BACKGROUND: To assess the feasibility and outcome of Continuous Cerebral and Myocardial Selective Perfusion (CCMSP) during aortic arch surgery in neonates. METHODS: This retrospective single-center study was conducted between 2008 and 2019 in neonates undergoing aortic arch surgery, accompanied or not by cardiac malformation repair. CCMSP at moderate hypothermic of 28°C was achieved using selective brachiocephalic artery and ascending aorta cannulation. Target rates of cerebral and myocardial perfusion were 25-35 mL/kg/min and 150/m2/min. Cardiopulmonary bypass (CPB) variables and clinical outcomes were analyzed. RESULTS: Overall, 69 neonates underwent either isolated aortic arch repair (n=31) or aortic arch repair with ventricular septal defect (VSD) closure (n=38). The mean age and weight were 9.79±7.1 days and 3.17±0.4Kg, respectively. Mean CPB and aortic clamping times were 133.5±47.0 and 25.2±5.3 min for isolated aortic arch repair, and 158.4±47.9 and 75.4±30.5 min for aortoplasty accompanied by VSD closure. Mean CCMSP time was 51.6±21.5 min with cerebral rate of 32.6±10.0mL/Kg/min. Two major complications arose: stroke (n=1; 1.44%) and transient renal failure requiring dialysis (n=2; 2.89%). Neither myocardial nor visceral ischemia occurred. In-hospital mortality was 1/69 (1.44%). CONCLUSIONS: CCMSP is a safe and reproducible strategy for cerebral, myocardial and visceral protection in neonatal aortic arch repair, with or without VSD closure, resulting in low complication and mortality.

Background: Cardiac surgeries use 10%–15% of red blood cells transfused in the United States, despite benefits of limiting transfusions. We sought to evaluate the the feasibility and impact of a restrictive transfusion protocol on blood use and clinical outcomes in patients undergoing isolated primary coronary artery bypass grafting (CABG). Methods: Blood conservation measures, instituted in 2012, include preoperative optimization, intraoperative anesthesia and pump fluid restriction with retrograde autologous priming and vacuum-assisted drainage, use of aminocaproic acid and cell saver, intra- and postoperative permissive anemia, and administration of iron and lowdose vasopressors if needed. Medical records of patients who underwent isolated primary CABG from 2009–2012 (group A; n=375) and 2013–2016 (group B; n=322) were compared. Results: CABG with grafting to 3 or 4 coronary arteries was performed in 262 (70%) and 222 (69%) patients and bilateral internal thoracic artery grafting in 202 (54%) and 196 (61%) patients in groups A and B, respectively. Mean preoperative and intraoperative hematocrit was 40.3% and 40.7%, 28.9% and 29.4% in groups A and B, respectively. Total blood transfusion was 24% and 6.5%, intraoperative transfusion 10% and 1.2%, postoperative transfusion 19% and 5.3% (p<0.0001 for all) in groups A and B, respectively. Median postoperative length of stay was 5.0 days in group A and 4.5 days in group B (p =.02), with no significant differences between groups in mortality or morbidity. Conclusions: A restrictive transfusion protocol reduced blood transfusions and postoperative length of stay without adversely affecting outcomes following isolated primary CABG.

Letter to the editor

A document by Shivaahnee Raveenthiran. Click on the document to view its contents.

Internal mammary harvesting: the long-lasting history and harvesting techniquesRunning Head: Internal mammary artery

Alternatives to traditional aortic valve replacement now form part of the valve surgeon's armamentarium. Sutureless valves offer decreased bypass and crossclamp times, excellent maneuverability, and promising outcomes. We present a case of a sutureless aortic valve replacement for a late failed David procedure, complicated by post-operative development of severe paravalvular regurgitation. We attempted off-label balloon post-dilation to improve expansion of the valve, however paravalvular regurgitation persisted. The patient underwent subsequent aortic valve replacement using a mechanical valve and experienced no further paravalvular leak.

Background: In severe cases, the COVID-19 viral pathogen produces hypoxic respiratory failure unable to be adequately supported by mechanical ventilation. The role of extracorporeal membrane oxygenation (ECMO) remains unknown, with the few publications to date lacking detailed patient information or management algorithms all while reporting excessive mortality. Methods: Case report from a prospectively maintained institutional ECMO database for COVID-19. Results: We describe veno-venous (VV) ECMO in a COVID-19 positive woman with hypoxic respiratory dysfunction failing mechanical ventilation support while prone and receiving inhaled pulmonary vasodilator therapy. After nine days of complex management secondary to her hyperdynamic circulation, ECMO support was successfully weaned to supine mechanical ventilation and the patient was ultimately discharged from the hospital. Conclusions: With proper patient selection and careful attention to hemodynamic management, ECMO remains a reasonable treatment option for COVID-19 patients.

