Background The European CE Mark approval study and the MOMENTUM 3 trial demonstrated safety and a reduction in hemocompatibility-related adverse events with use of HeartMate 3 (HM3) device. This single center study investigated the real-world experience in HM3 patients since FDA approval. Methods This retrospective, observational study included patients implanted with the HM3 LVAD as a primary implant between October 2017-March 2020. Patients were divided into trial group and postapproval group. Primary endpoint was survival at 6 months. Secondary endpoints were adverse events including pump thrombosis (requiring pump exchange), stroke, renal failure, acute limb ischemia, re-exploratory for bleeding, gastrointestinal bleeding, right ventricular failure, and driveline infection. Results A total of 189 patients were implanted with HM3 device during the study period. 174 patients met the inclusion criteria: 82 patients in the trial group and 92 patients in the postapproval group. The postapproval group had younger patients, higher pre-operative mean international normalized ratio, and greater numbers of patients with bridge to transplant (BTT) indications, IINTERMACS profile 1, and use of mechanical assist devices (other than IABP) than the trial group. Other characteristics between the two groups were comparable. Overall survival at 6 months in the postapproval group was 93.3% vs. 93.8% ( p=0.88). The postapproval group demonstrated a statistically significant lower incidence of re-explorative surgery for bleeding (10.9% vs 46.3,  p=0.01) than the trial group. Conclusion In this single-center study, the real-world 6-month survival in the postapproval group was comparable to the trial results. Further studies are needed to monitor long-term outcomes.

“Letter to the Editor: Cardiac Surgery in patients with atrial isomerism : Long-term results and outcomes.”Dr Sara AhmedShalamar medical college, Lahore, PakistanDr Muhammad SohaibAllama Iqbal medical college, Lahore, Pakistan.

Mitral valve repair (MVR) is undisputedly associated with better clinical and functional outcomes than any other type of valve substitute. Conventional mitral valve surgery in dedicated high-volume centers can assure excellent results in terms of mortality and freedom from mitral regurgitation (MR) recurrence but requires cardiopulmonary bypass (CPB) and cardioplegic heart arrest. Trying to replicate the percentage of success of surgical MVR is the aim of all new transcatheter mitral dedicated devices. In particular transapical beating-heart mitral valve repair by artificial chordae implantation with transesophageal echocardiography (TEE) guidance is an expanding field. The safety and feasibility of the procedure have already been largely demonstrated with Neochord and more recently with Harpoon systems. Wang et al. present the outcomes of the first-in-human experience using a novel artificial chordae implantation device, the Mitralstitch system. Despite a quite small cohort of only 10 patients treated, 1-year results are satisfying and comparable to the early experience with former devices (4 patients with moderate or more MR recurrence). The comparison with surgical MVR is still unfavorable and requires further studies and significant procedure improvement. However, the device permits the treatment of anterior and posterior leaflets prolapse and performs quite easily edge-to-edge reparation. It will be interesting to evaluate longer follow-up in larger cohorts of patients as well as the possibility to shift to the transfemoral approach.

Over the last few years cardiac changed radically and so has the average age of the heart disease population progressively increased. Mitral valve surgery has a significant margin for progress in conservative vs replacement strategy. Mitral disease due to insufficiency in the elderly population has historically suffered from lower repair rates but deficiency alone should not limit repair operations in a specialized environment ensuring good survival.

Abstract Systemic infections and chronic graft rejection represent common causes of mortality and morbidity in heart transplant patients. In severe cases, cardiogenic shock (CS) may occur and require hemodynamic stabilization with temporary mechanical circulatory support (tempMCS).1 Under these devastating circumstances, treatment of sequelae of left ventricular dysfunction, such as secondary mitral regurgitation (MR) is challenging, especially when surgical repair is deemed futile. In non-transplant patients, interventional mitral valve repair strategies such as the MitraClip system (Abbott Cardiovascular, Plymouth, MN, USA) have been used to successfully treat secondary MR and allow for weaning from tempMCS.2 We report about the first patient in whom profound cardiogenic shock after heart transplantation was stabilized with tempMCS followed by interventional elimination of secondary MR.

This is an invited commentary. I did not think abstracts were required for commentaries.

Significant dilemma exists regarding management of the aortic root pathology in acute aortic dissections. Several strategies for both repair and replacement exist and there is a lack of clarity on the superiority of one over the other. Important factors that influence management strategies include involvement of the sinuses, competence of the aortic valve, presence of Marfan's syndrome and connective tissue disorders, as well as availability of surgical expertise. The wide variability in these factors makes it unlikely for any one technique to be suitable for management of all aortic roots and the root pathology has to be tailored to an individual patient.

