to the success of the portfolio, and we aim to reduce the burden for authors during the submission and peer-review process. Significant strides have already been made in this area. We eliminated the limit on the number of authors for published articles, recognizing that more submissions are coming from multidisciplinary clinical teams. We significantly reduced the number of submissions receiving statistical review from 80% of all submissions to the 20% of manuscripts likely to be published in JTCVS that require attention from a statistician. Doing so has improved our turnaround times for authors. The average time to first decision for JTCVS submissions is now 25 days. We understand that to provide a high-quality author experience we must support authors not only during submission and peer review but also after their article publishes—to promote their work and enhance its discoverability. To this end, we have appointed Tom Nguyen, MD, as Feature Editor of Digital Scholarship & Media. Dr Nguyen has convened an editorial committee composed of outstanding individuals who will help formulate the digital media strategy of the AATS journals. The committee members will generate ideas to improve reader and author engagement through social media activities. I am excited to announce we will hold the second annual AATS Journals Forum during the 103rd Annual Meeting in Los Angeles, California. The session will be dedicated to how JTCVS can advance the careers of surgeons. Publishing in the AATS journals provides many opportunities, and we will hear from one of the most prolific authors publishing in JTCVS about how the Journal has helped advance his career. Additionally, senior authors and editors will discuss the benefits of digital scholarship and media to drive author and readership engagement, extend the reach and accessibility of the authors' work, and increase its impact. To conclude, I would like to highlight a few items included in this issue that demonstrate some of the accomplishments we have worked to achieve in the past year. First, we are pleased to publish the names of the 844 peer reviewers who completed reviews of manuscript submissions in 2022. We are extremely grateful for all our dedicated reviewers who provide expert evaluations of manuscripts. Their insightful comments and suggestions for revisions are integral to the publication process and undoubtedly improve the articles we publish. The importance of their contributions cannot be overstated. Second, readers will notice the inclusion of author replies to Commentaries. Overall, we have reduced the number of invited Commentaries in the journals, and we have started to offer some authors the opportunity to reply to the invited Commentary that will publish with their original article. Selected authors can read the Commentary before it publishes and decide if they want to write a response to be published together. We hope this enhances the discussion of published articles. Third, we published a Featured Case Report from Igor Konstantinov, MD, that marks a return of very high-quality, select Case Reports in JTCVS. We anticipate this will become a popular regular feature. We hope the readers enjoy these recent developments in JTCVS.

Central MessageThe present article clarifies the editorial policies and practices of the AATS Journals and offers insight and expert advice for writing impactful papers.This editorial is an update on the following editorial: “How to get your paper published” https://doi.org/10.1067/mtc.2001.114493. The present article clarifies the editorial policies and practices of the AATS Journals and offers insight and expert advice for writing impactful papers. This editorial is an update on the following editorial: “How to get your paper published” https://doi.org/10.1067/mtc.2001.114493. The American Association for Thoracic Surgery (AATS) journals program is a robust example of a field-leading society journal portfolio. The Journal of Thoracic and Cardiovascular Surgery (JTCVS) continues to lead the field of cardiothoracic surgery journals both in terms of impact and citation activity. The AATS has taken a progressive approach by launching JTCVS Open and JTCVS Techniques to expand and enhance the portfolio. The other journals in the AATS portfolio, Operative Techniques in Thoracic and Cardiovascular Surgery, Seminars in Thoracic and Cardiovascular Surgery, and The Pediatric Cardiac Surgery Annual, have continued their strong performance and appreciation by the readership. Together, the 6 AATS journals provide a platform for the cardiothoracic surgery community to disseminate important novel findings that ultimately drive innovation and lead to improved patient outcomes. The editorial team at the AATS Journals strives to provide a forum for scholarship through high-quality peer review, exceptional author support, and global engagement. Our Editors and reviewers work with authors to revise and improve manuscripts before publication and are dedicated to minimizing the burden that this process can place on authors. The Editors and reviewers are committed to improving the quality and impact of submitted manuscripts, and the Editorial Office endeavors to offer professional and timely support to all authors. The present article offers insight and expert advice for writing impactful papers. By highlighting relevant articles, webinars, and presentations by Editors, Editorial Board members, and reviewers, this piece clarifies the editorial aims, policies, and practices of the AATS Journals, serving as a complement to the Information for Authors1Information for AuthorsThe Journal of Thoracic and Cardiovascular Surgery.https://www.jtcvs.org/content/authorinfoDate accessed: January 30, 2023Google Scholar and International Committee of Medical Journal Editors (ICMJE) Recommendations.2International Committee of Medical Journal Editors (ICMJE)Recommendations for the conduct, reporting, editing, and publication of scholarly work in medical journals.https://www.icmje.org/recommendations/Date: 2022Date accessed: January 30, 2023Google Scholar Herein, our editorial team has updated the original “How to get your paper published,” published in 2001 by Ms Pamela W. Fried and Dr Andrew S. Wechsler.3Fried P.W. Wechsler A.S. How to get your paper published.J Thorac Cardiovasc Surg. 2001; 121: S3-S7https://doi.org/10.1067/mtc.2001.114493Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar The foundation of all high-quality, high-impact publications occurs by first formulating a focused, clinically relevant research question that addresses an important research gap. Authors should begin with a relevant clinical question and form a hypothesis before determining which data sources will be analyzed and which study design is most appropriate. The Editors encourage hypothesis-driven research rather than database-driven research. The research question will guide the entire paper, pinpointing what the authors sought to find out and giving the manuscript a clear focus and purpose. To sharpen the research question, authors may find utility in research frameworks such as FINER4FINER: a research framework. Elsevier author services.https://scientific-publishing.webshop.elsevier.com/research-process/finer-research-framework/Date accessed: January 30, 2023Google Scholar and PICO(T).5Clinical questions: PICO and PEO researchElsevier author services.https://scientific-publishing.webshop.elsevier.com/research-process/clinical-questions-pico-and-peo-research/Date accessed: March 2, 2023Google Scholar Authors should undertake a thorough literature review to avoid completing a study that will merely reconfirm what is already known. During this initial research process, the authors should be diligent to avoid overlooking relevant, recent, and seminal studies. Overlooking key works will result in a less informed and therefore less impactful study. In addition, the researcher should stay up-to-date on the literature that emerges during the execution of the study and during the peer-review process. There are valuable resources available to authors from JTCVS Editors who offer expert advice for constructing high-impact scientific works. In 2022, Associate Editor Dr Vinay Badhwar moderated an AATS Journals webinar in which he and other Editors and Editorial Board members offered candid insights and practical advice for achieving high-impact publication.6Badhwar V. Hui D.S. Antonoff M.B. Bacha E.A. Mehaffey J.H. The art and science of reviewing and preparing scientific contributions. AATS Journals webinar. August 24, 2022.https://www.aats.org/resources/the-art-and-science-of-reviewing-and-preparing-scientific-contributions?