A document by Sebastian Velasteguí. Click on the document to view its contents.

Much has changed since the introduction of surgical valve repair in the 1950s, from the introduction bioprosthetic valves to percutaneous approaches to valve repair. Yet, despite substantial advancements in bioprosthetic valve technology, there has been a lack of direct, independent comparison between bioprosthetic mitral valve devices, accompanied by a marked heterogeneity in approaches to the sizing and selection thereof. Wang et al. have hence endeavoured to evaluate, head-to-head, the technical successes and biomechanical outcomes associated with three different bioprosthetic mitral valves (Epic, Abbott, IL; Mosaic, Medtronic, MN; Mitris Resilia, Edwards Lifesciences, CA) in a porcine model, under standardised haemodynamic and anatomical conditions. With a robust experimental technique, they have made clear the heterogeneity in both sizing and biomechanical properties between bioprosthetic mitral valves, and have further emphasised the need for a uniform approach to the manufacturing and sizing of bioprosthetic valves.

Objective: This study aimed to establish a risk assessment model to predict postoperative severe acute lung injury (ALI) risk in patients with acute type A aortic dissection (ATAAD). Methods: Consecutive patients with ATAAD admitted to our hospital were included in this retrospective assessment and placed in the postoperative severe ALI and non-severe ALI groups based on the presence or absence of ALI within 72 h postoperatively (oxygen index (OI) ≤100 mmHg). Patients were then randomly divided into training and validation groups in a ratio of 8:2. Logistic regression analyses were used to statistically assess data and establish the prediction model. The prediction model’s effectiveness was evaluated via tenfold cross-validation of the validation group to facilitate construction of a nomogram. Results: After screening, 479 patients were included in the study: 132 (27.5%) in the postoperative severe ALI group and 347 (72.5%) in the postoperative non-severe ALI group. Based on logistics regression analyses, the following variables were included in the model: coronary heart disease (CHD), cardiopulmonary bypass (CPB) ≥257.5 min, left atrium (LA) diameter ≥35.5 mm, hemoglobin ≤139.5 g/L, preCPB OI ≤100 mmHg, intensive care unit (ICU) OI ≤100 mmHg, left ventricular posterior wall thickness (LVPWT) ≥10.5 mm, and neutrophilic granulocyte percentage (NEUT) ≥0.824. The area under the receiver operating characteristic (ROC) curve of the modeling group was 0.805, and differences between observed and predicted values were not deemed statistically significant via the Hosmer–Lemeshow test (χ2=6.037, df=8, P=0.643). For the validation group, the area under the ROC curve was 0.778, and observed and predicted value differences were insignificant when assessed using the Hosmer–Lemeshow test (χ 2=3.3782, df=7; P=0.848). The average tenfold cross-validation score was 0.756. Conclusions: This study established a prediction model and developed a nomogram to determine the risk of postoperative severe ALI after ATAAD. Variables used in the model were easy to obtain clinically and the effectiveness of the model was good.

Background: Left ventricular assist devices have been a significant development in the treatment of patients with advanced heart failure supporting circulation as a bridge to transplant, recovery or long-term destination therapy. When ventricular recovery occurs, there are multiple described ways of proceeding. HM2 decommissions are well described with varying degrees of explant operations, less so in HM3 due to the novelty of the device. In certain situations, invasive surgery can carry high risk and so a minimally invasive decommission, leaving the LVAD essentially intact in situ can be considered. Case report In this report, we describe the case of a 35-year-old male diagnosed with an idiopathic dilated cardiomyopathy requiring an LVAD with subsequent identification of cardiac recovery with the asymptomatic thrombosis of the 2 nd HM3 device. Investigations demonstrated absent flow through the pump whilst the patient-reported NYHA I functional class symptoms. The Driveline was cut with the remaining internal pump components decommissioned and left in situ. At 1 year the patient continues to do well with continued features of cardiac recovery with an LVEF of over 40%. Conclusion LV recovery is well recognized with typical management being LVAD explant surgeries performed. Each case should be analyzed for risks and benefits to the patient and future research showed be directed towards levels of decommissioning surgery and management post-LVAD decommission patient care.

