Background: With the limited number of available suitable donor hearts resulting in plateaued numbers of heart transplantations, short- and long-term mechanical circulatory support devices, including the implantation of total artificial hearts (TAH) are modalities that are increasingly being used as treatment options for patients with end-stage heart failure. The superior vena cava syndrome has been described in this context in various disease processes. We report successful venoplasty for superior vena cava syndrome in a patient with a TAH. Case Presentation: A 65 years old man with a history of non-ischemic cardiomyopathy had received a left ventricular assist device, and then two years later underwent orthotopic heart transplantation using the bicaval anastomosis technique. The post procedural course was complicated by primary graft failure, resulting in the need for the implantation of a TAH. About 5 months after the TAH implantation he started to develop complications such as volume retention, swelling of the upper extremities, and was diagnosed to have a superior vena cava syndrome. The patient underwent a successful venoplasty of his superior vena cava by interventional radiology with resolution of upper body edema, normalization of renal and liver function. Conclusion: Potential fatal complications caused by catheter or wire entrapment in the right sided mechanical valve of a TAH have been reported. We describe a safe method for the treatment of superior vena cava syndrome in patients with TAH.

Background Fractional flow reserve (FFR) is a well-established method for the evaluation of coronary artery stenosis before PCI. However, whether FFR assessment should be routinely used before CABG remains unclear. Our aim was to compare the outcomes of using FFR with that of conventional CAG (coronary angiography) in guiding CABG. Method This systematic review and meta-analysis was performed according to the PRISMA guidelines. Six studies were included, of which four were double-arm (two prospectively randomised) and two single-arm, reporting data on 1931 patients. A meta-analysis was done for double-arm studies, comparing rates of overall death, MACCE, target vessel revascularisation, spontaneous MI and graft patency. The data of all six studies were entered in a pooled analysis for the endpoints of overall death, spontaneous MI and target vessel revascularisation. Results Meta-analysis demonstrated significantly lower death rates in the FFR-guided than the CAG-guided group (p=0.03) and no significant differences in the rates of MACCE, target vessel revascularisation, spontaneous MI and graft patency. In pooled analysis, FFR-guided group was linked with lower rates of overall death and spontaneous MI. Graft occlusion rate was significantly lower after FFR in one retrospective study, however, this difference was lost in meta-analysis (p=0.24). Conclusion In this meta-analysis, FFR-guided CABG was associated with lower overall death rate and was, at least, non-inferior in the endpoints of MACCE, target vessel revascularisation, spontaneous MI and graft patency than CAG-guided CABG. Further randomized trials are needed to define the role of FFR in guiding CABG surgery.

Postoperative thoracic aortic graft infection (TAGI) is a serious and potentially fatal complication. The classical approach is to replace the infected graft. However, this approach has a high mortality rate. Alternatively, treatment of TAGI without graft replacement can be performed. Herein, we present successful treatment of the case of a 72-year-old patient with mediastinitis and graft infection after type A aortic dissection operation for whom we performed omental flap coverage following vacuum-assisted wound closure therapy without graft replacement. The patient had an uneventful postoperative course and remained infection free for the last 36 months to date.

Background and aim: Revascularization guidelines support routine heart team (HT) discussion of appropriate patients. The effect of HT on decision making and clinical outcomes hasn’t been explored. The aim of our study is to investigate the impact of the HT on the mode and delay to revascularization. Methods: We compared data from a prospective cohort of consecutive patients with multivessel coronary artery disease referred for HT discussion between 2016-2017 (HT group) with a historic control group of patients matched according to clinical and angiographic characteristics treated between 2005-2015 (No HT group). Results: There were 93 patients in each group. The HT group and the No HT groups had a similar rate of ACS as well as cardiovascular risk factors and significant left ventricular (LV) dysfunction. No difference was observed in the mean Society of Thoracic Surgery (STS) score (2.5± 3 vs. 3 ±3 p=0.32) and the mean SYNTAX score was low and similar in both groups (21±6 vs. 19±6 p=0.59). The treatment recommendations changed greatly, with 63% of patients being referred for coronary artery bypass grafting (CABG) after HT discussion but only 23% in the no HT group (p<0.01). HT discussion led to a significant delay to PCI (8±5 vs. 1.8±4 days, p=0.02), while surgical revascularization times were not affected. Conclusion: HT discussion in patients with multivessel CAD was associated with an increased referral to CABG but led to a significant delay in revascularization by angioplasty. The impact of these findings on patient satisfaction and outcome should be further investigated.

