The Recurring Theme of Gender Difference in Cardiac Surgical OutcomesJohn S. Ikonomidis MD, PhDDivision of Cardiothoracic Surgery, University of North Carolina at Chapel HillWord Count: 1144References: 13Address correspondence to:John S. Ikonomidis MD, PhDProfessor and Chief,Division of Cardiothoracic SurgeryUniversity of North Carolina at Chapel Hill3034 Burnett Womack Building160 Dental Circle,Chapel Hill, NC27599e-mail: [email protected]: (919) 966-3381In this issue of the Journal of Cardiac Surgery,1Newell and colleagues examined contemporary national outcomes following surgical resection of benign primary atrial and ventricular tumors. The 2016-2018 Nationwide Readmissions Database was queried for all patients > 18 years of age with a primary diagnosis of benign neoplasm of the heart who underwent resection of the atria, ventricles, or atrial/ventricular septum. A weighted total of 2,557 patients met inclusion criteria. Mean age was 61 years, 67.9% were female, and patients had relatively low comorbidity burdens. The authors found that while there was no difference in 30-day mortality (2.1% vs 1.3%, p=0.550), 30-day readmission (7.0% vs 9.1%, p=0.222), or 30-day composite morbidity (56.8% vs 53.8%, p=0.369) between females and males respectively, on multivariable analysis, female sex was independently associated with increased risk of 30-day mortality (OR 2.65, p=0.028).Overall, this was a well study which documents a large contemporary cohort of benign cardiac tumor resections. However, perhaps the most interesting feature of this study is the finding of sex as an independent predictor of 30 day mortality after propensity matching. Cardiac surgery suffers from a gender gap in terms of its outcomes. It has been well established that for many procedures such coronary bypass surgery (CABG), aortic valve replacement, mitral valve surgery, and aortic surgery.2 For CABG, women referred for surgery are typically older than men, have a higher comorbidity (hypertension, renal failure, diabetes, peripheral vascular disease) profile, and more often present in urgent or emergent status for surgery.3 Large, risk-adjusted, propensity matched studies have documented increased mortality in women as compared with men.4-7 This difference also extends into the interventional cardiology realm, where mortality and complication rates have been shown to be higher in women following percutaneous interventions for ST-elevation myocardial infarction.8For aortic valve replacement, a Nationwide Inpatient Sample study of 166809 patients with aortic stenosis from 2003 to 2014 found that women experience higher inpatient mortality (5.6% versus 4%, P<0.001) which persisted after propensity matching (3.3% versus 2.9%, P<0.001).9 For mitral valve surgery, a randomized controlled trial of patients with severe ischemic mitral insufficiency undergoing repair versus replacement found that women had higher mortality than men (27.1% versus 17.4%, p<0.03).10 For aortic surgery, female gender was associated with a higher mortality after both aortic dissection and aortic arch repair.11,12 Reduction in surgical stress through application of minimally invasive approaches still resulted in female sex being a risk factor for higher in-hospital mortality.13 The findings of the present study add further support to the above observations, with the potential addition that, in contrast to the other disease processes described, the majority of patients presenting for surgical removal of benign cardiac tumors were likely free of either symptoms or cardiac sequelae due to the disease, but nevertheless still the gender disparity in mortality persisted.While it is obvious that the above disease processes and their related surgical remedies are quite disparate, the association with increased mortality seen in females seems to be constant. Why is this? A considerable amount has been written regarding sex bias in referral patterns for surgery and even decreased functional reserve and health profiles of women when they are referred for surgical intervention compared with men.2 With regard to these referral patterns, published guidelines directing practitioners regarding indications for surgery are, in general, based upon studies in which the majority of patients were male. Interestingly, in the present study, females made up over two thirds of the patient population.1 While this suggests that females carry a disproportionately more benign cardiac tumors amenable to surgery, the post-surgical mortality disparity remained.The exact reasons for the above disparity remain unelucidated and further work is required to eliminate the gender gap in cardiac surgical outcomes. There is considerable focus on the removal of sex bias in animal and human research, as well as the development of disease treatment guidelines that consider gender in the algorithms. Hopefully and these and other sex-balanced approaches will reveal new insights that will allow us to bring equipoise to gender-stratified cardiac surgical outcomes.

Invasion in cardiac surgery is maximum when cardiopulmonary bypass(CPB) is used. The period is of no consequence as all complications such as Bleeding, Cerebral. Renal , vascular and Inflammatory responses are initiated when CPB is used. The term minimally invasive is therefore most inappropriate when CPB is used irrespective of the type of operation, incision, cosmesis, and use of sophisticated technology.This editorial highlights the misuse of the term Minimally invasive cardiac surgery.

