Background and Aim: The P2Y12 platelet receptor inhibitor ticagrelor is widely used in patients following acute coronary syndromes or in those who have received coronary stents. Bentracimab is a monoclonal antibody-based reversal agent that is being formally evaluated in a Phase 3 clinical trial. Here, we probe the knowledge, attitudes, and practice patterns of cardiac surgeons regarding their perioperative management of ticagrelor and potential application of a ticagrelor reversal agent. Methods: A questionnaire was developed by a working group of cardiac surgeons to inquire into participants’ practices and beliefs regarding ticagrelor and disseminated to practicing Canadian cardiac surgeons. Results: A total of 70 Canadian cardiac surgeons participated. Bleeding risk was identified as the most significant consideration when surgically revascularizing ticagrelor-treated patients (90%). There is variability in the duration of withholding ticagrelor prior to coronary artery bypass graft procedure in a stable patient; 44.3% wait 3 days and 32.9% wait 4 days or longer. Currently, 14.3% of cardiac surgeons prophylactically give platelet transfusions and/or fresh frozen plasma intraoperatively following protamine infusion in patients who have recently received ticagrelor. Interestingly, 47.1% of surveyed surgeons were aware of a reversal agent for ticagrelor, 91.4% of cardiac surgeons would consider utilizing a ticagrelor reversal agent if available, and 51.4% acknowledged that the introduction of such an agent would be a major advance in clinical practice. Conclusions: The present survey identified ticagrelor-related bleeding as a major concern for cardiac surgeons. Surgeons recognized the significant unmet need that a ticagrelor reversal agent would address.

In recent years, the use of bioprosthetic valve (BPV) has increased significantly with both surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) due to reasons such as the advantage of not using anticoagulants. Nevertheless major disadvantage of all BPV is the risk of early structural valve deterioration, leading to valve dysfunction, and requires reoperation, which significantly increases the risk of mortality or major morbidity especially after SAVR. There are a limited number of TAV-in-TAV case reports due to TAVI BPV degeneration. In our knowledge this is the second report of TAV-in-TAV implantation wherein a previously implanted transfemoral 25-mm nonmetallic Direct Flow SVD valve treated with ViV TAVI via Edwards Sapien XT.

Objective: Although elderly patients undergoing surgery for acute type A aortic dissection (ATAAD) is increasing, their physical activities are not fully understood. We report the physical activities and surgical outcomes in the elderly patients who underwent ATAAD. Methods: From 2009 to 2019, 103 consecutive patients underwent surgery for ATAAD at our institution. Surgical outcomes along with pre- and postoperative physical activities in 52 elderly patients (≥70 years old) were compared with those in 51 younger patients (<70 years old). Postoperative walking difficulty was defined as taking ≥30 days to regain the ability to walk 200 m postoperatively or as the inability to walk at discharge. Results: It took longer for elderly patients to regain the ability to walk 100 or 200 m postoperatively. ROC analysis revealed the AUC of the duration for walking 200 m postoperatively as a prognostic indicator for late deaths was 0.878, with the highest accuracy at 30 days (sensitivity = 83.3%, specificity = 91.8%). Hospital mortality within 30 days was 3.8%, and 1-, 3-, and 5-years survival rates were 92%, 84.7%, 84.7%, respectively, for elderly patients, with no significant differences between groups. Cox proportional hazard analysis showed postoperative walking difficulty was an independent risk factor for late mortality in all cohorts (P = 0.017). Conclusions: Elderly patients undergoing surgical ATAAD repair showed acceptable surgical outcomes. However, they were more likely to decrease their physical activities postoperatively. Postoperative difficulty in walking was an independent risk factor for the late mortality in patients with ATAAD.

