We report a case of redo mitral and tricuspid valve repair via right thoracotomy under hypothermia and systemic potassium administration with axillary artery cannulation in a patient after coronary artery bypass grafting (CABG) with patent bilateral internal thoracic artery (ITA) grafts crossing over the sternum. Redo mitral valve surgery is challenging through re-sternotomy as previous CABG with patent ITA poses a risk of injury due to dense adhesion. Herein, dangerous dissection around the aorta and functional ITA grafts was avoided by performing the procedure under systemic hypothermia via thoracotomy. Furthermore, considering the presence of atheroma in the aorta, the axillary artery was used as a perfusion route to prevent stroke events. Performing axillary artery cannulation and right thoracotomy under hypothermic cardiac arrest with systemic hyperkalemia without clamping the patent bilateral ITAs and aorta allowed us to execute redo mitral valve surgery after CABG without major postoperative cardiac or cerebral complications.

Very few aortic dissections have been published following a heart transplant. Most of these have been reported as donor aortic dissections. Recipient aortic dissection is extremely rare. Here, surgical treatment of chronic Stanford type A recipient aortic dissection in a 40-year-old patient who underwent an orthotopic heart transplant 10 years ago will be discussed in the light of the literature.

Objective: To develop a machine learning-based model for predicting the risk of acute respiratory distress syndrome (ARDS) after cardiac surgery. Methods: Data were collected from 1011 patients who underwent cardiac surgery between February 2018 and September 2019. We developed a predictive model on ARDS by using the random forest algorithm of machine learning. The discrimination of the model was then shown by the area under the curve (AUC) of the receiver operating characteristic curve. Internal validation was performed by using a 5-fold cross-validation technique, so as to evaluate and optimize the predictive model. Model visualization was performed to reveal the most influential features during the model output. Results: Of the 1011 patients included in the study, 53 (5.24%) suffered ARDS episodes during the first postoperative week. This random forest distinguished ARDS patients from non-ARDS patients with an AUC of 0.932 (95% CI=0.896-0.968) in the training set and 0.864 (95% CI=0.718-0.997) In the final test set. The top 10 variables in the random forest were cardiopulmonary bypass time, transfusion red blood cell, age, EUROSCORE II Score, albumin, hemoglobin, operation time, serum creatinine, diabetes, and type of surgery. Conclusion: Our findings suggest that machine learning algorithm is highly effective in predicting ARDS in patients undergoing cardiac surgery. The successful application of the generated random forest may guide clinical decision making and aid in improving the long-term prognosis of patients.

A 77-year-old woman underwent mitral valve replacement and tricuspid annuloplasty for severe mitral stenosis and tricuspid regurgitation with pulmonary hypertension. Two months later, the patient was readmitted because of marked edema. A new harsh pansystolic murmur was auscultated, and echocardiography revealed a jet from the left ventricle to the right atrium but no perivalvular leakage was detected at the mitral valve position. At operation, an 6mm defect adjacent to the tricuspid annulus in the interatrial septum and detachment of the anterior edge of the tricuspid ring were detected. The defect was closed using a pericardial patch. An inadequate stitch at the anteroseptal commissure in the previous operation led to left ventricular-right atrial communication.

Background The Perceval S is a sutureless, rapid deployment, bovine pericardial aortic prosthesis on a nitinol stent, which has limited data on outcomes and cost from the United States. Methods We performed a retrospective review of Perceval S implantation at a single center between 2015 and 2018. After exclusion criteria, we compared 262 patients who underwent sutureless aortic valve (SLV) implantation with 394 patients who underwent standard sutured aortic valves (SAVR). Hospital cost data was reviewed, and risk adjustment, done by propensity score and inverse probability weighting, was used to compare outcomes. Results The SLV group was older, had more females, and had a higher proportion of multicomponent operations. For isolated AVR, partial upper hemisternotomy was more frequent in SLV. The median cardiopulmonary bypass and cross clamp times for isolated SLV were significantly lower than SAVR. SLV had a risk-adjusted 11.3% permanent pacemaker (PPM) rate vs 6.1% in SAVR (p=0.016). There were no differences in other postoperative complications (postoperative atrial fibrillation, stroke, renal failure, prolonged ventilation; P>.05 for all). Mortality at any time did not differ between groups. Median hospital costs were higher in the SLV group, likely due to permanent pacemaker rate leading to longer length of stay. Conclusion Sutureless tissue aortic valves can be used safely with lower cardiopulmonary bypass and clamp times than sutured prostheses and facilitate use of minimally invasive approaches with cost neutrality. This valve may be advantageous in older, higher risk patients requiring complex operations.

