We present an unusual combination of lesions in an eight months old child diagnosed with Tetralogy of Fallot (TOF), Anomalous origin of Right Pulmonary artery (AORPA) and anomalous coronary artery (ACA) crossing the pulmonary annulus. The association of AOPA and TOF is extremely rare with an incidence of 0.4%. (1) The incidence of anomalous coronary artery in TOF is 10.3%. (3) However a combination of all three lesions poses challenges to surgical repair and has not been previously reported.

Under the unprecedented pressures of the global coronavirus disease 2019 (COVID-19) pandemic, there is an urgent requisite for successful strategies to safely deliver cardiac surgery. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first described in early December 2019, and the rapid spread and emergence of this virus has caused significant disruptions in the delivery of healthcare services worldwide.1,2 In particular, provision of cardiac surgery has been disproportionally affected due to reallocation of intensive care resources, such as ventilators.2Additionally, patients with pre-existing cardiovascular disease are likely to have comorbidities which are associated with poorer clinical outcomes in confirmed SARS-CoV-2 cases.3,4 Despite this, Yandrapalli and colleagues have reported the first case of a successful coronary artery bypass graft (CABG) operation in a patient with asymptomatic SARS-CoV-2 infection, which offers insights into how cardiac surgery could be adapted to solve the challenges of this pandemic.5In response to the burden of COVID-19 on healthcare systems in the United Kingdom (UK), elective cardiac surgeries have been delayed owing to the redistribution of intensive care resources and the unquantifiable risk of acquiring COVID-19.2 Likewise, cardiac surgery services have undergone structural remodelling into a centralised system in an attempt to continue provisions of emergency surgery alongside hospital management of COVID-19 patients.2Unsurprisingly, most cardiac surgery units across the globe have seen a sharp decline in surgeries as a result, and one unit reported an 83% reduction in cardiac index cases between 23rd March to 4th May 2020.2 Similar models have been used in Europe to manage healthcare services and increase intensive care capacity. For example in the Lombardy region of Italy, 16 out of 20 cardiac surgical units discontinued services and all urgent cases have been consequently diverted to the remaining four units for centralised services.6 Whilst these measures have been beneficial for supporting the focused management of COVID-19 patients, it is important to reflect upon the future consequences of delayed elective cardiac surgery. Indeed, such patients are likely to have progressive conditions and further work is needed to investigate the long-term impact of COVID-19 on mortality and morbidity in this cohort.The case report by Yandrapalli and colleagues highlight the importance of routine SARS-CoV-2 testing for all patients requiring cardiac surgery, especially for detecting asymptomatic or subclinical infections.5 Active SARS-CoV-2 infection may precipitate an overproduction of early response proinflammatory cytokines in post-operative period, leading to unfavourable surgical outcomes.7,8 Moreover, preliminary studies have shown that patients with established cardiovascular diseases may have a greater risk of increased SARS-CoV-2 infection severity and prognosis.9 Taken together, assessment for active infection is crucial for risk stratification. In addition, clinicians should consider the threshold for surgery when selecting patients for cardiac surgery. An international, multi-centre cohort study by COVIDSurg Collaborative which included 1128 confirmed SARS-CoV-2 patients undergoing a broad range of surgeries revealed that 30-day mortality risk was significantly associated with the patient demographics of male sex, an age of 70 years or older, and poor preoperative physical health status.10 Collectively, the risks and benefits of cardiac surgery should be carefully considered in such patients due to higher mortality risk.10Alternative therapeutic procedures with rapid discharge, such as percutaneous intervention or medical therapy, may be more appropriate to reduce SARS-CoV-2 related mortality and nosocomial infection risk.11Current evidence is limited for postoperative outcomes in cardiac surgery cases. In the aforementioned cohort study by COVIDSurg Collaborative, the 30-day mortality rate was 23.8%.10In addition, the study reported that 51.2% of patients had postoperative pulmonary complications, which was associated with a higher mortality rate of 38.0%.10 In another case report describing an emergency CABG operation, the asymptomatic patient succumbed to pulmonary complications arising from a SARS-CoV-2 infection confirmed postoperatively.12 The authors acknowledge that the undiagnosed infection may have triggered a refractory pathological response after cardiac surgery. Indeed, recent literature has suggested that patients with SARS-CoV-2 are at higher risk of developing thromboembolisms, possibly mediated by the interaction with angiotensin-converting enzyme 2 (ACE2) receptors.13Similarly, there is a consensus that SARS-CoV-2 has direct adverse effects on the myocardium due to high expression of ACE2.14 As such, SARS-CoV-2 can potentially trigger multisystem complications which require vigilant monitoring, especially in patients requiring cardiopulmonary bypass and at high risk of developing thromboembolisms. Cardiac surgery patients represent a vulnerable patient population, and this cohort may experience worse outcomes with SARS-CoV-2 infection based on the current available evidence. In the latest recommendation, UK currently advises all patients who are listed for elective cardiac surgery to self-isolate for 14 days prior to surgery date, in a measure to limit and contain the exposure of such cohort to the smallest possibilities of acquiring COVID-19.Currently, the future of cardiac surgery after the pandemic is unclear as the evidence is still emerging. However, the lessons learnt from these unprecedented times can be taken forward to inform future service planning. Moving forwards, routine screening of patients for SARS-CoV-2 infection will undoubtedly play a key role in identifying asymptomatic or subclinical infections. The preoperative UK National Health Service testing recommendations should be broadened so that all patients undergoing cardiac surgery are screened, given the higher risk of postoperative complications in this population. Similarly, repeat testing is important for monitoring patients for concomitant infections. Alongside changes to hospital protocol, service delivery will inevitably shift. The successful application of telemedicine during the pandemic has already been reported in the delivery of oncology services.15 Moreover, the benefits of telecardiology outside of the COVID-19 era have been previously reported, and cardiology services will likely embrace the utilisation of telemedicine for managing outpatient consultations.16 Units will also have to address the vast backlog of surgeries caused by cancellation of elective cardiac operations in a sustainable manner, with adequate hospital space and personal protective equipment availability.17 In order to resume success services, planning for this eventuality should begin now and patients at significant mortality risk due to delayed surgery need to be prioritised.Ultimately, clear guidelines should be implemented to ensure safe resumption of surgical services, whilst also reassuring patients concerned about safety.3 Whilst the future trajectory of this pandemic is uncertain, the insights from the impact of COVID-19 on cardiac surgery will undoubtedly shape the future delivery of cardiac surgery.