Infectious complications after percutaneous transluminal coronary angioplasty are uncommon and can occur at any point of time leading to high morbidity and mortality. We report a case of delayed coronary artery stent infection and rupture, with epicardial infected false aneurysm formation, and right coronary artery to right atrium fistula formation, presenting after one month of pyrexia.

This is an invited commentary on robotic reoperative surgery without cardioplegia. Tips and shortfalls are discussed.

Objectives Pulmonary atresia (PA) with ventricular septal defect (VSD) and systemic-pulmonary collateral arteries (SPCA’s) has a variable anatomy with regard to the pulmonary vasculature, asking for an individualized surgical treatment. A protocol was applied consisting of staged unifocalization and correction. Methods Since 1989 39 consecutive patients were included (median age at first operation 13 months). In selected cases a central aorto-pulmonary shunt was performed as first procedure. Unifocalization procedures were performed through a lateral thoracotomy. Correction consisted of shunt takedown, VSD closure and interposition of an allograft between the right ventricle and the reconstructed pulmonary artery. Postoperatively and at follow up echocardiographic data were obtained. Results In 39 patients 66 unifocalization procedures were performed. Early mortality was 5%. Seven patients were considered not suitable for correction, four of them died. One patient is awaiting further correction. Correction was done successfully in 28 patients. Operative mortality was 3% and late mortality 11%. Median follow-up after correction was 19 years. Eleven patients needed homograft replacement. Freedom from conduit replacement was 88%, 73% and 60% at 5, 10 and 15 years respectively. Right ventricular function was reasonable or good in 75 % of the patients. Conclusions After complete unifocalization 30/37 patients (81%) were considered correctable. The main reasons for palliative treatment without correction were pulmonary hypertension and/or inadequate outgrowth of pulmonary arteries. Staged approach of PA, VSD and SPCA’s results in adequate correction and good functional capacity. RV function after correction remains reasonable or good in the majority of patients.

We describe a case of dynamic obstruction of the mesenteric arteries caused by aortic dissection. The flow pattern demonstrates a periodic flow variation, during which peak systolic velocity varied fourfold.

Abstract Objectives: The use of minimally invasive or transcatheter interventions rather than standard full sternotomy operations to treat Tricuspid valve disease is increasing. Debate however is still open regarding venous drainage management during cardiopulmonary bypass and wheatear or not superior and inferior vena cava should be occluded during opening of the right atrium to avoid air entrance in the venous line. The aim of the present study is to report operative outcomes and mid-term follow-up results of minimally invasive tricuspid valve surgery performed without caval occlusion. Methods: This is a retrospective outcome evaluation from institutional records with prospective data entry. We searched for all the patients who underwent right mini-thoracotomy tricuspid valve surgery isolated or combined with mitral valve surgery during the period June 2013 – February 2020. Results: During the study period 68 consecutive patients underwent minimally invasive tricuspid valve surgery without occlusion of cava veins. Survival at a 5-year and 8-year follow up was 100% and 79%, respectively. At follow-up no patient had an NHYA class greater than two, only one patient was re-hospitalized for heart failure for an atrial fibrillation episode. One patient was hospitalized for a pericardiocentesis twenty days after discharge No severe tricuspid regurgitation was evident at echocardiographic follow up. Five patients had 2+ TR. Conclusion Our results show that performing tricuspid surgery without caval occlusion is safe. There is no clinical evidence of gas embolism. Mid-term follow up data confirm that minimally invasive approach does not alter the quality of surgery.

Background: While enhanced recovery after surgery (ERAS) pathways have been successfully applied for cardiac surgery, there has been limited research directly comparing ERAS protocols to ad hoc narcotic use after surgery. We hypothesized that a standardized ERAS protocol would provide similar pain management and psycho-emotional outcomes while decreasing the use of opioids in the hospital and after discharge. Methods: As part of a 7-month quality improvement project, cardiac surgery patients on a fast tracked to extubate pathway were assigned PRN narcotic pain management for 3 months (n=49). After a 1-month ERAS protocol optimization period, a separate group of patients were given the ERAS protocol (n=34). Clinical outcomes were gathered, and participants completed a quality of recovery survey that allowed for the assessment of pain and symptom control at 4 time-points post-surgery. Results: Among 83 participants, 66% were male and the mean age was 53 years. There were no differences in patient characteristics between PRN and ERAS groups (all p>0.244). There were no differences between ERAS and PRN groups for surgery characteristics (all p>0.060), inpatient outcomes (all p>0.658), or after-discharge outcomes (all p>0.397). Furthermore, across all time-point comparisons, there were no supported differences in patient-reported outcome and pain control between the ERAS and PRN narcotic groups (all p>0.075). Conclusions: An ERAS protocol demonstrated similar patient outcomes and pain control to traditional opioid use for postoperative cardiac surgery patients. Further research is recommended to further confirm the results of this study.

