There are no solid evidence from literature that compare Cox-Maze with pulmonary vein isolation technique for atrial fibrillation in the context of concomitant mitral valve surgery. While the first is perhaps more effective and linked to higher freedom form atrial fibrillation, it is more invasive compared to the pulmonary isolation.

The catastrophe of hypoxia in complex aortic surgery

Background While open surgical repair continues to be the mainstay option for aortic arch reconstruction, the associated mortality, morbidity, and high turn-down rates have led to a need for the development of minimally invasive options for aortic arch repair. Though RELAY™ Branched (Terumo Aortic, Inchinnan, UK) represents a promising option for complex endovascular aortic arch repair, neurological complications remain a pertinent risk. Herein we seek to present multi-centre data from Europe documenting the neurological outcomes associated with RELAY™ Branched. Methods Prospective data collected between January 2019 and January 2022 associated with patients treated with RELAY™ single-, double-, and triple-branched endoprostheses from centres across Europe was retrospectively analysed with descriptive and distributive analysis. Follow up data from 30 days and 6-, 12-, and 24 months postoperatively was included. Patients follow up was evaluated for the onset of disabling stroke (DS) and non-disabling stroke (NDS). Results Technical success was achieved in 147 (99.3%) cases. Over 24 months period, in total, 6 (4.1%) patients suffered DS and 8 (5.4%) patients suffered NDS after undergoing aortic arch repair with RELAY™. All patients that developed postoperative DS had been treated with the double-branched RELAY™ endoprosthesis. Discussion The data presented herein demonstrates that RELAY™ Branched is associated with favourable neurological outcomes and excellent technical success rates. Key design features of the endoprosthesis and good perioperative management can contribute greatly to mitigating neurological complications following endovascular aortic arch repair.

Objective Functional tricuspid regurgitation(FTR) levels can vary over time and its longitudinal changing patterns may predict right ventricular dysfunction(RVD) risk. We aim to identify different trajectories of FTR in those who received mitral valve replacement(MVR) and investigate the association between longitudinal trajectory groups and RVD risk in a cohort study. Methods and results A prospective cohort study, reported usual FTR levels at baseline in 2005–2015 and the participants of MVR have been followed up for 5~6 years, approximately every one years, and so far, the data have been collected across five subsequent phases. Five-year longitudinal trajectories of FTR were identified using group-based trajectory modelling(GBTM). We identified 3 distinct trajectories using a GBTM, labeled by initial value and changing pattern: stable group(258/378, 68.2%), increasing-slow group(67/378, 17.6%) and increasing-fast group(53/378, 14.2%). Treating the stable group as the reference, the age- and sex-adjusted odds ratio(OR) was 25.84 (95% confidence interval, 11.78-56.65) for the increasing-slow group and 139.94(95% confidence interval, 45.47-430.68) for the increasing-fast group by logistic regression model. After adjustment for every potential confounding factors, the OR is 14.21(95% confidence interval, 4.36-46.33)、49.34(95% confidence interval, 8.88-273.87) respectively. Conclusions The longitudinal trajectories of worsening FTR were mostly associated with increased risk of RVD outcomes, which is independent of other factors including FTR levels. These findings have implications for intervention and prevention of RVD among individuals who received MVR.

A document by Sara Zaidi. Click on the document to view its contents.

Background/Aim: A transposition complex with an interrupted aortic arch (IAA) is rare and surgically challenging because of its anatomical diversity and complexity. Herein, we aimed to present our 20-year experience with one-stage arterial switch surgery associated with IAA repair. Methods: From January 2000 to April 2017, 11 patients were diagnosed with transposition complex and IAA and underwent one-stage repair at our center. These patients were retrospectively reviewed. Two patients had transposition of the great arteries, while the others had double outlet right ventricles, of whom eight had subpulmonary ventricular septal defects (Taussig-Bing anomalies), and one had a non-committed ventricular septal defect. In terms of the IAA, three patients underwent repair by extended end-to-end anastomosis, and one 16-mm prosthetic vascular graft was replaced in an elder patient. The remaining patients underwent autologous pericardial patch enlargement. All the variables were summarized and reported with descriptive statistics. Results: Three early deaths occurred in this study. The median follow-up time was approximately 5 years (range: 3 – 14 years). No late deaths were reported. Only one patient required percutaneous re-intervention for recurrent coarctation. Moderate aortic regurgitation was observed in three patients. However, there was no requirement for aortic valvuloplasty or valve replacement. One patient had more than moderate tricuspid regurgitation. The other survivors are presently healthy. Conclusions: Although one-stage repair for transposition complex and IAA still has non-negligible mortality even in older children, the late outcomes of survivors are acceptable. Owing to the high rate of valve regurgitation, closer follow-up is necessary for these patients.

