Being able to perform surgery first-hand represents the backbone of every training program and the key to successful development of the new generation of skilful surgeons. In this issue of the Journal, Comanici et al. presented a thorough systematic summary of the current evidence on the outcomes of cardiothoracic operations performed by trainees.1 Taking for granted the importance of training young surgeons, it is paramount to identify and tackle any potential obstacles hindering the surgical growth of a trainee.

Background: The hemodynamics of most prosthetic valves are often inferior to that of the normal native valve, and a significant proportion of patients undergoing surgical (SAVR) or transcatheter aortic valve replacement (TAVR) have high residual transaortic pressure gradients due to prosthesis–patient mismatch (PPM). Since the experience with TAVR has increased and long-term outcomes are reported, a close look at the PPM literature is required in light of new evidence. Methods: For this review, we searched the Embase, Medline, and Cochrane databases from 2000 to 2022. Articles reporting PPM as an outcome following aortic valve replacements were identified and reviewed. Results: The impact of PPM on clinical outcomes aortic valve replacement has not been clear since multiple studies failed to report PPM incidence. However, the PPM after SAVR vary greater than after TAVR, ranging from 8% to almost 80% in SAVR and from 24%-35% in TAVR. Incidence of severe PPM following redo SAVR is ranging from 2 to 9% and following valve-in-valve TAVR is from 14 to 33%, however, while PPM is higher in valve-in-valve TAVR, patients had better survival rates. Conclusions: The gap between valve performance and clinical outcomes in TAVR and SAVR could be reduced by carefully selecting patients for either treatment option. Understanding predictors of PPM can add to the safety, effectiveness, and increased survival benefit of both TAVR and SAVR.

The Vasoactive-Inotropic Score at 48 hours is a good surrogate marker for adverse postoperative events in pediatric patients undergoing cardiac surgery with cardiopulmonary bypass and is limited by its ability to delineate the underlying cause for an unfavourable clinical course. Thus, other predictors such as the Technical Performance Score are likely to highlight the underlying cause and can be used to improve outcomes. However, patients with a high postoperative VIS score at 48 hours may benefit from closer longer-term follow for outcomes such as late survival, functional class, and need for reoperation.

Objectives: New temperature management concepts of moderate and mild hypothermic circulatory arrest during aortic arch surgery have gained weight over profound cooling. Comparisons of all temperature levels have rarely been performed. We performed direct and indirect comparisons of deep hypothermic circulatory arrest (DHCA) (≤20°C), moderate hypothermic circulatory arrest (MHCA) (20.1°C to 25°C), and mild hypothermic circulatory arrest (mild HCA) (≥25.1°C) in a network meta-analysis. Methods: The literature was systematically searched for all papers published through February 2022 reporting on clinical outcomes after aortic arch surgery utilizing DHCA, MHCA and mild HCA. The primary outcome was operative morality. The secondary outcomes were postoperative stroke and acute kidney failure (AKI). Results: A total of 34 studies were included, with a total of 12 370 patients. DHCA was associated with significantly higher postoperative incidence of stroke when compared with MHCA (odds ratio (OR), 1.46, 95% (confidence interval) CI, 1.19-1.78) and mild HCA: (OR, 1.50, 95% CI, 1.14-1.98). Furthermore, DHCA and MHCA were associated with higher operative mortality when compared with mild HCA (OR 1.71, 95% CI, 1.23-2.39 and OR 1.50, 95% CI, 1.12-2.00, respectively). Separate analysis of randomized and propensity score matched studies showed sustained increased risk of stroke with DHCA in contrast to MHCA and mild HCA (OR, 1.61, 95% CI, 1.18-2.20, P-value = 0.0029 and OR, 1.74, 95% CI, 1.09-2.77, P-value = 0.019). Conclusions: In the included studies, the moderate to mild hypothermia strategies were associated with decreased operative mortality and the risk of postoperative stroke. Large-scale prospective studies are warranted to further explore appropriate temperature management for the treatment of aortic arch pathologies.

Background: Acute type A aortic dissection (ATAAD) is a life-threatening medical condition requiring urgent surgical attention. It is estimated that 50% of ATAAD die within 24 hours of onset, with the mortality rate is increasing by 1-2% every additional hour without prompt intervention. A variety of ATAAD surgical repair techniques exist which has sparked controversy within the literature, with the main two strategies being proximal aortic replacement (PAR) and total arch replacement (TAR). Nevertheless, the question of which of these two strategies if the more optimal is still debatable. Aims: This commentary aims to discuss the recent study by Sa and colleagues which presents a pooled analysis of Kaplan-Meier-derived individual patient data from studies with follow-up comparing aggressive (TAR) and conservative (PAR) approaches to manage ATAAD patients. Methods: A comprehensive literature search was performed using multiple electronic databases including PubMed, Ovid, Google Scholar, EMBASE and Scopus in order to collate the relevant research evidence. Results: The more aggressive TAR approach for treating ATAAD seems to yield more favourable results including more optimal long-term survival as well as a lower need for reoperation. The frozen elephant trunk (FET) technique can be considered the mainstay TAR technique. Conclusion: It is valid to conclude that TAR with FET is the superior strategy for managing ATAAD patients.

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.

