Although mid- and long-term outcomes after the Ross procedure for aortic valve disease have been increasingly improving over the years, this is still a rather challenging operation in neonates and small children. This is particularly true for patients with associated congenital heart defects and critical clinical conditions. Herein we describe the application of this procedure as a rescue operation in emergency circumstances in a low-birth-weight neonate with severe aortic stenosis, aortic regurgitation and mitral regurgitation after a previous aortic coartectomy.

Outcomes of operations for total anomalous pulmonary venous connection (TAPVC) have improved.However, postoperative pulmonary venous obstruction (PVO) remains the most significant complication, with high morbidity and mortality. We introduce a window anastomosis technique for repair of supracardiac TAPVC in infants. The mainstay of the surgical technique is to resect the anterior wall of the pulmonary vein confluence(PVC) and part of the posterior wall of the left atrium to form a large and undistorted “window to window” anastomosis.

A 60-year-old male presented with sudden onset chest pain and pulmonary oedema. Investigation confirmed torrential aortic regurgitation of a bicuspid valve. At surgery a ruptured chordae tendineae was identified which had been supporting the left-right cusp commissure with loss of attachment to the aortic wall. This case demonstrates that chordae tendineae may be present as a supporting structure of the aortic valve, and rupture can be a rare cause of torrential aortic regurgitation, similar in pathogenesis to how it may be associated with acute severe mitral regurgitation.

In this issue, Zhao et al. investigate the effects of subclinical hypothyroidism in coronary bypass grafting particularly with respect to the incidence of atrial fibrillation. While not the first of its kind, the authors analyze this controversial topic in a well powered, statistically comprehensive manner that furthers our understanding of the effects of SCH in CABG patients.

Surgical implantation of a complete or incomplete ring to reduce the valve annulus and improve leaflet coaptation is the mainstay of mitral valve surgery. The Cardioband® system (Edwards Lifesciences, Irvine, CA, USA) was designed to address the pathophysiological mechanism of annular dilatation through a catheter-based approach. We present the histopathological workup of a Cardioband® device, which had been implanted 21 months earlier in a 34-year-old male with ischemic cardiomyopathy. Device examination demonstrate a well-positioned and securely anchored device. The described tissue reactions may have an impact on choice of device and timing in case of re-do surgery.

Radiologic evidence of aortic disease is not always consistent with the diagnosis. With lack of accompanying symptoms or with an atypical presentation, diagnosis of aortic pathology relies greatly on imaging techniques. We report the case of a 58 year-old female who presented with incidental radiographic findings consistent with a type A aortic intramural hematoma and a vague left-sided chest discomfort. After follow-up imaging was consistent with disease progression and hematoma expansion, the affected segment was resected and pathology reported lymphoplasmacytic aortitis as the underlying etiology of the imaging findings rather than an intramural hematoma. The patient lacked symptoms or serology consistent with rheumatologic disease and the postoperative course was uneventful. The management of a suspected ascending intramural hematoma is controversial, especially when the patient presents with atypical signs and symptoms. Features of disease progression may warrant urgent surgical intervention.

Objectives We aimed to summarize the clinical presentations, therapeutic approaches, and outcomes of type B intramural hematoma (IMHB) patients with and without type 2 diabetes mellitus (DM). Methods Patients with uncomplicated IMHBs were included between January 2016 and January 2018 and divided into two groups according to whether or not they had DM. Cox proportional hazard analysis was utilized to investigate the risk factors for aortic-related mortality. Kaplan-Meier survival analysis was used to estimate cumulative mortality and aortic-related mortality. Results A total of 149 patients were included and were divided into the two groups (DM group [n=60] and non-DM group [n=89]). Patients in the non-DM group underwent thoracic endovascular aortic repair treatment more frequently (12% vs 2%, P=0.028) and had a higher reintervention rate during the follow-up (9 in 81 patients, 11% vs 2%, P=0.043). There were significant differences between the two groups regarding the aorta-related mortality rate during the acute phase (9% vs 0%, P=0.042) and the all-cause mortality rate (22% vs 7%, P=0.011). Ulcer-like projection (ULP) development (during the acute phase) (hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.01-1.31, P=0.008), C-reactive protein (CRP) levels (HR, 1.92; 95% CI, 1.51-2.49, P<0.001) and MMP-9 levels (HR, 16.82; 95% CI, 7.52-28.71, P<0.001) were associated with an elevated risk for aorta-related mortality. Conclusions IMHBs without DM are not benign and have a considerably high aortic-related mortality rate. ULP development (during the acute phase), CRP levels and maximum MMP-9 levels are associated with an elevated risk for aorta-related mortality.