I read with interest the article by Vendramin and colleagues , reminding us with the 70th anniversary for the first artificial heart valve that was invented by Hufnagel and was first implanted in 1952. This was in an era, where standard heart valve replacement was not feasible, and the heart lung machine was in its very primitive phase to allow such operation to be performed in the way we do it today. This made me dig a bit in the literature and read more in depth about Dr. Hufnagel, one of the most gifted American surgeons and his pioneer work.

Title pageTitle : Letter to the Editor: Long-term results of aortic root replacement for endocarditisArticle type : Letter to the editor

Minimally invasive mitral valve surgery can be performed with or without robotic assistance. In this issue of the journal Zheng et al compare between these two approaches in a propensity matched study over a 5 year period and show that the two techniques have similar successful short and mid term outcomes. Although we are proponents of the robotic approach, we agree with their conclusions and discuss in this commentary some of the previously published studies that have shown similar findings.

The implementation of automatic fasteners such as the Cor-knot ® device (LSI Solutions, Inc.) has revolutionized the field of minimally invasive valvular surgery. Nonetheless, paravalvular regurgitation, valvular embolization, and early leaflet perforation are all potential complications which may occur. Late manifestations of leaflet perforation (>5-year post-implantation) are rare. Herein, we discuss a patient who underwent remote Trifecta ® (St. Jude, Inc.) surgical aortic valve replacement (SAVR) presenting with symptomatic critical aortic regurgitation secondary to leaflet perforation from automatically fastened metallic Cor-knot ® sutures.

Some would argue that kids aren’t just little adults, but what about their sternums? We are reviewing a manuscript by Horriat, McCandless, and colleagues in the Journal of Cardiac Surgery1 describing their experience with managing sternal wound infections (SWI) after congenital heart surgery. They report encouraging results in 14 patients who required plastic surgery consultation to manage their sternal wounds. The nature of congenital cardiac abnormalities and the necessary steps to repair them leads to physiologic derangements predisposing patients to SWI. Rates of SWI vary and have been reported at 1.53% in this population. There is little guidance on how the management of the congenital cardiac surgery patient should differ from the adult patient.2

Background: Mitral valve apparatus is complex and involves the mitral annulus, the leaflets, the chordae tendinae, the papillary muscles as well as the left atrial and ventricular myocardium. Secondary mitral regurgitation is consequence of regional or global left ventricle remodeling due to an acute myocardial infarction (75% of cases) or idiopathic dilated cardiomyopathy (25% of cases). It is associated with an increase in mortality and poor outcome. There is a potential survival benefit deriving from the reduction in the degree of severity of mitral regurgitation. So the correction of the valve defect can change the clinical course and prognosis of the patient. The rationale for mitral valve treatment depends on the mitral regurgitation mechanism. Therefore, it is essential to identify and understand the pathophysiology of the mitral valve regurgitation. Aim of the study: The aim of this review is to describe the crucial role of transthoracic and trans-esophageal echocardiography, in particular with 3D echocardiography, for the assessment of the severity of secondary mitral regurgitation, anatomy and hemodynamic changes in the left ventricle. Moreover, the concept that the mitral valve has no organic lesions has been abandoned. The echocardiography must allow a complete anatomical and functional evaluation of each component of the mitral valve complex, also useful to the surgeon in choosing the best surgical approach to repair the valve. Conclusions: Echocardiography is the first-line imaging modality for a better selection of patients, according to geometrical modifications of mitral apparatus and left ventricle viability, especially in preoperative phase.