Type A dissection complicated by cerebral malperfusion and coma may pose decision-making challenges. We describe the case of a patient who presented coma in the context of acute type A aortic dissection, without cardiac tamponade. Brain MRI was performed 4 hours after the onset of symptoms to evaluate the brain perfusion and viability. We discuss the potential role of the currently available emergency brain MRI as an additional tool in the workup of aortic dissection, and its potential to discriminate between irreversible brain injury and brain viability.

Abstract Introduction：Surgery is the mainstay of treatment for aortic dissection which lesion affected the aortic arch. Conventional surgical methods usually use unilateral cerebral perfusion by cardiopulmonary bypass (CPB) to maintain the perfusion of the brain, and the reconstruction of arch branches must be performed under CPB. Unilateral cerebral perfusion with prolonged CPB may lead to complications of cerebral hypoperfusion. We propose a new technique that can accomplish aortic arch branches replacement without the use of cardiopulmonary bypass and maintain bilateral cerebral perfusion at all times. Materials and Methods: From January 2018 to July 2021, we performed the new technique in 23 patients. Furthermore, we performed a retrospective analysis with patients undergoing conventional surgery during the same period, comparing perioperative data and follow-up data between two groups. Result: The CPB time, deep hypothermic circulatory arrest time and aortic cross-clamping time of new technique group was significantly shorter than conventional group. Other perioperative data and follow-up data were not statistically different. Discussion: Simplified arch-first technique can significantly shorten CPB, aortic cross-clamping and deep hypothermic circulatory arrest time. The technique is theoretically safer because it can better protect the cerebral perfusion during the operation. The short-term efficacy of this technique is the same as that of conventional surgery, and it is more convenient for surgeons to operate. Conclusions: Compared with the conventional method, the simplified arch-first technique is non-inferior, friendly in operation and safer in theory, and is worthy of promotion. Key words: Aortic dissection; Arch-first; Cardiopulmonary bypass; Aortic arch reconstruction

Objective: To evaluate the hemostatic system with ROTEM in patients undergoing surgery for acute type aortic dissection (ATAAD) using elective aortic procedures as controls. Design: This was a prospective, controlled, observational study. Setting: The study was performed at a tertiary referral center and university hospital. Participants: Twenty-three patients with ATAAD were compared to 20 control patients undergoing elective surgery of the ascending aorta or the aortic root. Results: ROTEM (INTEM, EXTEM, HEPTEM and FIBTEM) was tested at 6 points in time before, during and after surgery for ATAAD or elective aortic surgery. The ATAAD group had an activated coagulation coming into the surgical theatre. The two groups showed activation of both major coagulation pathways during surgery, but the ATAAD group consistently had larger deficiencies. Reversal of the coagulopathy was successful, although none of the groups reached elective baseline until postoperative day 1. ROTEM did not detect low levels of clotting factors at heparin reversal nor low levels of platelets. Conclusions: This study demonstrated that ATAAD is associated with a coagulopathic state. Surgery causes additional damage to the hemostatic system in ATAAD patients as well as in patients undergoing elective surgery of the ascending aorta or the aortic root. ROTEM does not adequately catch the full coagulopathy in ATAAD. A transfusion protocol in ATAAD should be specifically created to target this complex coagulopathic state and ROTEM does not negate the need for routine laboratory tests.

Left atrioventricular valve aneurysm is rare. We present a rare case of partial atrioventricular septal defect with an extremely thin left atrioventricular valve aneurysm mimicking valve perforation. The preoperative echocardiography demonstrated severe left sided atrioventricular valve regurgitation on the “cleft” and leaflet perforation. But in per-operative, we discovered a left sided atrioventricular valve aneurysm instead of valve perforation. The “cleft” edge and a aneurysm were closed.

Purposes: Pediatric open cardiac surgical patients usually suffer from acute pain after operation. The aim of this study was to investigate the effect of bilateral PIFB in children undergoing open cardiac surgery. Methods. A group of 110 pediatric patients were randomly allocated to either receive bilateral PIFB (PIF group) or no nerve block (SAL group). The primary endpoint was postoperative pain at rest and exercise. Secondary outcomes included time to drain removal, time to extubation, intraoperative and postoperative fentanyl consumption, time to first feces, length of stay in the ICU and the length of hospital stay. Results. The trends of MOPS were significantly higher at 24 hours after operation both at rest and during coughing in SAL group compared with PIF group. The PIF group reported significantly less intraoperative and postoperative fentanyl consumption. Time to extubation, time to first flatus, length of stay in the ICU and the length of hospital stay were significantly decreased in the PIF group. Conclusion. Bilateral PIFB in pediatric open cardiac surgical patients provide effective analgesia and reduce the length of hospital stay .