Rheumatic mitral valve disease is now rare in high income countries, except for migrant and older residents, it remains an important and ongoing cause of preventable heart disease in Indigenous populations. Despite our major advances in medical technology and understanding, rheumatic fever remains a serious public health problem throughout the world.

Null hypothesis significance testing (NHST) and p-values are widespread in the cardiac surgical literature but are frequently misunderstood and misused. The purpose of the review is to discuss major disadvantages of p-values and suggest alternatives. We describe diagnostic tests, the prosecutor’s fallacy in the courtroom, and NHST, which involve inter-related conditional probabilities, to help clarify the meaning of p-values, and discuss the enormous sampling variability, or unreliability, of p-values. Finally, we use a cardiac surgical database and simulations to explore further issues involving p-values. In clinical studies, p-values provide a poor summary of the observed treatment effect, whereas the three- number summary provided by effect estimates and confidence intervals is more informative and minimises over-interpretation of a “significant” result. P-values are an unreliable measure of strength of evidence; if used at all they give only, at best, a very rough guide to decision making. Researchers should adopt Open Science practices to improve the trustworthiness of research and, where possible, use estimation (three-number summaries) or other better techniques.

Commentary to JOCS-2020-OA-1345

This letter is in response to the case report by Kuzmin et al. entitled “Left atrial appendage occlusion device causing coronary obstruction: A word of caution” , published in November 2020 issue of Journal of Cardiac Surgery. The report describes a circumflex lesion occurring following mitral valve (MV) repair, tricuspid valve repair, and left atrial appendage closure (LAAO) using AtriClip device. The authors concluded that LAAO is a safe procedure, but in the setting of a concomitant MV surgery LAAO may be a contributor to the reported event. Circumflex coronary artery occlusion or impingement during MV repair is well described in the literature. On the reported two-dimensional cine, the position of the stenosis is typical of mitral repair induced injury. A ring suture can gather and compress tissue adjacent to the coronary creating stenosis without a discrete ligation. It is also true that vigorous traction on the LAA without due attention to distortion of the adjacent circumflex might be capable of creating compression or accordioning of the vessel. To mitigate this, the clip should be placed at the true base of the appendage. A residual pouch carries as much or more risk as not attempting to close the appendage at all. The authors’ recommendation to place the clip more distally will inevitably lead to incomplete closures. In conclusion, the reported event was more likely due to a mitral stitch, the path of which is not directly visualized after it breaches the endocardium.

Background: This study evaluated the impact of various sizing metrics on outcomes of female donor to male recipient orthotopic heart transplantation (OHT). Methods: We queried the United Network of Organ Sharing database to analyze all isolated, primary adult OHTs from 1/12010-3/20/2020. Patients were stratified by donor-recipient sex pairing. Logistic regression was used to investigate risk-adjusted effects of current size matching criteria (weight ratio, body mass index (BMI) ratio, predicted heart mass (pHM) ratio) on one-year post-transplant mortality. Kaplan-Meier analysis was used to compare posttransplant survival among cohorts. Results: A total of 22,450 patients were analyzed, of which 3,019 (13.4%) underwent female-to-male transplantation. Of sex-matched pairs, female-to-male donation had the lowest proportion of undersized hearts using weight and BMI ratio metrics (10.5% and 5.2%) but had the highest proportion of undersizing using pHM metrics (48.1%) (all P<0.001). Female-to-male recipients had the lowest rate of unadjusted one-year survival (90.0%, P = 0.0169), and increased hazards of mortality after risk adjustment (OR 1.17, 95% CI 1.01-1.36, P=0.034)). Undersizing using pHM (donor-recipient ratio < 0.85) was the only metric found to be associated in increased mortality after risk adjustment (OR 1.32, 95% CI 1.02 to 1.71, P=0.035). Conclusions: Female-to-male heart transplantation has the worst survival of all sex-matching combinations. Although female donors in this cohort are appropriately sized using traditional metrics, half are under-sized using pHM. This, combined with its strong association with mortality, underscores the importance of routine pHM assessment when evaluating female donors for male recipients.