Background. We sought to determine the relationship between tricuspid right ventricular (RV) and tricuspid valve (TV) remodeling and late failure of tricuspid annuloplasty. Methods. From May 2009 to December 2015, 423 patients undergoing tricuspid annuloplasty (TA) for functional TR at a single were analyzed. Residual TR was defined TR moderate-or-more at discharge. Recurrent TR was defined TR-moderate-or-more at follow up. RV remodeling was defined RV dysfunction and/or dilatation. Results. Residual TR after TA was recorded in 54. Five-year freedom from TR recurrence was 86.3±2.3% for patients without residual TR vs 57.6±7.6% for patients with residual TR, p<0.001. Evaluating late results of 369 patients without residual TR, following risk factors were identified: preoperative pulmonary pressure, pre RV remodeling, pre TR and TV remodeling, functional mitral regurgitation. Conclusions. Prophylactic tricuspid annuloplasty should be encouraged among surgeons. TA at the time of left-sided valve surgery should take into consideration not only annular size, but also tethering severity and RV remodeling.

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

Multi-disciplinary teams present the framework in the increasingly challenging care provided for patients. Wang et al. present a 37 year old female who is 35 weeks pregnant when a rare cardiac angiosarcoma is diagnosed.

Background: Transplant patients are known to be at increased risk of developing de novo malignancies (DNM). As heart transplant survival has increased, DNM represent an obstacle to further improving survival. We sought to examine the incidence, risk factors, and prognostic factors of post-transplant DNM. Methods: We studied adult heart transplant recipients from the Organ Procurement and Transplantation Network database (1987-2018). Kaplan-Meier survival analysis was performed to determine annual probabilities of developing DNM, excluding squamous and basal cell carcinoma. Rates were compared to the general population in the Surveillance, Epidemiology, and End Results database. Cox proportional hazards regression was performed to calculate hazard ratios for risk factors of DNM development, all-cause, and cancer-specific mortality. Results: Over median follow-up of 6.9 years, 18% of the 49,361 patients developed DNM, which correlated with an incidence rate 3.8 times that of the general population. The most common malignancies were lung, post-transplant lymphoproliferative disorder, and prostate. Risk was most increased for female genital, tongue/throat, and renal cancers. Male gender, older age, smoking history, and impaired renal function were risk factors for developing DNM, whereas the use of MMF for immunosuppression was protective. Cigarette use, increasing age, the use of ATG for induction and calcineurin inhibitors for maintenance were risk factors for cancer-specific mortality. The development of a DNM increased the risk of death by 40% (p<0.001). Conclusions: Heart transplant patients are at increased risk of malignancy post-transplant, particularly rare cancers. Strict cancer surveillance and attention to immunosuppressive regimens are critical for further prolonging post-transplant survival.

Machine learning and artificial intelligence (AI) in medicine has arrived in medicine and the healthcare community is experiencing significant growth in its adoption across numerous patient care settings. There are countless applications for machine learning and AI in medicine ranging from patient outcome prediction, to clinical decision support, to predicting future patient therapeutic setpoints. This commentary discusses a recent application leveraging machine learning to predict one year patient survival following orthotopic heart transplantation. This modeling approach has significant implications in terms of improving clinical decision making, patient counseling, and ultimately organ allocation and has been shown to significantly outperform preexisting algorithms. This commentary also discusses how adoption and advancement of this modeling approach in the future can provide increased personalization of patient care. The continued expansion of information systems and growth of electronic patient data sources in healthcare will continue to pave the way for increased use and adoption of data science in medicine. Personalized medicine has been a long-standing goal of the healthcare community and with machine learning and AI now being continually incorporated into clinical settings and practice, this technology is well on the pathway to make a considerable impact to greatly improve patient care in the near future.

