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Background:  Manouguian aortic root enlargement (ARE) has been a standard root enlargement procedure to assist in patients with a small annular size. We describe a modification to the Manouguian ARE similar to Yang et al. This approach could serve as an alternate technique for performing ARE; to date only case reports have defined this approach and no studies have evaluated its efficacy or safety. Methods:  A retrospective case series was performed on patients who underwent ARE for surgical aortic valve replacement via the modified Manouguian procedure at a single institution. Thirteen patients were identified between 2015-2021, and all surgeries were performed by a single operator. Data were collected via the Society of Thoracic Surgeons database and chart review. The primary outcome was difference in valve size after the procedure.  Results:  The most common indication for surgery was aortic stenosis (12, 92%), with the most common etiology being degenerative calcification (7, 54%). Congenital bicuspid or uni-cuspid valves were identified in 5 (38%) patients. The majority (10, 77%) of patients received a mechanical valve. This procedure was successfully performed in all 13 of the patients. Additionally, 13 of the 13 patients (100%) were upsized to a satisfactory valve size based on pre-operative echocardiography sizing. Conclusions:  The modified Manouguian aortic enlargement technique can be safely and effectively used as an aortic enlargement procedure in a broad sample of patients.

More than 1.6 million Americans have at least moderate to severe tricuspid regurgitation, yet fewer than 8000 tricuspid valve operations are performed annually in the USA.The under-treatment for isolated tricuspid regurgitation might be related to the fact that in the past years no clear guidelines on how and when to treat tricuspid regurgitation were issued. Here, we discuss the meta-analysis by Sarris-Michopoulos et al, and we comment what is available in literature on diagnosis and decision making for tricuspid valve intervention.

Risk of permanent pacemaker implantation after transcatheter aortic valve replacement: How do we manage beyond risk assessment?

The authors present an excellent retrograde analysis of a rare condition of a phenomenal number of cases and their surgical outcomes. A majority of the studies in published literature are anecdotal case reports which are a rare and dreadful entity. A comprehensive countrywide view of the UK National Adult Cardiac Surgery Audit database is presented in this study. This study represents the changing trends in the risk factors, management strategies, and outcomes of ventricular septal rupture for over 23 years in a nutshell.

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.

Over the course of time, new developments associated with embryogenesis of the murine heart have served to clarify the developmental processes observed in the human heart. This evidence allows for creation of a developmental framework for many congenital cardiac defects. Here, we aim to solidify the framework related to the categorization of both solitary and multiple ventricular septal defects. Mice having genetic perturbation of the Furin enzyme have demonstrated perimembranous and juxta-arterial ventricular septal defects, permitting the inference to be made that these defects can co-exist with defects occurring within the apical muscular septum. Based on developmental evidence, furthermore, all interventricular communications can be placed into one of three groups, namely, those which are perimembranous, juxta-arterial, and muscular. All of the defects are described based on their borders as seen from the morphologically right ventricle. Our focus here will be on those defects within the muscular ventricular septum, recognizing that such defects can co-exist with those that are perimembranous. We discuss the differentiation of multiple discrete defects from those referred to as the ‘Swiss cheese’ variant. As we show, appropriate surgical management requires understanding of the specific terminology, as the surgical approach may differ depending on the combination of the individual defects. Data from the Society for Thoracic Surgeons revealed that both mortality and morbidity were increased in the setting of multiple as opposed to solitary ventricular septal defects.

Background: Heart transplantations are ideal for most patients with end-stage heart failure refractory to medical treatment. The transplantation program at the Peruvian National Heart Institute started with a 10-year-continuity in 2010. Objective: To report the results of a 10-year heart transplantation experience at the Peruvian National Heart Institute. Methods: We studied 83 patients who underwent orthotopic heart transplantation at a single center between January 2010 and December 2019. The recipients’ profiles and survival were analyzed according to sex and age group, ensuring the information’s confidentiality. Results: The recipients’ mean age was 41.2 ± 17 years, 88% were adult, and 68.7% were male. The main indications for transplantation were idiopathic dilated cardiomyopathy. 85.5% of recipients were clinically categorized as INTERMACS Profile 1 to 3 before transplantation. There was a significant difference between sexes regarding the preoperative left ventricular ejection fraction and between age groups regarding the waiting time. The average ischemia time was 3.1 hours, operating time was 6.1 hours, cardiopulmonary bypass time was 3 hours, and aortic cross-clamp time was 1.7 hours. The principal early postoperative complications were hematological disorders and acute kidney failure. The principal late ones were kidney failure and severe anemia. The postoperative mortality was 15.9%, and the principal causes were infection and then acute rejection. The survival at one, five, and ten years was 87.5%, 79.8%, and 79.8%, respectively. The survival results were not influenced by sex or age group. Conclusion: Our patients’ postoperative complications, mortality, and survival rates coincided with those reported by the ISHLT registry.

