Management of aortic arch pathologies remains challenging. Open total arch replacements have been associated with significant morbidity and mortality owing to the need for cardiopulmonary bypass and circulatory arrest. On the other hand, aortic arch branched stent grafts are not widely available. In this context, hybrid techniques combining open arch debranching with endovascular graft placement have been identified as an attractive option in select patients. However, there still is a paucity of literature on their application and outcomes. A case is presented of an elderly frail patient diagnosed with a pseudoaneurysm of the aortic arch and who was successfully treated by an off-pump arch debranching followed by endovascular arch repair. This case highlights (i) the feasibility of hybrid debranching techniques, (ii) their technical challenges, and (iii) the need for long-term follow-up data.

Although mid- and long-term outcomes after the Ross procedure for aortic valve disease have been increasingly improving over the years, this is still a rather challenging operation in neonates and small children. This is particularly true for patients with associated congenital heart defects and critical clinical conditions. Herein we describe the application of this procedure as a rescue operation in emergency circumstances in a low-birth-weight neonate with severe aortic stenosis, aortic regurgitation and mitral regurgitation after a previous aortic coartectomy.

Background and Aim: We assessed the anatomical variations in coronary arterial patterns relative to the techniques of reimplantation in the setting of the arterial switch operation, relating the variations to influences on outcomes. Methods: We reviewed pertinent published investigations, assessing events reported following varied surgical techniques for reimplantation of the coronary arteries in the setting of the arterial switch procedure. Results: The prevalence of reported adverse events, subsequent to reimplantation, varied from 2% to 11%, with a bimodal presentation of high early and low late incidence. The intramural pattern continues to contribute to mortality, with some reports of 28% fatality. The presence of abnormal course relative to the arterial pedicles in the setting of single sinus origin was associated with a three-fold increase in mortality. Abnormal looping with bisinusal origin of arteries was not associated with increased risk. Conclusion: The techniques of transfer of the coronary arteries can be individually adapted to cater for the anatomical variations. Cardiac surgeons, therefore, need to be familiar with the myriad creative options available to achieve successful repair when there is challenging anatomy. Long-term follow-up will be required to affirm the superiority of any specific individual technique. Detailed multiplanar computed-tomographic scanning can now reveal all the variants, and elucidate the mechanisms of late complications. Coronary angioplasty or surgical revascularization may be considered in selected cases subsequent to the switch procedure.

Background We evaluated short- and mid-term outcomes with use of aortic valve-sparing root replacement to treat bicuspid aortic valves. Methods From December 2007 to January 2022, all patients with bicuspid aortic valves who underwent aortic root replacement using Tirone’s procedure were included. This study based on department database information for retrospective and follow-up data. Results Among 51 adults undergoing aortic root replacement using Tirone’s procedure, the mean age was 47.4±12.5 years, and most were men (92.2%). Three presented with a dysmorphic syndrome and one had Marfan’s syndrome. All patients were alive at 30 days, and as of January 2022, 45 were alive, two were lost to follow-up, and there were four noncardiac deaths. Two patients had infectious endocarditis and needed a Bentall’s procedure. One patient had a double biologic valve replacement in the context of severe mitral insufficiency with moderate aortic stenosis at 4.5 years post-procedure. Echocardiographic follow-up showed a left ventricular ejection fraction of 63±7% (n=36), V max 2±0.6 m/s (n=17), and a mean gradient of 9.4±5.4 mmHg (n=27). No patients had grade 3 or 4 aortic regurgitation, one patient had grade 2, and four had grade 1. Conclusion Tirone’s procedure is an option for bicuspid aortic valve surgery, with good safety and outcomes, especially in younger patients.

A systematized description of the morphology of congenitally malformed hearts is recognized as essential for the understanding of the important features that will determine the appropriate clinical and surgical approaches.

Cervantes-Salazar and colleagues report the long-term surgical outcomes of 414 patients with total anomalous pulmonary venous connection (TAPVC) from January 2003 to June 2019. With an overall survival rate of 87.2% from 2003 to 2019, the authors found that an increased mortality risk was associated with infra-cardiac TAPVC, pulmonary venous obstruction (PVO), and postoperative mechanical ventilation. Their comprehensive study with a large sample size of varying age groups, and patients with late referrals for surgery, provide valuable insight into TAPVC surgical outcomes. Improved survival for these patients continues to be a major goal of clinical teams striving to transform treatment paradigms. The comprehensive and promising results of the study reported by Cervantes-Salazar and colleagues gives our field hope for a better future for these patients.

