Background The European CE Mark approval study and the MOMENTUM 3 trial demonstrated safety and a reduction in hemocompatibility-related adverse events with use of HeartMate 3 (HM3) device. This single center study investigated the real-world experience in HM3 patients since FDA approval. Methods This retrospective, observational study included patients implanted with the HM3 LVAD as a primary implant between October 2017-March 2020. Patients were divided into trial group and postapproval group. Primary endpoint was survival at 6 months. Secondary endpoints were adverse events including pump thrombosis (requiring pump exchange), stroke, renal failure, acute limb ischemia, re-exploratory for bleeding, gastrointestinal bleeding, right ventricular failure, and driveline infection. Results A total of 189 patients were implanted with HM3 device during the study period. 174 patients met the inclusion criteria: 82 patients in the trial group and 92 patients in the postapproval group. The postapproval group had younger patients, higher pre-operative mean international normalized ratio, and greater numbers of patients with bridge to transplant (BTT) indications, IINTERMACS profile 1, and use of mechanical assist devices (other than IABP) than the trial group. Other characteristics between the two groups were comparable. Overall survival at 6 months in the postapproval group was 93.3% vs. 93.8% ( p=0.88). The postapproval group demonstrated a statistically significant lower incidence of re-explorative surgery for bleeding (10.9% vs 46.3,  p=0.01) than the trial group. Conclusion In this single-center study, the real-world 6-month survival in the postapproval group was comparable to the trial results. Further studies are needed to monitor long-term outcomes.

Patients with a bicuspid aortic valve (BAV) are at increased risk of valvular regurgitation compared to their counterparts with a tri-leaflet aortic valve. There is now increasing emphasis to offer BAV repair to mitigate the risks of prosthesis-related complications, including thromboembolism, haemorrhage and endocarditis, as well as structural valve deterioration and future re-operation with conventional valve replacement, particularly in younger populations. Furthermore, over the preceding two decades, our greater understanding of the functional anatomy of the BAV, pathophysiological mechanisms of BAV insufficiency and the development of a functional classification of aortic regurgitation have significantly contributed to the evolution of aortic valve reconstructive surgery. In this commentary, we discuss a recent article from the Journal of Cardiac Surgery comparing external annuloplasty and subcommissural annuloplasty as techniques for BAV repair.

Robotic totally endoscopic techniques to perform the LITA to LAD graft, coupled with PCI, provides the least invasive option to achieve hybrid coronary revascularization (HCR). Shorter hospital stay and reduced need for blood transfusions have been consistently being reported by several studies along with similar long-term outcomes. Considerable variations exist in the definition of HCR which can be single or two-staged with surgical revascularization being carried out after PCI or vice versa. Variations also exist with respect to usage of cardiopulmonary bypass, surgical incisions, and use of minimally invasive robotic techniques. The different strategies of HCR do not lead to similar outcomes and the findings of one strategy cannot be extrapolated to the entire group. Studies reporting different strategies of HCR, should ideally provide more granular data when reporting outcomes.

A document by Daniele Ronco. Click on the document to view its contents.

The surgical ventricular restoration is an evolution of treatment of left ventricle aneurysm. The aetioloy of left ventricle aneurysm and the dilated post AMI cardiomiopaty is the same; the difference is in the extension of scarred tissue and in the quality of remote zone. Because in this anatomical situation the geometry of left left ventricle can be deeply affected, it can very difficult to have point of reference as position of apex or papillary mussles. Using a sizer and combine different surgical thecniques allow to rebuilt a ventricle with appropriate volume and shape.

Case Video Summary: This video demonstrates the principle of spiral PA plasty whereby the length of branch pulmonary arteries can be increased simultaneous to the increase in diameter by using a patch that is anastomosed spirally around the vessels.

We present a reply to the invited commentary by Jubouri and Abdelhaliem published in response to our original article titled: Prevention vs Cure: is BioGlue priming the optimal strategy against E-Vita Neo graft oozing? The authors highlight key issues associated with the E-Vita Open NEO aortic arch prosthesis, chiefly, the propensity for the prosthesis to exhibit post-anastomotic oozing. We read with great interest their commentary and concur that the issues highlighted therein are significant and warrant discussion.

