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: Transcatheter mitral valve implantation (TMVI) is a promising and minimally invasive treatment for high-risk mitral regurgitation (MR). The purpose of this study was to investigate the feasibility of a novel self-expanding valved stent for transcatheter mitral valve implantation via apical access. Methods: A novel self-expanding mitral valved stent system was designed and fabricated for the in vivo evaluation. It is consists of an atrial flange and a saddle-shaped ventricular body connected by two opposing anchors and two opposing extensions. During the valve deployment, each anchor is controlled by a recurrent string. TMVI was performed in ten pigs using the valve prosthesis through the apical access to verify technical feasibility. Echocardiography and ventricular angiography were used to assess hemodynamic data and valve function. The surviving pigs were sacrificed four weeks later to confirm stent deployment. Results: Ten animals underwent transapical mitral valve implantation with the novel mitral valved stent. Optimal valve deployment and accurate anatomical adjustment were obtained in nine animals. Implantation failed in one case, and the animal died one day later due to stent mismatch. After stent implantation, the hemodynamic parameter of other animals was stable and valve function was normal. The mean pressure across the mitral valve and left ventricular outflow tract (LVOT) were 2.98±0.91mmHg and 3.42±0.66 mmHg, respectively. The macroscopic evaluation confirmed the stable and secure positioning of the stents in the mitral valve. No obvious valve displacement, embolism, and paravalvular leakage were observed four weeks after valve implantation. Conclusions: This study proved that the novel mitral valved valve stent is technically feasible in animals. This device features opposing anchors, opposing recurrent strings, and saddle-like ventricular portions, providing structural design details for reducing TMVI complications. However, the long-term feasibility and durability of this valved stent need to be improved and verified.

Background and aim of the study. Wrapping of the ascending aorta (AA), isolated or associated with aortoplasty, has never been completely accepted. Some complications, as folding of the aortic wall, compression of the vasa vasorum and changes in the flow pattern, with consequent dilatation of the proximal arch, have been described. We used fresh autologous pericardium (FAP), so far never reported, to wrap the AA, with the aim to stabilize its size when moderately dilated, maintaining the preoperative dimension or limiting the reduction to a few mm. Material and Methods. From 2015 to 2019, 10 patients, who were operated on for valve or coronary surgery or both, underwent wrapping of the AA with FAP. Mean age was 69±7 years and ESII 3.5±1.7. Four patients had moderately impaired ejection fraction (35-49%). Results. There was no early or late mortality. One patient was reoperated on after 48 months for severe mitral regurgitation. At a follow up of 53±14 months, a transthoracic echocardiogram showed that the AA size reduced slightly but significantly, from 45.2±2.0 to 42.5±4.1 mm, p=0.03. The diameter of the proximal arch remained unchanged, from 37.1±1.6 to 36.3±2.9 mm, p=0.20. Conclusions. In presence of moderately dilated AA wrapping can be a reasonable option. The use of FAP stabilizes the size of the aorta after a follow up of 53 months. Maintaining a size similar to the preoperative one avoids the complications related to the procedure.

Pericardiectomy for Constrictive Pericarditis after Mediastinal Irradiation – Need for Functional AssessmentSiddharth Pahwa, MD1

Background: While enhanced recovery after surgery (ERAS) pathways have been successfully applied for cardiac surgery, there has been limited research directly comparing ERAS protocols to ad hoc narcotic use after surgery. We hypothesized that a standardized ERAS protocol would provide similar pain management and psycho-emotional outcomes while decreasing the use of opioids in the hospital and after discharge. Methods: As part of a 7-month quality improvement project, cardiac surgery patients on a fast tracked to extubate pathway were assigned PRN narcotic pain management for 3 months (n=49). After a 1-month ERAS protocol optimization period, a separate group of patients were given the ERAS protocol (n=34). Clinical outcomes were gathered, and participants completed a quality of recovery survey that allowed for the assessment of pain and symptom control at 4 time-points post-surgery. Results: Among 83 participants, 66% were male and the mean age was 53 years. There were no differences in patient characteristics between PRN and ERAS groups (all p>0.244). There were no differences between ERAS and PRN groups for surgery characteristics (all p>0.060), inpatient outcomes (all p>0.658), or after-discharge outcomes (all p>0.397). Furthermore, across all time-point comparisons, there were no supported differences in patient-reported outcome and pain control between the ERAS and PRN narcotic groups (all p>0.075). Conclusions: An ERAS protocol demonstrated similar patient outcomes and pain control to traditional opioid use for postoperative cardiac surgery patients. Further research is recommended to further confirm the results of this study.

Emergency surgery for Type A Aortic Dissection in Octogenarians – do we still err on the side of caution?

