Kawasaki Disease (KD) is a systemic vasculitis of small and medium arteries, preferably affecting coronary arteries. It is one of the most frequent causes of acquired heart disease in children. Despite being comprehensively studied, its etiopathogenesis is not totally explained. The surgical procedures usually become necessary during the late follow-up and may be coronary artery bypass grafting, cardiac defibrillator implantation with or without cardiac resynchronization therapy, or cardiac transplantation.

Thoracic endovascular aortic repair (TEVAR) has quickly become the mainstay of treatment for acute aortic dissection, in particular cases of acute complicated Stanford Type B dissection (co-TBAD). Necessarily, TEVAR carries with it the risk of postoperative complications, including stroke and renal failure. As a result, the management of patients with uncomplicated type B aortic dissection (un-TBAD), which is generally accepted as being less severe, are safely managed via optimal medical therapy (OMT) alone. However, despite OMT, patients with un-TBAD are at substantial risk of severe disease progression requiring delayed intervention. The cost-benefit ratio associated with TEVAR for un-TBAD is therefore of key interest. Howard and colleagues produced a fascinating systematic review and meta-analysis investigating the clinical outcomes of TEVAR for complicated and uncomplicated TBAD. Their data suggests that there is no significant difference in in-hospital mortality or 5-year survival between TEVAR for un-TBAD and co-TBAD, although the 30-day mortality rate appeared to be higher in the co-TBAD cohort. Patients with co-TBAD appeared to also be at a higher risk of postoperative stroke and TEVAR endoleak, while un-TBAD patients were at a higher risk of postoperative renal failure. Further prospective research into these relationships are recommended to fully elucidate the comparative efficacies of TEVAR for un-TBAD and co-TBAD.

Background: Acute type A aortic dissection (ATAAD), is a surgical emergency often requiring intervention on the aortic root. There is much controversy regarding root management; aggressively pursuing a root replacement, versus more conservative approaches to preserve native structures. Methods: Electronic database search we performed through PubMed, Embase, SCOPUS, google scholar and Cochrane identifying studies that reported on outcomes of surgical repair of ATAAD through either root preservation or replacement. The identified articles focused on short- and long-term mortalities, and rates of re-operation on the aortic root. Results: There remains controversy on replacing or preserving aortic root in ATAAD. Current evidence supports practice of both trends following an extensive decision-making framework, with conflicting series suggesting favourable results with both procedures as the approach that best defines higher survival rates and lower perioperative complications. Yet, the decision to perform either approach remains surgeon decision and bound to the extent of the dissection and tear entries in strong correlation with status of the aortic valve and involvement of coronaries in the dissection. Conclusions: There exists much controversy regarding fate of the aortic root in ATAAD. There are conflicting studies for impact of root replacement on mortality, whilst some study’s report no significant results at all. There is strong evidence regarding risk of re-operation being greater when root is not replaced. Majority of these studies are limited by the single centred, retrospective nature of these small sample sized cohorts, further hindered by potential of treatment bias.

The emergence of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in December 2019, presumed from the city of Wuhan, Hubei province in China and the subsequent declaration of the disease as a pandemic by the World Health Organization (WHO) as COVID-19 in March 2020, had significant impact on health care systems globally. Each country responded to this disease in different ways but broadly by fortifying and prioritising health care provision as well as introducing social lockdown aiming to contain the infection and minimizing the risk of transmission. In the United Kingdom, a lockdown was introduced by the government on 23rd of March 2020 and all health care services were focussed to challenge the impact of COVID-19. To do so, the United Kingdom National Health Service had to undergo widespread service reconfigurations and the so-called “Nightingale Hospitals” were created de novo to bolster bed provision and industries were asked to direct efforts to the production of ventilators. A government led public health campaign was publicised under the slogan of: “Stay home, Protect the NHS (National Health Service), Save lives”. The approach had a significant impact on delivery of all surgical services but particularly cardiac surgery with its inherent critical care bed capacity. This paper describes the impact on provision for elective and emergency cardiac surgery in the United Kingdom, with a focus on Aorto-vascular disease. We describe our Aorto-vascular activity and outcomes during the period of UK lockdown and present a patient survey of attitudes to aortic surgery during COVID-19 pandemic.

