The authors share their experience of managing the cardiac surgery services across London during the challenging Covid-19 pandemic. The Pan London Emergency Cardiac Surgery Service model could serve as a blueprint to design policies applicable to other surgical specialities and parts of the UK and worldwide.

This is a response to the Letter to Editor received regarding the article “The effect of patient obesity on extracorporeal membrane oxygenator outcomes and ventilator dependency.” We aim to address the authors’ comments regarding the relationship between BMI and survival after venoarterial extracorporeal membrane oxygenation (VA-ECMO).

Background and aim: Revascularization guidelines support routine heart team (HT) discussion of appropriate patients. The effect of HT on decision making and clinical outcomes hasn’t been explored. The aim of our study is to investigate the impact of the HT on the mode and delay to revascularization. Methods: We compared data from a prospective cohort of consecutive patients with multivessel coronary artery disease referred for HT discussion between 2016-2017 (HT group) with a historic control group of patients matched according to clinical and angiographic characteristics treated between 2005-2015 (No HT group). Results: There were 93 patients in each group. The HT group and the No HT groups had a similar rate of ACS as well as cardiovascular risk factors and significant left ventricular (LV) dysfunction. No difference was observed in the mean Society of Thoracic Surgery (STS) score (2.5± 3 vs. 3 ±3 p=0.32) and the mean SYNTAX score was low and similar in both groups (21±6 vs. 19±6 p=0.59). The treatment recommendations changed greatly, with 63% of patients being referred for coronary artery bypass grafting (CABG) after HT discussion but only 23% in the no HT group (p<0.01). HT discussion led to a significant delay to PCI (8±5 vs. 1.8±4 days, p=0.02), while surgical revascularization times were not affected. Conclusion: HT discussion in patients with multivessel CAD was associated with an increased referral to CABG but led to a significant delay in revascularization by angioplasty. The impact of these findings on patient satisfaction and outcome should be further investigated.

Background: We report our experience in aortic arch repair with the E-vita Open hybrid prosthesis and describe the changes in our technique over time. Methods: Between October 2013 and December 2019, 56 patients underwent a total aortic arch replacement with the E-vita Open hybrid prosthesis. Main indications were thoracic aorta aneurysm (n=27) and acute type A aortic dissection (n=18). We analyze the technique and results in the overall series, and compare both between our early (Group I, 25 patients) and late experience (Group II, 31 patients). Results: Overall in-hospital mortality was 7.1% (4), and permanent stroke and spinal cord injury were 3.6% and 1.8% respectively. 15 patients (26.8%) underwent a planned second procedure on the distal aorta: 13 endovascular, 1 open and 1 hybrid. Survival at 1 and 3 years was 90.7% and 80.7%. Group II included more patients with acute dissection (45.2% vs 16%, p=0.02), a higher rate of bilateral cerebral perfusion (100% vs 64%, p<0.001), left subclavian artery perfusion during lower body circulatory arrest (87.1% vs 0%, p<0.001), early reperfusion (96.8% vs 40%, p<0.001), and zone 0-2 distal anastomosis (100% vs 72%, p=0.02). In-hospital mortality (3.2% vs 12%) and permanent stroke (0% vs 8%) tended to be lower in Group II. Conclusions: Total arch replacement with E-vita Open hybrid prosthesis in complex thoracic aorta disease is safe. One-stage treatment is feasible when pathology does not extend beyond the proximal descending thoracic aorta. In any case, it facilitates subsequent procedures on distal aorta if needed.

Background: Controversy exists regarding durability and survival after mitral valve repair between sternotomy and a small right anterior thoracotomy approaches. Methods: Between February 2004 and July 2015, 410 patients underwent mitral valve repair via either sternotomy (ST, n=135) or small right anterior thoracotomy (RAT, n=275). Mean follow up was 72.7  38.9 months. Postoperative echocardiograms were obtained in 310 patients (75.6%) at a mean of 20.3  21.4 months. Results: Overall survival at 1, 3, 5, and 10 years were 96.3, 93.0, 93.0, and 91.4% for the ST group and 99.3, 98.9, 98.4, and 97.0% for the RAT group (Log-Rank p = 0.004). There was no difference between groups in the cumulative incidence of need for mitral valve reoperation or progression of mitral regurgitation (MR) considering death as a competing outcome over time (p=0.94 and 0.53, respectively). Propensity score weighted multivariate Cox Proportional hazard modeling built on baseline differences between the RAT and ST groups, showed presence or absence of posterior or anterior leaflet pathology was not associated with mortality, need for reoperation, or progression of MR. A RAT approach was associated with a decreased mortality on adjusted analysis (hazard ratio, 0.32, 95% confidence interval, 0.13-0.82, p=0.018), however, this result was less significant when those with coronary artery disease were removed (hazard ratio, 0.34, 95% confidence interval, 0.12-0.96, p=0.041). Conclusions: Mitral valve repair via a small right anterior thoracotomy incision in select patients can be performed with surgical results and survival that are equivalent to the sternotomy approach.