I read with interest the articles by Wang and colleagues about comparison of risk scores for predicting outcomes after isolated tricuspid valve surgery and the commentary by Russo and colleagues about prediction of mortality in isolated tricuspid surgery1

Background and Aim: We showed in our anatomical review, ventricular septal defects existing as multiple entities can be considered in terms of three major subsets. We address here the diagnostic challenges, associated anomalies, the role and techniques of surgical instead of interventional closure, and the outcomes. including reinterventions, for each subset. Methods: We reviewed 80 published investigations, noting radiographic findings, and the results of clinical imaging elucidating the location, number, size of septal defects, and associated anomalies, and the effect of severe pulmonary hypertension. Results: Overall, perioperative mortality for treatment of residual multiple defects has been cited to be between zero and 14.2%, with morbidity estimated between 6% to 13%. Perioperative mortality is twice as high for perimembranous compared to muscular defects, with need for reoperation is over four times higher. Perventricular hybrid approaches are useful for closure of high anterior or apical defects. Overall, results have been unsatisfactory. Pooled data reveals incidences between 2.8% and 45% for device-related adverse events. Currently, however, outcomes cannot be assessed on the basis of the different anatomical sub-sets. Conclusions: We have addressed the approaches, and the results, of therapeutic treatment in terms of co-existing discrete defects, the Swiss-cheese septum, and the arrangement in which a solitary apical muscular defect gives the impression of multiple defects when viewed from the right ventricular aspect. Treatment should vary according to the specific combination of defects.

Background Since the introduction of the E-Vita Open NEO aortic prosthesis in 2020, several incidences of post-anastomotic oozing from the polyester portion of the graft have emerged. The use of BioGlue to prime E-Vita Open NEO to prevent this has been suggested as a way to mitigate this worrying complication. We investigate the extent of graft oozing in E-Vita Open NEO and evaluate the use of BioGlue in preventing oozing, both experimentally and in terms of potential clinical complications. Methods and materials E-Vita Open NEO (in straight and branched configurations) was implanted in a perfused model. The distal stent-graft and side branches were clamped, and the graft pressurised with blood to 120 mmHg. The volume of blood (ml) oozing from the graft within 60 seconds was measured. Non-pressurised grafts were coated with BioGlue up to a thickness 1-, 2-, and 3 mm, and the volume (mm3) of BioGlue required to do so was recorded. Results Within 60 seconds, 250.0 ml of blood oozed from the grafts tested. 43.694 mm3, 87.389 mm3, and 174.778 mm3 of BioGlue was required to coat the device with 1-, 2-, and 3 mm of BioGlue. Conclusion Graft oozing from E-Vita Open NEO represents an omnipresent and worrying risk. The use of BioGlue herein is likely associated with several adverse consequences, which are an additional risk on top of that posed by graft oozing. These risks call into question the suitability of E-Vita Open NEO, especially when compared to alternative devices not affected by oozing.

Objective: The study aimed to evaluate the indications and describe the aortic valve reconstruction techniques by Ozaki’s procedure in Vietnam and report mid-term outcomes of this technique in Vietnam. Methods: Between June 2017 and December 2019, 72 patients diagnosed with isolated aortic valve disease, with a mean age of 52.9 (19 – 79 years old), and a male:female ratio of 3:1 underwent aortic valve reconstruction surgery by Ozaki’s technique at Cardiovascular Center, E Hospital, Vietnam. Results: The aortic valve diseases consisted of aortic stenosis (42%), aortic regurgitation (28%), and a combination of both (30%). In addition, the proportion of aortic valves with bicuspid morphology and small annulus (≤ 21 mm) was 28% and 38.9%, respectively. The mean aortic cross-clamp time was 106 ± 13.8 minutes, mean cardiopulmonary bypass time was 136.7 ± 18.5 minutes, and 2.8% of all patients required conversion to prosthetic valve replacement surgery. The mean follow-up time was 26.4 months (12- 42 months), the survival rate was 95.8%, the reoperation rate was 2.8%, and rate of postoperative moderate or higher aortic valve regurgitation was 4.2%. Postoperative valvular hemodynamics was favorable, with a peak pressure gradient of 16.1 mmHg and an effective orifice area index of 2.3 cm 2. Conclusions: This procedure was safe and effective, with favorable valvular hemodynamics and a low rate of valvular degeneration. However, more long-term follow-up data are needed.

Deferring non-emergent cardiac surgery became the strategy of choice for several international healthcare systems afflicted by high case burdens of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2/COVID-19) in order to both conserve valuable healthcare resources and protect patients from possible exposure. Missing from the available dataset to help guide policy development has been a clear understanding of the extent to which COVID-19 infection modulates cardiac surgery outcomes. In their investigation, Bonalumi and colleagues uncovered an inpatient COVID-19 positivity rate of almost 10 times higher than that of the general Italian population, as well as a mortality rate over 20 times higher amongst cardiac surgery patients with perioperative COVID-19 infection compared to those COVID-negative. While the summation of available evidence points to the serious consideration cardiac surgeons must give to delaying surgeries during the COVID-19 pandemic, recognition must be given to the risks that postponing cardiac surgery may have on patient outcomes. Emerging data is beginning to demonstrate the efficacy of vaccination in preventing postoperative COVID-19 infection and morbidity.