This case report describes the management of a large iatrogenic ventricular septal defect (VSD) created by the coring device during systemic ventricular assist device (RVAD) insertion in a 16 year-old patient with congenitally corrected transposition of the great arteries. The VSD was closed by bovine pericardial patch and the ventriculotomy was extended laterally to relocate the VAD sewing ring. After RVAD implantation, patient initially remained cyanotic, potentially due to a tiny VSD patch leak with right to left shunting. Hypoxia was successfully corrected by rescue nitric oxide infusion and patient was bridged to transplant after 91 days.

during Ozaki procedure, relocating a valvular commisure could be technically demanding. This novel technique provides an easy tool to achieve valvular simmetry avoiding commisure shifting.

We reported a case of a 3-month-old infant presented with supravalvular aortic stenosis with congenital right coronary artery deficiency. According to cardiovascular CT results, Doty technique was adopted to restore the aortic root geometry under cardiopulmonary bypass. An angioplasty was performed to establish right coronary blood flow at the same time. The patient had no abnormal cardiac symptoms after surgery.

Infectious complications have been shown to increase the morbidity of venous-venous extracorporeal membrane oxygenation (VV-ECMO) population, including the use of right ventricular assist devices. We aimed to evaluate our VV-ECMO population for ECMO related bloodstream infections (E-BSI) and characteristics that affect risk and overall outcomes. We report a low infection rate of 2.7%. We postulate our low BSI rate may be due to our use of perioperative antimicrobials as well as a majority of our cannulations occurring in the operating room. Further investigation into trends, risks, and outcomes related to E-BSI is needed.

We present a reply to the invited commentary by Jubouri and Abdelhaliem published in response to our original article titled: Prevention vs Cure: is BioGlue priming the optimal strategy against E-Vita Neo graft oozing? The authors highlight key issues associated with the E-Vita Open NEO aortic arch prosthesis, chiefly, the propensity for the prosthesis to exhibit post-anastomotic oozing. We read with great interest their commentary and concur that the issues highlighted therein are significant and warrant discussion.

Case Video Summary: This video demonstrates the principle of spiral PA plasty whereby the length of branch pulmonary arteries can be increased simultaneous to the increase in diameter by using a patch that is anastomosed spirally around the vessels.

Open surgery for chronic type B aortic dissection has been shown to have considerable risks of cerebrovascular complications. Because retrograde perfusion is a potential cause of intraoperative cerebrovascular events, we report our transapical cannulation strategy for descending aorta replacement in chronic type B aortic dissection repair with circulatory arrest. This technique provides an easy and quick establishment of cardiopulmonary bypass by way of a left thoracotomy, and prevention of cerebrovascular event. Transapical cannula can be also used as a vent to ensure a bloodless field during proximal anastomosis and to prevent extension of left ventricle during rewarming. Transapical cannulation is a useful option in open repair of the descending aorta for chronic type B aortic dissection by way of left thoracotomy.

Background and Aim of the Study: Congenital heart disease is the most common congenital defect among infants born in the United States. Within the first year of life, 1 in 4 of these infants will need surgery. Only one generation removed from an overall mortality of 14%, many changes have been introduced into the field. Have these changes measurably improved outcomes? Methods: The literature search was conducted through PubMed MEDLINE and Google Scholar from inception to October 31, 2021. Ultimately, 78 publications were chosen for inclusion. Results: The outcome of overall mortality has experienced continuous improvements in the modern era of the specialty despite the performance of more technically demanding surgeries on patients with complex comorbidities. This modality does not account for case-mix, however. In turn, clinical outcomes have not been consistent from center to center. Furthermore, variation in practice between institutions has also been documented. A recurring theme in the literature is a movement towards standardization and universalization. Examples include mortality risk-stratification that has allowed direct comparison of outcomes between programs and improved definitions of morbidities which provide an enhanced framework for diagnosis and management. Conclusions: Overall mortality is now below 3%, which suggests that more patients are surviving their interventions than in any previous era in congenital cardiac surgery. Focus has transitioned from survival to improving the quality of life in the survivors by decreasing the incidence of morbidity and associated long-term effects. With the transformation towards standardization and interinstitutional collaboration, future advancements are expected.

