CABG (Coronary Artery Bypass Grafting) has been the treatment of choice for coronary artery disease for over 50 years and is the most common cardiac surgery procedure performed. Traditionally CABG was performed with the use of cardiopulmonary bypass and the use of cardioplegia to allow the surgeon to operate on a stable field. In the mid-1990s, interest emerged in performing CABG without the use of cardiopulmonary bypass - off pump CABG. This invited commentary focuses on sharing our experience with Low Ejection fraction off-pump CABG and why this approach could be beneficial to this patient population.

Nitric oxide has been used to treat respiratory failure in post-pediatric cardiac surgical patients. High frequency oscillator ventilation is used to rescue infants who have failed conventional ventilation. In this issue a study is presented showing the benefit of combining these two therapies for improved outcomes in infants with hypoxic respiratory failure after congenital heart surgery

Objectives Redo sternotomy and explantation of left ventricular assist devices (LVAD) for heart transplantation (HT) involve prolonged dissection, potential injury to mediastinal structures and/or bleeding. Our study compared a complete expanded polytetrafluoroethylene (ePTFE) wrap versus minimal or no ePTFE during LVAD implantation, on outcomes of subsequent HT. Methods Between July 2005 and July 2018, 84 patients underwent a LVAD implant and later underwent HT. Thirty patients received a complete ePTFE wrap during LVAD implantation (Group 1), and 54 patients received either a sheet of ePTFE placed in the anterior mediastinum or no ePTFE (Group 2). Results Baseline characteristics were similar between Groups 1 and 2. Surgeons reported subjective improvements in speed, predictability and safety of dissection with complete ePTFE compared with minimal or no ePTFE. Time from incision to initiation of cardiopulmonary bypass (CPB) were similar between groups (97±38 min vs 89±29 min, p=0.3). Injury to mediastinal structures during the dissection was similar between groups (10% vs 11%, p>0.9). While surgeons reported less intraoperative bleeding in Group 1 (43% vs 61%), this trend did not reach significance (p=0.1). In-hospital mortality, ICU length of stay and hospital length of stay were similar between both groups. Conclusions In patients undergoing LVAD explant-HT, there was a trend towards reduced surgeon reported intraoperative bleeding with ePTFE placement. Despite qualitatively reported greater ease and speed of mediastinal dissection with ePTFE membrane placement, time to initiation of CPB did not differ, likely because surgeons remained cautious, allowing extra time for unanticipated difficulties.

Background: Functional mitral regurgitation (FMR) is common in patients with myocardial infarction or dilated cardiomyopathies, and portends a poor prognosis despite guideline-directed medical therapy. Surgical or transcatheter mitral repair for FMR from recent randomized clinical trials showed disappointing or conflicting results. Aims: To provide an update on the role of surgical repair in the management of FMR. Materials & Methods: A literature search was conducted utilizing PubMed, Ovid, Web of Science, Embase and Cochrane Library. The search terms included secondary/functional mitral regurgitation, ischemic mitral regurgitation, mitral repair, mitral replacement, mitral annuloplasty, transcatheter mitral repair, and percutaneous mitral repair. Randomized clinical trials over the past decade were the particular focus of this current review. Results: Recent data underlined the complexity and poor prognosis of FMR. Guideline-directed medical therapy and cardiac resynchronization, when indicated, should always be applied. Accurate assessment of the interplay between ventricular geometry and mitral valve function is essential to differentiate proportionate FMR from the disproportionate subgroup, which could be helpful in selecting appropriate transcatheter intervention strategies. Surgical repair, most commonly performed with an undersized ring annuloplasty, remains controversial. Adjunctive valvular or subvalvular repair techniques are evolving and may produce improved results in selected FMR patients. Conclusion: FMR resulted from complex valve-ventricular interaction and remodeling. Distinguishing proportionate FMR from disproportionate FMR is important in exploring their underlying mechanisms and to guide medical treatment with surgical or transcatheter interventions. Further studies are warranted to confirm the clinical benefit of appropriate surgical repair in selected FMR patients.

ABSTRACT: Objective To investigate the Aneurysmal of the left sinus of Valsalva, and to improve the understanding of the disease and the level of diagnosis and treatment. Methods This article mainly reports a case of huge Aneurysmal of the left sinus of Valsalva patients treated with surgical treatment. Results After surgery, the prognosis of the case was good. Conclusion Aneurysmal of the left sinus of Valsalva has low incidence，which is rare in clinical with no clinical specific symptoms leading to difficulty in early detection. The appropriate surgical method should be considered to the patient condition, to prevent the tumor rupture and the death of patients.