_zs=bgfOQ1&_zl=DLao6withDate accessed: January 30, 2023Google Scholar Dr Badhwar7Badhwar V. Assessing high-impact submissions. AATS 2022 Annual Meeting presentation. May 15, 2022.https://www.aats.org/resources/1262Date accessed: January 30, 2023Google Scholar also provides a concise overview of the tenets of high-impact publications through his presentation at the 2022 AATS Journals Forum. With her strong statistical background, Feature Editor Dr Lisa Brown provides an in-depth overview of well-designed, well-written scientific works through her 2022 AATS Journals Forum presentation8Brown L.M. Reviewing for JTCVS and the AATS journals: Writing a quality review. AATS 2022 Annual Meeting presentation. May 15, 2022.https://www.aats.org/resources/1264Date accessed: January 30, 2023Google Scholar and through her comprehensive, expertly written 2017 JTCVS article9Brown L.M. David E.A. Karamlou T. Nason K.S. Reviewing scientific manuscripts: A comprehensive guide for peer reviewers.J Thorac Cardiovasc Surg. 2017; 153: 1609-1614https://doi.org/10.1016/j.jtcvs.2016.12.067Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar alongside Drs Katie Nason, Elizabeth David, and Tara Karamlou. Finally, in 2023, Associate Editor Dr Robert Jaquiss moderated an AATS Journals webinar10Jaquiss R.D.B. Andersen N.D. Bichell D.P. Barron D.J. Karamlou T. How to review a congenital cardiac paper for JTCVS. AATS Journals webinar. January 25, 2023.https://www.aats.org/resources/how-to-review-a-congenital-cardiac-paper-for-jtcvsDate accessed: January 30, 2023Google Scholar in which he and other Editors and Editorial Board members offered advice for reviewing congenital papers; however, much of the advice can be viewed through the lens of an author in any cardiothoracic subspecialty. We strongly recommend authors utilize the aforementioned resources. The manuscript title and abstract are nearly always the first elements of the manuscript Editors and reviewers examine. By crafting these elements thoughtfully and deliberately, authors can help ensure the Editors and reviewers understand the intention of the work and appreciate its potential impact. The title should clearly and concisely convey the study's main message. Readers appreciate titles that get straight to the point and relay what was found. If a manuscript undergoes significant revision during the review process, the title should be adjusted accordingly. When crafting titles, authors should avoid uncommon words, surgical jargon, and redundancies such as “A study of.” Authors should avoid colons and dashes, as they tend to make titles needlessly long and overly detailed. Brand names, abbreviations, and acronyms are not permitted in article titles. The Structured Abstract is limited to 250 words and follows a 4-part structure:•Objective(s): Describe the hypothesis or the purpose of the study.•Methods: Specify the study design and statistical methods.•Results: Present the outcomes and any statistical findings.•Conclusions: Convey the relevance and importance of the results. The Structured Abstract should provide an accurate, objective, concise summary of the manuscript. The abstract conclusions should be drawn from the results presented in the abstract. Conclusions that are not directly supported by the information provided in the abstract results belong in the Discussion section of the manuscript. The abstract should be free from unwarranted generalizations and statements of “need for further studies.” Specialist jargon should be avoided. Abbreviations and acronyms should be used sparingly and limited to those that are standard and common in the field of study.

Central MessageThe transplant ecosystem is evolving with better management strategies—leading to a precision medicine approach to preservation, transportation, and management of organs optimized for transplantation.See Commentaries on pages 169, 171, and 173.Feature Editor Note—Although lung transplantation continues to evolve with the refinement of surgical techniques and improvements in organ preservation, there continues to be a critical shortage of donor lungs available, and a substantial number of donor lungs are discarded due to questionable quality. The University of Toronto group has published extensively on the use of ex vivo lung perfusion (EVLP) to evaluate marginal donor lungs, demonstrating that many of these lungs can be successfully transplanted. However, the necessary equipment, logistical support, and expertise are not readily available at most transplant centers. Dr Keshavjee is an authoritative expert in this area, and this Invited Expert Opinion article provides an excellent overview of the development of EVLP organ repair centers, which would not only make EVLP more widely available but offer the potential for incorporating precision diagnostics into organ management and repairing damaged donor lungs in the future. The article draws parallels between the development of centralized, standardized blood banks and the potential for regional EVLP organ repair centers to become part of an organ-management ecosystem. The establishment of 2 lung bioengineering centers has brought the concept of EVLP organ repair centers closer to fact than fiction and has the potential to transform lung transplantation by increasing donor lung use and possibly improving long-term outcomes.Jules Lin, MD The transplant ecosystem is evolving with better management strategies—leading to a precision medicine approach to preservation, transportation, and management of organs optimized for transplantation. See Commentaries on pages 169, 171, and 173. Organ transplantation therapy has continued to evolve and enjoy increased success. The development of organ transplantation was made possible by the development of surgical techniques and organ-preservation strategies. Preservation started with recovery of an organ from a person who had died and essentially aimed at preserving the organ in the state in which it was found. We traditionally would rush through retrieval, transport, and implantation with the hope that cold flush preservation would preserve the organ, hopefully preventing significant degradation so we could implant an organ in as close as possible state to that in which we found it. This has served us for well over 50 years. The question is, how do we take transplantation to the next level? Can we develop better systems for organ management and delivery of transplant care? Can we aspire to make organs better—can we make a lung or a heart that is better than the way we found it in the person who died? Can we engineer and pre-prepare organs that look like “self” so that they won't be rejected? Can we make an organ that will outlive the recipient in which it is placed? We set out set out some years ago on a quest to do just that—to develop strategies to repair donor lungs, ultimately to engineer lungs that are pre-prepared for transplantation. Given the logistical challenges of working on organs in the multiorgan donor, we set out to develop an ex vivo support system for lungs, such that you could maintain lungs outside of the body at normal body temperature. This allows one to work on the organ—apply precision diagnostics and therapeutics of modern medicine, just as we do in patients. We put together all that we had learned over many years about ideal protective perfusion and ventilation strategies for the lung, creating a system that could maintain the lung outside the body for 12 hours and not inflict significant damage. The concept is not a stress test but a protective support system for the organ.1Cypel M. Yeung J.C. Hirayama S. Rubacha M. Fischer S. Anraku M. et al.Technique for prolonged normothermic ex vivo lung perfusion.J Heart Lung Transplant. 