The Fontan operation has improved the survival of children born with single ventricle physiology. Selecting candidates for the Fontan operation may be difficult on borderline cases. No clear criterion has been established on the risk for staged Fontan palliation. Another aspect that remains controversial is the indications for fenestration. Intraoperative pulmonary flow study may identify high-risk patients for the procedure. In this report, the authors describe their results with Fontan procedures in children with pulmonary pressure >15 mmHg.

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.

Objective: There is paucity of data on outcomes after isolated tricuspid valve surgery. This meta-analysis aims to compile available data on isolated tricuspid valve surgery and compare isolated tricuspid valve repair (iTVr) with isolated tricuspid valve replacement (iTVR) to elucidate outcomes after tricuspid valve surgery. Methods: A literature search of 6 databases was performed. The primary outcomes was 30-day mortality. Secondary outcomes were early stroke, post-op pacemaker placement, and tricuspid reoperation within 5 years. Publication bias was explored using the funnel plot. Results: Ten retrospective studies involving 1407 patients (iTVr group = 779 patients and iTVR group = 628 patients) were included. A cumulative analysis demonstrated a significant difference favoring iTVr for 30-day mortality [odds ratio – 10 studies (95% confidence interval) 0.34 (0.18-0.66)]; 4.7% versus 12.6%, for iTVr and iTVR, respectively. Post-op pacemaker placement favored iTVr [odds ratio – 6 studies (95% confidence interval) 0.37 (0.18-0.77)]. Although stroke rates and TV reoperation favored iTVr, they did not reach statistical significance. No publication bias was identified. Conclusions: This meta-analysis demonstrates that iTVr has better 30-day mortality and fewer permanent pacemaker placements. Etiology and severity of TR, as well as careful patient selection remain the most important factors for optimal outcomes.

Objectives: To elucidate the impact of regulation of tricuspid regurgitation (TR) using tricuspid annuloplasty on postoperative changes in right ventricular (RV) systolic and diastolic functions. Methods: We enrolled 69 patients who underwent aortic or mitral valve surgery between July 2016 to March 2018 without recurrence. Patients with concomitant coronary artery bypass grafting or a history of previous cardiovascular surgery were excluded, remaining 45 patients enrolled. Patients were divided into 2 groups according to concomitant tricuspid annuloplasty (T: n=12 vs non-T: n=33). RV global longitudinal strain (RVGLS), RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE) and early tricuspid inflow velocity/early diastolic tricuspid annular velocity ratio (tricuspid E/e’) were assessed as functional indices at preoperative, postoperative and 1-year follow-up periods. Results: RVFAC deteriorated postoperatively but recovered at follow-up in group T, whereas that in group non-T showed gradual deterioration overtime. RVGLS and TAPSE showed similar temporary deterioration and recovery between groups. Tricuspid E in group T increased postoperatively and showed significant difference, which was kept until follow-up period. Tricuspid e’ decreased postoperatively, and recovered slightly in both groups. As a result, postoperative RV diastolic function (tricuspid E/e’) showed significant difference between groups. This difference was maintained until follow-up. Conclusions: RV systolic function deteriorated postoperatively, but there was a tendency to improve at follow-up regardless of tricuspid annuloplasty. RV diastolic function may potentially be impaired when TR was regulated by tricuspid annuloplasty.