COMMENTARY: Slow and steady wins the race -- Building a Robotic Mitral Valve Program

Background: Persistence or recurrence of stenosis is a complication of initial coarctation repair. This study aims to report short-term outcomes of surgical management of recurrent coarctation and initial repair analysis. Methods: We retrospectively reviewed our experience with 51 patients undergoing recoarctation surgical repair between 2008 and 2019 using antegrade cerebral perfusion technique. Results: Surgical correction included prosthetic patch aortoplasty in 23 (45%), resection with wide end-to-end anastomosis in 15 (29%) and a tube interposition graft in 13 (25%) patients. Median age at initial correction and reintervention were 12 month and 9 years. Median interval from primary repair to reintervention was 60 months. Initial repair analysis revealed 33% of patients had initial correction in the neonatal period, 72,5% of patients were done via a left thoracotomy approach and 63% of patients had end-to-end anastomosis at initial surgery. Conclusion: Our study demonstrates that surgical repair of recurrent coarctation of the aorta using antegrade cerebral perfusion technique can be performed safely and with excellent results.

Objective: To investigate the effect of aortic esophageal fistula treatment after thoracic aortic endovascular repair (TEVAR) with artificial vessel bypass. Methods: The clinical data of 6 consecutive patients who received surgical treatment at Shanghai Deda Hospital from September 2019 to June 2021 due to aortic esophageal fistula after TEVAR were retrospectively analyzed. There were 6 males, aged (47.7±8.2) years old (range: 35-56 years old). All patients had recurrent fever, and 4 patients had positive blood cultures. According to the specific conditions of the patients, all patients underwent artificial blood vessel bypass and jejunostomy under general anesthesia without extracorporeal circulation. One case underwent artificially infected vascular segment resection and esophageal repair at the same time. 5 cases underwent artificial infection vascular resection, 4 of them underwent esophageal repair, and 1 case had a large intraoperative fistula and local resection of the esophagus. Sensitive antibacterial drugs were continued after the operation for 6 to 8 weeks. Results: There were 2 deaths in hospital, 1 case of large cerebral infarction early postoperatively, and 1 case of septic shock. The remaining 4 patients recovered well after the operation and were discharged. The follow-up period was 2 to 23 months. During the follow-up period, the remaining patients had no recurrence of infection and esophageal fistula. Conclusion ：In patients with aortic esophageal fistula after TEVAR, the establishment of artificial vascular bypass, the resection of the infected vascular segment, contemporaneous or staged esophageal repair, regular anti-infective treatment can obtain a good prognosis.

Introduction: In this study, we aimed to compare the early postoperative period results of type 2 diabetes patients taking oral antidiabetics or insulin medications, with microalbuminuria and normal creatinine levels after coronary artery bypass. Materials and methods: Eighty patients with type 2 diabetes and taking oral antidiabetics or receiving insulin medication all with normal creatinine levels with microalbuminuria were included in this study. Preoperative creatinine values of the patients, albumin levels in spot urine, creatinine levels on the postoperative 3rd day, duration of ventilation, amount of drainage, length of stay in the intensive care unit, length of stay in the hospital, mediastinitis and mortality rates were recorded. Results: A statistically significant increase in creatinine was found in both taking oral antidiabetics type 2 diabetes and insulin medication patient groups with microalbuminuria. When the two groups were compared with each other, increase in creatinine levels of the patients using insulin was higher than the patients taking oral antidiabetics, and was statistically significant. Conclusion: According to the result of our study it can be suggested that postoperative creatinine elevation is observed in patients with type 2 diabetes mellitus with microalbuminuria and with normal creatinine levels, either having insulin medication or not. The elevation is higher in patients having insulin medication while other results are similar, except for impaired renal function. Keywords: Type 2 diabetes mellitus, insulin, microalbuminuria, coronary artery bypass.

Objective: To describe experience with using intraoperative Transesophageal Echocardiography to reliably predict the size of the rapid deployment prosthetic valve by measuring the native aortic annulus Methods: Retrospective review of single institution series of patients undergoing Aortic Valve Replacement with Rapid Deployement Bioprosthetic Valves. Included were patients that had their native aortic valve replaced either isolated or as part of any additional procedure. Aortic annulus was measured prior to initiation of the operation using transesophageal echocardiography (TEE). Correlation analysis was conducted between Echocardiographic annular measurements and actual implanted valve sizes. Results: Twenty five patients underwent rapid deployment valve implantation in the aortic position. Of these, 36% of patients had the same size valve as the measured aortic annulus, 48% of patients had a valve implanted that was 1 mm different, and 16% of patients had 2 mm difference. The mean annular size based was 22.4 mm (range: 21-28 mm). The mean valve size implanted was 23.3 mm (range: 21-27 mm). There was no statistically significant difference between the mean annular measurement and the valve size selected (0.9 mm , p = 0.8). Conclusion: TEE can further enhance valve sizing and guidance through a proper and safe deployment. Although evident in our experience, larger scale studies are needed to further elucidate conclusions on the importance of avoiding under-sizing valves.