Changes in the heart allocation system have led to transplant programs traveling greater distances for donor organs. At the same time, several new technologies have emerged to provide improvements in donor organ protection when compared with traditional strategies. These new developments have increased the need for a better understanding of risks associated with donor injury related to various types of ischemia.

Title : Submitral Aneurysm: Exploring a Rare PathologyAuthors : Kellen Round BS1, Jake L. Rosen BA1, Colin C. Yost BA1, T. Sloane Guy MD, MBA21Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St #100, Philadelphia, PA 191072Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University, Curtis Bldg, Ste 620, 1015 Walnut St Philadelphia, PA 19107Running Title: Submitral Aneurysm Commentary

Background The decision to conserve or replace the native aortic valve following acute type-A aortic dissection (ATAAD) is an area of cardiac surgery without standardised practice. This single centre retrospective study analysed the long-term performance of the native aortic valve and root following surgery for ATAAD. Methods Between 2009 and 2018 all cases ATAAD treated at Royal Brompton and Harefield NHS Foundation Trust were analysed. Patients were divided into 2 groups: a) ascending aorta (interposition) graft (AAG) without valve replacement; and b) non-valve-sparing aortic root replacement (ARR). Pre-operative covariates were compared, as well as operative characteristics and post-operative complications. Long-term survival and echocardiographic outcomes were analysed using regression analysis. Results In total, 116 patients were included: 63 patients in the AAG group and 53 patients in the ARR group. In patients where the native aortic valve was conserved, 9 developed severe aortic regurgitation and 2 patients developed dilation of the aortic root requiring subsequent replacement during the follow-up period. Aortic regurgitation at presentation was not found to be associated with subsequent risk of developing severe aortic regurgitation or reintervention on the aortic valve. Overall mortality was observed to be significantly lower in patients undergoing AAG (17.5% vs. 41.5%, p=0.004). Conclusions With careful patient selection, the native aortic root shows good long-term durability both in terms of valve competence and stable root dimensions after surgery for ATAAD. This study supports the consideration of conservation of the aortic valve during emergency surgery for type-A dissection, in the absence of a definitive indication for root replacement, including in cases where aortic regurgitation complicates the presentation.

Take the bull by its horn: ‘Prophylactic aortic intervention’ in uncomplicated type B aortic dissectionRunning title: Prophylactic intervention in uncomplicated TBADDr. A. Mohammed Idhrees MCh, FIASORCID ID : 0000-0001-5981-9705Consultant,Institute of Cardiac and Aortic Disorders (ICAD),SRM Institutes for Medical Science (SIMS Hospital), Chennai.