A 57-year-old man suffered chest pain during the COVID-19 pandemic, but he delayed medical treatment due to fear of infection. Four months later, symptoms chest tightness and shortness of breath appeared. Electrocardiogram (ECG) revealed old myocardial infarction; color sonography and myocardial CT revealed apical myocardial defect. He refused surgery and percutaneous transcatheter closure, and follow-up observation. After 22 months, the symptoms of chest tightness and shortness of breath aggravated. He recovered after percutaneous transcatheter closure, and was discharged. This case shows delayed closure is one of the possible options for the patients without severe organ dysfunction or hemodynamic disturbance.

Keeping up with the surgical training might be difficult during the time of COVID-19 pandemic: with most of the health care resources dedicated to face this reality, trainees can improve themselves deep diving in scientific literature, study, Telemedicine and Social Media professional platforms. Moreover, they might be directly involved in COVID patient care, facing a still a still elusive disease with a high lethality rate. Often the frustration of having no valid treatment and a poor incisiveness on the natural course of the COVID19 could lead to a blue mood or a burnout. Eventually, the natural adaptability and the survival instinct prevail and teach us the real meaning of resilience. Every trainee has to be prepared for the second phase, when the new normality will force everyone to cohabit with the virus. Even the obvious teething troubles, this could be the right moment for all the Residents to “grow-up” and develop their own future Character.

Objective Affecting 1 in 500 individuals; Hypertrophic cardiomyopathy (HCM) is an autosomal dominant cardiovascular disorder which is prevalent throughout the world. Surgical myectomy and alcohol septal ablation (ASA) are two methods currently used for the management of drug refractory Hypertrophic obstructive cardiomyopathy (HOCM). ASA may prove to be a useful, less invasive tool when confronting patients with HOCM especially those who are more elderly or deemed to be a higher surgical risk. Methods Electronic literature search was conducted to identify relevant articles that discussed invasive methods to treat drug refractory HOCM. No limits were placed on timing of the publication or the type of article. Key words and MeSH terms were used to conduct the search and the results were summarized in the relevant section. Results Current evidence suggests that alcohol septal ablation is a safe and effective procedure in treating patients with HOCM with similar short- and long-term outcomes when compared with surgical myectomy. Selection of patient with appropriate assessment is the key for satisfactory outcomes. Conclusion ASA has been shown to be a safe and reliable procedure; advanced imaging techniques and dedicated multi-disciplinary teams can be used to carefully select patients with HOCM. Though surgical myectomy is recommended as gold standard treatment for drug refractory HOCM, however, ASA may play an increasing role in the near future due an ageing population; both ASA and SM can have a synergistic effect in treating those who are affected by HOCM.

Large studies demonstrated that moderate or severe patient-prosthesis mismatch (PPM) occurs in 44.2% to 65% of patients undergoing aortic valve replacement. If there is general agreement that patients with PPM have worse outcome than patients without, it is difficult to understand how to prevent this dangerous complication. The formula used to calculate the effective orifice area (EOA) of an implanted aortic prosthesis has many weak points that produce inconsistent results using the same prosthetic valve (type and size). The observed EOA (3 to 6 months postoperatively) of a #23 biological prosthesis can range from 0.9 to 3.5 cm², making PPM prevention impossible using projected EOA, where only the mean value is reported (1.83 cm² for the same #23 biological prosthesis). An EACTS-STS-AATS Valve Labelling Task Force has been established to suggest the manufacturers to present essential information on valvular prosthesis characteristics in standardized Valve Charts. For valves used in the aortic position, Valve Charts should include a standardized PPM chart to assess the probability of PPM after implantation. This will not solve completely the conundrum of prevention, but most likely it will be a step ahead.

The incidence of mechanical complications of acute coronary syndromes (ACS) needing cardiac surgery has reduced significantly in the last years due to early diagnosis and treatments. Covid-19 pandemic, however, would generate in the patients a sense of fear regarding access to the ERs so they probably underestimate symptoms such as chest pain or angina equivalents until situation does not became critical. In this way, this behaviour could create a vast pool of patients who will enter the hospital in much more critical situations and with mechanical complications of an evolving ACS needing cardiac surgery treatment.