2008; 27: 1319-1325Abstract Full Text Full Text PDF PubMed Scopus (370) Google Scholar We translated this to clinical practice in the Toronto Ex Vivo Lung Perfusion (EVLP) System (Figure 1), demonstrating that we could safely transplant lungs we would not have used before.2Cypel M. Yeung J.C. Liu M. Anraku M. Chen F. Karolak W. et al.Normothermic ex vivo lung perfusion in clinical lung transplantation.N Engl J Med. 2011; 364: 1431-1440Crossref PubMed Scopus (760) Google Scholar This has transformed the approach to organ preservation and changed the field of transplantation. A whole new industry is growing around ex vivo organ perfusion systems and the development of techniques to support and treat not just lungs, but all organs outside the body. Is normothermia necessary? The fundamental premise of hypothermic flush preservation that has made the miracle of transplantation possible is that cold temperature decreases the metabolic rate of the organ. Cold slows down the consumption of metabolic substrate, the production of wastes, and essentially slows down the dying process. However, cold also slows down opportunities to diagnose, repair, and regenerate the organ. Thus, although cold is needed for certain phases of the transplant process, normothermia is also necessary if we are to aspire to repair and regenerate organs. Now with EVLP, for the first time, we have the opportunity to manipulate preservation temperature as needed. This provides time to accurately assess and diagnose the organ, which has significantly improved use and the opportunity to treat, recover, and repair organs in a precision medicine approach, where we can confirm the results such that we can more confidently transplant an organ with a predictable outcome. This will ultimately improve the safety and long-term outcomes of transplantation. We first introduced EVLP clinically at Toronto General Hospital (TGH) in 2008 and since then have performed more than 600 cases. As mentioned, we demonstrated that we could successfully transplant extended donor lungs that we would have otherwise declined for transplantation. Now, with more than a decade of EVLP experience, we have shown that these lungs have an equivalently good long-term outcome to standard donor lungs used in our program.3Divithotawela C. Cypel M. Martinu T. Singer L.G. Juvet S. Binnie M. et al.Long-term outcomes of lung transplantation with ex-vivo lung perfusion: a single centre 10 year experience.JAMA Surg. 2019; 154: 1143-1150Crossref PubMed Scopus (69) Google Scholar The use of the Toronto EVLP System has essentially led to a doubling of the number of lung transplants performed per year at our center in the last 5 years, where we now perform more than 200 lung transplants per year. To take this concept to the next level, we need to exploit the real opportunity that EVLP provides, the opportunity to improve donor lungs—to treat infections, perform gene modifications to manipulate the immune response, use stem cells to repair and regenerate the organ, and use other pharmacologic and biologic therapies to improve organs and truly engineer organs that are superior to the condition in which we found them. One may think that this is taking an already-complex, challenging, and expensive process, that is, transplantation, and making it even more so. Historically, the field of transplantation has developed organically; the current state is highly inefficient and not conducive to the scaling of activity that will be required. We need to examine how we can modify and develop the transplant ecosystem to optimize the use of organs and resources to enhance access to life-saving organ transplantation. We can take a lesson from the development of blood transfusion (Figure 2, A). The first blood transfusion described was from a healthy soldier in the field to a soldier that was hemorrhaging, to save his life. You can imagine with that practice that they saved quite a few lives, but they also likely killed a few people with blood transfusion reactions and infections. Therefore, we developed small “blood banks” in MASH units and in hospitals around the country, where typed units of blood were kept to be more readily available. This did a little better with rudimentary blood typing, but standardization of practice and quality was lacking. There was risk of error and there was no really efficient way to preserve and distribute this scarce resource. Thus, we went on to develop centralized, standardized collection centers, processing centers, and distribution centers. We now have standardized operating protocols with oversight of processing, quality, infection control, shelf life, inventory, and distribution tracking. Moreover, with advanced processing techniques, we have also optimized use of this scarce resource with the separation of blood into components so that a patient only receives the component they need (eg, red cells, platelets, cryoprecipitate, etc) and each unit of blood provides life-saving therapy for multiple patients. This has allowed us to scale up and achieve remarkable safety and access as well as cost and use efficiencies in transfusion practice. We can apply these same concepts to the processing and management of organs for transplantation. Instead of having 5 Lear jets fly out every night, with 5 surgical teams to pick up 1 organ each and then fly back to 5 different hospitals, you will have organs being transported to an organ repair center, processed, optimized, and then transported to each patient (Figure 2, B). Furthermore, why would you need a whole jet to transport and organ that weighs less than 2 kg? In fact, we are now developing Remote Piloted Aircraft Systems (RPAS, or drones) to deliver organs. This is the future of transplantation (Figure 3). This may sound like science fiction but we, in fact, established the first Organ Repair Center in the world more than 10 years ago at TGH—essentially a mini-operating room to support and treat organs for transplant. We started with lung and then expanded to liver, kidney, and now heart ex vivo perfusion. We demonstrated the possibility of providing a service of lung repair for another center. In a compassionate case, we flew a lung from a remote donor hospital to Toronto for EVLP and then flew it to the recipient hospital where it was successfully transplanted—the first case demonstrating the “organ repair center” concept of remote organ perfusion treatment for transplantation.4Wigfield C.H. Cypel M. Yeung J. Waddell T. Alex C. Johnson C. et al.Successful emergent lung transplantation after remote ex vivo perfusion optimization and transportation of donor lungs.Am J Transplant. 2012; 12: 2838-2844Crossref PubMed Scopus (39) Google Scholar To expand this concept into the United States, in partnership with United Therapeutics, the subsidiary called Lung Bioengineering was founded. Lung Bioengineering 1 (LB1) is a 28,000-square foot facility in Silver Spring, Maryland, that is the world's first “lung hospital,” designed to repair lungs for clinical transplantation. There are 6 procedure rooms that have the capacity to treat 1800 lungs a year in that facility alone. Organ perfusion specialists trained at TGH perform EVLP for transplant centers in the United States. There is complete data-monitoring and information feed where the transplant surgeon receives all the physiologic and biologic parameters as well as imaging by radiography or bronchoscopy remotely by data, audio, and video contact directly on a smartphone or tablet device. More than 100 lungs have been transplanted after EVLP at LB1 to date. Lung Bioengineering 2 (LB2) has recently opened in Jacksonville, Florida, to provide both redundancy and expansion of service. These 2 facilities alone have the capability to potentially cover EVLP services for the whole continent, as has been demonstrated by the Toronto Lung Transplant Program experience with remote organ retrieval and transplantation, opening the door to the possibility of semi-elective lung transplantation.5Yeung J.C. Krueger T. Yasufuku K. de Perrot M. Pierre A.F. Waddell T.K. et al.Outcomes after transplantation of lungs preserved for more than 12 h: a retrospective study.Lancet Respir Med. 2017; 5: 119-124Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar,6Cypel M. Yeung J.C. Keshavjee S. Introducing the concept of semielective lung transplantation through the use of ex vivo lung perfusion.J Thorac Cardiovasc Surg. 2018; 156: 2350-2352Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar The organ repair center concept is indeed a reality that has now moved into the phase of a commercial entity to provide the service of EVLP for transplant centers in the United States. The development of regional organ procurement centers7Chang S.H. Kreisel D. Marklin G.F. Cook L. Hachem R. Kozower B.D. et al.Lung focused resuscitation at a specialized donor care facility improves lung procurement rates.Ann Thorac Surg. 2018; 105: 1531-1536Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar is complementary and synergistic to the development of regional ex vivo organ procurement centers. In fact, optimization of donor organ use and outcomes will likely be achieved by a combination of both concepts. A further requirement will be the development and application of rapid advanced diagnostics to the field of organ preservation and management (Figure 4). Currently, donor