Background and Aims- A fracture and retention of guidewire after cardiac resynchronization therapy device implant has not been reported so far, although it is an uncommon but known complication during cardiac interventions like percutaneous coronary interventions and other cardiac catheterization procedures. Methods- A 53 years old female patient presented to us, who had been diagnosed as a case of dilated cardiomyopathy with severe left ventricular dysfunction and underwent cardiac resynchronization therapy (CRT-D) device implant three years back and subsequently underwent lead replacement 6 months back due to lead dysfunction, with severe pain over the left arm and shoulder for last 1-2 days. On evaluation, it was found that she had a coronary guidewire which might have fractured and retained inadvertently in previous surgical procedure and has caused her symptoms that might have been aggravated by the movements of her arm. Emergency surgical exploration was done and the guidewire which was impacted in deltoid muscle was removed. Results, and Conclusion- We are reporting the case due to a very unlikely and unusual delayed presentation of retained intervention guide-wire post cardiac resynchronization therapy, retrieved from left deltoid muscle.

Cryoglobulinemia is a cold-reactive autoimmune disease. A 64-year-old man with active cryoglobulinemia presented Stanford type A acute aortic dissection. He had been treated with immunosuppressive drugs and plasma exchange (PE) at our hospital; subsequently, qualitative analysis of cryogobulin (CG) was negative. He underwent emergency ascending aorta replacement using cardiopulmonary bypass (CPB) under deep hypothermia circulatory arrest with selective cerebral perfusion. The total CPB time, aortic cross clamp time, and selective cerebral perfusion time were 255, 153, 56 minutes, respectively, and the minimal nasopharyngeal temperature was 17.3°C. Our patient had no significant perioperative complications. Hence, if PE is performed appropriately and CG is negative, patients with cryoglobulinemia who exhibit severe preoperative symptoms can safely undergo surgery with deep hypothermia.

Over the last two decades, the medical community witnessed an outstanding and accelerated development on minimally invasive therapies. With the dorsal spine of supportive data from large randomized control trials, transcatheter aortic valve replacement (TAVR), aortic and mitral valve-in-valve, mechanical circulatory support and peripheral endovascular interventions all share the need of accessing a vascular bed with a large bore catheter. Nevertheless, to date, there has yet to be a universal consensus on defining large-bore vascular access (LBVA) in the world of transcatheter therapies. We explore the evolution, characteristics and vascular compatibility of the current commercially available devices, analyze the devices along with access site-specific complications rates and finally review the present methods for percutaneous vascular closure.

The authors present a case report about elective replacement of a mechanical bental with a bioprosthetic valve. The authors describe a technique whereby the mechanical valve is ‘broken’ off it’s mechanism and the new valve is sutured in the old cuff.

Objectives: Though guidelines are set by the American Board of Thoracic Surgery for the operative cases that cardiothoracic surgery residents must perform to be board-eligible, no such recommendations exist to assess competency for the wide range of high-risk bedside procedures. Our department created and implemented a multi-disciplinary developed course designed to standardize common high-risk bedside procedures and credential our residents. The aim of this study was to survey the attitudes of residents to and query the efficacy of such a course. Methods: The course was designed with the goal of standardizing endotracheal intubation, arterial line insertion (radial and femoral), central venous line insertion, pigtail tube thoracostomy and nasogastric tube placement. The course consisted of an online module followed by a 4-hour hands on simulation session. Knowledge based pre and post evaluations were administered as well as Likert based survey regarding multiple aspects of the residents’ perceptions of the course and the procedures. Results: Twenty-three (7 traditional and 16 integrated) cardiothoracic surgical residents participated in the course. Residents reported that 48% of the time, bedside procedures were historically taught by other trainees rather than faculty. All residents endorsed increased standardization of all procedures after the course. Likewise, residents showed increased confidence in all procedures except for pigtail and thoracentesis as well as nasogastric tube placement. 43.5% of the participants demonstrated improvement in the pre and post-test knowledge-based evaluations. ConclusionCardiothoracic residents have favorable attitudes towards standardization and credentialing for high risk bedside procedures and utilizing such courses may help standardize procedural techniques.

