A rare case of mixed total anomalous pulmonary venous connection (TAPVC) associated to right extra-lobar bronchopulmonary sequestration (BPS) was diagnosed at birth in a full-term newborn. At one month of age, the patient underwent embolization of the BPS, complicated by coil entrapment in the right common iliac artery requiring urgent laparotomy. Few days later, the congenital cardiac repair was accomplished uneventfully. At 12-months follow-up, the patient did not have pulmonary hypertension, but presented a moderate stenosis of the right femoral artery, which was effectively treated with anticoagulation therapy.

Background The role of percutaneous repair of functional mitral regurgitation (MR) is evolving. Left ventricle remodeling is known to be different between men and women; however, outcomes following percutaneous repair of functional MR have not considered the impact of sex. Methods Between 2012 and 2018, 175 patients underwent percutaneous repair of functional MR with the Mitra Clip NT/NTR (Abbott, Irvine CA) at our institution. Patients were assessed in a dedicated clinic with a follow-up that averaged 0.7±1.2 years and extended to 5.7 years. Results Men had a larger body surface area than women (p<0.001), whereas women were more likely than men to have diabetes preoperatively (p=0.02). There were no deaths or instances of single leaflet detachment. Immediate post-procedure MR was <2+ in 158 (90%) with a mean trans-mitral valve repair gradient of 3.4±1.0 and 3.5±2.1 mm Hg, respectively for women and men (p=0.8). One- and 2-year freedom from MR >3+ was 86.0±3.5% and 77.6±5.1%, respectively. After adjusting for differences between male and female patients, women were more likely to have recurrent MR >3+ (hazard ratio 4.7, 95% confidence interval 1.2-18.4, p=0.03). Upon adjusted analysis, there was also no association between gender and survival (p=0.2). One- and 2- year survival was 69.8±4.3% and 54.3±5.5%, respectively. Conclusion Women are more likely to have recurrent severe MR after percutaneous repair of functional MR. The mechanism for this remains undetermined.

Commentary:

Objectives: The goal of this study was to describe and evaluate our simulation training program on biological models for the cardiovascular surgery residency program at our institution. Material and Methods: Since 2016, with the purpose to develop better practical performance and evaluate the improvement of resident’s surgical skills, it was implemented a simulation training program, composed of some elemental procedures in cardiovascular surgery. It was established one wet lab session weekly lasting 2 hours, coached by 2 expert cardiovascular surgeons. Bovine and porcine hearts were used as biological models. At the end of the hands on program, an objective assessment consisting of 2 practical modules was applied and performance was rated by way of a 5-point scale. In addition, to provide a subjective assessment, each resident filled out a questionnaire consisting of 3 items reviewing the overall quality of the workshops on a 10-point scale. Results: The objective evaluation applied at the end of the training program consisted by valve replacement and coronary artery bypass grafting (CABG) modules. The mean performance rating scores for valve replacement module ranged from 4.2 to 4.79, and to CABG, from 4.33 to 4.87. Regarding subjective assessment, all items evaluated, such as expert’s didactics, simulation performance and biological simulator fidelity, received high grades (above 9 on a 10-point scale). Conclusions: Simulator training on biological models for cardiac surgery medical residents is a simple and effective learning method of surgical skills.

In this issue, Zhao et al. investigate the effects of subclinical hypothyroidism in coronary bypass grafting particularly with respect to the incidence of atrial fibrillation. While not the first of its kind, the authors analyze this controversial topic in a well powered, statistically comprehensive manner that furthers our understanding of the effects of SCH in CABG patients.

Background: This study evaluates the impact of peak preoperative troponin level on outcomes of coronary artery bypass grafting (CABG) for non-ST-elevation myocardial infarction (NSTEMI). Methods: This was a retrospective review of patients undergoing isolated CABG from 2011-2018 with presentation of NSTEMI. Patients were stratified into low- and high-risk groups based on median preoperative peak troponin (1.95ng/dL). Major cardiac and cerebrovascular events (MACCE) and mortality were compared. Multivariable analysis was performed to model risk factors for MACCE and mortality. Results: This study included 1,211 patients, 607 low- (≤1.95ng/dL) and 604 high-risk (>1.95ng/dL). Patients were well-matched with respect to age and comorbidity. High-risk patients had lower median preoperative ejection fraction (46.5% [IQR 35.0%-55.0%] vs 53.0% [IQR 40.0%-58.0%]) and higher incidence of preoperative intra-aortic balloon pump (15.9% vs 8.73%). Intensive care unit (47 hours [IQR 26-82] vs 43 hours [IQR 25-69]) and hospital lengths of stay (10 days [IQR 8-13] vs 9 days [IQR 8-12]) were longer in the high-risk group (each P<0.05). Postoperative complications and thirty-day, one- and five-year rates of both MACCE and survival were similar between groups. Peak troponin >1.95ng/dL was not associated with increased hazards for MACCE, mortality, or readmission in multivariable modeling. In sub-analyses, neither increasing troponin as a continuous variable nor peak troponin >10.00ng/mL were associated with increased hazards for these outcomes. Conclusions: Higher preoperative troponin levels are associated with longer lengths of stay but not MACCE or mortality following CABG. Dictating timing of CABG for NSTEMI based on peak troponin does not appear to be warranted.

