Background and Aim Endoscopic radial artery (RA) harvest (ERAH) is an alternative to open RA harvest (ORAH) technique. Our aim was to compare clinical outcome, patent satisfaction and 1-year angiographic patency rates after ERAH and ORAH. Patients and methods 50 patients undergoing multivessel CABG were prospectively randomized to two groups. In the ERAH group (25 patients) the RA was harvested endoscopically and in the ORAH group (25 patients) openly. Results There were not differences between the groups in preoperative characteristics. Length of skin incision was shorter in ERAH (p<0.001) but there were not differences in the length of RA, harvest time, blood flow and pulsatility index after ERAH and ORAH. Wound healing was uniformly smooth in ERAH and there were 2 haematomas and 1 infection in ORAH. Postoperatively, major neuralgias were present in 5 patients in ORAH and none in ERAH (p=0.05) and minor neuralgias in 11 and 3 patients (p=0.02) respectively. Twenty-four patients in ERAH and 4 in ORAH graded their experience as excellent (p<00001). One-year angiographic RA patency was 90% without intergroup difference. Target vessel stenosis < 90% adversely affected RA patency (p<0.0001). Conclusions In expert center, ERAH has no negative impact on time harvest, length and quality of RA conduit. Moreover, ERAH may provide better wound healing, and is associated with less neuralgias, excellent cosmetic result and better patient satisfaction. RA graft patency is unaffected by the harvesting technique and is excellent when placed to a target coronary artery vessel with stenosis > 90%.

The coronavirus disease 2019 (COVID-19) is an infectious disease which has rapidly evolved into a pandemic. Though it has affected all disciplines of medical sciences but it has some serious implications pertaining to cardiovascular sciences which have presented unique challenges in front of cardiac surgeons in particular. To flatten the curve of this pandemic, routine cardiac surgeries are being deferred indefinitely resulting in the pool of sick cardiac patients rising day by day. A different perspective is presented on this global catastrophe from the viewpoint of a cardiac surgeon.

Device embolization is a rare major complication of atrial septal defect percutaneous closures that requires surgical management if non-invasive retrieval fails. We report a symptomatic delayed embolization of an Amplatzer septal occluder device into the left ventricle outflow tract tangled with the mitral valve, complicated with ventricular arrhythmias and cardiac tamponade during percutaneous retrieval attempt. Emergent surgical treatment was performed, requiring combined approach through the right atrium and the aorta for surgical removal.

Pheochromocytoma is a rare catecholamine-secreting tumor derived from chromaffin cells in the adrenal glands. A pheochromocytoma ‘crisis’ (PCC) can cause haemodynamic instability and end-organ damage or dysfunction. An excessive stimulation of cardiac myocytes could lead to myocardial damage with cardiogenic shock (CS). Use of mechanical circulatory support (MCS) might find an indication in this scenario as a bridge to myocardial recovery. We present the case of a patient successfully supported with ECMO (ExtraCorporeal Membrane Oxygenation) combined with IMPELLA CP heart pump (Abiomed Danvers, MA), for left ventricular (LV) unloading. MCS was used to favour myocardial recovery and avoid cardiac remodeling.

Abstract The posterior rupture of the left ventricle has been a complication recognized since the beginning of mitral valve surgery and, despite advances in cardiac surgery, the outcome of the rupture of the left ventricle has remained tragic. During mitral valve surgery, care must be taken not to traumatize the free wall of the left ventricle. On the other side, septal Myectomy is performed on hypertrophied septums to address the left ventricular outflow tract obstruction. In this article I have presented a theory that could give a part of the explanation of the resistance of the interventricular septum of surgical trauma unlike the ventricular wall.

Bronchial artery aneurysms are a rare vascular entity. They can have various presentations ranging from an incidental finding on radiological examination to life-threatening hemoptysis. We report the case of a 60-year old woman with three posterior mediastinal bronchial artery aneurysms who presented with unilateral periscapular pain, shortness of breath, hoarseness, and dysphagia. The bronchial artery aneurysms were removed successfully via thoracotomy, with excellent recovery and relief of the periscapular pain. We use this case as a platform to discuss unilateral periscapular pain as an atypical referral pattern for a bronchial artery aneurysm, as well as implications for treatment.