Infectious complications have been shown to increase the morbidity of venous-venous extracorporeal membrane oxygenation (VV-ECMO) population, including the use of right ventricular assist devices. We aimed to evaluate our VV-ECMO population for ECMO related bloodstream infections (E-BSI) and characteristics that affect risk and overall outcomes. We report a low infection rate of 2.7%. We postulate our low BSI rate may be due to our use of perioperative antimicrobials as well as a majority of our cannulations occurring in the operating room. Further investigation into trends, risks, and outcomes related to E-BSI is needed.

We reported a case of a 3-month-old infant presented with supravalvular aortic stenosis with congenital right coronary artery deficiency. According to cardiovascular CT results, Doty technique was adopted to restore the aortic root geometry under cardiopulmonary bypass. An angioplasty was performed to establish right coronary blood flow at the same time. The patient had no abnormal cardiac symptoms after surgery.

during Ozaki procedure, relocating a valvular commisure could be technically demanding. This novel technique provides an easy tool to achieve valvular simmetry avoiding commisure shifting.

This case report describes the management of a large iatrogenic ventricular septal defect (VSD) created by the coring device during systemic ventricular assist device (RVAD) insertion in a 16 year-old patient with congenitally corrected transposition of the great arteries. The VSD was closed by bovine pericardial patch and the ventriculotomy was extended laterally to relocate the VAD sewing ring. After RVAD implantation, patient initially remained cyanotic, potentially due to a tiny VSD patch leak with right to left shunting. Hypoxia was successfully corrected by rescue nitric oxide infusion and patient was bridged to transplant after 91 days.

Emergency surgery for Type A Aortic Dissection in Octogenarians – do we still err on the side of caution?

Background: While enhanced recovery after surgery (ERAS) pathways have been successfully applied for cardiac surgery, there has been limited research directly comparing ERAS protocols to ad hoc narcotic use after surgery. We hypothesized that a standardized ERAS protocol would provide similar pain management and psycho-emotional outcomes while decreasing the use of opioids in the hospital and after discharge. Methods: As part of a 7-month quality improvement project, cardiac surgery patients on a fast tracked to extubate pathway were assigned PRN narcotic pain management for 3 months (n=49). After a 1-month ERAS protocol optimization period, a separate group of patients were given the ERAS protocol (n=34). Clinical outcomes were gathered, and participants completed a quality of recovery survey that allowed for the assessment of pain and symptom control at 4 time-points post-surgery. Results: Among 83 participants, 66% were male and the mean age was 53 years. There were no differences in patient characteristics between PRN and ERAS groups (all p>0.244). There were no differences between ERAS and PRN groups for surgery characteristics (all p>0.060), inpatient outcomes (all p>0.658), or after-discharge outcomes (all p>0.397). Furthermore, across all time-point comparisons, there were no supported differences in patient-reported outcome and pain control between the ERAS and PRN narcotic groups (all p>0.075). Conclusions: An ERAS protocol demonstrated similar patient outcomes and pain control to traditional opioid use for postoperative cardiac surgery patients. Further research is recommended to further confirm the results of this study.

Pericardiectomy for Constrictive Pericarditis after Mediastinal Irradiation – Need for Functional AssessmentSiddharth Pahwa, MD1

Background and aim of the study. Wrapping of the ascending aorta (AA), isolated or associated with aortoplasty, has never been completely accepted. Some complications, as folding of the aortic wall, compression of the vasa vasorum and changes in the flow pattern, with consequent dilatation of the proximal arch, have been described. We used fresh autologous pericardium (FAP), so far never reported, to wrap the AA, with the aim to stabilize its size when moderately dilated, maintaining the preoperative dimension or limiting the reduction to a few mm. Material and Methods. From 2015 to 2019, 10 patients, who were operated on for valve or coronary surgery or both, underwent wrapping of the AA with FAP. Mean age was 69±7 years and ESII 3.5±1.7. Four patients had moderately impaired ejection fraction (35-49%). Results. There was no early or late mortality. One patient was reoperated on after 48 months for severe mitral regurgitation. At a follow up of 53±14 months, a transthoracic echocardiogram showed that the AA size reduced slightly but significantly, from 45.2±2.0 to 42.5±4.1 mm, p=0.03. The diameter of the proximal arch remained unchanged, from 37.1±1.6 to 36.3±2.9 mm, p=0.20. Conclusions. In presence of moderately dilated AA wrapping can be a reasonable option. The use of FAP stabilizes the size of the aorta after a follow up of 53 months. Maintaining a size similar to the preoperative one avoids the complications related to the procedure.