- The Gerbode type of ventricular septal defect is rare and can be congenital or acquired. - The defect can be closed retrograde or through the transvenous approach. - Short term follow-up suggests that transcatheter closure of the Gerbode type defect is feasible, safe, and effective and should be considered an alternative to surgical repair

Primary cardiac leiomyosarcoma is not common but is lethal. Prompt surgery is mandatory for identifying the etiology while a comprehensive examination of pathology is crucial especially in the condition of two tumors with different etiologies. A 52-year-old man with medical history of systemic hypertension presented with chest discomfort and dyspnea. Echocardiography revealed the dilated right ventricle with a mass at right ventricular outlet tract (RVOT) (Figure 1A). It caused critical obstruction and resulted in severely pulmonary hypertension (estimated pulmonary systolic pressure up to 108mmHg). Cardiac magnetic resonance imaging confirmed a heterogeneous mass at RVOT with a high-intensity in T2 weighted image but failed to differentiate whether it is myxoma, metastasis or primary cardiac malignancy (Figure 1B). Given the exacerbating dyspnea, he received a prompt surgery which identified two tumors. One in the size of 9*4 cm originated from the RV dome extending to RVOT and pulmonary artery. The other smaller one (5*3 cm) mainly located within the RV (Figure 1C). The surgeon excised the smaller one for the frozen section while the immediate pathology reported that it was a benign lesion. Both tumors were removed. Surprisingly, post the operation the final pathology revealed that despite one tumor of benign degenerative tissues, the other of rare cardiac leiomyosarcoma at T1 stage. Immunohistochemical staining showed positive for smooth muscle actin and h-Caldesmon which is specific for leiomyosarcoma (Figure 1D). The patient subsequently received chemotherapies of Doxorubicin 75mg/m2 for 4 cycles.

Objective: Valve-sparing root replacement is commonly used for management of aortic root aneurysms in elective setting, but its technical complexity hinders its broader adoption for acute Type-A Aortic Dissection (ATAAD). The Florida Sleeve (FS) procedure is a simplified form of valve sparing aortic root reconstruction that does not require coronary reimplantation. Here, we present our outcomes of the Florida Sleeve (FS) repair in patients with dilated roots in the setting of an ATAAD. Methods: We retrospectively reviewed 24 consecutive patients (2002-2018) treated with FS procedure for ATAAD. Demographic, operative, and postoperative outcomes were queried from our institutional database. Long term follow-up was obtained from clinic visits for local patients, and with telephone and telehealth measures otherwise. Results: Mean age was 49 ± 14 years with 19 (79%) males. Marfan syndrome was present in 4 (16.7%) patients and 14 (58.3) had ≥2+ aortic insufficiency (AI). Nine (37.2%) had preoperative mal-perfusion or shock. The FS was combined with hemi-arch replacement in 15 (62.5%) patients and a zone-2 arch replacement in 9 (37.5%) patients. There were 2 (8.3%) early postoperative mortalities. Median follow-up period was 46 months (range; 0.3-146). The median survival of the entire cohort was 143.4 months. One patient (4.2%) required redo aortic valve replacement for unrelated aortic valve endocarditis at 30 months postoperatively. Conclusion: FS is simplified and reproducible valve-sparing root repair. In appropriate patients, it can be applied safely in acute Stanford type-A aortic dissection with excellent early and long-term results.

A document by Andrea Amabile. Click on the document to view its contents.

A document by Bilawal Nadeem. Click on the document to view its contents.

Objectives: Though guidelines are set by the American Board of Thoracic Surgery for the operative cases that cardiothoracic surgery residents must perform to be board-eligible, no such recommendations exist to assess competency for the wide range of high-risk bedside procedures. Our department created and implemented a multi-disciplinary developed course designed to standardize common high-risk bedside procedures and credential our residents. The aim of this study was to survey the attitudes of residents to and query the efficacy of such a course. Methods: The course was designed with the goal of standardizing endotracheal intubation, arterial line insertion (radial and femoral), central venous line insertion, pigtail tube thoracostomy and nasogastric tube placement. The course consisted of an online module followed by a 4-hour hands on simulation session. Knowledge based pre and post evaluations were administered as well as Likert based survey regarding multiple aspects of the residents’ perceptions of the course and the procedures. Results: Twenty-three (7 traditional and 16 integrated) cardiothoracic surgical residents participated in the course. Residents reported that 48% of the time, bedside procedures were historically taught by other trainees rather than faculty. All residents endorsed increased standardization of all procedures after the course. Likewise, residents showed increased confidence in all procedures except for pigtail and thoracentesis as well as nasogastric tube placement. 43.5% of the participants demonstrated improvement in the pre and post-test knowledge-based evaluations. ConclusionCardiothoracic residents have favorable attitudes towards standardization and credentialing for high risk bedside procedures and utilizing such courses may help standardize procedural techniques.