organ assessment is basically standard clinical assessment. Advanced rapid diagnostic profiling will be required to bring the precision medicine concept to the bedside of donor organ management. Is this lung okay to go straight to transplant, or do you need to repair it? If you do need to repair it, diagnose the problem, define your prescription of repair, repair it, confirm that your lung is repaired, and transport it to your recipient to implant an organ that is a known product with a predicable good outcome. A whole industry is developing around machines to perfuse organs, diagnostics to improve precision in decision making, and service providers to manage the organs. Furthermore, we cannot continue to build whole operating rooms to manage one organ at a time. Devices are being developed to automate these complex processes for each organ (lung, liver, kidney, heart), so that an organ perfusion specialist can monitor and treat multiple organs at the same time. Important health economic analyses should include examination of the combined cost effectiveness of EVLP in the context of the value of increased availability of donor lungs—which will save more lives and increased access to transplantation, and shorten the duration of care required for advanced end stage lung disease patients, combined with the benefit gained from more efficient organ management and transportation and ultimately from transplantation of organs with better and more predictable improved short and long term outcomes. The field of transplantation has changed. We have an unprecedented opportunity to use more organs and improve the outcomes of transplantation. The clinical translation of EVLP technology has demonstrated the way forward for the development of a redesigned transplant ecosystem. Organs will be retrieved from a donor by a regional surgical retrieval team (or in a donor-management center), transported by drone to an organ repair center, treated and optimized for transplantation, and transported to the recipient for elective transplantation. This is fact, not fiction: clinical organ repair centers are already up and running. Furthermore, the components are coming together to re-engineer the transplant ecosystem to create a much more efficient, cost-effective, and sustainable delivery strategy for clinical organ transplantation. Dr Keshavjee is Chief Scientific Officer and founding partner of Perfusix Canada Inc, Perfusix USA Inc, and XOR Labs Toronto; he is a consultant to Lung Bioengineering and United Therapeutics; and has received research support from XVIVO Perfusion, United Therapeutics, and CSL Behring. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. Commentary: Organ ARCs: Assessment and repair centers in transplantation as gateways to meaningful therapeutic interventionsJTCVS OpenVol. 3PreviewIn 2001, the world was shown the future of solid-organ transplantation with the successful ex vivo lung perfusion (EVLP) and transplantation performed by Steen and colleagues from Lund University Hospital, Lund, Sweden.1 Perhaps at the time, the revolutionary nature of the accomplishment was underappreciated, although it set into motion a vision that Dr Alexis Carrel and Charles Lindbergh had when they published their foreshadowing book The Culture of Organs in 1938.2 From what may have been perceived as Shelleyian science fiction, the University of Toronto Lung Transplant Program under the leadership of Dr Keshavjee has made a reality. Full-Text PDF Open AccessCommentary: Changing the equation by boosting the numeratorJTCVS OpenVol. 3PreviewDespite all the recent advances in organ-procurement organizations, allocation system, increased use of extended-criteria donors, use of lungs from donation after cardiac death donors, and increase in number of centers performing lung transplants globally, the number of patients requiring lung transplant each year continues to grow. Even though the number of donors continues to steadily increase, in the United States fewer than 1 in 4 pairs of lungs offered for donation will be eventually used for transplant, and hundreds of thousands of people around the world continue to die each year from end-stage lung disease. Full-Text PDF Open AccessCommentary: Quo vadis ex vivo lung perfusion—regionalization or centralization?JTCVS OpenVol. 3PreviewI read with great interest the article “Human Organ Repair Centers: Fact or Fiction?” published by Dr Keshavjee in the latest issue of the JTCVS Open.1 This work provides a comprehensive summary of the current state of ex vivo lung perfusion (EVLP) and proposes a centralized organizational structure for organ-repair facilities. Full-Text PDF Open Access

Central MessageOur goal at the AATS Journals is to enhance the author experience, bolster diversity and inclusion, and continue to provide the highest-quality, state-of-the-art cardiothoracic surgery content. Our goal at the AATS Journals is to enhance the author experience, bolster diversity and inclusion, and continue to provide the highest-quality, state-of-the-art cardiothoracic surgery content. It is my privilege to serve as Editor-in-Chief of the Journal of Thoracic and Cardiovascular Surgery (JTCVS) and the associated journals of the American Association for Thoracic Surgery (AATS). It is humbling indeed to succeed Dr Richard Weisel and the other legendary surgeons who have served as Editor-in-Chief. I have known Richard for more than 40 years and have long admired his commitment to academic excellence. Among many other awards, he is the 2010 recipient of the AATS Scientific Achievement Award. Dr Weisel has transformed the JTCVS, recruited a new editorial team, reconfigured the editorial board leadership, and expanded the global reach of the JTCVS—all while maintaining very high standards of scholarly publishing. This editorial team is committed to maintaining these high standards. Our goal is to continue to provide the highest-quality, state-of-the-art cardiothoracic surgery content for the JTCVS readership while also ensuring authors have a satisfying publication experience when submitting their work. We will commit to diversity and inclusion among the editorial board leadership. We plan to give voice and recognition to the editorial board. Readership and author surveys will inform future directions for JTCVS. Under Dr Weisel's leadership, the open access journals JTVCS Open and JTCVS Techniques were launched and have been very successful to date. We anticipate rapid growth for both open access publications. In 2021, Operative Techniques in Thoracic and Cardiovascular Surgery began increasing the amount of peer-reviewed technique articles per publication, which has allowed us to highlight a wider variety of important techniques. Seminars in Thoracic and Cardiovascular Surgery has similarly increased publication output, and we will discuss new publication opportunities for Seminars in addition to the facilitated manuscript transfers from JTCVS. In addition, the 2021 issue of Pediatric Annual featured a collection of 12 excellent articles stemming from the 2020 AATS Annual Meeting that all congenital heart surgeons should read. Successful initiatives such as the AATS Journal Alerts have helped to develop the digital communication of articles from AATS Journals. All members and interested readers can sign up on the AATS website to receive bimonthly email alerts about featured papers in each specialty. Most recently, more than 5000 articles from the 6 AATS journals are searchable directly from the AATS website at aats.org/journalsearch. We will focus on the continued development of the digital presence of the AATS journals, especially where there are opportunities for deeper integration with AATS online platforms. The more integrated the AATS journals are with the AATS digital universe, the better equipped we will be to navigate future transformations in scholarly and online publishing. Other initiatives are being planned and will be evident in forthcoming JTCVS issues over the next few months. Such efforts will be made with constant consideration of the preeminent position of the JTCVS in global cardiothoracic surgery and the core values of the AATS: vision, leadership, scholarship.

= 0.001). Nonetheless, the percentage of patients who were upstaged after histopathological analysis of the resected lymph nodes was similar between the two groups. In conclusion, RATS and VATS yielded comparable results for most of the short-term outcomes assessed. Further research is needed to validate the implementation of RATS and identify its potential benefits over VATS.

