Surgery for extensive thoracic aortic aneurysms is challenging. We report the case of a young woman with Takayasu’s arteritis who developed aortic dissection and was successfully treated with our novel extended arch repair method, which we termed “parabronchial approach”. Surgery was performed via a simple sternotomy. The left pulmonary artery was compressed caudally by a surgical assistant arm typically used for coronary artery bypass grafting. This method simplified the creation of a distal anastomosis to the descending aorta behind the left bronchus. Postoperative computed tomography revealed a distal anastomosis at the sixth thoracic vertebra . This parabronchial approach could reduce the frequency of choosing a highly invasive approach and can be a potential minimally invasive approach in cases requiring extensive thoracic aortic aneurysm repair.

The success of the left ventricular assist device (LVAD) as a treatment for terminal left-side heart failure is still restrained by some severe complications associated with mechanical circulatory support. Pump thrombus still affects many patients. It is associated with high morbidity and mortality. The therapeutic options include augmentation of anticoagulation and antiplatelet medication, intravenous or catheter-guided thrombolysis, and pump exchange. Heart transplantation would be a desirable option in this population, but unfortunately, it is only theoretical given the increasing number of LVAD implants and decreasing number of organ donors. A retrograde washout maneuver may be a treatment option in pre-pump thrombosis in selected patients. Therefore, the decision should be made on an individual basis after balancing the risks and benefits of different treatment approaches.

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

Frozen Elephant Trunk (FET) has revolutionized management of aortic arch and proximal descending aorta pathologies. Despite significant advancement in FET prosthesis design in recent years, adverse outcomes related with neurologic and visceral ischemic events remained unsolved. To address this issue, several publications evaluated protection strategies to reduce body lower ischemic time. In the present commentary we put the technique promoted as “Release and Perfuse Technique” on scale that is for achievement of less lower body circulatory arrest time.

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

This is an invited commentary and does not need a commentary.

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.

Background: Although concomitant pulmonary vein isolation (PVI) is used more frequently than the Cox-maze procedure, which is currently the gold standard treatment for AF, data on the comparative effectiveness of the two procedures after concomitant mitral valve (MV) surgery are still limited. Objective: We conducted a systematic review to identify randomized controlled trials (RCT) and observational studies comparing the mid-term mortality and recurrence of atrial fibrillation (AF) after concomitant Cox-Maze and PVI in patients with AF undergoing MV surgery based on 12-month follow-up. Methods: Medline, EMBASE databases, and the Cochrane Library were searched from 1987 up to March 2022 for studies comparing concomitant Cox-Maze and PVI. A meta-analysis of RCTs was performed to compare the mid-term clinical outcomes between these two surgical ablation techniques. Results: Three RCTs and 3 observational studies meeting the inclusion criteria were included in this systematic review with 790 patients in total (532 concomitant Cox-Maze and 258 PVI during MV surgery). Most studies reported that concomitant Cox-Maze procedure was associated with a higher freedom from AF at 12-month follow-up than PVI. Regarding AF recurrence, estimate pooled across the 3 RCTs indicated large heterogeneity and high uncertainty. In the largest and highest quality RCT, 12-month AF recurrence was higher in the PVI arm (RR=1.58, 95%CI 0.91-2.73). In 2 out of 3 higher quality observational studies, 12-month AF recurrence was higher in PVI than in Cox-Maze arm (estimated adjusted probabilities 11% vs. 8% and 35% vs. 17%, respectively). RCTs demonstrated comparable 12-month mortality between concomitant Cox-Maze and PVI, while observational studies demonstrated survival benefit of Cox-Maze. Conclusions: Concomitant Cox-Maze in AF patients undergoing MV surgery is associated with better mid-term freedom from AF when compared to PVI with comparable mid-term survival. Large observational studies suggest that there might be a mid-term survival benefit among patients after concomitant Cox-Maze. Further large RCTs with longer standardized follow-up are required in order to clarify benefits of concomitant Cox-Maze in AF patients during MV surgery.