Background. Right ventricular failure (RVF) is a severe event that increases perioperative mortality after Left Ventricle Assist Device (LVAD) implantation. RV function is particularly affected by the LVAD speed by changing RV preload and afterload as well as the position of the interventricular septum. However, there are no studies focusing on the relationship between pump speed optimization and risk factors for development of lateRVF. Methods. Between 2015 and 2019,50 consecutive patients received LVAD implantation at San Camillo Hospital in Rome. Of these, 38 who underwent pump speed optimization were included. Post optimization hemodynamic data were collected. We assessed: a new Hemodynamic Index (HI), calculated as follows HI=MAP x PCWP/CVP x RPM set/RPM max; risk factors for late RVF, which was defined as the requirement for 7 days or more of inotropic support. Results 10 patients had late RVF after LVAD implantation. 5 patients required diuretic therapy and speed optimization. In 3 patients inotropic support with adrenaline 0.05 g/kg/min was started. 2 patients required prolonged continuous veno-venous hemofiltration and high dosage inotropic support. Multivariate analysis revealed that a low HI (odds ratio 11.5, 95 % confidence interval,1.85-65.5,p[.003] was an independent risk factor for late RVF after LVAD implantation. Conclusion A low HI, according to our study, is a significant risk factor for the development of RVF after LVAD implantation. We suggest adopting this index during the follow-up to stratify the different hemodynamic profiles and modify the therapeutic strategies according to the different HI levels obtained for every single patient.

Background: The success of coronary artery bypass grafting surgery (CABG) is dependent on long-term graft patency, which is negatively related to early wall thickening. Avoiding high-pressure distension testing for leaks and preserving the surrounding pedicle of fat and adventitia during vein harvesting may reduce wall thickening. Methods: A single-centre, factorial randomised controlled trial was carried out to compare the impact of testing for leaks under high versus low pressure and harvesting the vein with versus without the pedicle in patients undergoing CABG. The primary outcomes were graft wall thickness, as indicator of medial-intimal hyperplasia, and lumen diameter assessed using intravascular ultrasound after 12 months. Results: 96 eligible participants were recruited. With conventional harvest, low-pressure testing tended to yield a thinner vessel wall compared to high-pressure (mean difference MD (low minus high) -0.059mm, 95%CI -0.12, +0.0039, p=0.066). With high pressure testing, veins harvested with the pedicle fat tended to have a thinner vessel wall than those harvested conventionally (MD (pedicle minus conventional) -0.057mm, 95%CI -0.12, +0.0037, p=0.066, test for interaction p=0.07). Lumen diameter was similar across groups (harvest comparison p=0.81; pressure comparison p=0.24). Low pressure testing was associated with fewer hospital admissions in the 12 months following surgery (p=0.0008). Harvesting the vein with the pedicle fat was associated with more complications during the index admission (p=0.0041). Conclusions: Conventional saphenous vein graft preparation with low pressure distension and harvesting the vein with a surrounding pedicle yielded similar graft wall thickness after 12 months, but low pressure was associated with fewer adverse events.

Bilateral antegrade selective cerebral perfusion has the undisputed advantage of being more physiological and theoretically ensuring complete perfusion of the whole brain. However, it requires longer execution times and manipulation of the epiaortic vessels. On the other hand, unilateral selective cerebral perfusion (u-ASCP) avoids the vessels manipulation, placement of catheters into the ostia of the great vessels which clutters the operative field and incurs both atherosclerotic and air embolism risk. Neverthless, an ongoing debate about which technique yields the best clinical outcomes is still open.