Central MessageMathematical modeling of the aorta requires careful attention to mathematical rigor, physical accuracy, and biological relevance.Mutationem motus proportionalem esse vi motrici impressae, et fieri secundum lineam rectam qua vis illa imprimatur.(The change in momentum is proportional to the motive force impressed, and in a direct line along which the force is impressed.)—Isaac Newton, Philosophiae Naturalis Principia Mathematica (1687)Ut tensio, sic vis.(As the extension, so the force.)—Robert Hooke (1678)See Article page 32. Mathematical modeling of the aorta requires careful attention to mathematical rigor, physical accuracy, and biological relevance. See Article page 32. Perhaps the most important concept in classical/macroscopic mechanics is the idea that a net force (independent variable) causes a change in motion (dependent variable) of a body, and that the nature of this functional relationship is mediated by the material properties of the body being subjected to the force. The canonical formulation of this principle is Newton's Second Law of Motion, commonly taught in the setting of constant mass as F = ma, or perhaps more accurately conveying the causality of the relationship, a = F/m. In particle mechanics, mass is the only material characteristic of the body. This concept from particle mechanics then extends to relatively more modern continuum mechanics, which is formulated in tensors. In continuum mechanics, due to the applied forces on the body, the body deforms, and the manner in which it deforms depends upon material properties. For elastic solid bodies, these material response relationships—termed constitutive relationships—are expressed between stress (which expresses a combination of body forces such as gravity, and contact forces through [normal] and along [shear] surfaces and strains [displacements]). Two points are relevant here with respect to nonlinearity. First, for large deformations (eg, those in the range of a few % or more), strains include nonlinear terms that depend upon displacement gradients. These nonlinear terms cannot be ignored in the setting of large deformations, whereas they may be in the setting of infinitesimal deformations. Second, there may be nonlinear relationships between stresses and strains. For homogeneous isotropic linearly elastic solids (aka, Hookean) undergoing small deformations, the relationship σ = Eε is used, with σ being stress, ε being a “linearized” strain, and E being the Young's modulus (a specific case of the “elastic modulus” for linearized elasticity). Material properties are the “black box” in the relationship between forces and motions, insofar as they too, like forces, are the other independent variable input causally regulating motion. However, as a general matter, they are the unknown variable in this relationship. Whereas forces and motions are measured, material properties are calculated. Importantly, as a definitional matter, material properties are intrinsic to the material. They may spatially vary in inhomogeneous and anisotropic materials, but this is distinct from a dependence upon geometric features of the body. Nonlinear materials exhibit nonlinear relationships between stress and strain, and there is no Young's modulus for such materials (so-called neo-Hookean materials have a single constant called a shear modulus that is not termed the Young's modulus). For example, σ may = kεg2 for some material for which εg is a generalized as opposed to linearized strain, where k is a constant. But if one erroneously uses a linear model and applies it to this nonlinear material, what this mathematically equates to is stating that E = kεg. One would then incorrectly conclude that there exists an E that is a function of εg, when “E” does not truly exist in the context of an accurate model, only k does. Furthermore, and at least as important, cardiovascular tissues do not undergo small deformations. They undergo large deformations. In such cases, the strain includes nonlinear terms that depend upon the displacement gradient. In the cases of large deformations, these terms cannot be ignored, whereas these nonlinear terms are often ignored in “linearized” elasticity applied to small deformations (examples of materials undergoing small deformations are metals such as steel). In this issue of JTCVS Open, Eliathamby and colleagues1Eliathamby D. Keshishi M. Ouzounian M. Forbes T. Tan K. Simmons C. et al.Aortic Symposium 2022: ascending aortic geometry and its relationship to the biomechanical properties of aortic tissue.J Thorac Cardiovasc Surg Open. 2023; 13: 32-44Scopus (3) Google Scholar have investigated purported relationships between “aortic mechanical properties” and “aortic geometry” in the context of aortic aneurysmal disease. They studied patients with aortic root and ascending thoracic aortic aneurysms who had preoperative aortic imaging and subsequently underwent operative treatment. The aortic specimens obtained at the time of operation were subjected to biaxial loading of known/prespecified magnitude and direction. The authors found that larger-diameter aneurysms exhibited greater extents of “energy loss,” or dissipation of the energy of blood (this in turn being overwhelmingly derived from left ventricular systolic function), although no relationships between diameter and “elastic modulus” or “delamination strength” were identified. No relationships between aneurysm length and any of the 3 aforementioned material parameters were identified. The authors conclude that, broadly speaking, aortic geometry and aortic mechanical properties poorly correlate. But we know this from clinical experience as well, because: (1) many large aortic aneurysms do not rupture or dissect, and (2) many small aortic aneurysms do (although of course highly variable aortic loading conditions contribute to these observations as well). However, as discussed previously, mechanical properties are definitionally independent of geometry. Why would one suspect that they correlate? (See to follow as to why this could be the case.) There are at least 4 inter-related issues with the current study, ranging from the conceptual to the interpretation of data.1.It is unclear what mathematical model the authors are using to capture aortic behavior. The authors ascertain “energy loss” and “elastic modulus,” but these are in fact incompatible and mutually exclusive terms. Elastic materials do not dissipate energy.2.Discussed previously, linearized elasticity can only apply to small deformations, whereas cardiovascular tissues undergo large deformations.3.Also discussed previously, based upon an incorrect choice of model, one could potentially incorrectly identify (as the authors did in the case of aneurysm diameter and “energy loss”) a relationship between 2 variables, when one variable does not really exist (eg, a single-valued “elastic modulus” in a nonlinearly elastic material).4.To whatever extent correlations between aortic material properties and aortic geometry could exist, they are and must be (definitionally, as previously) only that: correlations without causation. The pathophysiological mechanisms that underlie abnormal aortic mechanics likely are the same—or at least substantially overlapping—with those that underlie aortic dilatation. That is to say, a larger-diameter aortic aneurysm may have different material properties than when that same aneurysm was a smaller diameter, but that does not mean that the material properties depend upon the diameter. Again, material properties are definitionally independent of material geometry. Ascending aortic geometry and its relationship to the biomechanical properties of aortic tissueJTCVS OpenVol. 13PreviewThe objective of this study was to evaluate the relationship between ascending aortic geometry and biomechanical properties. Full-Text PDF Open AccessAuthor Reply to Commentary: Thinking nonlinearly about aortic biomechanicsJTCVS OpenVol. 13PreviewDrs Plestis and Rajagopal1 have provided a commentary on our study of the relationship between aortic geometry and material properties of the aorta. Unfortunately, our work was misread. Here, we will attempt to dispel any confusion by addressing each of their 4 points. Full-Text PDF Open Access

OBJECTIVES: Limited data are available from randomized trials comparing outcomes between transcatheter aortic valve replacement (TAVR) and surgery in patients with different risks and with follow-up of at least 4 years or longer. In this large, population-based cohort study, long-term mortality and morbidity were investigated in patients undergoing aortic valve replacement (AVR) for severe aortic stenosis using a surgically implanted bioprosthesis (surgical/biological aortic valve replacement; sB-AVR) or TAVR. METHODS: Individual data from the Austrian Insurance Funds from 2010 through 2020 were analysed. The primary outcome was all-cause mortality, assessed in the overall and propensity score-matched populations. Secondary outcomes included reoperation and cardiovascular events. RESULTS: From January 2010 through December 2020, a total of 18 882 patients underwent sB-AVR (n = 11 749; 62.2%) or TAVR (n = 7133; 37.8%); median follow-up was 5.8 (95% CI 5.7-5.9) years (maximum 12.3 years). The risk of all-cause mortality was higher with TAVR compared with sB-AVR: hazard ratio 1.552, 95% confidence interval (CI) 1.469-1.640, P < 0.001; propensity score-matched hazard ratio 1.510, 1.403-1.625, P < 0.001. Estimated median survival was 8.8 years (95% CI 8.6-9.1) with sB-AVR versus 5 years (4.9-5.2) with TAVR. Estimated 5-year survival probability was 0.664 (0.664-0.686) with sB-AVR versus 0.409 (0.378-0.444) with TAVR overall, and 0.690 (0.674-0.707) and 0.560 (0.540-0.582), respectively, with propensity score matching. Separate subgroup analyses for patients aged 65-75 years and >75 years indicated a significant survival benefit in patients selected for sB-AVR in both groups. Other predictors of mortality were age, sex, previous heart failure, diabetes and chronic kidney disease. CONCLUSIONS: In this retrospective national population-based study, selection for TAVR was significantly associated with higher all-cause mortality compared with sB-AVR in patients ≥65 years with severe, symptomatic aortic stenosis in the >2-year follow-up.