Objective: To compare outcomes of hemiarch versus total arch repair during extended ascending aortic replacement. Methods: Between 2004 and 2017, 261 patients underwent hemiarch (n=149, 57%) or total arch repair (aortic debranching or Carrell patch technique, n=112, 43%) in the setting of extended replacement of the ascending aorta. Median follow-up was 17.2 (IQR 4.2–39.1) months. Multivariable models considering preoperative and intraoperative factors associated with mortality and aortic reintervention were constructed. Results: Survival was 89.0, 81.3, and 73.5% vs. 76.4, 69.5, and 61.7% at 1, 3, and 5 years in the hemiarch versus total arch groups, respectively (log-rank p=0.010). After adjustment for preoperative and intraoperative factors, the presence of a total arch repair (adjusted HR 2.53, 95% CI 1.39 – 4.62, p=0.003), and increasing age (adjusted HR per 10 years of age, 1.76, 95% CI 1.37 – 2.28, p<0.001) were associated with increased mortality. The cumulative incidence of aortic reintervention with death as a competing outcome was 2.6, 2.6, and 4.4% and 5.0, 10.3, and 11.9% in the hemiarch and total arch groups, respectively. After adjustment, the presence of a total arch repair was significantly associated with need for aortic reintervention (SHR 3.21, 95% CI 1.01 – 10.2, p=0.047). Conclusions: Overall survival after aortic arch repair in the setting of extended ascending aortic replacement is excellent, however, total arch repair and increasing age are associated with higher mortality and reintervention rates. A conservative approach to aortic arch repair can be prudent, especially in those of advanced age.

BACKGROUND/AIM To evaluate outcomes of concurrent Cox-Maze procedures in elderly patients undergoing high-risk cardiac surgery. MEHODS We retrospectively identified patients aged over 70 years with Atrial Fibrillation (AF) from 2011 to 2017 who had two or more other cardiac procedures. They were subdivided into two groups: 1. Cox-Maze IV AF ablation 2. No-Surgical AF treatment. Patients requiring redo procedures or those who had isolated PVI or LAAO were excluded. Heart rhythm assessed from Holter reports or 12-lead ECG. Follow-up data collected through telephone consultations and medical records. RESULTS There were 239 patients. Median follow up was 61 months. 70 patients had Cox-Maze IV procedures (29.3%). Demographic, intra- and post-operative outcomes were similar between groups although duration of pre-operative AF was shorter in Cox-Maze group (p=0.001). One (1.4%) patient in Cox maze group with 30-day mortality compared to 14 (8.2%) the control group (p=0.05). Sinus rhythm at annual and latest follow-up was 84.9% and 80.0% respectively in Maze group - significantly better than No-Surgical AF treatment groups (P<0.001). 160 patients (66.9%) were alive at long-term follow-up with better survival curves in Cox Maze group compared to No-Surgical treatment group (p=0.02). There was significantly higher proportion of patients in NYHA 1 status in Cox-Maze group (p=0.009). No differences observed in freedom from stroke (p=0.80) or permanent pacemaker (p=0.33). CONCLUSIONS. Surgical ablation is beneficial in elderly patients undergoing high-risk surgery - promoting excellent long-term freedom from AF and symptomatic/prognostic benefits. Therefore, surgical risk need not be reason to deny benefits of concomitant AF-ablation.

Introduction: Nowadays micro-invasive procedures (off-pump, beating heart) for mitral valve repair (MVRe) are abruptly expanding with the potential to be adopted as a valuable alternative to surgery. In the present manuscript, the Authors review the available technologies intended to treat mitral regurgitation (MR) through transapical approach, including annuloplasty and chordal repair options. Annuloplasty: To date, Valcare Amend is the only transapical mitral valve (MV) ring to have been implanted in patients. The device allows for stabilization of the annulus through a complete semirigid D-shaped ring. The first-in-human successful procedure was performed in 2016 by our Group and subsequent clinical experience included a total of 14 implanted patients. Currently the technology is under clinical trial evaluation to validate the efficacy and safety profile of the device. Chordal Repair: Beating heart chordal implantation via trans-apical approach is a current feasible, safe and reproducible option. Neochord DS1000 is the most widely used technology in the field, with a solid procedural experience and good results in well-selected patients. Its clinical use has been validated in Europe since 2012, while it is still under clinical investigation in the United States. Harpoon TDS-5 system is a novel technology, recently CE mark approved for clinical use. Conclusions: Transapical micro-invasive technologies are current viable therapies to treat MR in selected patients. Embracing transcatheter MVRe therapies should guide the cardiac surgeon through the new revolution of micro-invasive MV tailored repair.