Frozen elephant trunk (FET) has in recent times become a mainstay for total arch replacement (TAR) in aortovascular surgery and is indicated in order to treat a spectrum of complex aortic pathologies. However, despite associated excellent post-operative results it is incredibly important to recognise potential adverse complications such as negative aortic remodelling, endoleak and distal stent-graft induced new entry so that outcomes can be further improved. Below we provide commentary on a recent article in the Journal of Cardiac Surgery discussing the topic. Despite the fascinating outcomes of this systematic review and meta-analysis the heterogeneity of the literature regarding these adverse outcomes remains an issue which can only be solved with large multi-centre trials directly comparing graft types as well as indications for surgery.

anomalous pulmonary veins drain into the right side of the left atrium is an uncommon variety of anomalous pulmonary venous return. Rarely, anomalous pulmonary venous drainage combined with cor triatriatum and atrial septal defect. We presented the imaging findings of a male patient who had anomalous pulmonary venous drainage which has not previously been described.

The outcomes of the arterial switch operation have improved over a period of time with the elimination of coronary artery anatomy as a risk factor for operative mortality in some series. However, cumulatively, when all the series published so far are analyzed, two coronary variations, namely the single sinus coronary artery origin and intramural type, persist as risk factors for an adverse operative outcome.

There are no solid evidence from literature that compare Cox-Maze with pulmonary vein isolation technique for atrial fibrillation in the context of concomitant mitral valve surgery. While the first is perhaps more effective and linked to higher freedom form atrial fibrillation, it is more invasive compared to the pulmonary isolation.

The catastrophe of hypoxia in complex aortic surgery

A document by Sara Zaidi. Click on the document to view its contents.

Minimally invasive mitral valve surgery can be performed with or without robotic assistance. In this issue of the journal Zheng et al compare between these two approaches in a propensity matched study over a 5 year period and show that the two techniques have similar successful short and mid term outcomes. Although we are proponents of the robotic approach, we agree with their conclusions and discuss in this commentary some of the previously published studies that have shown similar findings.

The implementation of automatic fasteners such as the Cor-knot ® device (LSI Solutions, Inc.) has revolutionized the field of minimally invasive valvular surgery. Nonetheless, paravalvular regurgitation, valvular embolization, and early leaflet perforation are all potential complications which may occur. Late manifestations of leaflet perforation (>5-year post-implantation) are rare. Herein, we discuss a patient who underwent remote Trifecta ® (St. Jude, Inc.) surgical aortic valve replacement (SAVR) presenting with symptomatic critical aortic regurgitation secondary to leaflet perforation from automatically fastened metallic Cor-knot ® sutures.

Some would argue that kids aren’t just little adults, but what about their sternums? We are reviewing a manuscript by Horriat, McCandless, and colleagues in the Journal of Cardiac Surgery1 describing their experience with managing sternal wound infections (SWI) after congenital heart surgery. They report encouraging results in 14 patients who required plastic surgery consultation to manage their sternal wounds. The nature of congenital cardiac abnormalities and the necessary steps to repair them leads to physiologic derangements predisposing patients to SWI. Rates of SWI vary and have been reported at 1.53% in this population. There is little guidance on how the management of the congenital cardiac surgery patient should differ from the adult patient.2

Background: Mitral valve apparatus is complex and involves the mitral annulus, the leaflets, the chordae tendinae, the papillary muscles as well as the left atrial and ventricular myocardium. Secondary mitral regurgitation is consequence of regional or global left ventricle remodeling due to an acute myocardial infarction (75% of cases) or idiopathic dilated cardiomyopathy (25% of cases). It is associated with an increase in mortality and poor outcome. There is a potential survival benefit deriving from the reduction in the degree of severity of mitral regurgitation. So the correction of the valve defect can change the clinical course and prognosis of the patient. The rationale for mitral valve treatment depends on the mitral regurgitation mechanism. Therefore, it is essential to identify and understand the pathophysiology of the mitral valve regurgitation. Aim of the study: The aim of this review is to describe the crucial role of transthoracic and trans-esophageal echocardiography, in particular with 3D echocardiography, for the assessment of the severity of secondary mitral regurgitation, anatomy and hemodynamic changes in the left ventricle. Moreover, the concept that the mitral valve has no organic lesions has been abandoned. The echocardiography must allow a complete anatomical and functional evaluation of each component of the mitral valve complex, also useful to the surgeon in choosing the best surgical approach to repair the valve. Conclusions: Echocardiography is the first-line imaging modality for a better selection of patients, according to geometrical modifications of mitral apparatus and left ventricle viability, especially in preoperative phase.

A document by Carlos Mestres. Click on the document to view its contents.

Background: The average living age of the population is constantly increasing and so is the incidence and prevalence of aortic valve disease. Surgical aortic valve replacement (SAVR) is the current gold standard treatment. Nevertheless, the use of prosthetic valves in SAVR is associated with issues that impact patients’ quality of life. Aortic valve neocuspidization (AV Neo) offers a means to solve this dilemma by minimising foreign valve tissue. AV Neo can either be performed using glutaraldehyde-treated autologous pericardium (Ozaki procedure) or bovine pericardium (Batista procedure). Aims: This commentary aims to discuss the recent study by Chan and colleagues which highlighted the surgical approach, clinical outcomes and limitations of the Ozaki procedure, and compare this to the Batista procedure. Methods: A comprehensive literature search was performed using multiple electronic databases including PubMed, Ovid, Embase and Scopus in order to collate the relevant research evidence. Results: Although the Ozaki procedure can achieve favourable results whilst mainly avoiding the need for life-long oral anticoagulation with mechanical valves, it still has several limitations that may hinder results. AV Neo using glutaraldehyde-treated bovine pericardium, developed by pioneer cardiac surgeon Dr. Randas J. Vilela Batista, yields superior clinical outcomes to Ozaki’s, including excellent survival, lower complications and minimal need for reoperation as well as shorter operative times. Conclusion: AV Neo offers a means to perform SAVR whilst escaping the prosthetic valve issues. However, the Batista procedure has shown beyond doubt that it can be considered the superior approach for AV Neo over the Ozaki procedure.