A quarter of coronary arteriovenous fistulas may present aneurysmal dilatation; however, spontaneous rupture of the aneurysm is rare. We present a rare case of ruptured coronary artery aneurysm (CAA) associated with coronary fistulas that presented cardiac tamponade. Subsequent to pericardial drainage, surgical repair of the CAA associated with coronary fistulas was performed electively. The aneurysm was located on the left anterior aspect of the pulmonary artery trunk. It communicated with both the left and right coronary arteries by anomalous fistulous vessels that drained into the pulmonary artery trunk. The feeding arteries and fistulous opening were ligated and closed, respectively, from within the aneurysm. Intraoperative fluorescence imaging was performed pre- and postoperatively to ensure no residual coronary fistulas were present. Although the rupture of CAA associated with coronary fistulas is rare, it should be considered as one of the potential causes of acute cardiac tamponade.

A 59-year-old male with a history of unstable angina was diagnosed with a myocardial bridge of the left anterior descending artery (LAD) and apical variant hypertrophic cardiomyopathy (AHCM). He underwent unroofing of the myocardial bridge and a left ventricular apical myectomy. Intraoperatively, epicardial ultrasound was used to identify the myocardial bridge with systolic compression of the LAD and confirm resolution of this compression postoperatively. Furthermore, epicardial ultrasound was used for guiding the degree of apical resection of the decompressed heart. This novel use of intraoperative epicardial ultrasound can help guide surgeons preoperatively and confirm results immediately after an operation.

Pyoderma Gangrenosum could mimic early postoperative sternal wound infection. Steroids therapy is the only method of treatment recognizing the fact that steroids can lead to immunosuppression and inhibits healing after major surgery.

The SARS-CoV-2, the causative agent of COVID-19, has been established to gain access to the human cell via the ACE2 receptor similar to its familial coronavirus SARS-CoV which led to the outbreak in 2003. A concern with the newer 2019 coronavirus is its 10-20-fold higher affinity to the ACE2 receptor that of SARS-CoV, aiding its effective human-to-human transmission which has led to this pandemic. ACE2 receptor expression is thought to be upregulated in use with ACE inhibitors. As ACE inhibitors are known to be a used extensively in the treatment of hypertension it was a concern regarding the risk of using these medications alongside a SARS-COV-2 infection. ACE inhibitors are also used in the treatment regime of other common conditions including diabetes and Cardiovascular disease (CVD). It is worth noting that ACE2 expression has found to be upregulated by the use of thiazolidinediones and ibuprofen too. Consequently, the increased expression of ACE2 would facilitate infection with COVID-19. Therefore, it would hypothesise that diabetes and hypertension treatment with ACE2-stimulating drugs would increase the risk of developing severe and fatal COVID-19.

Background: Despite improved survival and morbidity after durable left ventricular assist device (dLVAD), outcomes for cardiogenic shock patients are suboptimal. Temporary mechanical circulatory support (tMCS) can permit optimization prior to dLVAD. Excellent outcomes have been observed using minimally-invasive dLVAD implantation. However, some feel tMCS contraindicates this approach. To evaluate whether left thoracotomy/hemisternotomy (LTHS) dLVAD placement is safe in this setting, we compared patients who did and did not require tMCS. Methods: Outcomes for patients receiving dLVADs via LTHS were compared among those bridged with ECMO, IABP, or no tMCS. We evaluated demographics, comorbidities, laboratory and hemodynamic data, and intra- and postoperative outcomes. Results: Eighty-three patients underwent LTHS dLVAD placement. Fifty did not require tMCS, while 22 (26%) required IABP, and 11 (13%) ECMO. Non-tMCS patients were primarily INTERMACS 3 (56%), while IABP recipients were mainly INTERMACS 2 (45%). All ECMO patients were INTERMACS 1. Patients with tMCS had worse end-organ function. Operative outcomes were similar except more concomitant procedures and red-cell transfusions in ECMO patients. ICU and hospital length of stay and inotrope duration were also similar. There were no differences in bleeding, stroke, and infection rates. Three- and twelve-month survival were: No tMCS: 94%, 86%; IABP: 100%, 88%; ECMO: 81%, 81% (p=0.45). Conclusions: Patients with cardiogenic shock can safely undergo LTHS dLVAD implantation after stabilization with ECMO or IABP. Outcomes and complications in these patients were comparable to a less severely ill cohort without tMCS.