If it an’t broke, don’t fix itBerhane Worku MD1, Meghann M Fitzgerald21: Department of Cardiothoracic Surgery, Weill Cornell Medical College2. Department of Anesthesiology, Weill Cornell Medical CollegeAntifibrinolytics and TEGCorresponding Author:Berhane WorkuDepartment of Cardiothoracic SurgeryWeill Cornell Medical College525 East 68th Street M-404New York, NY 10065Despite evidence of associated morbidity and mortality, blood products are administered to over half of cardiac surgical patients, accounting for approximately 20% of their worldwide use1,2. These statistics attest to the ubiquitous and refractory nature of bleeding after cardiac surgery. In an attempt to curb the excessive use of blood products after cardiac surgery viscoelastic testing in the form of thromboelastography (TEG) and rotational thromboelastometry (ROTEM) have been increasingly utilized. Rapid intraoperative assessment allows for targeted correction of coagulopathy due to residual heparinization, coagulation factor deficiency, hypofibrinogenemia, and platelet dysfunction. Hyperfibrinolysis can also be assessed, although management is rarely altered as the routine administration of lysine analog antifibrinolytics has been given a class I recommendation by the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists and has become the standard practice at most cardiac surgical centers.Cardiopulmonary bypass is known to result in transient t-PA and subsequent d-dimer level elevations (a marker of hyperfibrinolysis)3,4. The efficacy of the lysine analog antifibrinolytics, tranexamic acid andε-aminocaproic acid, have been extensively studied in this setting. D-dimer levels are significantly blunted by antifibrinolytics, and an abundance of literature demonstrates reductions in chest tube bleeding, blood product use, and reoperation for bleeding with the use of these agents4-6. A similar amount of evidence points to their safety, with no increase in thrombotic complications, including stroke, myocardial infarction, graft closure, or mortality seen5-7. A higher risk of seizures is noted with tranexamic acid, although this appears to be dose dependent and nonexistent with ε-aminocaproic acid2. If the ultimate goal is to reduce bleeding and blood product usage, it would seem that antifibrinolytics offer one way to do this safely.In the current manuscript, Sussman et. al. retrospectively analyze 78 cardiac surgical patients who had an intraoperative TEG performed with the goal of describing the distribution of fibrinolytic phenotypes in this population8. Forty five percent demonstrated physiologic fibrinolysis, 32% hypo fibrinolysis, and 23% hyperfibrinolysis (LY30 <0.8%, 0.8-3%, >3%). Forty seven percent received antifibrinolytic agents. Outcomes including “morbidity” and time with chest tube were higher in those who received antifibrinolytics. This is a perhaps the first study of its kind to describe the prevalence of hyperfibrinolysis in cardiac surgical patients as measured by point of care testing. It is also a very relevant study in an era in which the benefits of targeted therapy for coagulopathy are increasingly recognized.The current data suggests that half of patients undergoing cardiac surgery demonstrate physiologic fibrinolysis and a third demonstratehypo fibrinolysis (a theoretically pro thrombotic state)8. The worse outcomes seen in patients receiving antifibrinolytics suggests that their administration in the setting of a potentially prothrombotic state was to blame. However, several limitations merit mention. It appears that TEG is not routinely performed on all patients. The population under study may therefore reflect one undergoing more extensive surgery with more coagulopathy in whom TEG is more likely to be performed. Since the actual timing of the TEG is not detailed, the true baseline fibrinolytic phenotype of patients treated with antifibrinolytics is not clear as the TEG results may have been obtained after the initiation of antifibrinolytics. Furthermore, while surgical procedures performed weren’t delineated, patients receiving antifibrinolytics more frequently had “valve disease” and “heart failure” and underwent on-pump surgery. Patients receiving antifibrinolytic therapy were therefore sicker and likely underwent more extensive on-pump valve surgery, while patients who did not receive antifibrinolytics were most likely undergoing off-pump coronary bypass surgery. Finally, the increased “morbidity” in patients receiving antifibrinolytics appear to be bleeding related (thrombotic complications were not listed separately). Perhaps additional antifibrinolytics were needed.The authors are to be commended for recognizing a lack of complete understanding of coagulation in the cardiac surgical population and attempting to determine the benefit of targeted antifibrinolytic therapy. Any time a practice is performed indiscriminately, there is room for improvement. However, before we contemplate altering an evidence-based practice that reduces bleeding, we need to demonstrate a benefit for such a change. Not all bleeding is purely surgical or purely medical; there is overlap. Few areas of medicine highlight how much art prevails over our current scientific understanding. Too many times since the introduction of point-of-care testing, the surgeon and anesthesiologist battle over the merits of administering blood products to a clinically bleeding patient with a normal coagulation profile. Targeted correction of coagulopathy is conceptually attractive, but the reality is not as clearly defined. Reductions in bleeding seen with antifibrinolytics occur both in on-pump and off-pump surgery which should be enough proof to continue its application until better evidence and understanding emerges6. Certainly, there is more work to be done, but with regard to antifibrinolytics it seems fitting to recognize: If it ain’t broke, don’t fix it.REFERENCESAbdelmotieleb M, Agarwal S. Viscoelastic testing in cardiac surgery. Transfusion 2020;60:52-60Harvey R, Salehi A. Con: Antifibrinolytics should not be used routinely in low-risk cardiac surgery. J Cardiothorac Vasc Anesth 2016;30:248-251Gielen C, Brand A, van Heerde W, Stijnen T, Klautz R, Eikenboom J. Hemostatic alterations during coronary artery bypass grafting. Thromb Res 2016;140:140-146Slaughter T, Faghih F, Greenberg C, Leslie J, Sladen R. The effects of ε-aminocaproic acid on fibrinolysis and thrombin generation during cardiac surgery. Anesth Analg 1997;85:1221-6Myles PS, Smith JA, Forbes A, Silbert B, Jayarajah M, Painter T, Cooper J, Marasco S, McNeil J, Bussieres JS, McGuinness S, Byrne K, Chan MTV, Landoni G, Wallace S. Tranexamic acid in patients undergoing coronary-artery surgery. N Engl J Med 2017;376:136-48Zhang Y, Bai Y, Chen M, Zhou Y, Yu X, Zhou H, Chen G. The safety and efficiency of intravenous administration of tranexamic acid in coronary artery bypass grafting (CABG): a meta-analysis of 28 randomized controlled trials. BMC Anesthesiol 2019;19:104Kasrki J, Djaiani G, Carroll J, Iwanochko M, Seneviratne P, Liu P, Kucharczyk W, Fedorko L, David T, Cheng D. Tranexamic acid and early saphenous vein graft patency in conventional coronary artery bypass graft surgery: A prospective randomized controlled clinical trial. J Thorac Cardiovasc Surg 2005;130:309-14Sussman MS, Urrechaga EM, Cioci AC, Iyengar RS, Herrington TJ, Ryon EL, Namias N, Galbut DL, Salerno TA, Proctor KG. Do all cardiac surgery patients benefit from antifibrinolytic therapy? J Card Surg in press