Background: This study was conducted to evaluate the surgical results of the arterial switch operation for Taussig-Bing variants, at a single institution in a lower-middle income country. Methods: Between June 2010 and December 2018, all consecutive patients diagnosed with Taussig-Bing variants who underwent the arterial switch operation and ventricular septal defect closure were included in the study. Results: A total of 72 patients of Taussig-Bing variants who underwent arterial switch operation and ventricular septal defect closure. There were 10 early deaths (13.9%) and 2 late deaths (2.8%). Intraoperative ventricular septal defect enlargement [hazard ratio (HR) 7.23, 95% confidence interval (CI) 3.1294-16.7167; P < 0.001], secondary aortic cross clamping (HR 28.38, 95% CI 4.8427-166.3484; P < 0.001), post-operative pneumonia (HR 5.64, 95% CI 1.2724-24.9917; P = 0.023), and post-operative sepsis (HR 5.28, 95% CI 1.3512-20.6553; p = 0.017) were risk factors for overall mortality by competing risk analysis. Sixty patients (83.3%) required septoparietal trabeculation division/resection during the arterial switch operation in an attempt to avoid right ventricular outflow tract obstruction. The reoperation rate for right ventricular outflow tract obstruction at last follow up was 6% (3 patients). The estimated freedom from reoperation for right ventricular outflow tract obstruction at 1 year, 5 year and 9 year was 98.3%, 91.9% and 91.9 , respectively. Conclusions: The results of arterial switch operation for Taussig-Bing variants were satisfactory in the operative setting of a lower-middle income country, and performing extensive septoparietal trabeculation division might reduce the reintervention rate for right ventricular outflow tract obstruction in these patients.

Background: Patients who undergo cardiac surgery are at increased risk of stroke, postoperative cognitive decline, and delirium. These neurocognitive complications have led to increased costs, intensive care unit stays, morbidity, and mortality. As a result, there is a significant push to mitigate any neurological complications in cardiac surgery patients. Near-infrared spectroscopy to measure regional cerebral oxygen saturations has gained consideration due to its non-invasive, user-friendly, and relatively inexpensive nature. Aim of Study: To provide a comprehensive summary of cerebral oximetry in cardiac surgery. The review interrogates multiple systematic reviews assessing different outcomes in cardiac surgery to assess if cerebral oximetry is effective. Further, the review analyzes all available interventions for an acute desaturation to determine the efficacy of individual interventions. Methods: A narrative review of randomized controlled trials, observational studies, and systematic reviews with metanalyses were performed through August 2021. Results: There is significant heterogeneity amongst studies regarding the definition of a clinically significant cerebral desaturation. In addition, the assessment of neurocognitive outcomes has large variability, making metanalysis challenging. To date, cerebral oximetry use during cardiac surgery has not been associated with improvements in neurocognitive outcomes, morbidity, or mortality. The evidence to support particular interventions for an acute desaturation is equivocal. Conclusions: Future research is needed to quantify a clinically significant cerebral desaturation and to determine which interventions for an acute desaturation effectively improve clinical outcomes.

Introduction: Opinion is divided about optimal early timing of the Fontan Operation (FO). While some studies have suggested 3 years-of-age, others have shown good outcomes below 2 years-of -age. We analyzed the impact of age ≤2-years as compared age >2-years on short-term outcome of the FO using a large national database. Methods: A retrospective analysis of the Kids Inpatient Database (2009-16) for the FO was done. The groups were divided into those who underwent FO at age ≤2-years (EF) as compared to age >2-years (LF). The data was abstracted for demographics, clinical characteristics, and operative outcomes. Standard statistical tests were used. Results: 3381 patients underwent FO during this period of which 1482 (44%) were EF. The mean ages of the EF and LF were 1.6 and 4.3, respectively (p< 0.001). LF were more likely to be non-White, female, and have Heterotaxy syndrome. HLHS was more common in EF. There was no difference in the discharge mortality, length of stay, disposition (majority went home), and mean total charges incurred. The overall discharge mortality was low at 0.7% (24/3381). In multivariate analysis: cardiac arrest, acute kidney injury, mechanical ventilation >96 hours, endocardial cushion defect and non-White ethnicity were predictors of a mortality and not age. Conclusion: Contemporary outcomes for FO are excellent with equivalent short-term outcomes in both the age groups. Occurrence of postoperative complications, non-white ethnicity and endocardial cushion defect diagnosis were predictive of a negative outcome.