Introduction: There are no guidelines regarding the use of bovine pericardial or porcine valves for aortic valve replacement, and prior studies have yielded conflicting results. The current study sought to compare short- and long-term outcomes in propensity-matched cohorts of patients undergoing isolated AVR with bovine versus porcine valves. Methods: This was a retrospective study utilizing an institutional database of all isolated bioprosthetic surgical aortic valve replacements performed at our center from 2010 to 2020. Patients were stratified according to type of bioprosthetic valve (bovine pericardial or porcine), and 1:1 propensity-score matching was applied. Kaplan-Meier survival estimation and multivariable Cox regression for mortality were performed. Cumulative incidence functions were generated for all-cause readmissions and aortic valve reinterventions. Results: A total of 1,502 patients were identified, 1,090 (72.6%) of whom received a bovine prosthesis and 412 (27.4%) of whom received a porcine prosthesis. Propensity-score matching resulted in 412 risk-adjusted pairs. There were no significant differences in clinical or echocardiographic postoperative outcomes in the matched cohorts. Kaplan-Meier survival estimates were comparable, and, on multivariable Cox regression, valve type was not significantly associated with long-term mortality (HR 1.02, 95% CI: 0.74, 1.40, p=0.924). Additionally, there were no significant differences in competing-risk cumulative incidence estimates for all-cause readmissions (p=0.68) or aortic valve reinterventions (p=0.25) in the matched cohorts. Conclusion: The use of either bovine or porcine bioprosthetic aortic valves yields comparable postoperative outcomes, long-term survival, freedom from reintervention, and freedom from readmission.

Title page:Title : Letter to the editor: Mitral valve repair with the edge‐to‐edge technique: A 20 years single‐center experienceArticle type : Letter to the editorCorrespondence : 1. Syed HussainContact : +923323230575 Email : [email protected] : Shaheed Mohtarma Benazir Bhutto Medical College Liyari KarachiAddress : R-75 Railway Housing Society, 13-D1, Gulshan-e-Iqbal, Karachi, 75300Co-authors : 2.Muhammad MaazContact : +923032194036 Email : [email protected] : Shaheed Mohtarma Benazir Bhutto Medical College Liyari KarachiAddress : Flat No. B-16, Hasham Apartment, Rafa-e-aam, Malir Halt, Karachi, 752103. Dr. Sumeet KumarContact : +92-3337351513Email :[email protected] : Dow University of Health Sciences, KarachiAddress : Mission Rd, New Labour Colony Nanakwara, Karachi, Karachi City, Sindh 74200Word count : 482Conflict of interest : NoneDeclaration : NoneAcknowledgment : None

A document by Carlos Mestres. Click on the document to view its contents.

Objectives: We sought to assess the safety of training in cardiothoracic surgery comparing outcomes of cases performed by trainees versus fully trained surgeons. Methods: EmBase, Scopus, PubMed, and OVID MEDLINE were searched in August 2021 independently by two authors. A third author arbitrated decisions to resolve disagreements. Inclusion criteria were articles on cardiothoracic surgery reporting on outcomes for trainees. Studies were assessed for appropriateness as per CBEM criteria. 892 results were obtained, 27 represented best evidence (2-Meta-analyses, 1-RCT and 24 retrospective cohort studies). Results: 474,160 operative outcomes were assessed for 434,535 CABG (431,329 on-pump vs 3206 off-pump), 3090 AVR, 1740 MVR/repair, 26,433 mixed, 3565 congenital and 4797 thoracic procedures. 398,058 cases were performed by trainees and 75,943 by consultants. 159 cases were indeterminate. There were no statistically significant differences in the patients’ pre-operative risk scores. All studies excluded extreme high-risk patients in emergency setting, patients with poor left ventricular function and re-operation cases that were undertaken by consultants. There were no differences in CPB and clamp times for CABG. Times for valve replacement and repair cases were longer for trainees. There were no differences in the post-operative outcomes including peri-operative myocardial infarction, resternotomy for bleeding, stroke, renal failure, ITU length of stay and total length of stay. One study reported no differences on angiographic graft patency at 1 year. There were no differences in in-hospital or mid-term mortality out to five-years. Discussion: Trainees can perform cardiothoracic surgery in dedicated high-volume units with outcomes comparable to those of fully trained surgeons.