The meta-analysis by He and collaborators [has the worth to cover, as much as possible, a gap of scientific evidence where conducting a randomized trial appears very complex for ethical and logistical reasons. The authors concluded that mitral valve repair (MVP) provide better pooled results, both early and late, with respect to mitral valve replacement (MVR). However, the superiority of MVP is driven by some single large cohort-studies where surgeons had wide experience in the field of MVP for IE. This finding is also confirmed by other studies. But if mitral repair produces such a better short- and long-term survival than replacement, why are there no clear indications from consensus and guidelines pushing surgeons toward the pursuit of a reconstructive procedure at almost any cost? We wonder but to repair or not to repair, is that really the question? The AATS consensus suggests to repair “whenever possible” but without providing more specific indications. If the two primary goals of surgery are total removal of infected tissues and reconstruction of cardiac morphology, including repair or replacement of the affected valve(s), probably MVP as to perform in case of less extensive tissue detriment by the infection. In more wide valve involvement, MVP may be the choice but only in very expert hands and in Centers with very large volume of valve repairing. This decision cannot therefore be the result of the choice of an individual but must derive from a careful multidisciplinary discussion to be held in an EndoTeam.

Background: Despite recent advancements in prevention, treatment, and management options, cardiovascular diseases contribute to one of the leading causes of morbidity and mortality. Several studies highlight the compelling evidence for the existence of healthcare inequities and disparities in the treatment and management control of cardiovascular diseases. Aims: To explore the role of racial disparities in the treatment of various cardiovascular diseases, highlighting the role of socioeconomic and cultural factors, and ultimately postulate solutions to eliminate the disparities. Methods: A comprehensive review of literature was conducted using appropriate keywords on search engines of SCOPUS, Wiley, PubMed, and SAGE Journals. Conclusion: By continued research to eliminate healthcare inequalities, there exists a potential to improve health-related outcomes in minority populations.

Background: This study investigates the use of modern machine learning (ML) techniques to improve prediction of survival after orthotopic heart transplantation (OHT). Methods: Retrospective study of adult patients undergoing primary, isolated OHT between 2000-2019 as identified in the United Network for Organ Sharing (UNOS) registry. The primary outcome was one-year post-transplant survival. Patients were randomly divided into training (80%) and validation (20%) sets. Dimensionality reduction and data re-sampling were employed during training. Multiple machine learning algorithms were combined into a final ensemble ML model. Discriminatory capability was assessed using area under receiver-operating-characteristic curve (AUROC), net reclassification index (NRI), and decision curve analysis (DCA). Results: A total of 33,657 OHT patients were evaluated. One-year mortality was 11% (n=3,738). In the validation cohort, the AUROC of singular logistic regression was 0.649 (95% CI 0.628-0.670) compared to 0.691 (95% CI 0.671-0.711) with random forest, 0.691 (95% CI 0.671-0.712) with deep neural network, and 0.653 (95% CI 0.632-0.674) with Adaboost. A final ensemble ML model was created that demonstrated the greatest improvement in AUROC: 0.764 (95% CI 0.745-0.782) (p<0.001). The ensemble ML model improved predictive performance by 72.9% ±3.8% (p<0.001) as assessed by NRI compared to logistic regression. DCA showed the final ensemble method improved risk prediction across the entire spectrum of predicted risk as compared to all other models (p<0.001). Conclusions: Modern ML techniques can improve risk prediction in OHT compared to traditional approaches. This may have important implications in patient selection, programmatic evaluation, allocation policy, and patient counseling and prognostication.