BACKGROUND: COVID-19 has significantly impacted the healthcare landscape in the United States in a variety of ways including a nation-wide reduction in operative volume. The impact of COVID-19 on the availability of donor organs and the impact on solid organ transplant remains unclear. We examine the impact of COVID-19 on a single, large-volume heart transplant program. METHODS: A retrospective chart review was performed examining all adult heart transplants performed at a single institution between March 2020 and June 2020. This was compared to the same time frame in 2019. We examined incidence of primary graft dysfunction (PGD), continuous renal replacement therapy (CRRT) and 30-day survival. RESULTS: From March-June 2020, 43 orthotopic heart transplants were performed compared to 31 performed during 2019. Donor and recipient demographics demonstrated no differences. There was no difference in 30-day survival. There was a statistically significant difference in incidence of post-operative CRRT (9/31 v. 3/43; p = .01). There was a statistically significant difference in race (23W/8B/1AA v. 30W/13B; P=.029). CONCLUSION: We demonstrate that a single, large-volume transplant program was able to grow volume with little difference in donor variables and clinical outcomes following transplant. While multiple reasons are possible, most likely the reduction of volume at other programs allowed us to utilize organs to which we would not have previously had access. More significantly, our growth in volume was coupled with no instances of COVID-19 infection or transmission amongst patients or staff due to an aggressive testing and surveillance program.

during Ozaki procedure, relocating a valvular commisure could be technically demanding. This novel technique provides an easy tool to achieve valvular simmetry avoiding commisure shifting.

The importance of del nido cardioplegia solution in coronary artery bypass surgeryMehmet Senel Bademcia MD, Cemal Kocaaslana MD Fatih Avni BayraktaraMD, Ahmet Oztekina MD, Huseyin Bilal Aydina MD, and Ebuzer Aydin a MD.a Istanbul Medeniyet University, Medicine Faculty, Department of Cardiovascular Surgery, Istanbul, TurkeyCorresponding Author: Mehmet Senel Bademci,M.D, Assist.Prof.Post Publication Corresponding Author: Mehmet Senel Bademci,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 by Algarni [1] published entitled “Routine use of del Nido cardioplegia compared with blood cardioplegia in all types of adult cardiac surgery procedures.” Algarni KD. Routine use of del Nido cardioplegia compared with blood cardioplegia in all types of adult cardiac surgery procedures. J Card Surg. 2020;10.1111/jocs.15060In this study; Del Nido cardioplegia group has shorter aortic cross-clamp time for coronary artery by pass graft patients. But there is no sufficient data about the number of distal anastomosis between cardioplegia groups. If there is a significant difference between groups, this answer can change the aortic cross clamp times regardless of cardioplegia.We congratulate Algarni et al. for their valuable manuscript about cardioplegia solutions in coronary artery bypass surgery. We would like to hear authors’ opinion on this matter.References:1. Algarni KD. Routine use of del Nido cardioplegia compared with blood cardioplegia in all types of adult cardiac surgery procedures. J Card Surg. 2020;10.1111/jocs.15060.

Cerebrovascular Accidents represent a dangerous complication of cyanotic children with tetralogy of fallot with incidence of 8.6%.Tetralogy of Fallot has been associated with raised haematocrit with low arterial Saturation. Here we describe an 18 months old female child of Tetralogy of Fallot with Cyanotic spells acute onset right sided hemiplegia with Right Atrial thrombus who underwent emergency surgery with intraoperative predicament.

The recognition of fibrinolysis phenotypes in trauma patients has led to a reevaluation of antifibrinolytic therapy (AF). Many cardiac patients also receive AF, however the distribution of fibrinolytic phenotypes in that population is unknown. The purpose of this study was to fill that gap. Methods: Data were retrospectively reviewed from 78 cardiac surgery patients. Phenotypes were defined as hypofibrinolytic (LY30 <0.8%), physiologic (LY30 0.8-3.0%) and hyperfibrinolytic (LY30 >3%). Continuous variables were expressed as M ± SD or median (interquartile range). Results: The study population was 65±10 yrs old, 74% male, average body mass index of 29±5 kg/m2. Fibrinolytic phenotypes were distributed as physiologic=45%, hypo=32% and hyper = 23%. There was no obvious effect of age, gender, race, or ethnicity on the distribution of fibrinolysis phenotypes; 47% received AF. The time with chest tube during post-operative recovery was longer in those who received AF (4[3,5] days) vs no AF (3[2,4] days), P=0.037). All cause morbidity occurred in 51% of patients who received AF vs 25% with no AF (p=0.017). However, with AF vs no AF, apparent differences in median chest tube output (1379 vs 820ml, p=0.075), hospital LOS (13 vs 10 days, P=0.873), estimated blood loss (1100 vs 775 ml, P=0.127), units of transfused RBCs (4 vs 2], P=0.152) or all-cause mortality (5.4% [2/37] vs 10% [4/41], P=0.518) were not statistically significant. Conclusion: This is the first description of three distinctly different fibrinolytic phenotypes in cardiac surgery patients. In this population, the use of AF was associated with increased morbidity.