Background The Organ Care System (OCS) is a revolutionary ex vivo organ perfusion technology that can potentially expand the organ retrieval range. The OCS Lung device uses packed red blood cells (pRBC) with a proprietary solution. We report the ability to reduce blood waste during this procedure by using a thermal packaging solution in conjunction with the OCS platform. Methods We retrospectively reviewed all OCS Lung recoveries performed by our recovery team, using packed red blood cells (pRBC) from May 2019 to January 2021. Initially, units were stored using passive refrigeration with the Performance cooler at a temperature range of 1 to 6 °C for 4 hours. Subsequently, thermal control technology with the ProMed cooler was utilized to maintain the same temperature range for 72 hours. Results Twenty-three recoveries were initiated with 63 pRBC. The Performance cooler was used for eight while the ProMed cooler for thirteen. 37.5% of pRBC transported with the Performance cooler was used within the validated time range, while 25.0% were used beyond the validated time range based on clinical judgment. In addition, 37.5% of pRBC transported with the Performance cooler were returned to the institution after canceled recoveries with an estimated loss of $1,800; the ProMed cooler had no wastage. Conclusions This study showed that using an advanced thermal packaging solution facilitates proper storage of pRBC and represents an advancement for extended donor lung preservation. The elimination of blood wastage in this initial study portends ongoing benefits for the limited blood supply and reduced cost.

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.

Importance: Cardiac tamponade requiring emergent intervention is a possible complication of COVID-19 infection. Favorable clinical outcomes are possible if timely management and drainage are performed, unless ventricular failure develops. Observations: Cardiac tamponade in COVID-19, based on the limited reported cases, seems to be more common among middle-aged men. Prognosis is worse amongst patients with concomitant ventricular failure. Design and methods: This is a case series of three COVID-19 patients complicated by cardiac tamponade, requiring surgical intervention at a single institution in New York. Interventions: Pericardial window, Pericardiocentesis Outcomes: One patient had recurrence of cardiac tamponade with hemorrhagic component but fully recovered and was discharged home. Two patients developed cardiac tamponade with concomitant biventricular failure, resulting in death. Conclusions and Relevance: Cardiac Tamponade with possible concomitant biventricular failure can develop in COVID-19 patients; incidence seems to be highest at the point of marked inflammatory response. Concomitant ventricular failure seems to be a predictor of poor prognosis.

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.

Background Pericardiectomy for post-radiation constrictive pericarditis has been reported to generally have unfavorable outcomes. This study sought to evaluate surgical outcomes in a large cohort of patients undergoing pericardiectomy for radiation-associated pericardial constriction. Methods A retrospective analysis of all patients (≥18years) who underwent pericardiectomy for a diagnosis of constrictive pericarditis with a prior history of mediastinal irradiation from June 2002 to June 2019 was conducted. There were 100 patients (mean age 57.2±10.1 years, 49% females) who met the inclusion criteria. Records were reviewed to look at surgical approach, extent of resection, early mortality and late survival. Results The overall operative mortality was 10.1% (n=10). The rate of operative mortality decreased over the study period; however, the test of trend was not statistically significant (P=0.062). Hodgkin’s disease was the most common malignancy (64%) for which mediastinal radiation had been received. Only 27% patients had an isolated pericardiectomy, and concomitant pericardiectomy and valve surgery was performed in 46% patients. Radical resection was performed in 50% patients, whereas 47% patients underwent a subtotal resection. Prolonged ventilation (26%), atrial fibrillation (21%) and pleural effusion (16%) were the most common post-operative complications. The overall 1,5- and 10-years survival was 73.6%, 53.4% and 32.1% respectively. Increasing age (HR 1.044, 95%CI 1.017-1.073) appeared to have a significant negative effect on overall survival in the univariate model. Conclusion Pericardiectomy performed for radiation associated constrictive pericarditis has poor long-term outcomes. The early mortality, though high (~10%), has been showing a decreasing trend in the test of time.

Background: Brazil is an upper-middle-income country in South America with the world’s sixth largest population. Little is known on the volume, outcomes and trends of coronary artery bypass grafting (CABG) in Brazil’s public health system. Objective: The aim of this study was to evaluate the outcome of CABG in the public health system in from January 2008 to December 2017 through the database DATASUS. Methods: This study is based on publicly available material obtained from DATASUS, the Brazilian Ministry of Health’s data processing system, on numbers of surgical procedures, death rates, length of stay, and costs. Only isolated CABG procedures were included in our study. We used the TabNet software from the DATASUS website to generate reports. Chi-square test was used to compare death rates. A p-value of <0.05 was considered statistically significant. Results: We identified 226,697 CABG procedures performed from January 2008 to December 2017. The overall in-hospital mortality over the 10-year period was 5.7%. We observed statistically significant differences in death rates between the five Brazilian macro regions. Death rates by state ranged from 2.6% to 13.1%. The national average mortality rate remained stable over the course of time. Conclusion: Over 10 years, a high volume of CABG was performed in the Brazilian Public Health System with significant differences in mortality, number of procedures, and distribution of surgeries by region. Future databases involving all centers that perform CABG and carry out risk-adjusted analysis will help improve Brazilian results, and enable policymakers to adopt appropriate health care policies for greater transparency and accountability.

In this report we describe the clinical presentation, laboratory findings and outcomes of four patients that were referred for urgent cardiothoracic intervention and tested positive for COVID-19. Though the majority of the patients undergoing surgery had low Society of Thoracic Surgeons score and uneventful operating time, mortality was very high and driven primarily by the viral syndrome. Laboratory markers that have been associated with disease severity in the general population were also prognostic in our population. Our study shows that these patients have very high mortality, whereas prevention and preoperative screening is required in preventing nosocomial spreading of the disease.