Extracorporeal membrane oxygenation (ECMO) is a technology that has allowed for further cardiopulmonary support in the setting of respiratory failure refractory to mechanical ventilation. While it has evolved since its first description, one area of improvement continues to be its implementation. With advancements in cannulation techniques, in recent years, there has been a plethora of new cannulas that has been introduced to the market. For urgent venous-venous cannulation, the right internal jugular vein along with either femoral veins remain the most utilized strategy due to minimal need for imaging support. This allows for safe bedside cannulation. However, as the number of days of ECMO support continue to increase bridging patients to an easier to ambulate and more comfortable cannulation strategy is preferred. Therefore, we describe a method for bridging right jugular-femoral cannulation to left subclavian placement of the CrescentTM Dual Lumen Catheter without interrupting ECMO support.

Background: Institutional factors have been shown to impact outcomes following orthotopic heart transplantation (OHT). This study evaluated center variability in the utilization of induction therapy for OHT and its implications on clinical outcomes. Methods: Adult OHT patients between 2010 and 2018 were identified from the UNOS registry. Transplant centers were stratified based on their rates of induction therapy utilization. Mixed-effects logistic regression models were created with drug-treated rejection within 1-year as primary endpoint and individual centers as random parameter. Risk-adjusted Cox regression was used to evaluate patient-level mortality outcomes. Results: In 17,524 OHTs performed at 100 centers, induction therapy was utilized in 48.6% (n=8411) with substantial variability between centers (IQR 21.4 – 79.1%).There were 36, 30, and 34 centers in the low (<29%), intermediate (29-66%), and high (>67%) induction utilization terciles groups, respectively. Induction therapy did not account for the observed variability in the treated rejection rate at 1-year among centers after adjusting for donor and recipient factors (p=0.20). No differences were observed in postoperative outcomes among induction utilization centers groups (all, p>0.05). Furthermore, there was a weak correlation between the percentage of induction therapy utilization at the center-level and recipients found to have moderate (r=0.03) or high (r=0.04) baseline risks for acute rejection at 1-year. Conclusions: This analysis demonstrates there is substantial variability in the use of induction therapy among OHT centers. In addition, there was a minimal correlation with baseline recipient risk or 1-year rejection rates, suggesting a need for better-standardized practices for induction therapy use in OHT.

ABSTRACT: Background: Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) has become a valuable option in patients with bioprosthetic failure. However, potential issues with ViV TAVR may occur in patients with high risk anatomy for coronary obstruction and patients with baseline smaller bioprosthetic valves at risk for patient prosthesis mismatch. The purpose of this study was therefore to use preoperative electrocardiography (ECG)-gated, multidetector computed tomography (MDCT) in patients undergoing isolated surgical aortic valve replacement (SAVR) to 1) identify which would be high risk for coronary occlusion with ViV TAVR, and 2) predict intraoperative SAVR sizing. Methods: Among 223 patients from our institutions’ database that underwent SAVR for aortic insufficiency (AI) or aortic stenosis (AS) between January 2012 and January 2020, 48 patients had MDCT imaging prior to surgery (AI; n=31, AS; n=17). Of all patients, 67% (n=32) were bicuspid morphology. Results: With the use of virtual valve implantation, all patients with AI and bicuspid AS had feasible anatomy for ViV TAVR, while 38% of patients with tricuspid AS were high risk for coronary obstruction. There was a strong correlation between actual valve size implanted and preoperative MDCT measurements using annulus average diameter, area and/or perimeter. Conclusion: Preoperative MDCT in patients undergoing SAVR is a useful tool for lifetime management, particularly in patients with tricuspid AS. Decisions for surgical management may change based on MDCT’s ability to predict intraoperative SAVR size and determine which patients may be high risk candidates for future ViV TAVR due to coronary artery obstruction.