Background and aim. Classical and paradoxical low-flow, low-gradient aortic stenosis (LFLGAS) are the most challenging aortic stenosis (AS) subtypes. The current therapeutic options are aortic valve replacement (AVR) and conservative management. The matter is controversial because AVR promotes long-term survival, but it is invasive, while no aortic valve replacement (noAVR) in non-invasive, but it is associated with poor prognosis. This meta-analysis aims to investigate the survival rate in patients with LFLGAS undergoing AVR versus noAVR interventions. Methods. A meta-analysis was conducted comparing the outcomes of AVR and noAVR in terms of survival. A meta-regression was carried out to investigate the impact of preserved and reduced left ventricular ejection fraction (LVEF) on survival in both the AVR and noAVR group. Results. The log IRR of survival between AVR group and noAVR group was 0.58 [0.28, 0.87] (p-value = 0.0001), suggesting that survival is significantly better in the AVR group compared to the noAVR group. The meta-regression revealed that low LVEF is related to higher survival rates in the AVR group (p-value = 0.04) when compared to preserved LVEF. LVEF has no impact on survival in the noAVR group (p-value = 0.18). Conclusions. Patients with LFLGAS have better survival in the AVR group rather than in the noAVR group. Reduced LVEF was related to better survival than preserved LVEF in the AVR, and no difference between low and preserved LVEF was found in the noAVR group.

The Perceval Valve is a true sutureless aortic bioprosthesis. Overall, excellent performances have been demonstrated in terms of hemodynamic outcomes, safety and versatility of use; furthermore, as a sutureless valve option, it has shown to reduce the surgical burden, shortening the operative times and simplifying minimally invasive procedures. Since the valve has got a high frame profile, the recommended implantation technique requires a high and transverse aortotomy. In case of unplanned Perceval valve implantation, when an extended aortotomy is required, we have come up with a simple technique to reshape the aortic root before the valve is delivered in place: symmetry is pivotal to prevent folding issues and to improve the annular sealing. Although we discuss an out-of-recommendation use, in our experience that technique has shown to be safe and effective.

We report a case of intravenous drug use-associated tricuspid valve endocarditis in a 28-year-old pregnant female at 26-weeks gestation. Despite appropriate intravenous antibiotics, the patient developed life-threatening complications and underwent planned cesarean delivery at 28 weeks 6 days gestation followed by interval tricuspid valve replacement one week later. Both the patient and her infant were successfully managed through the perioperative period.

While there is significant awareness regarding droplet and contact transmission, aerosols are generally underestimated as a potential mode of transmission of SARS-Cov-2 infection. With the gradual resumption of cardiac surgical activities, the cardiac surgical operating room will become an important potential source of infection to the cardiac surgeon and other healthcare workers participating in the operation. There is also diminished awareness about the different aerosol generating procedures (AGP) in the cardiac surgical operating room. In this mini-review we intend to highlight the various aerosol generating procedures that are common in cardiac surgery. This will help increase the awareness among surgeons to AGP. A practical approach to taking preventive measures have also been discussed.

Background: Prolonged pleural drainage after the Fontan procedure is a common complication. Various protocols have been described, but there is no definitive consensus for the treatment of this complication. Materials and Methods: Our primary aim was to determine the effect of the protocol on the duration of drainage and hospital stay. Our secondary aim was to determine parameters affecting prolonged drainage after the Fontan procedure. Ninety two consecutive patients who underwent the Fontan operation retrospectively analyzed. A protocol-based postoperative management was adopted at July 2018. Patients operated before the protocol were defined as Group 1(n=48), and patients operated after the protocol were defined as Group 2(n=44). Results: The mean age was 5(IQR 4.0-6.9) years the mean body weight was 17.3 (IQR 15.1-21.8) kg.There were statistically significant differences between groups in terms of total drainage, duration of pleural drainage, prolonged drainage and, LOHS(p=0.05,p=0.04, p=0.04,p=0.04,respectively). In the multivariate analysis, the application of the protocol was observed to be the only factor for prolonged drainage (OR:2.46, 95% CI Lower-Upper:1.03-5.86,p=0.04). Conclusion: Standardization and strict application of the medical treatment within a specific protocol without being affected by doctor, nurse or patient-based factors increases the success. After the changes in our medical management strategy, along with the decrease in total drainage and duration of pleural drainage, LOHS was also reduced, of course together with a reduction in the cost. Key Words: Fontan, pleural drainage, hospital stay, protocol