Central MessageTo provide a dedicated space for young surgeons. To provide a dedicated space for young surgeons. How does a specialty journal increase its value to the professionals it serves? This has been a central focus and directive of the editorial team led by Dr Richard Weisel since he took the reins as Editor-in-Chief. The barriers are significant. First is the near oppressive competition for time that affects all members of the profession. Second, the omnipresence of mobile access and an increasing volume of online reviews can diminish the value of reading individual investigations and reflecting on their applicability to practice. Finally, one must consider the mountain of publications that inundate our inboxes from an ever-growing number of journals. Although these hurdles appear daunting, there is another transformation that is influencing how members of a profession—or for that matter anyone on the planet—gather new information and knowledge. Journals, and really all forms of print publication, have been the mainstay of knowledge dissemination since Johannes Gutenberg democratized their availability. In 1450, when his first press began production, there were fewer than a million books on the planet. Within 50 years, 50 million books were in circulation. This massive influx of information initiated a tectonic societal change. John Lienhard, in his book How Invention Begins,1Lienhard J.L. Part III: Writing and showing.in: Lienhard J.L. How Invention Begins Echoes of Old Voices in the Rise of New Machines. 1st ed. Oxford University Press, London, England2006: 137-216Google Scholar outlines the massive social influence this sudden influx of knowledge had on humanity. These religious, political, and technological changes continue to be felt more than 500 years after the first books came off the press. But this mode of knowledge dissemination is increasingly less dominant. The Internet provides ubiquitous access to information through open-source publications and social media. Ideas can be shared nearly instantaneously. The old model of a privileged or handpicked source of new knowledge is being threatened by an open-source model facilitated by the Internet. Couple that with the fact that the Internet is <30 years old and we begin to realize that greater influence is yet to come. Readily available access to knowledge and ideas can be beneficial, but there is an inherent weakness: There is no reliable method to verify the content. Simply put, there is no filter. Any thought, belief, perception, suggestion, or opinion can be disseminated. The noise that such an approach produces can be deafening. So, although the Internet has challenged the utility of professional journals as vehicles for transmission of knowledge, it has also provided an opportunity for journals to innovate and address the many recognized drawbacks of the Web. This opportunity is being seized by Dr Weisel and the Journal of Thoracic and Cardiovascular Surgery (JTCVS). The intent is to create a space for open, thoughtful, evidence-based discussions that focus conversations and cut through the noise created by postings on the Web. Commentaries and editorials solicited to accompany high-quality articles has been 1 means to provide greater insights into research. Additionally, relevant work from other journals is highlighted, providing access and a forum for further reflection and discussion. Furthermore, space has been devoted for younger members of our profession, who are drawn to the Web, to voice their interests and concerns. This approach provides a unique and fresh view of our profession, a view that will allow a more complete understanding of all facets of our specialty, including diverse surgeon populations—from early trainees to those reflecting on their career. We began with 2 strategies: The first was to bring the print media to the Web by leveraging social media. Working with the editorial staff of The Annals of Thoracic Surgery and a cadre of dedicated young surgeons, the Thoracic Surgery Social Media Network (@TSSMN) was created. This group worked with Drs Weisel and Patterson to identify articles of relevance from their respective journal. The articles would be designated open access then linked to a Twitter chat that would allow open discussion of the work. The second approach was to invite young surgeons to engage with the print version of JTCVS by providing editorials addressing topics of interest and relevance to them. Initially, the topics of interest centered on issues widely recognized as pertinent to young surgeons just entering practice. However, as more of these editorials began to appear, issues relevant to the wider population of surgeons emerged. From the reviews, it became clear that the topics often crossed generations and were widely applicable with input from multiple sources. Allowing an open exchange of ideas enriches our profession. Cardiothoracic surgery is dynamic, and changes in health care finance, outcomes reporting, acuity of patient populations, technology, and surgical education are just a few of the hurdles to overcome. Innovation is more than ever accomplished by merging existing concepts rather than creating something new. Young surgeons are frequently at the point of the spear when adapting to changes in health care, technology, and new responsibilities. That—combined with their limited voice in print— justifies the need to maintain their role as originators of editorials. However, young surgeons' editorials can benefit from other views to more broadly reflect the interests of all readers. To achieve this end, we chose a framework adapted from an approach first advanced by the Journal of the American College of Cardiology.2Sharma G. Cullen M.W. Sinha S.S. How invention begins echoes of old voices in the rise of new machines.J Am Coll Cardiol. 2017; 69: 104-105Google Scholar Briefly, JTCVS will accept an initial outline of a proposed editorial describing its overall goal and proposed arguments. Examples include topics relating to training, mentorship, professional development, research initiatives, application of new technologies, and issues unique to international trainees.2Sharma G. Cullen M.W. Sinha S.S. How invention begins echoes of old voices in the rise of new machines.J Am Coll Cardiol. 2017; 69: 104-105Google Scholar There will no longer be an invitation from the editors to submit an article for the Young Surgeons’ Page. Rather, any interested young surgeon can submit an outline describing his or her proposal. We suggest that young surgeons should be within 5 years of the completion of their formal training. We also hope that a mentor will be recruited to assist with the preparation of the proposal. After the outline is submitted and reviewed by a group of associate editors and reviewers, suggestions will be provided to the author(s) with an opportunity to submit revisions. Once an approved version is generated, the authors will be invited to submit the manuscript that will undergo a formal review similar to conventional submissions. The goal is simple: Provide a voice and a dedicated space for young surgeons, allow them to apply that voice in the creation of meaningful dialog centered on topics of broad interest to our readers, and leverage that open dialog to stimulate innovation in our profession.