Title: Pasteurella Multiocida Infection Resulting in a Descending Thoracic Aorta Mycotic Pseudoaneurysm Objective: Highlight our management of a P. Multiocida infected descending thoracic aorta mycotic pseudoaneurysm Methods: Report a case of canine bite resulting in a P. Multiocida descending thoracic aorta mycotic pseudoaneurysm Results: We present a 61-year-old gentleman who was initially seen in an Emergency Department after a canine bite. He was admitted and treated with a course of IV antibiotics for P. Multiocida bacteremia and discharged. Three weeks post discharge, he continued to feel generalized malaise and work-up was significant for a descending thoracic aorta mycotic pseudoaneurysm. The patient underwent a low left posterior lateral thoracotomy and femoral-femoral cardiopulmonary bypass for complete resection and replacement with a 24 mm GelweaveTM graft (Terumo Cardiovascular Group, Ann Arbor, Michigan). Given purulence and gross infection we planned for a staged approach, with a secondary washout and omental flap for biologic coverage of the graft. The patient did well clinically and was discharged at 14 days to rehabilitation with six-week intravenous course of antibiotics. Conclusions: The patient’s clinical course with subsequent follow-up suggest that complete resection of the mycotic pseudoaneurysm, followed by omental flap coverage is a viable strategy to manage mycotic aortic infections with virulent organisms.

Cardiac wounds have been described for centuries and still remain often fatal. For a long period of time suture of a myocardial laceration was thought to be absolutely impossible if not sacrilege. It is only at the end of the 19th century that pioneers decided to defy such dogma in desperate cases. Nowadays it seems obvious that a cardiac stab wound require emergent surgery whenever possible. The story of cardiac wounds highlights nicely the change of mind that is required to accept progress and new procedures in medicine.

Abstract The objective of this study was to describe early respiratory outcomes of asymptomatic COVID-19 patients after cardiac surgery. In this retrospective clinical study (case series) we reviewed and analyzed patient clinical data of 25 covid-19 asymptomatic patients that underwent urgent or emergent cardiac surgery between February 29 and April 10, 2020 in Tehran Heart Center Hospital. Median of age was 63 years (IQR, 52-67), Euro SCORE 7.50 (IQR, 6.5-8.5) and body mass index 26.3 (IQR, 22.5-28.6). 68% of patients had one or more comorbidities. Hypertension (56%) was the most common followed by Diabetes type 2 (40%). Off-pump cardiac surgery was done in 4 patients and on-pump on 21 patients with median CPB time of 85 minutes (IQR, 50-147.50). Median anesthesia time was 4.5 hours (IQR, 4-5). Median oxygen index and Fio2 on ventilator were 10 cmH20 (IQR, 9.5-10.5) and 0.64(IQR, 0.60-0.64) respectively. Median pao2/Fio2 was 231(IQR, 184-261). There was one case of extubation failure. The Median intubation time and length of ICU stay were 13 hours (IQR, 9.5-18) and 3 days (IQR, 2-4) respectively. Overall mortality was 16%. Readmission rate to ICU was 16% with. In this group respiratory outcome was worse with median Pao2/Fio2 84.5 (75-122), oxygen index of 4.38(IQR, 3.77-5.1) and morality rate of 75%. Conclusion: Based on the results of this study, very early post-cardiac surgery respiratory outcomes in asymptomatic COVID-19 patients are apparently smooth; nonetheless, readmission to the ICU is high. Overall respiratory outcomes are poor especially for those who readmitted to ICU.

Anomalous origin of the left circumflex artery (LCA) arising from the right coronary sinus was observed in a 45 year-old man with aortic root aneurysm. Valve-sparing aortic root replacement (VSARR) was decided despite the subannular course of the LCA. A modified Tirone David procedure was performed with specific consideration for distribution of the proximal suture line due to the peri-aortic and subannular course of the LCA. Due to the risk of LCA injury, a coronary artery bypass grafting was performed using the left internal thoracic artery to secure the perfusion of the LCA. The challenging association of aortic root aneurysm and anomalous origin and course of the LCA was managed successfully during VSARR.

The impact of the COVID-19 pandemic in New York City (NYC) is dramatic. COVID-19 cases surged, hospitals expanded to meet capacity, and NYC remains the global epicenter of this pandemic. During this unprecedented time, a young woman with known Marfan syndrome presented with an acute complicated type B aortic dissection to our Aortic Center. Using the Provisional Extension to Induce Complete Attachment technique, we treated this patient and quickly discharged her the next day to decrease the risk of COVID-19 infection. Her progress was monitored using frequent phone calls and one office visit at two weeks.

