The called burden of cardiac heart failure (CHF) on healthcare systems and economies remains large and a major factor contributing to this burden is the high hospital admission rate for acute decompensated heart failure. These repeated heart failure hospitalizations (HFH) not only exert a high burden on healthcare systems, but also impact patient quality of life and have been associated with impaired prognosis and reduced life expectancy. The need for remote monitoring has become extremely important, mainly based on devices capable of measuring intracardiac filling pressures. If we assume that hemodynamic congestion precedes clinical congestion, the hemodynamic monitoring could be able to detect early signs of congestion and enables clinicians to intervene in a pre-symptomatic phase avoiding hospital admission. Dr. Veenis JF and colleagues present the results of implanting the CardioMEMS device in 10 patients who underwent heartmate 3 implantation. The authors describe the study design based on an earlier publication by the same author. The authors argue that the use of this device will allow the monitoring of patients pre, during hospitalization and after implantation, with a possible reduction in the number of readmissions for allowing the diagnosis and treatment of complications related to ventricular failure and volume overload.

Background: The high incidence of postoperative pulmonary venous obstruction (PVO) is a major mortality-associated concern in patients with right atrial isomerism and extracardiac total anomalous pulmonary venous connection (TAPVC). We evaluated new anatomical risk factors for reducing the space behind the heart after TAPVC repair. Methods: 18 patients who underwent TAPVC repair between 2014 and 2020 were enrolled. Sutureless technique was used in 12 patients and conventional repair in six patients. The angle between the line perpendicular to the vertebral body and that from the vertebral body to the apex was defined as the “vertebral-apex angle (V-A angle).” The ratio of post- and preoperative angles, indicating the apex’s lateral rotation, was compared between patients with and without PVO. Results: The median (interquartile range) age and body weight at repair were 102 (79-176) days and 3.8 (2.6-4.8) kg, respectively. The 1-year survival rate was 83% (median follow-up, 29 [11-36] months). PVO occurred in seven patients (39%), who showed an obstruction of one or two branches in the apex side. The postoperative V-A angle (46° [45°-50°] vs. 36° [29°-38°], P = 0.001) and the ratio of post- and preoperative V-A angles (1.27 [1.24-1.42] vs. 1.03 [0.98-1.07], P = 0.001) were significantly higher in the PVO group than in the non-PVO group. The cut-off values of the postoperative V-A angle and ratio were 41° and 1.17, respectively. Conclusions: A postoperative rotation of the heart apex into the ipsilateral thorax was a risk factor for branch PVO after TAPVC repair.

Abstract Background Subaortic stenosis (SAS) was a rare congenital heart disease of left ventricular outflow tract (LVOT), ranging from “isolated” lesions to “tunnel” or “diffuse” lesions. We conducted a retrospective study to describe the characteristics of patients with different lesions and analyze the risk factors for reoperation. Methods In this study, we examined a single-center retrospective cohort of SAS patients undergoing resection from 2010 to 2019. Patients were classified as simple lesion group (n = 37) or complex lesion group (n = 28). Demographics, perioperative findings, and clinical data were analyzed. Results The surgical effect of the two groups was significantly lower than that before the operation (p <0.05). The median age at operation was 6(3-11.8) years. There was no operative mortality. In complex lesion group, extracorporeal circulation time (CPB time), aortic cross clamp time (ACC time), mechanical ventilation time and ICU stay time were longer. The median follow-up period was 2.8 years (range 1-3.8), with two late death. Six patients (9.2%) required reoperation due to restenosis or severe aortic insufficiency. The freedom from reoperation rates at 5 years was 66.7% for simple lesion but only 52.3% for complex lesion (p = 0.036). Conclusions Although the lesions include many forms, subaortic stenosis resection was still satisfactory. However, the reoperation after initial surgical treatment was not infrequent, especially in patients with complex lesion.

Background: This study aims at better defining the profile of patients with a complicated versus non-complicated postoperative course following isolated tricuspid valve (TV) surgery to identify predictors of a favourable/unfavourable hospital outcome. Methods: All patients treated with isolated tricuspid surgery from March 1997-January 2020 at our institution were retrospectively reviewed. Considering the complexity of most of these patients, a regular postoperative course was arbitrarily defined as a length-of-stay in intensive care unit <4 days and/or postoperative length-of-stay <10days. Patients were therefore divided accordingly in two groups. Results: 172 patients were considered, among whom 97 (56.3%) had a regular (REG) and 75 (43.6%) a non-regular (NEG) postoperative course. The latter had worse baseline clinical and echocardiographic characteristics, with higher rate of renal insufficiency, previous heart failure hospitalizations, cardiac operations, and right ventricular dysfunction. NEG patients more frequently needed tricuspid replacement and experienced a greater number of complications (p<0.001) and higher in-hospital mortality (13% vs 0%, p<0.001). The majority of these complications were related to more advanced stage of the tricuspid disease. Among most important predictors of a negative outcome univariate analysis identified chronic kidney disease, ascites, previous right heart failure hospitalizations, right ventricular dysfunction, previous cardiac surgeries, TV replacement and higher MELD scores. At multivariate analysis, liver enzymes and diuretics’ dose were predictors of complicated postoperative course. Conclusions: In isolated TV surgery a complicated postoperative course is observed in patients with more advanced right heart failure and organ damage. Earlier surgical referral is associated to excellent outcomes and should be recommended.