Dear Editor, With great interest, I read the article by Flécher et al1 and congratulate them on the quality of the review carried out on the history of surgical treatment of cardiac wounds. It is an exciting topic, so I would like to briefly comment on some facts narrated in this work.The well-known surgical approach to the heart, described by Larrey in the subxiphoid region, should not be placed in a close historical relationship with the pericardiotomy he performed in 1810 through a thoracotomy. It was not until 1824 that, after treating a soldier who had suffered a penetrating wound between the xiphoid appendix and the 7th costal cartilage, the French surgeon began experimenting on cadavers in search of a faster route to the heart. In 1829 he proposed his oblique subcostal incision which is currently practically not used.2During Milton’s service in Egypt, he surely performed several thoracic surgeries in extremis situation, but there is no evidence to support the claim that median longitudinal sternotomy (MLS) was created during an emergency approach3 or that has been designed for this type of procedure. When he decided to operate on a living human being on January 25, 1897, he used it for an elective total sternectomy in a patient with sternal tuberculosis and ruled out its use in patients with true mediastinal tumors, who needed more urgent surgeries.On the other hand, it can hardly be said that MLS is currently the gold standard for cardiac surgeons to safely and quickly manage a cardiac stab wound. In patients such as those shown in the article,1 an approach using a MLS would be very difficult since lateral mobilization of the costal wall during the necessary separation of the two halves of the sternum would displace the knife, causing probably fatal bleeding.In the emergency room, the gold standard for quickly managing a penetrating cardiac injury is anterolateral thoracotomy in the fifth intercostal space. A 1906 article on experimental surgery in dogs has led some authors to mistakenly consider Spangaro to be the creator of this incision.4 They forget that in 1893 Daniel Hale William performed his famous pericardioraphy (the second in history) precisely using that approach.5References1. Flécher E, Leguerrier A, Nesseler N. An odyssey of suturing cardiac wounds: Lessons from the past. J Card Surg. 2020;35(7):1597-9.2. López de la Cruz Y, Quintero Fleites YF. Modifications to the classic simple-longitudinal inferior pericardiotomy (Sauerbruch technique). CorSalud. 2019;11(3):225-32.3. Milton H. Mediastinal Surgery. Lancet. 1897;1:872 - 5.4. Pust GD, Namias N. Resuscitative thoracotomy. International Journal of Surgery. 2016;33:202-8.5. Buckler H. Doctor Dan. Pioneer in American surgery. Boston: Little, Brown and Company; 1954.Correspondence: “July 26” Ave., No. 306, Apt. 18. Santa Clara. Villa Clara. Cuba. Postal code: 50 200. E-mail: [email protected]

An anomalous origin of the left circumflex coronary artery that arises as a side branch of the right coronary artery and encircles the aortic annulus is usually an incidental finding. However, in patients undergoing aortic valve/root procedures, its existence can significantly complicate the surgical treatment. We report our operative strategy with three different prostheses without valve downsizing.

Minimally Invasive Aortic Valve Replacement is not just a metric of the incision, but rather a holistic approach to minimize the surgical trauma: the technique should reproduce the gold-standard conventional procedure in terms of safety, effectiveness and operative times through a small and different incision. Moreover, the procedure should be simple and reproducible in every Center all over the world. In our experience, we rely more on surgical skills and technique optimization, rather than CT-scan planning: definitely, the pre-operative imaging is helpful in the beginning of the experience to rule out difficult cases.

We report a rare case of liver alveolar echinococcosis with an invasion of the hepaticocaval confluence, inferior vena cava, pericardium, right atrium, atrial septum, and superior vena cava, and its successful treatment by combined heart-liver transplantation