The coronavirus disease 19 (COVID-19) pandemic has resulted in widespread economic, health and social disruptions. The delivery of cardiovascular care has been stifled during the pandemic in order to adhere to infection control measures as a way of protecting patients and the workforce at large. This cautious approach has been protective since individuals with COVID-19 and cardiovascular disease are anticipated to have poorer outcomes and an increased risk of death. The combination of postponing elective cardiovascular surgeries, reduced acute care and long-term cardiac damage directly resulting from COVID-19 will likely have increased the demand for cardiac care, particularly from patients presenting with more severe symptoms. The combination of increased demand and inhibited supply will likely result in huge backlog of unmet patients’ needs. The novelty, virulence and infectivity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused substantial morbidity and mortality which have necessitated modifications to the UK government’s healthcare strategy. Without improving cost efficiency, the UK’s ageing population will likely need an increasing spend on cardiac surgery simply to maintain the same level of service. However, the government’s short-term increase in spending is unsustainable especially in the face of ongoing economic uncertainty. This means that the long-term impact of COVID-19 will only increase the need to find innovative ways of delivering equivalent or superior cardiac care at a reduced unit cost.

Objective Functional tricuspid regurgitation(FTR) levels can vary over time and its longitudinal changing patterns may predict right ventricular dysfunction(RVD) risk. We aim to identify different trajectories of FTR in those who received mitral valve replacement(MVR) and investigate the association between longitudinal trajectory groups and RVD risk in a cohort study. Methods and results A prospective cohort study, reported usual FTR levels at baseline in 2005–2015 and the participants of MVR have been followed up for 5~6 years, approximately every one years, and so far, the data have been collected across five subsequent phases. Five-year longitudinal trajectories of FTR were identified using group-based trajectory modelling(GBTM). We identified 3 distinct trajectories using a GBTM, labeled by initial value and changing pattern: stable group(258/378, 68.2%), increasing-slow group(67/378, 17.6%) and increasing-fast group(53/378, 14.2%). Treating the stable group as the reference, the age- and sex-adjusted odds ratio(OR) was 25.84 (95% confidence interval, 11.78-56.65) for the increasing-slow group and 139.94(95% confidence interval, 45.47-430.68) for the increasing-fast group by logistic regression model. After adjustment for every potential confounding factors, the OR is 14.21(95% confidence interval, 4.36-46.33)、49.34(95% confidence interval, 8.88-273.87) respectively. Conclusions The longitudinal trajectories of worsening FTR were mostly associated with increased risk of RVD outcomes, which is independent of other factors including FTR levels. These findings have implications for intervention and prevention of RVD among individuals who received MVR.

Background. To share the results of a web-based expert panel discussion focusing on the management of acute and chronic aortic disease during the COVID-19 pandemic. Methods. A web-based expert panel discussion on April 18th 2020 where 8 experts were invited to share their current experience with COVID-19 disease touching several aspects of aortic medicine, was performed. After each talk, specific questions were asked to the online audience and results were immediately evaluated and shared with faculty and participants. Results. As of April 18 2020, 73.3% of the 87 participants from 26 different countries answered that overall less than 200 COVID positive patients have been treated in their respective institutions. Sixty-five percent reported that their hospital was well prepared for the pandemic. In 57.7 %, the percentage of infected health care professionals was below 5% whereas 23% reported 5-10% and 19.2% reported between 10 and 20%. Three percent reported to have seen aortic ruptures in primarily elective patients having been postponed because of the anticipated need to provide sufficient ICU capacity because of the pandemic. Nearly 70% reported a decrease of acute aortic syndromes since the start of the pandemic. Conclusions. The current COVID-19 pandemic has- led to a decrease of referrals of acute aortic syndromes in many services. The reluctance of patients seeking medical advice seems to be a major driver. The number of patients who have been postponed due to provisioning ICU resources but having experienced aortic rupture in the waiting period, is still low.