The safety of transesophageal echocardiography (TEE) probes has been documented in pediatric patients (neonates, infants, and small children even < 2.5 Kg). The overall safety profile of TEE probe is quite favourable with a reported incidence of complications is about 1-3%. However, insertion of the TEE probe can induce vagal and sympathetic reflexes such as hypertension or hypotension, non-sustained ventricular and supraventricular tachyarrhythmias or bradyarrhythmias [3rd degree heart block], and even angina and myocardial infarction. We hereby document a repeated and fatal intraoperative VF precipitated by TEE probe in a 2-year-old, 10 kg paediatric patient diagnosed with ostium secundum atrial septal defect (OS-ASD), supravalvular pulmonary stenosis (PS) and severe right ventricular (RV) dysfunction.

It is an elegant albeit limited study reporting effects of pre op LVEF on long term results in patients with RHD undergoing DVR. Study includes146 pqtients out of 201 who underwent DVR in the study period. Although all had some improvement immediate post op, those with preserved EF and smaller left ventricles regardless of type of prostheses used, surgical techniques ( partial or full Sub-valvular Apparatus Preservation), had more sustained improvement after 3-4 years than those with lower EF and more dilation . It can be partially explained by more prevalence of aortic insufficiency in patients with pre op lower EF <50 and dilation ( average LVESD 49 mm vs 32 mm in EF >50). There are myocardial factors which also play a part , those with abnormal LV function have more extensive loss of myofibrils either due to disproportion of mitochondria-to-myofibril ratio or myofibrillar degeneration exhibiting the extent RHD involves myocardium. Structural adaptation may not all be just a result of hemodynamic abnormalities in these patients (1). The recommendation that surgical intervention should occur before the LV starts to dilate or EF drops is well founded and would be impactful in the developing world, an estimated 250,000 deaths occur annually worldwide and 10.5 million disability adjusted life years due to RHD, mostly in young people.

The surgical treatment of pulmonary hypertension (PH), with or without pulmonary artery aneurysm, has evolved during the last 40 years from heart-lung transplants to bilateral lung transplants as the treatment of choice for PH patients with preserved right and left ventricular function and without complex cardiac abnomalies.

Ravitch technique of chest correction has been considered, although invasive, as safe and efficacious surgical method. We describe a case of 35-year-old woman with cardiac tamponade and in cardiogenic shock due to exceptional late complication after pectus excavatum reconstruction by means of classic Ravitch technique 19 years earlier. This very late adverse event was caused by broken metal sternal wire that injured the wall of the ascending aorta. Patient underwent salvage repair of this segment of aorta in cardiopulmonary bypass. Postoperative course and post-discharge 3-year follow-up have been uneventful.

Cardiac ochronosis is a rare disease, estimated to affect 1 in 250,000 persons. While there is extensive evidence of the musculoskeletal alterations of the disease, cardiac involvement has not been widely studied and most information we currently have derives from case reports and case series. We report the case of a 64-year old patient with a known history of alkaptonuria who presented with dyspnea and weight loss. On evaluation, he was found to have severe aortic stenosis, coronary artery disease, and interventricular septal hypertrophy. Surgery revealed extensive ochronotic pigment deposition affecting the cardiac septum, both internal thoracic arteries, the native coronary arteries, and the aortic valve. Ochronotic heart disease is an often disregarded presentation of alkaptonuria. More information is needed on the course of the disease, as well as long-term outcomes after valve replacement surgery and/or CABG in patients with alkaptonuria.

Infectious complications after percutaneous transluminal coronary angioplasty are uncommon and can occur at any point of time leading to high morbidity and mortality. We report a case of delayed coronary artery stent infection and rupture, with epicardial infected false aneurysm formation, and right coronary artery to right atrium fistula formation, presenting after one month of pyrexia.

Response to Letter to the Editor: “Impact of preoperative troponin levels on cardiac function following coronary surgery for myocardial infarction”Nicholas Hess MD1, Arman Kilic MD2

Commentary to JOCS-2020-RA-1888

Cerebrovascular Accidents represent a dangerous complication of cyanotic children with tetralogy of fallot with incidence of 8.6%.Tetralogy of Fallot has been associated with raised haematocrit with low arterial Saturation. Here we describe an 18 months old female child of Tetralogy of Fallot with Cyanotic spells acute onset right sided hemiplegia with Right Atrial thrombus who underwent emergency surgery with intraoperative predicament.

We present a case of a young patient who presented with unstable angina due to coronary-pulmonary fistula caused by a nail-gun injury that stayed asymptomatic for 3 years. The patient has a successful surgical resection of the fistula and removal of the foreign body.