Title pageTitle : Letter to the Editor: Long-term results of aortic root replacement for endocarditisArticle type : Letter to the editor

Background: Complex cardiac operations may have better outcomes when performed by mid-career surgeons compared with surgeons in early or late stages of their career. However, it is unknown how cardiac case complexities are distributed among surgeons of different experience levels. Methods: We performed a cross-sectional study using New York (NY) and California (CA) statewide surgeon-level coronary artery bypass grafting (CABG) outcome data, including 336 cardiac surgeons who performed 43,604 CABGs. Surgeon-level data including observed mortality rate (OMR) and expected mortality rates (EMR) was collected from 2014-2016 in NY and 2015-2016 in CA. Surgeons’ number of years-in-practice was determined by searching for each surgeon’s training history on online registries. Loess and linear regression models were then used to characterize the relationship between surgeon EMR and surgeon years-in-practice. Results: The median number of surgeon years-in-practice was 20 (interquartile range [IQR] 11-28) with median case volume 103 (IQR 42,171). The median surgeon observed to expected mortality (O:E) ratio was 0.87 (IQR 0.19-1.4). Linear regression relating EMR to years in practice showed that EMR was similar across years in practice. Linear regression relating surgeon isolated CABG O:E ratio to years in practice also showed similar outcomes across years in practice. Conclusion: There is a relatively equal distribution of high and low risk CABG cases among surgeons of differing experience levels. This equal distribution of high and low risk cases does not reflect a triaging of more complex cases to more experienced cardiac surgeons, which prior research shows may optimize patient outcomes.

Tricuspid and pulmonary valve replacement in patients with carcinoid heart disease (CaHD) reduces right heart failure and improves prognosis. The surgical literature is limited concerning technical aspects of valve replacement in CaHD. Although dedicated multidisciplinary care is required, optimization of surgical details is important and may lead to better postoperative outcomes in these frail patients.

Objective.As aneurysm related events and rupture is not eliminated, postoperative lifelong surveillance is mandatory after endovascular aneurysm repair(EVAR).For surveillance colored Doppler ultrasound(CDUS) is a standard method of noninvasive evaluation having the advantages of availability, cost-effectiveness and lack of nephrotoxicity and radiation.We evaluated CDUS for primary surveillance tool after elective EVAR by comparing with computerized tomography. Methods.Between 2018-2020, 84 consecutive post-EVAR patients were evaluated.Firstly, CDUS was performed by two Doppler operators from the Radiology and computed tomographic angiography (CTA) was performed.A reporting protocol was organized for endoleak detection and largest aneurysm diameter. Results.Among 84 patients, there were 11 detected endoleaks(13,1%) with CTA and 7 of them was detected with CDUS (r=0,884,p<0.001).There is an insufficiency in detecting low flow by CDUS.Eliminating this frailty, there was a strong correlation of aneurysm sac diameter measurement between CTA and CDUS (r=0,777,p<0,001).The sensitivity and specificity of CDUS was 63,6% and 100% respectively.The accuracy was 95,2%.Positive and negative predictive values were 100% and 94,8%.Bland-Altman analysis and linear regression analysis showed no proportional bias (mean difference of 1.5±2.2mm,p=0.233). Conclusions.CDUS promises accurate results without missing any potential complication requiring intervention as Type I or III endoleak.Lack of detecting type II endoleaks may be negligible as sac enlargement was the key for reintervention in this situation and CDUS has a remarkably high correlation with CTA in sac diameter measurement. CDUS may be a primary surveillance tool for EVAR and CTA will be reserved in case of aneurysm sac enlargement,detection of an endoleak,inadequate CDUS or in case of unexplained abdominal symptomatology

Cardiac haemangiomas are rare entities and very few cases have been reported where they originate from the main arteries of the heart. We present a case of haemangioma arising from the main PA, which was completely resected with clear margins on the beating heart.