Background Post-Cardiotomy ECMO (PC-ECMO) represents a unique subset of critically ill patients, with a paucity of data regarding long-term survival, and characteristics correlated with short and long-term outcomes. We present a retrospective cohort PC patients supported with ECMO at a single institution, with outcomes at 1 and 3-year follow-up. Methods Data was collected retrospectively for all patients requiring ECMO within 72 hours of index cardiac operation, excluding assist devices and heart transplantation. Operative data, frozen mediastinum status, cannulation site, postoperative hemorrhage, and timing of cannulation (immediate versus delayed) were all collected and examined. Primary outcomes were ability to wean from ECMO, hospital survival, and long-term survival. Results 33 patients required PC ECMO, representing a total of 179 days of ECMO support. Overall survival data were: ability to wean 61%, hospital survival 55%, one month survival 45%. The estimated 12 and 36 month survival for all PC ECMO patients was 40% and 33% respectively. Twelve and 36 month survival for all hospital survivors was 66% and 60% respectively. Operative times, type of operation performed, open chest status, reoperation for hemorrhage and cannulation location (central/peripheral) were all compared. There were no statistically significant relationships of these variables short or long-term survival. Conclusions Overall 12 month survival for PC-ECMO patients was 40%, and was 33% at 36 months. For hospital survivors, 1 year survival was 66%, and was 60% at 36 months. These data support PC-ECMO as a reasonable salvage strategy, with mid-term survival comparable to other surgically treated diseases.

Abstract: The objective of this study was to identify patient and hospitalization characteristics associated with in-hospital mortality in infants with truncus arteriosus. We conducted a retrospective analysis of a large administrative database, the National Inpatient Sample dataset of the Healthcare Cost and Utilization Project for the years 2002–2017. We also sought to evaluate the resource utilization in the subgroup of subjects with truncus arteriosus and 22q11.2 deletion syndrome. Neonates with truncus arteriosus were identified by ICD-9 and ICD-10 codes. Hospital and patient factors associated with inpatient mortality were analyzed. Overall, 3009 neonates met inclusion criteria; a total of 326 patients died during the hospitalization (10.8%). Extracorporeal membrane oxygenation utilization was 7.1 %. Univariate and multivariate logistic regression analyses were used to identify risk factors for in-hospital mortality. Independent risk factors for mortality were prematurity (aOR = 2.43, 95% CI: 1.40–4.22, p = 0.002), diagnosis of stroke (aOR = 26.2, 95% CI: 10.1–68.1, p < 0.001), necrotizing enterocolitis (aOR = 3.10, 95% CI: 1.24–7.74, p = 0.015) and presence of venous thrombosis (aOR = 13.5, 95% CI: 6.7–27.2, p < 0.001). Patients who received ECMO support or had cardiac catheterization procedure during the hospitalization had increased odds of mortality (aOR = 82.0, 95% CI: 44.5–151.4, p < 0.001, and aOR = 1.65, 95% CI: 0.98–2.77, p = 0.060, respectively). 22q11.2 deletion syndrome was associated with an inverse risk of death despite having more non-cardiac comorbidities; this patient subpopulation also had a higher length of stay and increased cost of hospitalization.

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.

The current Covid-19 pandemic is a significant global health threat. The outbreak has profoundly affected all healthcare professionals, including heart surgeons. To adapt to these exceptional circumstances, cardiac surgeons had to change their practice significantly. We herein discuss the challenges and broad implications of the Covid-19 pandemic from the perspective of the heart surgeons.

Background Porcine aortic roots (PAR) have been reported in the literature with acceptable short and long-term outcomes for the treatment of aortic root aneurysms. However, their efficacy in type A aortic dissection (TAAD) is yet to be defined. Methods Using data from a locally collated aortic dissection registry, we compared the outcomes in patients undergoing aortic root replacement for TAAD using either of two surgical options: i) PAR or ii) composite valve grafts (CVG). A retrospective analysis was conducted for all procedures in the period 2005-2018. Results A total of 252 patients underwent procedures for TAAD in the time period. Sixty-five patients had aortic root replacements (PAR n=30, CVG n=35). Between group comparisons identified a younger CVG group (50.5 vs 64.5, p<0.05) although all other covariates were comparable. Operative parameters were comparable between the two groups. The use of PAR did not significantly impact operative mortality (OR 0.93, 95% CI 0.22-3.61, p=0.992), stroke (OR 2.91, 0.25 – 34.09, p=0.395), re-operation (OR 0.91, 95% CI 0.22 – 3.62, p=0.882) or length of stay (coef 2.33, -8.23 – 12.90, p=0.659) compared to CVG. Five-year survival was similar between both groups (PAR 59% vs CVG 69%, p=0.153) and re-operation was negligible. Echocardiography revealed significantly lower aortic valve gradients in the PAR group (8.69 vs 15.45 mmHg, p<0.0001), and smaller left ventricular dimensions both at 6 weeks and 1 year follow up (p<0.05). Conclusions This study highlights the comparable short and mid-term outcomes of PAR in cases of TAAD, in comparison to established therapy.