Background: This study evaluated 20-year survival following adult orthotopic heart transplantation (OHT). Methods: The United Network of Organ Sharing Registry database was queried to study adult OHT recipients between 1987-1998 with over 20-year posttransplant follow-up. The primary and secondary outcomes were 20-year survival and cause of death following OHT, respectively. Multivariable logistic regression was used to identify significant independent predictors of long-term survival, and long-term survival was compared among cohorts stratified by number of predictors using Kaplan Meier survival analysis. Results: 20,658 patients undergoing OHT were included, with median follow-up of 9.0 (IQR 3.2-15.4) years. Kaplan-Meier estimates of 10-, 15-, and 20-year survival were 50.2%, 30.1%, and 17.2%, respectively. Median survival was 10.1 (IQR 3.9-16.9) years. Increasing recipient age (>65 years), increasing donor age (>40 years), increasing recipient BMI (>30), black race, ischemic cardiomyopathy, and longer cold ischemic time (>4 hours) were adversely associated with 20-year survival. Of these 6 negative predictors, presence of 0 risk factors had the greatest 10-year (59.7%) and 20-year survival (26.2%), with decreasing survival with additional negative predictors. The most common cause of death in 20-year survivors was renal, liver, and/or multisystem organ failure whereas graft failure more greatly impacted earlier mortality. Conclusions: This study identifies six negative preoperative predictors of 20-year survival with 20-year survival rates exceeding 25% in the absence of these factors. These data highlight the potential for very long-term survival following OHT in patients with end-stage heart failure and may be useful for patient selection and prognostication.

ABSTRACT Introduction and Objective: There are various management options for newborns with single ventricle physiology, ventriculoarterial discordance and subaortic stenosis (SOS), classically involving the early pulmonary banding and aortic arch repair, the restricted bulboventriculer foramen(BVF) enlargement or the Norwood and the Damus Kaye Stansel (DKS) procedures. The aim of this study is to evaluate the midterm results of our clinical experience with palliative arterial switch operation (pASO) for this subset of patients. Method: We hereby retrospectively evaluate the charts of patients going through pASO, as initial palliation through Fontan pathway, starting from 2014 till today. Results: 10 patients underwent an initial palliative arterial switch procedure. 8 of 10 patients survived the operation and discharged. 7 of 10 patients completed stage II and 1 patient reached the Fontan completion stage and the other six of ten (6/10) patients are doing well and waiting for the next stage of palliation. There are two mortalities in the series (2/10) and one patient lost to follow-up (1/10). Conclusions: The pASO can be considered as an alternative palliation option for patients with single ventricle physiology, transposition of the great arteries and systemic outflow obstruction. It not only preserves systolic and diastolic ventricular function, but also provides a superior anatomic arrangement for following stages. Keywords: Congenital Heart Disease, Single Ventricle, Arterial Switch Operation

We want to thank Dr. Raveenthiran and Dr. Harky for their interest in our paper and in the topic of Marfans in the setting of pregnancy. Certainly, the reduction of adverse outcomes would be improved with early knowledge of Marfans syndrome in the mother which would aid in preparation and clinical consideration during the perioperative period, and, prior to pregnancy.

This Editorial Comment explores important issues raised by this manuscript.

Transcatheter repair systems are becoming increasingly popular as a potential solution for high-risk and inoperable patients with mitral regurgitation. The Cardioband (Edwards Lifesciences, Irvine, California) is a transcatheter direct annuloplasty device, based on the concept of an undersized ring annuloplasty. We report a case of minimally invasive surgical explantation of a failed Cardioband device 21 months after its implantation. Intraoperatively, it was found that3 anchors of the Cardioband device were detached from the posterior annulus at P2. In this report, a “cut and unscrew” technique with some tips and tricks is presented for the removal of the device.

Radial arteriovenous fistula post coronary artery intervention is rare. Here we describe an extremely rare case of radial arteriovenous fistula (AVF) with retrograde filling through the deep palmar arch and presenting as early ischemic changes.

Cryoglobulinemia is a cold-reactive autoimmune disease. A 64-year-old man with active cryoglobulinemia presented Stanford type A acute aortic dissection. He had been treated with immunosuppressive drugs and plasma exchange (PE) at our hospital; subsequently, qualitative analysis of cryogobulin (CG) was negative. He underwent emergency ascending aorta replacement using cardiopulmonary bypass (CPB) under deep hypothermia circulatory arrest with selective cerebral perfusion. The total CPB time, aortic cross clamp time, and selective cerebral perfusion time were 255, 153, 56 minutes, respectively, and the minimal nasopharyngeal temperature was 17.3°C. Our patient had no significant perioperative complications. Hence, if PE is performed appropriately and CG is negative, patients with cryoglobulinemia who exhibit severe preoperative symptoms can safely undergo surgery with deep hypothermia.