The Recurring Theme of Gender Difference in Cardiac Surgical OutcomesJohn S. Ikonomidis MD, PhDDivision of Cardiothoracic Surgery, University of North Carolina at Chapel HillWord Count: 1144References: 13Address correspondence to:John S. Ikonomidis MD, PhDProfessor and Chief,Division of Cardiothoracic SurgeryUniversity of North Carolina at Chapel Hill3034 Burnett Womack Building160 Dental Circle,Chapel Hill, NC27599e-mail: [email protected]: (919) 966-3381In this issue of the Journal of Cardiac Surgery,1Newell and colleagues examined contemporary national outcomes following surgical resection of benign primary atrial and ventricular tumors. The 2016-2018 Nationwide Readmissions Database was queried for all patients > 18 years of age with a primary diagnosis of benign neoplasm of the heart who underwent resection of the atria, ventricles, or atrial/ventricular septum. A weighted total of 2,557 patients met inclusion criteria. Mean age was 61 years, 67.9% were female, and patients had relatively low comorbidity burdens. The authors found that while there was no difference in 30-day mortality (2.1% vs 1.3%, p=0.550), 30-day readmission (7.0% vs 9.1%, p=0.222), or 30-day composite morbidity (56.8% vs 53.8%, p=0.369) between females and males respectively, on multivariable analysis, female sex was independently associated with increased risk of 30-day mortality (OR 2.65, p=0.028).Overall, this was a well study which documents a large contemporary cohort of benign cardiac tumor resections. However, perhaps the most interesting feature of this study is the finding of sex as an independent predictor of 30 day mortality after propensity matching. Cardiac surgery suffers from a gender gap in terms of its outcomes. It has been well established that for many procedures such coronary bypass surgery (CABG), aortic valve replacement, mitral valve surgery, and aortic surgery.2 For CABG, women referred for surgery are typically older than men, have a higher comorbidity (hypertension, renal failure, diabetes, peripheral vascular disease) profile, and more often present in urgent or emergent status for surgery.3 Large, risk-adjusted, propensity matched studies have documented increased mortality in women as compared with men.4-7 This difference also extends into the interventional cardiology realm, where mortality and complication rates have been shown to be higher in women following percutaneous interventions for ST-elevation myocardial infarction.8For aortic valve replacement, a Nationwide Inpatient Sample study of 166809 patients with aortic stenosis from 2003 to 2014 found that women experience higher inpatient mortality (5.6% versus 4%, P<0.001) which persisted after propensity matching (3.3% versus 2.9%, P<0.001).9 For mitral valve surgery, a randomized controlled trial of patients with severe ischemic mitral insufficiency undergoing repair versus replacement found that women had higher mortality than men (27.1% versus 17.4%, p<0.03).10 For aortic surgery, female gender was associated with a higher mortality after both aortic dissection and aortic arch repair.11,12 Reduction in surgical stress through application of minimally invasive approaches still resulted in female sex being a risk factor for higher in-hospital mortality.13 The findings of the present study add further support to the above observations, with the potential addition that, in contrast to the other disease processes described, the majority of patients presenting for surgical removal of benign cardiac tumors were likely free of either symptoms or cardiac sequelae due to the disease, but nevertheless still the gender disparity in mortality persisted.While it is obvious that the above disease processes and their related surgical remedies are quite disparate, the association with increased mortality seen in females seems to be constant. Why is this? A considerable amount has been written regarding sex bias in referral patterns for surgery and even decreased functional reserve and health profiles of women when they are referred for surgical intervention compared with men.2 With regard to these referral patterns, published guidelines directing practitioners regarding indications for surgery are, in general, based upon studies in which the majority of patients were male. Interestingly, in the present study, females made up over two thirds of the patient population.1 While this suggests that females carry a disproportionately more benign cardiac tumors amenable to surgery, the post-surgical mortality disparity remained.The exact reasons for the above disparity remain unelucidated and further work is required to eliminate the gender gap in cardiac surgical outcomes. There is considerable focus on the removal of sex bias in animal and human research, as well as the development of disease treatment guidelines that consider gender in the algorithms. Hopefully and these and other sex-balanced approaches will reveal new insights that will allow us to bring equipoise to gender-stratified cardiac surgical outcomes.

Background: Remote ischemic preconditioning (rIPC) has been applied to attenuate tissue injury. We tested the hypothesis that rIPC applied to fetal lambs undergoing cardiac bypass (CB) reduces fetal systemic inflammation and placental dysfunction. Methods: Eighteen fetal lambs were divided into 3 groups: sham, CB control, and CB rIPC. CB rIPC fetuses had a hindlimb tourniquet applied to occlude blood flow for 4 cycles of a 5-minute period, followed by a 2-minute reperfusion period. Both study groups underwent 30 minutes of normothermic CB. Fetal inflammatory markers, gas exchange, and placental and fetal lung morphological changes were assessed. Results: The CB rIPC group achieved higher bypass flow rates (p<.001). After CB start, both study groups developed significant decreases in PaO2, mixed acidosis and increased lactate levels (p<.0004). No significant differences on tissular edema were observed on fetal lungs and placenta (p>.391). Expression of toll-like receptor-4 and ICAM-1 in the placenta and fetal lungs did not differ among the 3 groups, as well as with VCAM-1 of fetal lungs (p>.225). Placental VCAM-1 expression was lower in the rIPC group (p<.05). Fetal interleukin-1 (IL-1) and thromboxane A2 (TXA2) levels were lower at 60 minutes post-CB in the CB rIPC group (p<.05). There was no significant differences in TNF-α, PGE2, IL-6 and IL-10 plasma levels of the three groups at 60-minute post-bypass (p>.133). Conclusion: Although rIPC allowed for increased blood flow during fetal CB and decreased in IL-1 and TXA2 levels and placental VCAM-1, it did not prevent placental dysfunction in fetal lambs undergoing CB.