The authors conducted a prospective, observational study to evaluate the correlation of fluid responsiveness with commonly used carotid doppler-derived indices like carotid artery blood flow (CBF), carotid corrected flow time (FTc), respirophasic variation in carotid artery blood flow peak velocity (ΔVpeak) in patients undergoing CABG. They claimed that altough only ΔVpeak demonstrated some predictive power with areas under receiver operating characteristic (AUROC) of 0.671, carotid doppler ultrasound indices were found to be not dependable as a substitute for invasive methods to assess fluid responsiveness. The presence of studies advocating quite different sentiments in the literature regarding feasibility and reliability show that there is a long way gone and a long way to go.

Severe Aortic stenosis: Is urgent transcatheter aortic valve replacement better than Balloon aortic valvuloplasty better than?Wael Awad FRCS(C/Th)1, Mohammed Idhrees MS, MCh, FAIS2, Mohamad Bashir MD, PhD, MRCS 31. Department of Cardiothoracic Surgery, Barts Heart Centre, St. Bartholomew’s Hospital,West Smithfield, London, UK2. Institute of Cardiac and Aortic disorders, SRM Institues for Medical Science (SIMS Hospital), India3. Department of Vascular Surgery, Royal Blackburn Teaching Hospital, Haslingden Road,Blackburn, UK

Clinical assessment or scoring model for acute lung injury: a crossing path?

Background: The purpose of this study was to investigate the incidence, predictors, and long-term impact of gastrointestinal (GI) complications following adult cardiac surgery. Methods: Index Society of Thoracic Surgeons (STS) adult cardiac operations performed between January 2010 and February 2018 at a single institution were included. Patients were stratified by the occurrence of postoperative GI complications. Outcomes included early and late survival as well as other associated major postoperative complications. A sub-analysis of propensity score matched patients was also performed. Results: 10,285 patients were included, and the overall rate of GI complications was 2.4% (n=246). Predictors of GI complications included dialysis dependency, intra-aortic balloon pump, congestive heart failure, chronic obstructive pulmonary disease, and longer aortic cross-clamp times. Thirty-day (2.6% vs 24.8%), one- (6.3% vs 41.9%), and three-year (11.1% vs 48.4%) mortality were substantially higher in patients who experienced GI complications (all P<0.001). GI complication was associated with a three-fold increased hazard for mortality (HR 3.1, 95% CI 2.6-3.7) after risk adjustment, and there was an association between the occurrence of GI complications and increased rates of renal failure (39.4% vs 2.5%), new dialysis dependency (31.3% vs 1.5%), multisystem organ failure (21.5% vs 1.0%), and deep sternal wound infections (2.6% vs 0.2%)(all P<0.001). These results persisted in propensity-matched analysis. Conclusions: GI complications are infrequent but have a profound impact on early and late survival, and often occur in association with other major complications. Risk factor modification, heightened awareness, and early detection and management of GI complications appears warranted.

Objectives: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is increasingly being used in acutely deteriorating patients with end-stage lung disease as a bridge to transplantation (BTT). It can allow critically ill recipients to remain eligible for lung transplant (LTx) while reducing pretransplant deconditioning. We analyzed early and mid-term postoperative outcomes of patients on VV-ECMO as a BTT and the impact of preoperative VV-ECMO on posttransplant survival outcomes. Methods: All consecutive LTx performed at our institution between January 2012 and December 2018 were analyzed. After matching, BTT patients were compared with non-bridged LTx recipients. Results: Out of 297 transplanted patients, 21 (7.1%) were placed on VV-ECMO as a BTT. After matching, we observed a similar 30-day mortality between BTT and non-BTT patients (4.6% vs. 6.6%, p=0.083) despite a higher incidence of early postoperative complications (need for ECMO, delayed chest closure, acute kidney injury). Furthermore, preoperative VV-ECMO did not appear associated with 30-day or 1-year mortality in both frequentist and Bayesian analysis (OR 0.35, 95%CI 0.03-3.49, p=0.369; OR 0.27, 95%CrI 0.01-3.82, P=84.7%, respectively). In sensitivity analysis, both subgroups were similar in respect to 30-day (7.8% vs. 6.5%, p=0.048) and 1-year mortality (12.5% vs. 18%, p=0.154). Conclusions: Patients with acute refractory respiratory failure while waiting for LTx represent a high-risk cohort of patients. We observed that these patients can be successfully bridged to LTx with VV-ECMO with post-transplant mortality comparable to non-BTT patients.

The coronavirus disease 2019 (COVID-19) pandemic has presented unique challenges to international health care systems. Management of the current pandemic puts a huge strain on health care sectors and leads to new strategies conducting by health care systems in countries across the world. In the present article, we review the epidemiologic data, Iranian health care system response, as well as the effects of COVID-19 pandemic on cardiac surgery practice in Iran