Impact of prior sternotomy on survival and allograft function after heart transplantation: a single-center matched analysisPrior sternotomy versus primary heart transplantEditorialE. Potapov, J. SteinIn the presented study, the authors showed that prior sternotomy in heart transplant candidates does not impact survival after heart transplantation (reference). The analysis was performed between 106 propensity score-matched pairs (212 patients).The results of published studies are contradictory and confusing. The small, single-center study published by Sert D, 2020, showed an increased early mortality in HTx recipients with prior sternotomy1, with no increased bleeding risk and a similar 4-year survival. In contrast, yet another single-center study with a similar design –no sternotomy vs. VAD-supported vs. prior sternotomy other than for VAD– published by Gaffey in 2015 showed no differences regarding early and long-term mortality, but a significantly higher risk of postoperative bleeding and a greater use of blood products2. A further single-center study with a comparable number of patients published in 2018 by Still S yet again showed that HTx recipients with prior sternotomy required more blood transfusions and showed an increased incidence in postoperative pneumonia, wound infection, and longer hospital stays. A stepwise multivariable regression model identified prior sternotomy as a predictor of primary graft dysfunction with a subsequently higher short-term and 1-year mortality3. However, in these studies the impact of confounding variables was not eliminated.Having said that, the presented study attempts to overcome imbalances in confounding variables by comparing survival and complications between propensity score-matched patient groups. The matching procedure was based on established risk factors including recipients’ baseline characteristics, donor age, sex mismatch, risk scores, ECLS, PVR, serum creatinine, and serum bilirubin, and ultimately produced 106 matched pairs. However, the benefit of balanced confounders is achieved at the cost of a reduced number of patients and therefore less power to detect differences between patient groups. The lack of significant differences in this study cannot merely be explained by a low power, but is instead due to the similarity of effects: Authors report a 30-day mortality of 5.7 % for prior sternotomy vs. 7.5 % for first-time sternotomy and no impact of prior sternotomy on long-term survival with an HR of 0.87 [95% CI: 0.57, 1.56]. Contradicting the above-mentioned studies, these results do not even come close to indicating a trend towards worse long- and short-term survival for patients with prior sternotomy. This also holds true for long-term survival in the unmatched population of 131 patients with and 381 patients without redo surgery.Now how about a larger registry-based analysis? An analysis based on the UNOS database comprising 11,266 patients showed that prior sternotomy was associated with an excess 3.3 % mortality and higher morbidity within the first 60 days after heart transplantation, as measured by the frequency of dialysis, drug-treated infections, and strokes. Conditional 5-year survival after 60 days is unaffected by prior sternotomy4. Five years later, another group performed an analysis of the same UNOS database (meanwhile comprising 14,730 patients) and showed again that prior sternotomy is a risk factor for worse survival after cardiac transplantation, mainly due to an increased early postoperative mortality5.Why are we interested in knowing the effect of prior sternotomy on post-transplant outcomes? Since a prospective, randomized study is not possible due to ethical reasons, we have to rely on retrospective analyses. From a practical perspective, a comparison is meaningless – patients with prior sternotomy would never be refused for HTx due to this fact alone, even if we knew that morbidity and mortality in these patients may be higher.In our opinion, such an analysis may be performed to identify and support the advantages of less invasive LVAD implantation regarding the outcome of later HTx, as was performed in a first analysis of 46 patients (sic!, the lowest number of patients among the discussed studies) published by Riebandt J, 20216. The study showed that patients supported with LVAD implanted via full sternotomy required more packed red blood cells with no increased risk of bleeding, and subsequently developed more donor-specific antibodies, however, without any impact on short- and long-term survival, similar to the studies discussed above2,3.However, the virgin chest is not comparable to that of patients supported with an LVAD implanted via a less invasive approach, even if no7 or partial sternotomy8 is performed. In either of the groups the pericardium remains intact. Regardless of the technique used, the left pleura is opened, as is the pericardium around the ascending aorta and the apex of the right and left ventricles, and the graft is placed into the pericardial space, causing adhesions making any efforts to suggest, that the HTx in the “virgin chest”is similar to that after less invasive LVAD implantation not appropriate.Finally, the authors should nonetheless be congratulated on their outstanding surgical experience and the resulting very good outcomes in HTx – better than in the majority of centers worldwide.References1. Sert DE, Kervan Ü, Kocabeyoğlu SS, et al. Early and long-term results of heart transplantation with reoperative sternotomy. Turk gogus kalp damar cerrahisi dergisi 2020;28:120-6.2. Gaffey AC, Phillips EC, Howard J, et al. Prior Sternotomy and Ventricular Assist Device Implantation Do Not Adversely Impact Survival or Allograft Function After Heart Transplantation. The Annals of thoracic surgery 2015;100:542-9.3. Still S, Shaikh AF, Qin H, et al. Reoperative sternotomy is associated with primary graft dysfunction following heart transplantation. Interactive cardiovascular and thoracic surgery 2018;27:343-9.4. Kansara P, Czer L, Awad M, et al. Heart transplantation with and without prior sternotomy: analysis of the United Network for Organ Sharing database. Transplantation proceedings 2014;46:249-55.5. Axtell AL, Fiedler AG, Lewis G, et al. Reoperative sternotomy is associated with increased early mortality after cardiac transplantation. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 2019;55:1136-43.6. Riebandt J, Wiedemann D, Sandner S, et al. Impact of Less Invasive Left Ventricular Assist Device Implantation on Heart Transplant Outcomes. Seminars in thoracic and cardiovascular surgery 2021.7. Potapov EV, Kukucka M, Falk V, Krabatsch T. Off-pump implantation of the HeartMate 3 left ventricular assist device through a bilateral thoracotomy approach. The Journal of thoracic and cardiovascular surgery 2017;153:104-5.8. Nersesian G, Potapov E, Starck CT, et al. Surgical Implantation Techniques of Modern Continuous Flow Ventricular Assist Devices. Surgical technology international 2021;37:263-9.