BACKGROUND Postoperative pain after cardiac surgery is a very important issue and affects recovery, risk of postoperative complications and quality of life. The pain management has been traditionally based on intravenous opioids with growing evidence suggesting the use of opioid-free and opioid-sparing techniques to reduce its adverse effects. CASE PRESENTATION We report the case of a 75-years-old frail patient underwent awake mediastinal revision with subxiphoid access due to deep sternal wound infection using a Pectoralis-Intercostal Rectus Sheath (PIRS) plane block. During the procedure the patient never reported pain receiving acetaminophen 1 g every 8 hours for postoperative pain management without others pain relievers. CONCLUSION Ultrasound guided PIRS block could be an effective and safe analgesic technique to manage sternal and subxiphoid drainage pain in patients undergoing cardiac surgery via subxiphoid approach.

A document by Michel Skaf. Click on the document to view its contents.

Frozen Elephant Trunk (FET) has revolutionized management of aortic arch and proximal descending aorta pathologies. Despite significant advancement in FET prosthesis design in recent years, adverse outcomes related with neurologic and visceral ischemic events remained unsolved. To address this issue, several publications evaluated protection strategies to reduce body lower ischemic time. In the present commentary we put the technique promoted as “Release and Perfuse Technique” on scale that is for achievement of less lower body circulatory arrest time.

This is an invited commentary and does not need a commentary.

Background: Although concomitant pulmonary vein isolation (PVI) is used more frequently than the Cox-maze procedure, which is currently the gold standard treatment for AF, data on the comparative effectiveness of the two procedures after concomitant mitral valve (MV) surgery are still limited. Objective: We conducted a systematic review to identify randomized controlled trials (RCT) and observational studies comparing the mid-term mortality and recurrence of atrial fibrillation (AF) after concomitant Cox-Maze and PVI in patients with AF undergoing MV surgery based on 12-month follow-up. Methods: Medline, EMBASE databases, and the Cochrane Library were searched from 1987 up to March 2022 for studies comparing concomitant Cox-Maze and PVI. A meta-analysis of RCTs was performed to compare the mid-term clinical outcomes between these two surgical ablation techniques. Results: Three RCTs and 3 observational studies meeting the inclusion criteria were included in this systematic review with 790 patients in total (532 concomitant Cox-Maze and 258 PVI during MV surgery). Most studies reported that concomitant Cox-Maze procedure was associated with a higher freedom from AF at 12-month follow-up than PVI. Regarding AF recurrence, estimate pooled across the 3 RCTs indicated large heterogeneity and high uncertainty. In the largest and highest quality RCT, 12-month AF recurrence was higher in the PVI arm (RR=1.58, 95%CI 0.91-2.73). In 2 out of 3 higher quality observational studies, 12-month AF recurrence was higher in PVI than in Cox-Maze arm (estimated adjusted probabilities 11% vs. 8% and 35% vs. 17%, respectively). RCTs demonstrated comparable 12-month mortality between concomitant Cox-Maze and PVI, while observational studies demonstrated survival benefit of Cox-Maze. Conclusions: Concomitant Cox-Maze in AF patients undergoing MV surgery is associated with better mid-term freedom from AF when compared to PVI with comparable mid-term survival. Large observational studies suggest that there might be a mid-term survival benefit among patients after concomitant Cox-Maze. Further large RCTs with longer standardized follow-up are required in order to clarify benefits of concomitant Cox-Maze in AF patients during MV surgery.

In this article, the author provides synopses of the factors that have finally propelled healthcare education and practice to join, at times reluctantly, the overarching digital transformative process that has been swept other industries over the last few decades. The key contributors and driving forces that have energized the entry of healthcare education and practices are mentioned. The roles of major universities, large technology companies and the expanding roles of Artificial Intelligence and Machine Learning are described. The projected future developments are predicted to continue to be substantial, sweeping and forcing changes that are unprecedented. Thus, academicians and practitioners should be alerted to what the rapidly changing landscape is likely to become and accordingly take steps to manage and preserve their roles or risk be left behind or worse be forced out.