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

Surgical treatment of type A dissections is based on best evidence practice for the lack of controlled randomized studies providing definitive scientific evidence. Despite its widespread use, axillary cannulation still remains a debated topic as the preferred method of cannulation and perfusion strategy in the treatment of this complex condition.

We present a case of coronary artery bypass grafting in a 78-year-old man with triple vessel disease and concomitant cardiac amyloidosis. Postoperatively he developed a profound low cardiac output state and multi-organ failure. He died 3 weeks following surgery. Bypass surgery is rarely performed in patients with cardiac amyloidosis, and there is little in the literature regarding outcomes. The few published cases present a bleak picture, and hence percutaneous coronary intervention should always be preferred.

Sinus of Valsalva aneurysm is a rare disease characterized by the partial elevation of the aortic root. Few reports are available on the surgical treatment for infants. We report the repair of an extremely rare case of a sinus of Valsalva defect with a ventricular septal defect and right ventricular outflow tract stenosis in an infant. It was not a sinus of Valsalva aneurysm, but it exhibited abnormal partial bulging of the aortic root and forming an aneurysm-like cavity within the right ventricular myocardium. We performed direct closure of the sinus of Valsalva aneurysm-like cavities and intracardiac repair in two stages. Three years after total repair, the patient remained healthy and asymptomatic.

Background: Aortic complications, such as aortic tears and dissections, during cannulation must be managed urgently and often require hypothermic circulatory arrest. We report a unique management strategy to repair an aortic tear without dissection by modifying a Dacron ascending aortic graft with side-arm to serve both as a patch for the aortic tear and inflow for the bypass circuit. Case Presentation: A 32-year-old female patient undergoing reoperative cardiac surgery suffered an unexpected aortic tear during cannulation for cardiopulmonary bypass. After promptly transitioning to femoral cannulation and hypothermic circulatory arrest, the tear was repaired by utilizing a physician-modified ascending aortic graft with side-arm, in which the surrounding skirt of the side-arm was cut from the circumferential graft to patch the defect. The patient was rewarmed with the side-arm serving as arterial inflow for the bypass circuit, and the remainder of the operation proceeded without complication. Conclusion: This type of aortic repair for aortic tears without dissection can offer the patient the benefit of avoiding multiple aortotomies in a weakened aorta, reducing circulatory arrest time, and re-establishing a central cannulation strategy for cardiopulmonary bypass, consequently reducing the likelihood of distal limb ischemia.

The hemispherical aortic annuloplasty reconstructive technology (HAART) is an internal geometric annuloplasty ring designed to restore a natural elliptical shape to the aortic annulus as part of aortic valve repair. We present 4D flow hemodynamic analysis before and after implementation of the HAART ring in patients undergoing ascending aortic replacement. HAART patients displayed similar or improved flow profiles when compared to a patient undergoing ascending aortic replacement alone.

A document by Michel Skaf. Click on the document to view its contents.

In total arch replacement, using frozen elephant trunk (FET) or elephant trunk techniques ensures proximalization of the distal anastomosis. However, in some cases, the left subclavian artery (LSCA) is deeply located and difficult to visualize. Therefore, surgeons face technical challenges during the LSCA reconstruction. We report an end-to-side anastomosis technique that enables safer and easier anatomical reconstruction of the LSCA.

Commentary:

Case Video Summary: This video demonstrates the principle of spiral PA plasty whereby the length of branch pulmonary arteries can be increased simultaneous to the increase in diameter by using a patch that is anastomosed spirally around the vessels.

We present a case of a 3-year-old child with ventricular septal defect and infective endocarditis with mycotic pulmonary artery aneurysm. The case highlights the role of CT angiography in the diagnosis and characterization of aneurysm and in demonstrating the extent of thrombo-embolic complications in distal pulmonary arteries and lung parenchyma.