Background: The average living age of the population is constantly increasing and so is the incidence and prevalence of aortic valve disease. Surgical aortic valve replacement (SAVR) is the current gold standard treatment. Nevertheless, the use of prosthetic valves in SAVR is associated with issues that impact patients’ quality of life. Aortic valve neocuspidization (AV Neo) offers a means to solve this dilemma by minimising foreign valve tissue. AV Neo can either be performed using glutaraldehyde-treated autologous pericardium (Ozaki procedure) or bovine pericardium (Batista procedure). Aims: This commentary aims to discuss the recent study by Chan and colleagues which highlighted the surgical approach, clinical outcomes and limitations of the Ozaki procedure, and compare this to the Batista procedure. Methods: A comprehensive literature search was performed using multiple electronic databases including PubMed, Ovid, Embase and Scopus in order to collate the relevant research evidence. Results: Although the Ozaki procedure can achieve favourable results whilst mainly avoiding the need for life-long oral anticoagulation with mechanical valves, it still has several limitations that may hinder results. AV Neo using glutaraldehyde-treated bovine pericardium, developed by pioneer cardiac surgeon Dr. Randas J. Vilela Batista, yields superior clinical outcomes to Ozaki’s, including excellent survival, lower complications and minimal need for reoperation as well as shorter operative times. Conclusion: AV Neo offers a means to perform SAVR whilst escaping the prosthetic valve issues. However, the Batista procedure has shown beyond doubt that it can be considered the superior approach for AV Neo over the Ozaki procedure.

Background: The introduction of the frozen elephant trunk (FET) technique for total arch replacement (TAR) has revolutionized the field of aortovascular surgery. However, although FET yields excellent results, the risk of certain complications requiring secondary intervention remains present, negating its one-step hybrid advantage over conventional techniques. This systematic review and meta-analysis sought to evaluate controversies regarding the incidence of FET-related complications, with a focus on aortic remodeling, distal stent-graft induced new entry (dSINE) and endoleak, in patients with type A aortic dissection (TAAD) and/or thoracic aortic aneurysm. Materials and methods: A comprehensive literature search was conducted using multiple electronic databases including EMBASE, Scopus, and PubMed/MEDLINE to identify evidence on TAR with FET in patients with TAAD and/or aneurysm. Studies published up until January 2022 were included, and after applying exclusion criteria, a total of 43 studies were extracted. Results: A total of 5068 patients who underwent FET procedure were included. The pooled estimates of dSINE and endoleak were 2% (95% CI 0.01-0.06, I 2 = 78%) and 3% (95% CI 0.01-0.11, I 2 = 89%), respectively. The pooled rate of secondary thoracic endovascular aortic repair (TEVAR) post-FET was 7% (95% CI 0.05-0.12, I 2 = 89%) whilst the pooled rate of false lumen thrombosis at the level of stent-graft was 91% (95% CI 0.75-0.97, I 2 = 92%). After subgroup analysis, heterogeneity for dSINE and endoleak resolved among European patients, where Thoraflex Hybrid and E-Vita stent-grafts were used (both I 2 = 0%). In addition, heterogeneity for secondary TEVAR after FET resolved among Asians receiving Cronus (I 2 = 15.1%) and Frozenix stent -grafts (I 2 = 1%). Conclusion: Our results showed that the FET procedure in patients with TAAD and/or aneurysm is associated with excellent results, with a particularly low incidence of dSINE and endoleak as well as highly favorable aortic remodeling. However the type of stent-graft and the study location were sources of heterogeneity, emphasizing the need for multicenter studies directly comparing FET grafts. Finally, Thoraflex Hybrid can be considered the primary FET device choice due to its superior results.