Background: Transcatheter mitral valve implantation (TMVI) is a promising and minimally invasive treatment for high-risk mitral regurgitation (MR). The purpose of this study was to investigate the feasibility of a novel self-expanding valved stent for transcatheter mitral valve implantation via apical access. Methods: A novel self-expanding mitral valved stent system was designed and fabricated for the in vivo evaluation. It is consists of an atrial flange and a saddle-shaped ventricular body connected by two opposing anchors and two opposing extensions. During the valve deployment, each anchor is controlled by a recurrent string. TMVI was performed in ten pigs using the valve prosthesis through the apical access to verify technical feasibility. Echocardiography and ventricular angiography were used to assess hemodynamic data and valve function. The surviving pigs were sacrificed four weeks later to confirm stent deployment. Results: Ten animals underwent transapical mitral valve implantation with the novel mitral valved stent. Optimal valve deployment and accurate anatomical adjustment were obtained in nine animals. Implantation failed in one case, and the animal died one day later due to stent mismatch. After stent implantation, the hemodynamic parameter of other animals was stable and valve function was normal. The mean pressure across the mitral valve and left ventricular outflow tract (LVOT) were 2.98±0.91mmHg and 3.42±0.66 mmHg, respectively. The macroscopic evaluation confirmed the stable and secure positioning of the stents in the mitral valve. No obvious valve displacement, embolism, and paravalvular leakage were observed four weeks after valve implantation. Conclusions: This study proved that the novel mitral valved valve stent is technically feasible in animals. This device features opposing anchors, opposing recurrent strings, and saddle-like ventricular portions, providing structural design details for reducing TMVI complications. However, the long-term feasibility and durability of this valved stent need to be improved and verified.

The meta-analysis by He and collaborators [has the worth to cover, as much as possible, a gap of scientific evidence where conducting a randomized trial appears very complex for ethical and logistical reasons. The authors concluded that mitral valve repair (MVP) provide better pooled results, both early and late, with respect to mitral valve replacement (MVR). However, the superiority of MVP is driven by some single large cohort-studies where surgeons had wide experience in the field of MVP for IE. This finding is also confirmed by other studies. But if mitral repair produces such a better short- and long-term survival than replacement, why are there no clear indications from consensus and guidelines pushing surgeons toward the pursuit of a reconstructive procedure at almost any cost? We wonder but to repair or not to repair, is that really the question? The AATS consensus suggests to repair “whenever possible” but without providing more specific indications. If the two primary goals of surgery are total removal of infected tissues and reconstruction of cardiac morphology, including repair or replacement of the affected valve(s), probably MVP as to perform in case of less extensive tissue detriment by the infection. In more wide valve involvement, MVP may be the choice but only in very expert hands and in Centers with very large volume of valve repairing. This decision cannot therefore be the result of the choice of an individual but must derive from a careful multidisciplinary discussion to be held in an EndoTeam.

Technical details for complex cardiac tumor resection are sparse. We describe the operative technique of modified autotransplantation for resection of a complex pericardial synovial sarcoma in a 63-year-old, Caucasian female. Surgical exposure demonstrated tumor origin at the superior cavoatrial junction and invasion of the aorta, main pulmonary artery, superior pulmonary veins, and left atrial roof. Full macroscopic surgical resection was achieved. The patient received adjuvant radiation for microscopic positive margins and remains alive and with no tumor progression at one year postoperatively. We conclude that modified autotransplantation is a challenging but effective surgical technique when performed with careful patient selection and availability of skilled, cardiothoracic surgeons at a cardiac center of excellence.