Title: Learning the Learning Curve of Robotic Coronary Artery BypassAuthors : Saqib Masroor, MD, MBA1, Abdullah Nasif, MD1 1Division of Cardiothoracic Surgery, Department of Surgery, University of Toledo Medical Center Toledo, OH USAManuscript: The Learning Curve of Robotic Coronary Arterial Bypass Surgery: A Report from The STS DatabaseDisclosure : NoneWord Count : 1229Learning the learning curve of robotically assisted coronary artery bypass grafting is important for the advancement of this technique and the improvement in patient outcomes. There have been many reports of single surgeon learning curves.1, 2 But one can argue that they depict one surgeon’s journey, depicting his or her dedication to the field and making generalization to other surgeons difficult, if not impossible.In this issue of the Journal of Cardiac Surgery, Patrick et al, report on their investigation of the Society of Thoracic Surgeons (STS) database for Robotically Assisted Coronary Artery Bypass (RA-CABG) procedures and the beginner surgeon’s learning curve.3Between 2014 and 2018, a total of 1195 RA-CABGs were performed by 114 surgeons, with 74 surgeons performing <5 procedures and only 9 surgeons performing >25 procedures. The median number of cases performed was 2. The patient population was younger and relatively lower risk. The cases included single-vessel as well as multi-vessel Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) in addition to Totally Endoscopic Coronary Artery Bypass (TECAB) and there is no subgroup analysis reported for the different procedures. The authors conclude that the learning curve for procedural success is overcome by the 10th case, even though the curve for reoperation is still steep by the 25th case. Operative mortality however was similar in the two groups. The authors conclude that surgeon experience is an independent predictor of RA-CABG procedural success and that the learning curve consistently flattens after the surgeon’s 10th case. We agree with the first but not the second conclusion. Here is why!In 2013, Prof Mohr’s group in Leipzig reported on the learning curve of minimally invasive mitral valve surgery at their institution over a 17-year period involving 3895 operations performed by 17 surgeons performing their first minimally invasive procedure, using the sequential probability cumulative sum (CUSUM) statistical technique.4 Learning curves were then determined for total operation times, aortic cross-clamp times, and primary outcomes. The mean number of operations per surgeon was 189. The authors reported a learning curve of between 75-125 procedures, with evidence that surgeons needed to perform more than 1 cases per week to maintain good results. Importantly however, patient mortality was not compromised because of the learning curve.To assess the learning curve involved in performing a task, it is important that both the task and the tools needed for the task remain constant. The above publication fulfills both of these criteria. 82 percent of cases were mitral valve repair and 18 percent were mitral valve replacement. The surgical technique and technology used was nearly identical and robotic mitral valve procedures were excluded. The institution had the same leadership over the period, allowing for a very stable work environment as well as a consistent approach including case selection, operative technique etc. As much as possible, every variable was the same, except the variable under investigation-‘the beginner surgeon’. The same group had reported the learning curve for MIDCAB to be between 50-100 cases for 8 surgeons at their institution.5Now let us analyze the report from Patrick et al.3 In this report, the task is not the same and neither are the tools. Single vessel RA-MIDCAB is a less challenging procedure than multi-vessel RA-MIDCAB, with its associated variety of conduit procedures (such as bilateral Internal Mammary Artery (IMA) grafting, Radial Artery T-grafting from Left Internal Mammary Artery (LIMA) to the lateral wall, or aortocoronary Saphenous Vein bypass procedures). TECAB is a totally different beast altogether. Grouping all of them in one learning curve is not a valid assumption. As far as the tools/technique is concerned, some patients had beating heart surgery while others had arrested heart procedures, exposing the Left Anterior Descending Artery (LAD) in MIDCAB is a different task than exposing the lateral wall targets or the stabilizing the LAD endoscopically. Each one of those steps/techniques have their own learning curves.Another shortcoming of this study is the relatively small experience of most of the surgeons in the study. 74 out of the 114 surgeons in the study had < 5-case experience. Moreover, it is not clear what the experience of the surgeons was before embarking on this technique. In the Leipzig study, surgeons with less than 5 cases were excluded from analysis and the 17 surgeons had an experience of at least 40 mitral valve procedures via sternotomy before using the minimally invasive approach.1Finally, the definition of procedural success can be debated. It was defined as an inverse composite of the three primary outcomes - conversion, re-operation, and major morbidity/mortality. While this “procedural success” composite showed a flattening of the learning curve at 10 cases, the reoperation rate was still improving even after 25 cases. A chain is only as strong as the weakest link. If the reoperation rate is still improving after 25 cases, procedural success cannot be declared to have been mastered at 10 cases. Further analysis of the groups of surgeons with < 10 or > 10 cases reveals the procedural success to be 72.9% and 85.3% respectively. 15% failure of procedural success would not be consistent with overcoming the learning curve. We assume that surgeons must strive to continue improving the procedural success until it reaches well into the 90’s percent rate, which would be required for a successful RA-CABG program.The major advantage of a large clinical database such as the Adult Cardiac Surgery Database (ACSD) is the minimization of bias due to its large number of observations. However, for rare procedures such as RA-CABG, that advantage is lost. In fact, with such a small number of observations over such a diverse set of procedures and institutions, ACSD data is not granular enough to explore an individual surgeon’s learning curve because there is no control for numerous other variables at the departmental and institutional level that are not tracked by ACSD. A high-volume center in a steady-state clinical work environment controls for most variables that influence clinical outcomes. The only variable that changes, is the beginner surgeon, and the data thus obtained is more likely to represent the true “learning curve” of the procedure.It is important to have realistic expectations from new technology. Many beginners would embark on this journey, hoping to master the learning curve in 10 cases. And when that expectation is not fulfilled in real life, they might give up altogether on this very useful approach. The number and frequency of operations are important, not just for the surgeons, but even more so, for the rest of the operating room team including anesthesiologists and patient-side assistants. The whole team can be feel discouraged if they continue to have a learning curve beyond 10 or even 20 cases.In conclusion, querying the Adult Cardiac Surgery Database of STS may not be the best way of learning the learning curve of a rare procedure(s). There is a concern that setting an unrealistically optimistic expectation of 10 operative cases to master the learning curve of RA-CABG may be detrimental to the progress of this approach. A high-volume centers’ experience with multiple beginner surgeons may be a better representative of the learning curve of RA-CABG and that study has not yet been done. But based on the learning curves of other similar procedures and our own experience, it is our opinion that the learning curve of RA-CABG would be somewhere between 50 and 100 cases for MIDCAB and another 50-100 for TECAB.