We reported a case of a 53-year-old patient with coarctation of aorta and multiple aneurysmatic changes on aortic arch. Enhanced CT and reconstruction revealed significant coarctation and multiple aneurysmatic dilatation. The patient underwent stent implantation and was discharged with symptoms relived. Follow-up examination progression of aneurysms, however, without symptoms.

Title pageTitle : Letter to the Editor: Percardiac closure of large apical ventricular septal defects in infants: Novel modifications and mid-term results

Background: Transannular patch, which results pulmonary insufficiency (PI), is usually required during repair of Tetralogy of Fallot (TOF). In this study, we compared 3 types of pulmonary valve reconstruction techniques during transannular repair of TOF. Methods: Between February 2014 and January 2018, 50 patients with TOF underwent total repair with transannular patch. These patients were divided into three groups. In group 1, (n= 15), a single gluteraldehyde treated autologous pericardial monocusp (standard method) was reconstructed. In group 2, (n= 16) Nunn’s bileaflet pulmonary valve reconstruction technique was used with autologous pericardial patch. In group 3, (n= 19), Nunn’s bileaflet technique was performed with expanded polytetrafluoroethylene (e-PTFE) membrane. Outcomes of the patients with early and mid-term competency of the pulmonary valves were analyzed. Results: All three pulmonary valve reconstruction techniques were significantly effective in early postoperative period. Freedom from moderate to severe PI were 73.3%; 100% and 89.4% respectively. Mortality, duration of intensive care unit and hospital stay were similar between the groups. The mean follow-up period was 17.5±13.0 (3 to 57) months. Freedom from moderate to severe PI decreased to 40%; 81.2% and 73.7% respectively at the end of the follow-up period. Presence of moderate to severe PI was significantly higher in group 1 (p: 0,018 between group 1 and 2, p: 0,048 between group 1 and grup 3). Conclusions: All three pulmonary valve reconstruction techniques provided competent pulmonary valves. Nunn’s bileaflet technique had better outcome at midterm. This technique has a potential to delay right ventricular dysfunction at long-term.

We describe a case of frozen elephant trunk deployment unintentionally malpositioned into the false lumen. An 83-year-old man underwent total arch repair with a frozen elephant trunk for type A acute aortic dissection complicated by mesenteric malperfusion. However, intraoperative transesophageal echocardiography showed expansion of the false lumen in the descending aorta, suggesting a malpositioned frozen elephant trunk into the false lumen. Endovascular fenestration of the dissecting flap and subsequent endograft deployment from the inside of the malpositioned frozen elephant trunk graft to the true lumen of the descending aorta was successfully performed under intravascular ultrasound guidance.

COVID-19: The heart of the issue Beth Woodward BMedSc (Hons)1, Muhammed Kermali2College of Medical and Dental Sciences, University of Birmingham, Birmingham, UKSt. George’s, University of London, London, UKCorresponding author:Beth WoodwardBMedSc (Hons)College of Medical and Dental SciencesUniversity of BirminghamBirmingham, UKe-mail: [email protected]: 07947766140Funding: none obtainedConflict of Interest: none to be declaredKey words: COVID-19, angiotensin, ACEiBW and MK contributed equally.