In this article, the author provides synopses of the factors that have finally propelled healthcare education and practice to join, at times reluctantly, the overarching digital transformative process that has been swept other industries over the last few decades. The key contributors and driving forces that have energized the entry of healthcare education and practices are mentioned. The roles of major universities, large technology companies and the expanding roles of Artificial Intelligence and Machine Learning are described. The projected future developments are predicted to continue to be substantial, sweeping and forcing changes that are unprecedented. Thus, academicians and practitioners should be alerted to what the rapidly changing landscape is likely to become and accordingly take steps to manage and preserve their roles or risk be left behind or worse be forced out.

Title Page:Title: Letter to the Editor: Long-term outcomes of elderly patients receiving continuous flow left ventricular supportArticle Type: Letter to the EditorCorrespondence: 1. Saad Ahmed qureshiContact No: +92-3360135206. Email: [email protected]: Ziauddin medical college KarachiAddress: NHS phase 4 tower 5b flat 5/7ORCID: 0000-0003-0857-3818Co-Authors: 2. Hamid ullah khanContact No: +92-3040215080. Email: [email protected]: Ziauddin University karachiAddress: Plot no AS 04 sector 32-D Nasir colony Korangi no 01ORCID: 0000-0002-0938-6080Co-Authors: 3. Umer sami KhanContact No: +92-304044743. Email: [email protected]: Ziauddin University karachiAddress: B4, Block B, Gulshan-e-jamal, Rashid minhas Road, KarachiORCID: 0000-0003-0849-7915Word Count: 320

Title pageTitle: Letter to the Editor: Aortic valve repair in patients with ventricular septal defectArticle type: Letter to the editorCorrespondance : 1. Mahima KhatriContact: +92-3472651872 Email: [email protected]: Dow University of Health SciencesAddress: Bridgeview Karachi

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.

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.

A document by Jordan Llerena-Velastegui. Click on the document to view its contents.

A document by Jordan Llerena-Velastegui. Click on the document to view its contents.

A document by Muhammad Usman. Click on the document to view its contents.

TITLE PAGE Title: Letter to the Editor: Minimally invasive aortic valve repair using geometric ring annuloplastyArticle type: Letter to the editorCorrespondence : 1. Bilawal NadeemContact: +92-3137562580 Email: [email protected]: King Edward Medical University, LahoreAddress: Mianwal Ranjha Dera Allah Wadhaya Tehsil and District Mandi Bahauddin, 50400Words count: 418Conflict of interest: noneDisclosure: noneFunding: none

Background: There is emerging evidence to support pre-emptive thoracic endovascular aortic repair (TEVAR) intervention for uncomplicated type B aortic dissection (unTBAD). Pre-emptive intervention would be particularly beneficial in patients that have a higher baseline risk of progressing to complicated TBAD (coTBAD). There remains debate on the optimal clinical, laboratory, morphological and radiological parameters which would identify the highest-risk patients that would benefit most from pre-emptive TEVAR. Aim: This review summarises evidence on the clinical, laboratory, and morphological parameters that increase the risk profiles of unTBAD patients. Methods: A comprehensive literature search was carried out on multiple electronic databases including PubMed, EMBASE, Ovid and Scopus in order to collate all research evidence on the the clinical, laboratory, and morphological parameters that increase the risk profiles of unTBAD patients Results: At present, there are no clear clinical guidelines using risk-stratification to inform the selection of unTBAD patients for TEVAR. However, there are noticeable literature trends that can assist with the identification of the most at-risk unTBAD patients. Patients are at particular risk when they have refractory pain and/or hypertension, elevated C-reactive protein (CRP), larger aortic diameter and larger entry tears. These risks should be considered alongside factors that increase the procedural risk of TEVAR to create a well-balanced approach. Advances in biomarkers and imaging are likely to identify more pertinent parameters in future to optimise the development of balanced, risk-stratified treatment protocols. Conclusion: There are a variety of risk profiling parameters that can be used to identify the high-risk unTBAD patient, with novel biomarkers and imaging parameter emerging. Longer-term evidence verifying these parameters would be ideal. Further randomized controlled trials and multicentre registry analyses are also warranted to guide risk-stratified selection protocols.