Background: There is limited data to inform minimum case requirements for training in robotically-assisted coronary artery bypass grafting (RA-CABG). Current recommendations rely on non-clinical endpoints and expert opinion. Objectives: To determine the minimum number of RA-CABG procedures required to achieve stable clinical outcomes. Methods: We included isolated RA-CABG in The Society of Thoracic Surgeons (STS) registry performed between 2014 and 2019 by surgeons without prior RA-CABG experience. Outcomes were approach conversion, reoperation, major morbidity or mortality, and procedural success. Case sequence number was used as a continuous variable in logistic regression with restricted cubic splines with fixed effects. Outcomes were compared between operations performed earlier versus later in case sequences using unadjusted and adjusted metrics. Results: There were 1195 cases performed by 114 surgeons. A visual inflection point occurs by a surgeon’s 10th procedure for approach conversion, major morbidity or mortality, and overall procedural success after which outcomes stabilize. There was a significant decrease in the rate of approach conversion (7.7% and 2.5%), reoperation (18.9% and 10.8%), and major morbidity or mortality (21.7% and 12.9%), as well as an increase in rate of procedural success (72.9% and 85.3%) with increasing experience between groups. In a multivariable logistic regression model case sequences of >10 was an independent predictor of decreased approach conversion (OR 0.27, 95% CI 0.09 to 0.84) and increased rate procedural success (OR 1.96, 95% CI 1.00 to 3.84).

Background: The most worrisome complications in patients supported by left ventricular assist device (LVAD) are pump thrombosis, embolism, and bleeding. The actual rate of these events in patients with sickle-cell disease (SCD) has not well investigated. The aim of our study is to evaluate the outcomes of LVAD implantation in patients with sickle-cell hemoglobinopathy at our institution. Methods: This retrospective, observational, single-center study was conducted on patients with sickle-cell trait (SCT), who underwent LVAD implantation using the HeartMate3 LVAD. Results: LVAD devices were implanted in four patients with SCT. All procedures were performed successfully. All patients had uneventful post-implant course. Overall, the mean follow-up time was 25 months (range 21-28 months) and showed an unremarkable post-implant course. There was a significant improvement in hematological markers over the follow-up period. Conclusions: Despite the limited numbers of patients enrolled in this study, our findings indicate that LVAD surgery is safe in SCD patients and offers remarkable clinical improvement. Further studies are needed to provide more evidence regarding this type of patients undergoing LVAD implantation.

Ravitch technique of chest correction has been considered, although invasive, as safe and efficacious surgical method. We describe a case of 35-year-old woman with cardiac tamponade and in cardiogenic shock due to exceptional late complication after pectus excavatum reconstruction by means of classic Ravitch technique 19 years earlier. This very late adverse event was caused by broken metal sternal wire that injured the wall of the ascending aorta. Patient underwent salvage repair of this segment of aorta in cardiopulmonary bypass. Postoperative course and post-discharge 3-year follow-up have been uneventful.

The safety of transesophageal echocardiography (TEE) probes has been documented in pediatric patients (neonates, infants, and small children even < 2.5 Kg). The overall safety profile of TEE probe is quite favourable with a reported incidence of complications is about 1-3%. However, insertion of the TEE probe can induce vagal and sympathetic reflexes such as hypertension or hypotension, non-sustained ventricular and supraventricular tachyarrhythmias or bradyarrhythmias [3rd degree heart block], and even angina and myocardial infarction. We hereby document a repeated and fatal intraoperative VF precipitated by TEE probe in a 2-year-old, 10 kg paediatric patient diagnosed with ostium secundum atrial septal defect (OS-ASD), supravalvular pulmonary stenosis (PS) and severe right ventricular (RV) dysfunction.

Concomitant presence of acute type A dissection and coactation of aorta is rare (1). Levoatriocardinal vein has shown to be associated with left sided hypoplastic lesions as well as with normal hearts (2, 3 ). However, concurrent presence of levoatriocardinal vein with acute type A dissection, severe aortic regurgitation and Coarctation of aortic isthmus was not described. We here described a case of 20 year male presented to emergency department with acute chest pain radiating to back. On evaluation, he was found to have acute type A dissection with dilated aortic root, severe aortic regurgitation, normal mitral valve, severe coarctation of aorta and levoatriocardinal vein. Patient was managed successfully with composite valve conduit replacement of ascending aorta with ascending aortic to descending aortic graft (16mm graft) with levoatriocardinal vein ligation.