Central MessageCan we build thoracic surgery programs that eliminate/minimize complications? Harmonizing adverse events classifications across databases is a key issue that first must be addressed.“Behold, the people is one, and they have all one language; and this they begin to do: and now nothing will be restrained from them, which they have imagined to do.”—Genesis 11:6See Article page 250 in the June 2021 issue. Can we build thoracic surgery programs that eliminate/minimize complications? Harmonizing adverse events classifications across databases is a key issue that first must be addressed. See Article page 250 in the June 2021 issue. Can we build a thoracic surgery program that eliminates or minimizes all complications? Is this a lofty height which we are destined never to reach? Complications after thoracic surgery have been decreasing, in part due to global efforts to objectively assess, document, and improve on outcomes.1Sigler G. Anstee C. Seely A.J.E. Harmonization of adverse events monitoring following thoracic surgery: pursuit of a common language and methodology.J Thorac Cardiovasc Surg Open. 2021; 6: 250-256Google Scholar While descriptions of postoperative complications in thoracic surgeries are widely reported, Sigler and colleagues1Sigler G. Anstee C. Seely A.J.E. Harmonization of adverse events monitoring following thoracic surgery: pursuit of a common language and methodology.J Thorac Cardiovasc Surg Open. 2021; 6: 250-256Google Scholar identify how the variety of systems used to classify adverse events (AE) undermine the potential of multicenter collaboration and data synthesis. In this issue of JTCVS Open, the authors describe their approach to harmonizing AE across databases.1Sigler G. Anstee C. Seely A.J.E. Harmonization of adverse events monitoring following thoracic surgery: pursuit of a common language and methodology.J Thorac Cardiovasc Surg Open. 2021; 6: 250-256Google Scholar The discordance between thoracic surgery AE databases has been previously described.2Ivanovic J. Seely A.J.E. Anstee C. Villeneuve P.J. Gilbert S. Maziak D.E. et al.Measuring surgical quality: comparison of postoperative adverse events with the American College of Surgeons NSQIP and the thoracic morbidity and mortality classification system.J Am Coll Surg. 2014; 218: 1024-1031Google Scholar,3Salati M. Refai M. Pompili C. Xiumè F. Sabbatini A. Brunelli A. Major morbidity after lung resection: a comparison between the European Society of Thoracic Surgeons Database System and the thoracic morbidity and mortality system.J Thorac Dis. 2013; 5: 217-222Google Scholar As such, it is difficult to draw valid comparisons between the AE of patients characterized using different databases. This precludes centers from pooling their outcomes data for meaningful international collaboration and quality improvement. However, the authors offer a means to collect AE in the same manner for their translation into any of the commonly used AE classification systems. A system is only as strong as the underlying assumptions on which it is constructed. Herein lies an important, but perhaps currently inescapable, methodologic limitation identified by the authors; the definitions of harmonization and the manner in which judgments are made regarding degree of harmonization are currently subjective and somewhat opaque. To harmonize differing definitions of AE, the definition of harmonization itself was characterized by a single author (if “perfect”) or by consensus with 2 authors (if not “perfect”). This subverts the reproducibility of harmonized definitions due to the necessarily subjective interpretation of AE elements. Certainly, there are definitions in each classification system that are straightforward or approximate objective measurement. However, inter-rater reliability cannot be taken for granted, especially in a novel undertaking predicated on the interpretation of a single expert. The authors acknowledge that it is good practice to ensure multidisciplinary discussion in efforts to characterize AE within individual institutions. Efforts to characterize AE across institutions should be held to a similar standard, if not more rigorous due to the risk of data being “lost in translation.” Therefore, such consensus-based discussions around definitions require not only standardized definitions of AE categories but also requisite thresholds of agreement among experts for an AE to be characterized. In doing so, one ensures a robust foundation on which to build this synthesis of multiple classifications. Nevertheless, a major strength of this paper is that it establishes a framework for harmonization. This creates the unique opportunity to compare AE data from institutions across the world. Currently, centers that desire to collaborate across multiple AE databases must fill in their AE data for each separate system. However, the approach of Sigler and colleagues1Sigler G. Anstee C. Seely A.J.E. Harmonization of adverse events monitoring following thoracic surgery: pursuit of a common language and methodology.J Thorac Cardiovasc Surg Open. 2021; 6: 250-256Google Scholar is simple, with 4 drop-down menus that facilitate AE classification on researchers' behalf. Therefore, researchers neither must enter the same data repeatedly nor learn an entirely new system to harmonize. Rather, the authors' approach aligns already-existing systems to harmonize. Because it is practical and user-friendly in this way, this system also ensures accessibility to researchers who seek to collaborate internationally for the first time. At the end of the day, authors should be commended for tackling an important problem in the way that we all communicate with each other, which is a barrier to sustainable and large-scale quality improvement initiatives across jurisdictions. Given the long-reaching implications that may result from such harmonization endeavors, it is imperative that underlying assumptions about definitions and decisions for harmonization be abundantly clear and reproducible. Otherwise, the very human frailty of subjectivity, rather than any vengeful deity, will be what brings down our proverbial tower before we reach the lofty heights of zero complications. Harmonization of adverse events monitoring following thoracic surgery: Pursuit of a common language and methodologyJTCVS OpenVol. 6PreviewThoracic surgery carries significant risk of postoperative adverse events (AEs). Multiple international recording systems are used to define and collect AEs following thoracic surgery procedures. We hypothesized that a simple-yet-ubiquitous approach to AE documentation could be developed to allow universal data entry into separate international databases. Full-Text PDF Open Access

Central MessageThe study confirms that the effectiveness of the lysine analogs, tranexamic acid and epsilon-aminocaproic acid, in reducing bleeding and transfusion is comparable in adults undergoing cardiac surgery.See Article page 114. The study confirms that the effectiveness of the lysine analogs, tranexamic acid and epsilon-aminocaproic acid, in reducing bleeding and transfusion is comparable in adults undergoing cardiac surgery. See Article page 114. In this issue of the JTCVS Open, Broadwin and colleagues1Broadwin M. Grant P.E. Robich M.P. Palmeri M.L. Lucas F.L. Rappold J. et al.Comparison of intraoperative tranexamic acid and epsilon-aminocaproic acid in cardiopulmonary bypass patients.J Thorac Cardiovasc Surg Open. 2020; 3: 114-125Scopus (3) Google Scholar retrospective analyzed 66 patients who underwent cardiac surgery with cardiopulmonary bypass (CPB) and received either tranexamic acid (TXA) or epsilon-aminocaproic acid (EACA). The authors report comparable transfusion rate and chest tube drainage output. The study was not powered or designed to compare the safety of the 2 drugs. EACA inhibits binding of plasmin to fibrin by occupying the lysine-binding sites of the proenzyme plasminogen.2Mannucci P.M. Levi M. Prevention and treatment of major blood loss.N Engl J Med. 2007; 356: 2301-2311Crossref PubMed Scopus (367) Google Scholar TXA acts like EACA but is 10 times more potent on a molar basis. The number and quality of studies that assessed the effectiveness and safety of TXA outweighs those on EACA.3Henry D.A. Carless P.A. Moxey A.J. O'Connell D. Stokes B.J. Fergusson D.A. et al.Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion.Cochrane Database Syst Rev. 2011; : CD001886Google Scholar In a large study of 4662 patient undergoing coronary artery surgery, TXA was associated with a lower risk of bleeding than the placebo, without a greater risk of death or thrombotic complications within 30 days after surgery.4Myles P.S. Smith J.A. Forbes A. Silbert B. Jayarajah M. Painter T. et al.Tranexamic acid in patients undergoing coronary-artery surgery.N Engl J Med. 2017; 376: 136-148Crossref PubMed Scopus (197) Google Scholar TXA did not affect death or severe disability through to 1 year after surgery.5Myles P.S. Smith J.A. Kasza J. Silbert B. Jayarajah M. Painter T. et al.Tranexamic acid in coronary artery surgery: one-year results of the Aspirin and Tranexamic Acid for Coronary Artery Surgery (ATACAS) trial.J Thorac Cardiovasc Surg. 2019; 157: 644-652.e9Abstract Full Text Full Text PDF Scopus (16) Google Scholar To date, the number of studies comparing TXA and EACA is sparse. Although the BART (Blood Conservation Using Antifibrinolytics in a Randomized Trial) study mainly compared aprotinin with each of the lysine analogs, no clinically relevant difference was reported between the 2 drugs.6Fergusson D.A. Hébert P.C. Mazer C.D. Fremes S. MacAdams C. Murkin J.M. et al.A comparison of aprotinin and lysine analogues in high-risk cardiac surgery.N Engl J Med. 2008; 358: 2319-2331Crossref PubMed Scopus (873) Google Scholar In 2014, Falana and Patel7Falana O. Patel G. Efficacy and safety of tranexamic acid versus ε-aminocaproic acid in cardiovascular surgery.Ann Pharmacother. 