Background: Chest X-rays are routinely obtained after removal of chest drains in patients undergoing cardiac and thoracic surgical procedures. However, a lack of guidelines and evidence could question the practice. Routine chest X-rays increase exposure to ionising radiation, increase healthcare costs and lead to overutilisation of available resources. This review aims to explore the evidence in the literature regarding the routine use of chest X-rays following the removal of chest drains. Materials & Method: A systematic literature search was conducted in PubMed, Medline via Ovid, Cochrane central register of control trials (CENTRAL) and ClinicalTrials.gov without any limit on the publication year. The references of the included studies are manually screened to identify potentially eligible studies. Results: A total of 375 studies were retrieved through the search and 18 studies were included in the review. Incidence of pneumothorax remains less than 10% across adult cardiac, and paediatric cardiac and thoracic surgical populations. The incidence may be as high as 50% in adult thoracic surgical patients. However, the re-intervention rate remains less than 2% across the populations. Development of respiratory and cardiovascular symptoms can adequately guide for a chest X-ray following the drain removal. As an alternative, bedside ultrasound can be used to detect pneumothorax in the thorax after the removal of a chest drain without the need for ionising radiation. Conclusion: A routine chest X-ray following chest drain removal in adult and paediatric patients undergoing cardiac and thoracic surgery is not necessary. It can be omitted without compromising patient safety. Obtaining a chest X-ray should be clinically guided. Alternatively, bedside ultrasound can be used for the same purpose without the need for radiation exposure.

Severe shortage of donor hearts has increased the mortality of patients on the transplant waiting list. However, donor hearts with valvular dysfunction are rarely used. Utilizing donor hearts with valvular lesions that can be repaired or replaced at the time of transplant will decrease waitlist mortality and offer many patients a second chance in life.

The coronavirus disease 2019 (COVID-19) is an infectious disease which has rapidly evolved into a pandemic. Though it has affected all disciplines of medical sciences but it has some serious implications pertaining to cardiovascular sciences which have presented unique challenges in front of cardiac surgeons in particular. To flatten the curve of this pandemic, routine cardiac surgeries are being deferred indefinitely resulting in the pool of sick cardiac patients rising day by day. A different perspective is presented on this global catastrophe from the viewpoint of a cardiac surgeon.

Background Since the introduction of the E-Vita Open NEO aortic prosthesis in 2020, several incidences of post-anastomotic oozing from the polyester portion of the graft have emerged. The use of BioGlue to prime E-Vita Open NEO to prevent this has been suggested as a way to mitigate this worrying complication. We investigate the extent of graft oozing in E-Vita Open NEO and evaluate the use of BioGlue in preventing oozing, both experimentally and in terms of potential clinical complications. Methods and materials E-Vita Open NEO (in straight and branched configurations) was implanted in a perfused model. The distal stent-graft and side branches were clamped, and the graft pressurised with blood to 120 mmHg. The volume of blood (ml) oozing from the graft within 60 seconds was measured. Non-pressurised grafts were coated with BioGlue up to a thickness 1-, 2-, and 3 mm, and the volume (mm3) of BioGlue required to do so was recorded. Results Within 60 seconds, 250.0 ml of blood oozed from the grafts tested. 43.694 mm3, 87.389 mm3, and 174.778 mm3 of BioGlue was required to coat the device with 1-, 2-, and 3 mm of BioGlue. Conclusion Graft oozing from E-Vita Open NEO represents an omnipresent and worrying risk. The use of BioGlue herein is likely associated with several adverse consequences, which are an additional risk on top of that posed by graft oozing. These risks call into question the suitability of E-Vita Open NEO, especially when compared to alternative devices not affected by oozing.

On Time Surgery Start: Is Standardization The Answer?Olufunke Folasade Dada MD, Tanaya Sparkle M.B.B.S.University of Toledo Medical Center, Anesthesiology Department,3000 Arlington Avenue, Toledo, Ohio, USACorresponding Author: Dr. Tanaya Sparkle, M.B.B.S.Address for correspondence:University of Toledo Medical Center, Anesthesiology Department,3000 Arlington Avenue, Toledo, Ohio - 43614E-mail: [email protected]: 419-383-3531

The authors present an revolutionary study aiming to evaluate the effect of alterations in potassium concentrations in transfused packed red blood cells (PRBC) on neonate and infant potassium levels after congenital cardiac surgery. By establishing a strict protocol which restricts the rate of transfusion, the age of the transfused PRBC, and not transfusing a PRBC with a potassium level above 15 mmol/L, they accomplished to suggest a safe and easy way for preventing transfusion associated hyperkalemia.