Dear Editor,We read with interest the published article by Ikeda et al. [1], they performed thoracic endovascular aortic repair (TEVAR) in a patient with Marfan syndrome (MFS) for acute complicated type B aortic dissection (TBAD) during COVID-19 pandemic.The evidence around TEVAR for MFS is scarce and open repair remains the gold treatment[2]. During the COVID-19 pandemic, many patients are either being denied treatment or given inferior options on the basis of age, comorbidities and risk of COVID pneumonia; however, the guidelines for aortic intervention in the United Kingdom have remained largely unchanged from pre-COVID-19 era [3]. Our questions to the authors relate to whether their solution was an unnecessary compromise. There is no clear indication defined in their case as a cold leg doesn’t necessary means an ischaemic limb. The TEVAR procedure performed aiming to minimise hospital stay, yet this approach may have put the patient at higher risk of developing paraplegia and visceral organ malperfusion, while compromising her long-term care.There is need to clarify if she had risk factors that prone her to a higher risk acquiring severe COVID-19 which necessitated deviating from the traditional open surgery recommended for MFS patients with TBAD [2]. The authors did not report on renal function, evidence of bowel malperfusion or whether there was resistant hypertension that needed immediate intervention. If the need to expediate intervention was the fear of limb ischaemia, is it conceivable a femoro-femoral bypass could have saved the limb and definitive open surgery on her aorta could have been performed at a later stage, especially since she was haemodynamically stable.Moreover, as Marfan-diseased aortas are prone to further dilatation, we believe their justification for opting for endovascular repair should also have been more balanced, exploring the know high rate of long-term TEVAR-associated complications in MFS patients including endoleaks, retrograde dissection, stent-graft-induced new entry tears, surgical conversions and reintervention. There is also need for imaging follow-up to assess the success of TEVAR and early detection of aforementioned complications.

Background and aim. Classical and paradoxical low-flow, low-gradient aortic stenosis (LFLGAS) are the most challenging aortic stenosis (AS) subtypes. The current therapeutic options are aortic valve replacement (AVR) and conservative management. The matter is controversial because AVR promotes long-term survival, but it is invasive, while no aortic valve replacement (noAVR) in non-invasive, but it is associated with poor prognosis. This meta-analysis aims to investigate the survival rate in patients with LFLGAS undergoing AVR versus noAVR interventions. Methods. A meta-analysis was conducted comparing the outcomes of AVR and noAVR in terms of survival. A meta-regression was carried out to investigate the impact of preserved and reduced left ventricular ejection fraction (LVEF) on survival in both the AVR and noAVR group. Results. The log IRR of survival between AVR group and noAVR group was 0.58 [0.28, 0.87] (p-value = 0.0001), suggesting that survival is significantly better in the AVR group compared to the noAVR group. The meta-regression revealed that low LVEF is related to higher survival rates in the AVR group (p-value = 0.04) when compared to preserved LVEF. LVEF has no impact on survival in the noAVR group (p-value = 0.18). Conclusions. Patients with LFLGAS have better survival in the AVR group rather than in the noAVR group. Reduced LVEF was related to better survival than preserved LVEF in the AVR, and no difference between low and preserved LVEF was found in the noAVR group.

Background The Carpentier-Edwards Perimount valves have a proven track record in aortic valve replacement: good durability, hemodynamic performance, rates of survival, and infrequent valve-related complications and PPM. The St. Jude Medical Trifecta is a newer valve that has shown comparable early and midterm outcomes. Studies show reoperation rates of Trifecta are comparable to Perimount valves, with a few recent studies bringing into focus early SVD, and increased midterm SVD in younger patients. Given that midterm data for Trifecta is still sparse, we wanted to confirm the early low reoperation rates of Trifecta persist over time compared to Perimount. Methods The Maritime Heart Centre Database was searched for isolated AVR or AVR+CABG between January 2011 and December 2016. Primary end point of the study was all-cause reoperation rate. Results 711 Perimount and 453 Trifecta implantations were included. The reoperation hazards were determined for age: 0.96 (0.92-0.99, p=0.02), female (vs male): 0.35 (0.08-1.53, p=0.16), smoker (vs non-smoker): 2.44 (0.85-7.02, p=0.1), and Trifecta (vs Perimount): 2.68 (0.97-7.39, p=0.06). Kaplan-Meier survival analysis in subgroups—age < 60, age ≥ 60, male, female, smoker, and non-smoker—showed Perimount having lower reoperation rates than Trifecta in patient younger than 60 (p=0.02) and those with smoking history (p<0.01). Conclusions The rates of reoperation of Perimount and Trifecta were comparable, with Trifecta showing higher rates in patients younger than 60 years, and current smokers. Continued diligence and further independent reporting of midterm reoperation and SVD rates of the Trifecta, including detailed echocardiographic follow up, are needed to confirm these findings.