Objectives: Short-term outcomes for those with a prolonged length of stay (LOS) in intensive care (ITU) following cardiac surgery are poor, with higher rates of in-hospital mortality and morbidity. Consequently, discharge from hospital has been considered the key measure of success. However, there has been a shift towards long-term outcomes, functional recovery and quality of life (QoL) as measures of surgical quality. The aim of this review is to compare and critique the findings of multiple studies in order to determine the long-term effects of prolonged ITU stay post-cardiac surgery. Methods: A computerised literature search of CINAHL, EMBASE and Google Scholar databases, based on keywords ‘long-term effects’; ‘prolonged ITU stay’; ‘cardiac surgery’, with rigorous CASP critique, was undertaken. Results: The search yielded 12 papers meeting the inclusion criteria, with eight retrospective and four prospective studies. Eight of these 12 papers identified inferior long-term survival or higher mortality rates for those who had prolonged LOS in ITU in comparison to ‘normal’ LOS or a control. The greatest burden of mortality was six months to one year post-discharge. Three papers found that quality of life was adversely affected or worse for those who had experienced prolonged LOS in ITU. Conclusions: Further research is required to provide better quality evidence into QoL, following prolonged stay in ICU post cardiac surgery. The evidence reviewed suggests that the risk of mortality in this demographic of patients is higher, especially within the first year and, therefore, more frequent medical surveillance of these patients is recommended.

A 75 years old man with previous aortic abdominal aneurysm surgery through a transverse laparotomy underwent bilateral internal mammary artery (BIMA) to coronary artery bypass grafting (CABG). He immediately thereafter developed a severe chest and upper abdominal walls ischemia with metabolic acidosis, and finally deep sternum wound infection and upper abdominal wall necrosis. He benefitted from sternal reconstruction and vaccum assisted treatment, with delayed pectus major flap reconstruction. Chest and abdominal wall infarction following BIMA harvesting is a very rare but life-threatening complication. Caution use of BIMA should be in order in patients with inferior epigastric artery flow impairment.

The authors of “Outcomes of truncus arteriosus repair and predictors of mortality” carried out a retrospective analysis of more than 3000 infants with truncus arteriosus using the National Inpatient Sample dataset of the Healthcare Cost and Utilization Project database. Logistic regression was used to identify factors associated with in-hospital mortality. The authors also identified a seemingly protective effect of 22q11.2 deletion. But do these findings offer a complete understanding of surgical risk factors for patients with truncus arteriosus?

Background: Atrial fibrillation (AF) is common in patients with reduced left ventricle ejection fraction (RLVEF). The impact of concomitant surgical atrial fibrillation ablation (SAFA) in patients with RLVEF is uncertain. The purpose of this study was to assess the outcomes of concomitant SAFA in patients with RLVEF undergoing heart surgery on heart failure (HF) rehospitalization and mortality. Methods: Using a local registry and electronic health records linked with provincial civil register survival data from July 2002 to April 2019, we analyzed treatment and outcomes in a cohort of patients with AF and HF defined by left ventricle ejection fraction (LVEF) ≤ 40%. Health records were used to collect treatment and International Classification of Diseases (ICD 10) codes to determine outcomes. A negative binomial model was used to compare outcomes such as all-cause mortality and rehospitalization for heart failure. Results: The cohort included 682 patients with RLVEF and AF who underwent coronary artery bypass graft and/or valve surgery. A total of 196 patients (29%) underwent concomitant SAFA. After matching, 132 patients with concomitant SAFA were compared to 159 patients who did not undergo concomitant SAFA. At 6.0±3.7 years of follow-up, concomitant SAFA was not associated with lower all-cause mortality (P=0.9861) and reduction in rehospitalizations for heart failure decompensation (P=0.31) compared to patients who did not have concomitant SAFA performed. Post-operatively, concomitant SAFA might be associated with less vasopressor and mechanical support use (p=0.01). Conclusions: Concomitant SAFA during index cardiac surgery is safe but does not reduce mortality or rehospitalizations for HF. The effects of concomitant SAFA in the context of RLVEF needs to be better studied with prospective trials.

Here we report the seven-year long-term survival after Aspergillus fumigatus mediastinitis after heart transplantation, an uncommonly described condition. A 66-year-old male developed infection with A. fumigatus covering the entire thoracic cavity with a fungal turf after orthotopic heart transplantation. Repeated surgical removal of infectious and necrotic tissue together with innovative topical treatment using voriconazole and chlorhexidine combined with systemic antifungal treatment lead to control of infection. Definitive wound closure was achieved by standard sternal refixation and latissimus dorsi muscle flap plasty. Survival after A. fumigatus mediastinitis after heart transplantation was achieved with sequential debridement in combination with topical application of antifungal agents.

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.