It is known that LIMA-to-LAD is the major determinant of the patient’s prognosis and long term survival for a large percentage of the population with coronary artery disease Off pump, minimally invasive LIMA-to-LAD provides excellent long-term results ). As Awad et al state, this pandemic has disrupted and challenged delivery of health care services worldwide ). LIMA-to-LAD can be performed with minimal resources in an isolated area from COVID-19 facilities within the hospital.Hybrid treatment of coronary heart disease is another option for patients under these circumstances . Surgeons must take the lead and play an active role in the decision process. . As the authors conclude, given fluidity of the current situation, there is need for new processes and clinical decision – making that will allow patients to receive appropriate treatment,

Covid has blatantly uncovered the disconnect between the healthcare professionals who have the responsibility for the health of the nation but little of the authority, and politicians and business people who have the authority and political power over healthcare, but none of the responsibility for the health of the nation. The time has come to review this dichotomy and to reinvent medical education in order to empower and train healthcare professionals, particularly mid-career ones, to become adept in the business of medicine; including budgeting, management, leadership, hiring and firing, brand building and other important aspects of running complex healthcare entities. It is no longer acceptable for physicians to accept backseat for non-physician managers and concede their rules and regulations without question. The time is now for health professionals to train themselves and take charge of the profession.

Type A acute aortic dissection (TAAD) during pregnancy is a life-threatening event for both the mother and unborn baby. Pregnancy has been recognised as an independent risk factor for TAAD, postulated to be due to physiological changes that cause hyperdynamic circulation. Presentation can be atypical in many cases and further concern from clinicians of fetal radiation exposure can result in missed or delayed diagnoses. Investigation via quickest form of imaging, whether CT, MRI or transoesophageal echocardiography, should be carried out promptly due to the high risk of mortality. Surgical management of TAAD in pregnancy revolves primarily around the decision to deliver the foetus concomitantly or to perform aortic repair with the foetus in utero. This review will summarise the difficulties faced when managing TAAD in pregnancy, and important questions for future research.

Over the last two decades, the medical community witnessed an outstanding and accelerated development on minimally invasive therapies. With the dorsal spine of supportive data from large randomized control trials, transcatheter aortic valve replacement (TAVR), aortic and mitral valve-in-valve, mechanical circulatory support and peripheral endovascular interventions all share the need of accessing a vascular bed with a large bore catheter. Nevertheless, to date, there has yet to be a universal consensus on defining large-bore vascular access (LBVA) in the world of transcatheter therapies. We explore the evolution, characteristics and vascular compatibility of the current commercially available devices, analyze the devices along with access site-specific complications rates and finally review the present methods for percutaneous vascular closure.

A document by Akhil Raj Anumolu. Click on the document to view its contents.

Background: Despite clear clinical benefits, there is limited evidence regarding possible complications of the novel mechanical support device Impella. Aortic and mitral valve regurgitation or injury are rare but potential complications following implantation of the Impella device. Methods: To evaluate valvular complications after the Impella device implantation, we have performed a comprehensive search of literature on multiple sites on this topic. Results and Conclusion: Ten case reports and one observational retrospective study were identified, with a total number of 19 patients identified. This article aims to draw attention to potential periprocedural complications relating to the Impella, in particular iatrogenic aortic and mitral valve injuries. Moreover, we have summarized our recommendations emphasizing the need for careful management and meticulous follow-up of these patients to avoid such potentially devastating complications.

Transcatheter repair systems are becoming increasingly popular as a potential solution for high-risk and inoperable patients with mitral regurgitation. The Cardioband (Edwards Lifesciences, Irvine, California) is a transcatheter direct annuloplasty device, based on the concept of an undersized ring annuloplasty. We report a case of minimally invasive surgical explantation of a failed Cardioband device 21 months after its implantation. Intraoperatively, it was found that3 anchors of the Cardioband device were detached from the posterior annulus at P2. In this report, a “cut and unscrew” technique with some tips and tricks is presented for the removal of the device.