BACKGROUND: To assess the feasibility and outcome of Continuous Cerebral and Myocardial Selective Perfusion (CCMSP) during aortic arch surgery in neonates. METHODS: This retrospective single-center study was conducted between 2008 and 2019 in neonates undergoing aortic arch surgery, accompanied or not by cardiac malformation repair. CCMSP at moderate hypothermic of 28°C was achieved using selective brachiocephalic artery and ascending aorta cannulation. Target rates of cerebral and myocardial perfusion were 25-35 mL/kg/min and 150/m2/min. Cardiopulmonary bypass (CPB) variables and clinical outcomes were analyzed. RESULTS: Overall, 69 neonates underwent either isolated aortic arch repair (n=31) or aortic arch repair with ventricular septal defect (VSD) closure (n=38). The mean age and weight were 9.79±7.1 days and 3.17±0.4Kg, respectively. Mean CPB and aortic clamping times were 133.5±47.0 and 25.2±5.3 min for isolated aortic arch repair, and 158.4±47.9 and 75.4±30.5 min for aortoplasty accompanied by VSD closure. Mean CCMSP time was 51.6±21.5 min with cerebral rate of 32.6±10.0mL/Kg/min. Two major complications arose: stroke (n=1; 1.44%) and transient renal failure requiring dialysis (n=2; 2.89%). Neither myocardial nor visceral ischemia occurred. In-hospital mortality was 1/69 (1.44%). CONCLUSIONS: CCMSP is a safe and reproducible strategy for cerebral, myocardial and visceral protection in neonatal aortic arch repair, with or without VSD closure, resulting in low complication and mortality.

Objective: The arterial switch operation is the standard treatment for the transposition of the great arteries. The timely variation in the residual pressure gradient across the pulmonary arteries is ill-defined. This work is aimed to study the progressive changes in the pressure gradient across the pulmonary valve and pulmonary arteries after arterial switch operation (ASO). Methods: All eligible patients for this study who underwent arterial switch operation between 2000 and 2019 were reviewed. Transthoracic echocardiography (TTE), was used to estimate the peak pressure gradient across the pulmonary artery and its branches. The primary outcome was the total peak pressure gradient (TPG) which is the sum of peak pressure gradients across the main pulmonary artery and pulmonary artery branches. Furthermore, a longitudinal data analyses with mixed effect modeling were used to determine the independent predictors for the changes in pressure gradient. Results: 309 patients were included in the study. Over 17-year follow up, the freedom from pulmonary stenosis reintervention was 95% (16 out of the 309 patients underwent reintervention = 5%). the Longitudinal data analyses of serial 1844 echocardiographic studies for the included patients revealed that the TPG recorded in the first postoperative echocardiogram across pulmonary valve, right and left pulmonary artery branches was the most significant predictor for reintervention. Conclusion: The total peak gradient measured in the first postoperative echocardiogram is the most important predictor for reintervention. We propose that a total peak gradient in the first postoperative echocardiography of 55 mmHg or more is a predictor for reintervention

Background: This bibliometric analysis is used to identify publications and highlights the key areas that have significantly shaped modern clinical practice for aortic valve replacement (AVR), which is becoming increasingly relevant. The top 100 most cited manuscripts for AVR were analysed. Method: The Thomson Reuters Web of Science database was searched using the terms ‘aortic valve replacement’, ‘replacement’, ‘aortic valve’ and/or ‘AVR’ for full manuscripts in English Language. The results were ranked by citation number and the top 100 articles were further analysed by subject, author, journal, year of publication, institution and country of origin. Results: 26,782 eligible papers were returned and accumulated 76,680 citations in total, with a mean citation of 767 per manuscript (350-3667). The New England Journal of Medicine accumulated the most citations whereas Circulation published the most papers. Majority of manuscripts examined patients with aortic stenosis, of which half also included aortic regurgitation. The United States of America contributed 51 manuscripts, accumulating 43629 citations. Conclusion: The most cited manuscript, by Leon et al., assessed the outcomes of transcatheter aortic valve implantation in patients with severe aortic stenosis who were unfit for surgical replacement. By providing the most influential references this work serves as a guide to topics of interest in the field of AVR.

We report an emergent complex hybrid repair of a type A Intramural Hematoma with a tear of the aortic arch at the site of Kommerell's Diverticulum and an Aberrant Right Subclavian Artery. We identified a type Ia endoleak intraoperatively, which was managed immediately with proximal extension. Performing this operation in the hybrid operating room facilitated optimal surgical management.

We present an unusual combination of lesions in an eight months old child diagnosed with Tetralogy of Fallot (TOF), Anomalous origin of Right Pulmonary artery (AORPA) and anomalous coronary artery (ACA) crossing the pulmonary annulus. The association of AOPA and TOF is extremely rare with an incidence of 0.4%. (1) The incidence of anomalous coronary artery in TOF is 10.3%. (3) However a combination of all three lesions poses challenges to surgical repair and has not been previously reported.