Objectives: Though guidelines are set by the American Board of Thoracic Surgery for the operative cases that cardiothoracic surgery residents must perform to be board-eligible, no such recommendations exist to assess competency for the wide range of high-risk bedside procedures. Our department created and implemented a multi-disciplinary developed course designed to standardize common high-risk bedside procedures and credential our residents. The aim of this study was to survey the attitudes of residents to and query the efficacy of such a course. Methods: The course was designed with the goal of standardizing endotracheal intubation, arterial line insertion (radial and femoral), central venous line insertion, pigtail tube thoracostomy and nasogastric tube placement. The course consisted of an online module followed by a 4-hour hands on simulation session. Knowledge based pre and post evaluations were administered as well as Likert based survey regarding multiple aspects of the residents’ perceptions of the course and the procedures. Results: Twenty-three (7 traditional and 16 integrated) cardiothoracic surgical residents participated in the course. Residents reported that 48% of the time, bedside procedures were historically taught by other trainees rather than faculty. All residents endorsed increased standardization of all procedures after the course. Likewise, residents showed increased confidence in all procedures except for pigtail and thoracentesis as well as nasogastric tube placement. 43.5% of the participants demonstrated improvement in the pre and post-test knowledge-based evaluations. ConclusionCardiothoracic residents have favorable attitudes towards standardization and credentialing for high risk bedside procedures and utilizing such courses may help standardize procedural techniques.

Abstract Giant right coronary artery aneurysm is a rare coronary artery pathology. We describe a 45-year-old gentleman who presented with unstable angina of recent onset. Diagnostic work up including chest CT angiography and left heart catheterization demonstrated 3-vessel coronary artery disease with giant proximal right coronary artery aneurysm. In the view of the severity of the coronary artery disease and the risk of rupture associated with the giant right coronary artery aneurysm and the clinical presentation, patient was successfully treated by coronary artery bypass surgery. During this procedure, the right coronary artery aneurysm was ligated at both inflow and outflow. Patient recovered well and was discharged home.

Rupture of a congenital left ventricular diverticulum (CLVD), a rare anatomical anomaly, is a catastrophic event, with potential fatal consequences. Repair techniques documented in the literature include primary closure and single patch closure. We describe a case of a 57-year-old woman with symptomatic anterolateral CLVD. Our approach involves a linear incision through the epicardial surface of the diverticulum with exclusion of the cavity, and restoration of normal ventricular geometry via a two patch technique.

A 42-year old man with thrombophilia (prothrombin gene mutation) required the insertion of an inferior vena cava filter because of recurrent gastrointestinal bleeding associated with oral anticoagulation. However, it penetrated through the retro-hepatic vena cava into the liver, being manifested by constant, blunt abdominal pain. Endovascular retrieval was considered of extreme risk, though a surgical approach was performed under cardiopulmonary bypass with deep hypothermic circulatory arrest. The patient has recovered uneventfully with complete symptom relief.

A flail chest can occur when cardiopulmonary resuscitation causes extensive rib fractures. Despite successful cardiopulmonary resuscitation, if the flail chest is not treated, the patient may not survive regardless of the correction of the primary condition that caused the cardiac arrest. Therefore, if flail chest persists despite proper conservative management to correct the flail chest, active surgical management is essential. We present a successful surgical treatment with pectus bar for a patient with flail chest, caused by extensive segmental rib fractures sustained during cardiopulmonary resuscitation for a massive pulmonary thromboembolism.

Background and aim of the study: In developed countries, the shortage of viable donors is the main limiting factor of heart transplantation. The aim of this study is to determine whether the same reality applies to Brazil. Methods: Between January 2012 and December 2014, 299 adult heart donor offers were studied in terms of donor profiles, and reasons of refusal. European donor scoring system was calculated, being high-risk donors defined as >17 points. Donor scoring system used to objectively determine the donor profile and correlate with donor acceptance and post-transplant primary graft dysfunction and recipient survival. Cox proportional hazard model was used in determining predictors of long-term mortality. Results: Rate of donor acceptance and heart transplants performed were 45.8% and 19.3%, respectively. Reasons for refusal were mostly non-medical (53.7%). The majority of donors were classified as high-risk (65.5%). Hearts from high-risk donors did not impact on primary graft dysfunction (14.3% vs 10%, P=0.6), neither on long-term survival (P=0.4 by log-rank test). Recipient’s age greater than 50 years (HR 6.02, CI95% 2.41 – 16.08, P<0.0001) was the only predictor of long-term mortality. Conclusions: Shortage of donors is not the main limiting factor of heart transplantation in Mid-West of Brazil. Non-medical issues represent the main reason of organ discard. Most of the donors were classified as high-risk which indicates that an expanded donor pool is a routine practice in our region, and donor scoring does not seem to influence to proceed with the transplant.