Carcinoid heart disease is a rare condition that occurs in half of patients with carcinoid syndrome. The disease mostly affects right-sided heart valves; however, in 5-10%, it can also involve left-sided valves. This case illustrates the most complicated form of the disease with involvement of four heart valves.

Background: Epicardial pacemakers are known as an alternative for endocardial pacemakers in some cases such as heart block, and complex congenital heart diseases. Considering recent advances and improvement of epicardial lead subtypes, it is essential to investigate the long-term function of them. In this study, we aimed to assess the sensing and pacing characteristics, and survival of bipolar steroid-eluting and unipolar non-steroid-eluting epicardial pacemakers. Methods: We conducted an entirely concentrated search on the documents of all patients who had undergone epicardial lead implantation in the Shaheed Rajaie Cardiovascular, Medical & Research Center during 2015-2018. Implant, and follow up data were extracted. Kaplan Meier analysis and Weibull regression hazards model were applied for the survival analysis. Results: eighty-nine leads were implanted for 77 patients. Of the total leads, 52.81%, 53.93%, and 47.19% were implanted in children (under-18-year-old), females, and patients with congenital heart diseases, respectively. Bipolar steroid-eluting leads comprised 33.71% of 89 leads. Pacing threshold of unipolar non-steroid-eluting leads that were implanted on the left ventricle and right atrium increased significantly during the follow up to greater records than bipolar steroid-eluting leads. Survival analysis also revealed that bipolar steroid-eluting leads are significantly better in 48-month survival (Weibull HR: 0.13 (95%CI, 0.02-0.99), p-value, 0.049). Age, ventricular location of the lead, and acute pacing characteristics were not associated with survival. Conclusions: Bipolar steroid-eluting epicardial leads have an acceptable survival compared with unipolar non-steroid-eluting, without a significant difference regarding patients age. Therefore, they could be an excellent alternative for endocardial ones.

Background: The introduction of the frozen elephant trunk (FET) technique for total arch replacement (TAR) has revolutionized the field of aortovascular surgery. However, although FET yields excellent results, the risk of certain complications requiring secondary intervention remains present, negating its one-step hybrid advantage over conventional techniques. This systematic review and meta-analysis sought to evaluate controversies regarding the incidence of FET-related complications, with a focus on aortic remodeling, distal stent-graft induced new entry (dSINE) and endoleak, in patients with type A aortic dissection (TAAD) and/or thoracic aortic aneurysm. Materials and methods: A comprehensive literature search was conducted using multiple electronic databases including EMBASE, Scopus, and PubMed/MEDLINE to identify evidence on TAR with FET in patients with TAAD and/or aneurysm. Studies published up until January 2022 were included, and after applying exclusion criteria, a total of 43 studies were extracted. Results: A total of 5068 patients who underwent FET procedure were included. The pooled estimates of dSINE and endoleak were 2% (95% CI 0.01-0.06, I 2 = 78%) and 3% (95% CI 0.01-0.11, I 2 = 89%), respectively. The pooled rate of secondary thoracic endovascular aortic repair (TEVAR) post-FET was 7% (95% CI 0.05-0.12, I 2 = 89%) whilst the pooled rate of false lumen thrombosis at the level of stent-graft was 91% (95% CI 0.75-0.97, I 2 = 92%). After subgroup analysis, heterogeneity for dSINE and endoleak resolved among European patients, where Thoraflex Hybrid and E-Vita stent-grafts were used (both I 2 = 0%). In addition, heterogeneity for secondary TEVAR after FET resolved among Asians receiving Cronus (I 2 = 15.1%) and Frozenix stent -grafts (I 2 = 1%). Conclusion: Our results showed that the FET procedure in patients with TAAD and/or aneurysm is associated with excellent results, with a particularly low incidence of dSINE and endoleak as well as highly favorable aortic remodeling. However the type of stent-graft and the study location were sources of heterogeneity, emphasizing the need for multicenter studies directly comparing FET grafts. Finally, Thoraflex Hybrid can be considered the primary FET device choice due to its superior results.

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.

Background: The advent of Frozen elephant trunk (FET) for reconstruction of elective and non-elective aortic arch surgery has augmented the treatment of complex aortic pathologies in a single-stage operation. To date, no studies have been focused on the prevalence and predictors of coagulopathy potentiated by FET procedure. Methods: In a systematic review, we searched databases up to June 2020 for studies reporting coagulopathy complications after FET procedure. A proportional meta-analysis was carried out using STATA software (StataCorp, TX, USA). Results: In total, 46 studies including 6313 patients were eligible. The pooled estimation of reoperation for postoperative bleeding was 7% (95% confidence interval [CI] 5 to 8; I2 = 84.73%; reported by 39 studies including 4796 patients). The mean volume of transfused packed blood cells and fresh frozen plasma was 1677 ml (95% CI 1066.4-2287.6) and 1016.5 ml (95% CI 450.7-1582.3). The subgroup by stent type showed a decrease in the heterogeneity (I2 = 0.01%, I2 = 53.95%, I2 = 0.01%, and I2 = 54.41% for Thoraflex® Hybrid, E-vita®, Frozenix®, and Cronus®, respectively). The subgroup by chronicity of operation resulted in less heterogeneity among patients undergoing elective compared to non-elective operation (I2 = 29.22% versus I2 = 80.56% in non-elective). Meta-regression analysis showed that age and male gender significantly impacted on the reoperation for postoperative bleeding. Conclusions: The FET procedure for arch replacement is associated with coagulopathy and the transfusion of blood products. Male, age, and selective choice of FET use were identified as heterogeneity sources of reoperation for postoperative bleeding.

The coronavirus disease 2019 (COVID-19) pandemic has presented unique challenges to international health care systems. Management of the current pandemic puts a huge strain on health care sectors and leads to new strategies conducting by health care systems in countries across the world. In the present article, we review the epidemiologic data, Iranian health care system response, as well as the effects of COVID-19 pandemic on cardiac surgery practice in Iran

Background: The COVID19 pandemic gripped every nation’s healthcare system and provisions on all levels. In cardiac and aortic surgery, as it is with most specialities, elective surgeries were halted. Aims of the study: We captured reflections, contingencies, and current practices across of high-volume centres in cardiac and aortic surgery globally. We also aimed this study to assess decision on prioritization of the surgical patients, the need for personal protection equipment and choice of preoperative investigations in current dynamic and fluid climate. Methods: A validated web-based questionnaire was constructed and was circulated to the international surgeons amongst high volume cardiac and aortic surgery centres. Their intrinsic feedback on decision making, impact of the lockdown and perspectives for the future ahead us all were noted. Mixed method approach was constructed. Qualitative data analysis was introduced to signify the impact globally. Results: Overall, 23 centers from 18 countries participated in this international study. 91.7% of the respondents stopped operating on elective patients during the pandemic. Majority of the surgeons agreed that acute aortic dissection (87.1%) should be operated as emergency procedure and stable triple vessel disease (87.1%) to be considered as elective procedure. Three-fifth (60%) of the respondents relied on CT chest as a preoperative screening modality. Conclusion: In the present climate where there is paucity of evidence, this will give an interim consensus for the cardiac surgeons. With the increase in cumulative number of COVID19 patients, careful utilization of the resources regarding hospital beds and manpower is of paramount importance.