Prediction scores and metrics are being increasingly utilized throughout the fields of cardiothoracic and congenital cardiac surgery to identify areas for perioperative optimization or guide therapeutic intent. Here, we review a novel submission by Yang and colleagues to the Journal of Cardiac Surgery identifying preoperative factors which predict adverse postoperative outcomes from cone reconstruction for Ebstein's anomaly.

The use of radial artery (RA) grafts for coronary bypass surgery has recently gained newer attention since it has been associated with significant reduction in the risk of midterm cardiac events. Surprisingly the use on the RA graft as second ‘best’ conduit has been limited among the surgical community. There may be several explanations for the little popularity of the RA graft; one of the reasons that could prevent surgeons to include the RA in the daily surgical armamentarium it is that patients with RA grafts may require postoperative calcium-channel blocker (CB) therapy. Due to the thick muscular wall, it seems possible that the RA would needs CB in order to prevent spasm and ameliorate patency. CBs are, however, associated with important side effects; also they have hypotensive effect that can hamper the use of other therapy such as beta-blocker or angiotensin-converting enzyme inhibitors. The evidence supporting the use of CB after RA graft (either in the early phase or as chronic calcium-blocker (CCB)) is weak. A the post-hoc analysis from the ‘RADIAL’ (Radial Artery Database International ALliance), showed that in patients with RA, the use of CB for at least 12 months was associated with better clinical and angiographic outcomes at mid-term follow-up, but confounders and bias may be responsible for the reported findings (as healthier patients are more likely to tolerate CB) . This review aims to summarize current evidences available on the topic and to serve as benchmark for evidence-based decision-making for CB prescription after RA grafting.