Migration of sternal wires into vital structures is a rare but potentially life-threatening complication. While a few cases have been reported, the sternal wires were broken in those cases. To our knowledge, this is the first report of multiple, non-broken migrated sternal wires stabbing vascular grafts. A 65-year-old woman with a long history of treatment for extended aortic pathology, which included replacement of the aortic root (Bentall procedure, coronary artery reconstruction with Piehler technique), aortic arch and thoracoabdominal aorta, as well as thoracic endovascular repair (TEVAR), underwent mitral valve replacement due to severe mitral regurgitation under third median sternotomy. The postoperative course was uneventful, and she was followed as an outpatient. Two years after the surgery, she complained of anterior chest discomfort. Computed tomography (CT) revealed hemorrhaging around the vascular grafts in the mediastinum and migration of several non-broken sternal wires into the vascular grafts. We suspected graft injury due to the sternal wires, and open repair by reopening the sternotomy incision was performed. During redo sternotomy, massive bleeding occurred, so cardiopulmonary bypass was urgently established via femoral cannulation, and her body temperature was brought down. After careful dissection, tearing of the grafts at both the ascending aorta and left coronary artery was found under circulatory arrest with moderate hypothermia. Polypropylene sutures were placed to control bleeding.

Coronavirus disease 2019 (COVID-19) is a remarkably challenging health issue that provoked all the health-care providers to contemplate some measures about the situation. All the health-care workers frontline (esp. emergency service, pulmonologists, infection disease specialist and anesthesiologist) have produced recommendations on prevention and taking care of COVID-19 patient (1,2). Whereas, at the second line another important issue is the ongoing healthcare for the continual disease situations.There are two main critical issues on cardiovascular surgery in this pandemic. Firstly, to delay the elective surgeries is essential to sustain the health-care service. Elective case triage is trickier for cardiovascular procedures which are relatively progressive conditions. Definitive decision to defer a procedure should be made regarding firstly to the capacity of health-care system, and then availability of surgical/anesthesia staff, intensive care unit beds, need for isolation beds, ventilators, cardiopulmonary bypass machine, extracorporeal membrane oxygenator, supplies such as sutures, grafts, valves and blood and blood product availability. The patient status should be taken into account to defer or to perform the procedure, as well. Therefore, we developed “Level of Priority” (LoP) statement for cardiovascular procedures (3). Elective cases are defined as LoP I that may be postponed as much as possible. LoP II to IV cases should be reconsidered by individual basis by “Heart Team”. The situations that can be managed by percutaneous coronary intervention, endovascular procedures and etc. may be handled by non-operative manners.The second one is the personal protection equipment and infection measures while dealing with a suspected / confirmed COVID-19 patient. It is obvious that a suspected / confirmed COVID-19 patient ought to be assessed with specific measures for any medical or surgical intervention. Personal protection equipment (PPE) is the most crucial measure during the pandemic. It is recognized that many centers are facing PPE shortages and there are recommendations to re-sterile the masks to be effective for reuse.(4) More measures should be taken into consideration for sterile environment such as surgical procedures. Some added measures such as face shield may be recommended for surgical procedures. The surgical team who scrubbed in, must wear extra equipment such as surgical coat and double gloves. It may be recommended to fix the long-sleeve gloves to the surgical coat by adhesive drapes (3). It is obvious that this kind of working environment with all this equipment is challenging, sometimes irritating and disquieting. One other big problem is the fraught feeling of health-care providers to be diseased or to be contagious for their family. Therefore, health-care providers may need enormous support for burnouts during the pandemic.The other measures such as preparation of the operating room (OR), anesthesiologic management, transportation of patients and disinfection of OR were discussed in the referring article (3).In conclusion, it is important to assess the “Level of Priority” for surgical procedures to support the service of health-care facility. More than that, whole surgical team should be protected by adequate PPE and should take the time to get full protected.