Bleeding Control Strategies In Coronary Artery Bypass SurgeryFatih Avni Bayraktara MD, Mehmet Senel Bademcia MD, Cemal Kocaaslana MD, Ahmet Oztekina MD, and Ebuzer AydinaMD.a Istanbul Medeniyet University, Medicine Faculty, Department of Cardiovascular Surgery, Istanbul, TurkeyCorresponding Author: Fatih Avni Bayraktar, M.D, Assist.Prof.Post Publication Corresponding Author: Fatih Avni Bayraktar,M.D, Assist.Prof.Istanbul Medeniyet University Medicine Faculty, Department of Cardiovascular Surgery.Address: Dr. Erkin St. No:12 Kadikoy, Istanbul, 34722, Turkey.Mail address: [email protected] Editor;We read with interest the article entitled “Factors associated with excessive bleeding following elective on‐pump coronary artery bypass grafting” by Bastopcu et al (1).In this retrospective study, the authors focused on preoperative and operative factors affecting excessive bleeding after on-pump coronary artery bypass graft surgery. Some points in the article caught our attention. Inherited bleeding disorders need pre-planning in the preoperative and operative period of cardiac surgery (2). Were the bleeding disorders questioned, while taking the anamnesis of the included patients?Atrial fibrillation is one of the most common complications after coronary artery bypass surgery (3). Anticoagulant therapy is inevitable in patients with atrial fibrillation. Patients with anticoagulation therapy due to atrial fibrillation or any other cause is not mentioned in the text which may be associated with postoperative bleeding.And finally, when the current literature is reviewed, it is seen that the use of peroperative tranexamic acid has a reducing effect on bleeding after coronary bypass surgery. (4). In this study, did the authors use tranexamic acid? We congratulate the authors about their manuscript. We look forward to hear the authors’ opinions on these matters.Bastopcu M, Özhan A, Erdoğan SB, Kehlibar T. Factors associated with excessive bleeding following elective on-pump coronary artery bypass grafting. J Card Surg . 2021;36(4):1277-1281.Bhave P, McGiffin D, Shaw J, et al. Guide to performing cardiac surgery in patients with hereditary bleeding disorders. J Card Surg . 2015;30(1):61-69.Eikelboom R, Sanjanwala R, Le ML, Yamashita MH, Arora RC. Postoperative Atrial Fibrillation After Cardiac Surgery: A Systematic Review and Meta-Analysis. Ann Thorac Surg . 2021;111(2):544-554.Boer C, Meesters MI, Milojevic M, et al. Task Force on Patient Blood Management for Adult Cardiac Surgery of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Cardiothoracic Anaesthesiology (EACTA). 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth . 2018;32(1):88-120.

Resection or exclusion of scars following a myocardial infarction on the LAD territory started even before the beginning of the modern era of cardiac surgery. Many techniques were developed, but there is still confusion on who did what. The original techniques underwent modifications that brought to a variety of apparently new procedures that, however, were only a “revisitation” of what described before. In some case old techniques were reproposed and renamed, without giving credit to the surgeon that was the original designer. Herein we try to describe which are the seminal procedures and some of the most important modifications, respecting however the merit of who first communicated the procedure to the scientific world.

We have reported a case of trans-cuff leakage that occurred in a composite graft of bio-Bentall operation. The leakage resolved several months after surgery, similar to the trans-cuff leakage seen in simple aortic valve replacement. We have proposed hypotheses on the mechanism of trans-cuff leakage during a bio-Bentall operation and suggested ways to prevent it from occurring.

Here, we report the case of a patient who presented to our institution with severe, destructive, and un-reconstructable prosthetic valve endocarditis which required the planned implantation of a total artificial heart (TAH) to function as a bridge to cardiac transplantation.

One of the surgical options available for ischemic mitral regurgitation is mitral valve repair but is limited by recurrent regurgitation as it is experienced by a significant percent of patients and has a negative impact on patient outcomes. Efforts to model and identify predictors of recurrent MR rely on complicated echocardiographic and clinical measurements that are subjective and not routinely collected. Kachroo et. al. approached this problem in a unique way by using the STS database and Machine Learning to develop models that predict recurrent MR or death at one year. The STS database contains many routinely collected demographic and clinical parameters but requires a methodology, such as Machine Learning, that will accommodate collinearity and the unknown significance of many predictors. Kachroo et. al. developed three good Machine Learning models with AUC 0.72-0.75. Data- driven selection of important predictors showed that three revascularization targets, peripheral vascular disease and use of beta blockers are most predictive of recurrent mitral regurgitation. We applaud the authors in pioneering a novel methodology and paving the way for a bright future in Machine Learning which includes integrating medical imaging, waveform, and genomic data to practice personalized medicine for our patients.