Background and aim of the study: We report our one-year single-center experience of a new technique of aortic valve replacement using a rapid-deployment valve (RD-AVR) to avoid postoperative complications. We also report the unexpected pitfalls and handling techniques that we have seen in past cases. Methods: We performed aortic valve replacement on 38 patients between May 2019 and April 2020. Their mean age was 74 years. The primary outcomes were in-hospital mortality and short-term results during a one-year follow-up period, while the secondary outcomes were related to prosthetic valve function, especially paravalvular leakage (PVL). We further analyzed the relationship between the new technique and its outcomes. Results: The mean operative time was 196 min. There were no in-hospital deaths, and the mean duration of postoperative hospital stay was 11.8 days. Valvular measurements using 3-dimensional computed tomography (3D-CT) were larger and more accurate than those measured using ultrasonic echocardiography Postoperative RD-AVR prosthetic valve function was excellent. However, PVL occurred in 4 cases one week and one year postoperatively and regurgitation did not improve. A gap associated with PVL was identified below the right-noncoronary commissure. To prevent PVL, we additionally stitched this gap in the later 18 cases; there was no case of PVL and no new pacemaker implantation in these cases. Conclusions: PVL is more likely to occur if there is a gap below the R-N commissure, especially in cases with a large annulus; therefore, applying an additional stitch to the R-N commissure is extremely useful.

CABG (Coronary Artery Bypass Grafting) has been the treatment of choice for coronary artery disease for over 50 years and is the most common cardiac surgery procedure performed. Traditionally CABG was performed with the use of cardiopulmonary bypass and the use of cardioplegia to allow the surgeon to operate on a stable field. In the mid-1990s, interest emerged in performing CABG without the use of cardiopulmonary bypass - off pump CABG. This invited commentary focuses on sharing our experience with Low Ejection fraction off-pump CABG and why this approach could be beneficial to this patient population.

Introduction: Extracorporeal membrane oxygenation (ECMO) has been used as a refractory treatment for acute respiratory distress syndrome (ARDS) due to COVID-19, but there has been little evidence of its efficacy. We conducted this study to share our experience using ECMO as a bridge to recovery for ARDS due to COVID-19. Methods: All adult patients who were placed on ECMO for ARDS due to COVID -19 between April 2020 and June 2020 (during the first wave of COVID-19) were identified. The clinical characteristics and outcomes of these patients were analyzed with a specific focus on the differences between patients who survived to hospital discharge and those who did not. Results: 20 COVID-19 patients were included in this study. All patients were placed on veno-veno ECMO. Comparing between survivors and non-survivors, older age was associated with hospital mortality (p=0.02). The following complications were observed: renal failure requiring renal replacement therapy (35%, n=7), bacteremia during ECMO (20%, n=4),coinfection with bacterial pneumonia (15%, n=3), cannula site bleeding (15%, n=3), stroke (10%, n=2), gastrointestinal bleeding (10%, n=2), and liver failure (5%, n=1). The complications associated with patient mortality were culture positive septic shock (p=0.01), culture-negative systemic inflammatory response syndrome (p=0.01), and renal failure (p=0.01). The causes of death were septic shock (44%, n=4), culture-negative systemic inflammatory response syndrome (44%, n=4), and stroke (11%, n=1). Conclusions: Based on our experience, ECMO can improve refractory ARDS due to COVID-19 in select patients. Proper control of bacterial infections during COVID-19 immunomodulation therapy may be critical to improving survival.

Commentary:When Starting a MICS Program, Don’t Assume Excellence: Prove It!Rachel Eikelboom MD1,2, Rashmi Nedadur MD3,Roberto Vanin Pinto Ribeiro MD3, Bobby Yanagawa MD PhD31 Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada2 Division of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada3 Division of Cardiac Surgery, St Michael’s Hospital, University of Toronto, Toronto, Ontario, CanadaCorresponding author:Bobby Yanagawa MD, PhD, FRCSC Program Director, Division of Cardiac Surgery, University of Toronto Assistant Professor, Division of Cardiac Surgery, St. Michael’s Hospital  30 Bond Street, 8th Floor, Bond Wing Toronto, ON M5B 1W8 Canada Tel: 416 864 5706 Fax: 416 864 5031 Email: [email protected] count: 430Conflict of interest: The authors have no conflict of interest and have not received any funding.Central Figure:

A 53-year-old male undergoing emergency aortic valve replacement for infective endocarditis developed a hypertensive crisis early during the operation. Suspecting a pheochromocytoma, intravenous phentolamine was immediately administered, after which the procedure was completed as scheduled. Although quite rare, a pheochromocytoma can be encountered during emergency open heart surgery, thus early recognition of abnormal blood pressure change and appropriate management are important. Here, we present details of blood pressure control mainly by phentolamine use in this case to demonstrate effective management of a hypertensive crisis during emergency cardiac surgery because of a pheochromocytoma.

Commentary to JOCS-2020-OA-1345