Objective: To evaluate the perioperative clinical efficacy of preoperative human fibrinogen treatment in patients with acute Stanford type A aortic dissection (ATAAD). Methods: Data of 159 patients with ATAAD who underwent emergency surgical treatment in our hospital from January 2019 to December 2020 were retrospectively analyzed. Patients were divided into two groups according to whether human fibrinogen was administered before surgery. The preoperative clinical data, surgical data, postoperative data, complications related to the coagulation function, and mortality of the two groups were compared and analyzed. Results: The in-hospital mortality was similar in the two groups (2.9% versus 9.3%, P = 0.122). However, group A had a significantly shorter operation time (279.24±39.03 versus 298.24±45.90, P=0.008), lower intraoperative blood loss (240.48±96.75 versus 353.70±189.80, P＜0.001), and reduced intraoperative transfusion requirement of red blood cells (2.61±1.18 versus 6.05±1.86, P＜0.001). The postoperative suction drainage within 24 hours in group A was significantly decreased (243.24±201.52 versus 504.22±341.08，P=0.002). The incidence of postoperative acute kidney injury (AKI) in group A was lower than that in group B (3.8% versus 14.8%, P =0.023). Similarly, the incidence of postoperative hepatic insufficiency in group A was lower than that in group B (1.9% versus 9.3%, P =0.045). In group A, the mechanical ventilation time was shorter (47.68±28.61 versus 118.21±173.16, P=0.004) along with reduced ICU stay time (4.06±1.18 versus 8.09±9.42, P=0.003), and postoperative hospitalization days (19.20±14.60 versus 23.50±7.56, P=0.004). Conclusion: Preoperative administration of human fibrinogen in patients undergoing ATAAD surgery can effectively reduce the intraoperative blood loss, blood transfusion amount, shorten the operation time, reduce postoperative complications, and improve the early prognosis of patients, in addition to being highly safe.

Closure of muscular ventricular septal defects remains a challenge for cardiac surgeons and interventional cardiologists. Different techniques, approaches, and devices are available to increase the success of these procedures. Changwe et al, in this issue of the Journal, describe a novel approach with the usage of a probe-guided system, with encouraging results.

A 40-year-old male with Becker muscular dystrophy presented with severe mitral regurgitation and underwent mitral valve repair. Following the surgery, the patient became tachycardic, and developed a continuous high grade-fever and hyperbilirubinemia. The patient's condition worsened and we eventually tested his thyroid levels and discovered abnormally high thyroid levels. After diagnosing a severe thyroid storm, the patient was treated with oral administration of Lugol's iodine and thiamazole, as well as an intravenous steroid, which led to an immediate improvement of symptoms. The incidence of thyroid storm after open-heart surgery is extremely rare but highly life-threatening if unrecognized.

Tracheo-innominate fistula (TIF) is a reported complication of tracheostomy that typically presents with a herald bleed. The phenomenon of an aorto-tracheal fistula has similar pathology and presentation to TIF, but no standard surgical repair. In the manuscript by Musgrove et al. in the Journal of Cardiac Surgery the authors propose a surgical treatment, that is reproduceable for the correct anatomic configuration - an ascending and aortic arch replacement, pericardial patch of the tracheal defect, and omental flap coverage to prevent infection. While this intervention seems a large undertaking for a small defect, it is a safe and durable repair.