Background: This study investigates the use of modern machine learning (ML) techniques to improve prediction of survival after orthotopic heart transplantation (OHT). Methods: Retrospective study of adult patients undergoing primary, isolated OHT between 2000-2019 as identified in the United Network for Organ Sharing (UNOS) registry. The primary outcome was one-year post-transplant survival. Patients were randomly divided into training (80%) and validation (20%) sets. Dimensionality reduction and data re-sampling were employed during training. Multiple machine learning algorithms were combined into a final ensemble ML model. Discriminatory capability was assessed using area under receiver-operating-characteristic curve (AUROC), net reclassification index (NRI), and decision curve analysis (DCA). Results: A total of 33,657 OHT patients were evaluated. One-year mortality was 11% (n=3,738). In the validation cohort, the AUROC of singular logistic regression was 0.649 (95% CI 0.628-0.670) compared to 0.691 (95% CI 0.671-0.711) with random forest, 0.691 (95% CI 0.671-0.712) with deep neural network, and 0.653 (95% CI 0.632-0.674) with Adaboost. A final ensemble ML model was created that demonstrated the greatest improvement in AUROC: 0.764 (95% CI 0.745-0.782) (p<0.001). The ensemble ML model improved predictive performance by 72.9% ±3.8% (p<0.001) as assessed by NRI compared to logistic regression. DCA showed the final ensemble method improved risk prediction across the entire spectrum of predicted risk as compared to all other models (p<0.001). Conclusions: Modern ML techniques can improve risk prediction in OHT compared to traditional approaches. This may have important implications in patient selection, programmatic evaluation, allocation policy, and patient counseling and prognostication.

In this case report we describe how to recycle the Left Internal Thoracic Artery (LITA) when misused but not damaged. 8 years after a Left Anterior Small Thoracotomy followed by LAD stenting for STEMI in 1st post-operative day, a 67 years old woman had a NSTEMI with angiographic evidence of intra-stent re-stenosis with a perfectly patent LITA, harvested only from the 4th to the 6th intercostal space. During redo surgery, LITA was harvested as a pedicle from the anastomosis to the 4th intercostal space and primarily from the 1st to the 4th intercostal space. Special attention was paid at the level of the 4th intercostal space where the vessel was stuck to the sternum: a 15 blade was used being scissors or cautery too dangerous. At the end of harvesting, the LITA was full-length available for a new coronary anastomosis on LAD, distal to the previous one.

Background: The treatment of complex thoracic aorta pathologies remains a challenge for cardiovascular surgeons. After introducing Frozen Elephant Trunk (FET), a significant evolution of surgical techniques has been achieved. The present meta-analysis aimed to assess the efficacy of FET in acute type A aortic dissection (ATAAD) and the effect of circulatory arrest time on post-operative neurologic outcomes. Methods: A standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses search was conducted for all observational studies of patients diagnosed with ATAAD undergoing total arch replacement with FET reporting in-hospital mortality, bleeding, and neurological outcomes. A random-effect meta-analysis was performed using STATA software (StataCorp, TX, USA). Results: Thirty-five studies were eligible for the present meta-analysis, including 3211 patients with ATAAD who underwent total arch replacement with FET. The pooled estimate for in-hospital mortality, postoperative stroke, and spinal cord injury were 7% (95% CI 5 – 9; I2 = 68.65%), 5% (95% CI 4 – 7; I2 = 63.93%), and 3% (95% CI 2 – 4; I2 = 19.56%), respectively. Univariate meta-regression revealed that with increasing the duration of hypothermic circulatory arrest time, the effect sizes for postoperative stroke and SCI enhances. Conclusions: It seems that employing the FET procedure for acute type A dissection is associated with acceptable neurologic outcomes and a similar mortality rate comparing with other aorta pathologies. Besides, increasing hypothermic circulation arrest time appears to be a significant predictor of adverse neurologic outcomes after FET.

We thank Shixiong Wei et al for their interest in our technical paper on Robotic Septal myectomy for HOCM and their letter to the editor. Their technique of using the Computed Tomography Angiography (CTA) along with 3D Printing technology for the better delineation of the anatomy of HOCM has been an evolving way to approach the problem. As they have mentioned in their letter, we used cardiac magnetic resonance imaging (MRI) predominantly for all our patients who undergo septal myectomy. Using 3D printing technology augmenting CTA or MRI can certainly augment the surgical planning in complex patients. In their case report, Wei et al have shaved off most of the subvalvular tissue along with the mitral valve. Removal of the entire mitral valve definitely would have enhanced the exposure to the mid-ventricular cavity and the apex for their thoracoscopic approach. It will be interesting to know whether they tried to repair the valve before replacement. Our technique of Robotic mitral valve repair, septal myectomy, and particularly papillary muscle re-orientation tries to preserve the sub-valvular apparatus even after completely relieving the mid-cavitary obstruction and this may provide better ventricular re-modeling. We congratulate them on providing a successful surgical option to this complex subset of patients using novel evolving technology and meticulous surgical planning.