2014; 48: 1563-1569Crossref PubMed Scopus (20) Google Scholar performed a single-center retrospective study of 120 patients who underwent cardiovascular surgery with or without CPB and received at least 1 dose of TXA or EACA. The authors concluded that there were no differences in the efficacy and safety of TXA and EACA. In a randomized, double-blinded trial, Leff and colleagues8Leff J. Rhee A. Nair S. Lazar D. Sathyanarayana S.K. Shore-Lesserson L. A randomized, double-blinded trial comparing the effectiveness of tranexamic acid and epsilon-aminocaproic acid in reducing bleeding and transfusion in cardiac surgery.Ann Card Anaesth. 2019; 22: 265-272Crossref PubMed Scopus (16) Google Scholar compared the effectiveness of EACA and TXA in reducing blood loss and transfusion requirements in 114 patients undergoing cardiac surgery with CPB. The authors did not report any statistically significant difference between groups when analyzing chest tube drainage. However, they found a significant difference in the administration of any blood product transfusion intraoperatively to 24 hours postoperatively, with less transfusion in patients receiving EACA compared with TXA (25% vs 44.8%, respectively; P = .027). One of the concerns associated with the administration of lysine analogs has been the dose-dependent increase in the risk of clinical seizures.4Myles P.S. Smith J.A. Forbes A. Silbert B. Jayarajah M. Painter T. et al.Tranexamic acid in patients undergoing coronary-artery surgery.N Engl J Med. 2017; 376: 136-148Crossref PubMed Scopus (197) Google Scholar,9Lecker I. Wang D.-S. Romaschin A.D. Peterson M. Mazer C.D. Orser B.A. Tranexamic acid concentrations associated with human seizures inhibit glycine receptors.J Clin Invest. 2012; 122: 4654-4666Crossref PubMed Scopus (131) Google Scholar In their study, Martin and colleagues10Martin K. Knorr J. Breuer T. Gertler R. Macguill M. Lange R. et al.Seizures after open heart surgery: comparison of ε-aminocaproic acid and tranexamic acid.J Cardiothorac Vasc Anesth. 2011; 25: 20-25Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar reported a significant lower new onset of clinical seizures in patients treated with EACA compared with TXA (3.3% vs 7.6%, P = .019). In another study by Makhija and colleagues,11Makhija N. Sarupria A. Kumar Choudhary S. Das S. Lakshmy R. Kiran U. Comparison of epsilon aminocaproic acid and tranexamic acid in thoracic aortic surgery: clinical efficacy and safety.J Cardiothorac Vasc Anesth. 2013; 27: 1201-1207Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar the authors also reported a tendency for greater incidence of seizure with TXA. Clinical safety and efficacy data for EACA are limited, and some authors have reported an increased risk for postoperative renal dysfunction after EACA administration.10Martin K. Knorr J. Breuer T. Gertler R. Macguill M. Lange R. et al.Seizures after open heart surgery: comparison of ε-aminocaproic acid and tranexamic acid.J Cardiothorac Vasc Anesth. 2011; 25: 20-25Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar,11Makhija N. Sarupria A. Kumar Choudhary S. Das S. Lakshmy R. Kiran U. Comparison of epsilon aminocaproic acid and tranexamic acid in thoracic aortic surgery: clinical efficacy and safety.J Cardiothorac Vasc Anesth. 2013; 27: 1201-1207Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar In summary, EACA could be considered as a cost-effective alternative to TXA for the prevention of bleeding and transfusion in cardiac surgical patients. However, EACA and TXA have only been compared in small retrospective studies, and safety concerns have been raised for EACA. Further large prospective studies comparing EACA and TXA would therefore be needed before EACA could be considered a safe alternative to the well-studied TXA. Comparison of intraoperative tranexamic acid and epsilon-aminocaproic acid in cardiopulmonary bypass patientsJTCVS OpenVol. 3PreviewTo compare tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA) in patients undergoing cardiac surgery with cardiopulmonary bypass. Full-Text PDF Open Access

Clinical practice guidelines consolidate and evaluate all pertinent evidence available at their time of formulation on a specific topic, the goal being to assist physicians in determining the most effective management strategies for patients with a particular condition. These guidelines assess the impact on patient outcomes and weigh the risk–benefit ratio of various diagnostic or therapeutic approaches. Although not a replacement for textbooks, they provide supplementary information on topics relevant to current clinical practice, becoming an essential tool to support physicians' decision making in daily practice. Nonetheless, it is crucial to understand that these recommendations are intended to guide but not dictate clinical practice; they should be adapted to each patient's unique needs. Clinical situations vary, presenting a diverse array of variables and circumstances.

Abstract Pain in the postoperative period is a common patient experience that can subsequently lead to other postoperative complications if not managed appropriately. While opioids are a common pharmacologic tool for managing pain, there are risks associated with liberal opioid use. Multimodal analgesic strategies, however, can adequately manage postoperative pain and minimize the risks associated with opioids. In this review, common pharmacological treatments for multimodal analgesia will be reviewed for efficacy, risks, and benefits, including gabapentinoids, opioids, alpha-2 agonists, ketamine, Non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids. While this may not be a comprehensive list of medication options, it represents some of the most commonly used pharmacologic techniques for managing pain in the perioperative period. In addition, newer regional anesthetic techniques will be discussed to review their efficacy, risks, and benefits as well. The goal of this review is to summarize the various options for a multimodal analgesic protocol that we encourage providers to utilize when managing postoperative pain to facilitate conservative opioid usage and improve patient outcomes overall. Graphical Abstract

“Aortic aneurysmal disease is multifocal and needs total aortic screening for diagnosis; best results are obtained by complete replacement of all disease” , this is the most important message delivered by Dr. Crawford in the presidential address, titled ‘‘Aortic Aneurysm: A Multifocal Disease’’ , during the annual International Society for Cardiovascular Surgery Conference in 1982 (1). Despite more than thirty years has elapsed this concept is still actual. Recently Corvera et al. (2) from the Indiana University in the US brought us to the past with the interesting manuscript published on the Journal of Thoracic and Cardiovascular Surgery (JTCVS), entitled: “Open repair of chronic thoracic and thoracoabdominal aortic dissection using deep hypothermia and circulatory arrest”.

Postoperative atrial fibrillation (POAF) after cardiac surgery is associated with elevated morbidity and mortality. Although current prediction models have limited efficacy, several perioperative interventions can reduce patients' risk of POAF. These begin with preoperative medications, including beta-blockers and amiodarone. Moreover, patients should be screened for preexisting atrial fibrillation (AF) so that concomitant surgical ablation and left atrial appendage occlusion can be performed in appropriate candidates. Intraoperative interventions such as posterior pericardiectomy can reduce mediastinal fluid accumulation, which is a trigger for POAF. Furthermore, many preventive strategies for POAF are implemented in the immediate postoperative period. Initiating beta-blockers, amiodarone, or both is reasonable for most patients. Overdrive atrial pacing, colchicine, and steroids have been used by some, although the evidence base is less robust. For patients with POAF, rate-control and rhythm-control strategies have comparable outcomes. Decision-making regarding anticoagulation should recognize that the stroke risk associated with POAF appears to be lower than that for general nonvalvular AF. The evidence that oral anticoagulation reduces stroke risk is less clear for POAF patients than for patients with general nonvalvular AF. Given that POAF tends to be shorter-lived and is associated with greater bleeding risks in the perioperative period, decisions regarding anticoagulation should be individualized. Finally, wearable technology and machine learning algorithms for better predicting and managing POAF appear to be coming soon. These technologies and a comprehensive clinical program could meaningfully reduce the incidence of this common complication.

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