Background. Deep hypothermic circulatory arrest (DHCA) at ≤20°C for aortic arch surgery has been widely used for decades, with or without cerebral perfusion (CP), antegrade (ACP) or retrograde. In recent years nadir temperature progressively increased to 26-28 °C (moderately hypothermic circulatory arrest, MHCA), adding ACP. Aim of this multicentric study is to evaluate early results of aortic arch surgery and if DHCA with 10-minute of cold reperfusion at the same nadir temperature of the CA before rewarming (delayed rewarming, DR) can provide a neuroprotection and a lower body protection similar to that provided by MHCA+ACP. Methods. Two-hundred-ten patients were included in the study. DHCA+DR was used in 59 patients and MHCA+ACP in 151. Primary endpoints were death, neurologic event (NE), temporary (TNE) or permanent (permanent neurologic deficit, PND), and need of renal replacement therapy (RRT). Results. Operative mortality occurred in 14 patients (6.7%), NEs in 17 (8.1%) and PNDs in 10 (4.8%). Twenty-three patients (10.9%) needed RRT. Death+PND occurred in 21 patients (10%) and composite endpoint in 35 (19.2%). Intergroup weighed logistic regression analysis showed similar prevalence of deaths, NDs and death+PND, but need of RRT (OR 7.39, CI 1.37-79.1) and composite endpoint (OR 8.97, CI 1.95-35.3) were significantly lower in DHCA+DR group compared with MHCA+ACP group. Conclusions. The results of our study demonstrate that DHCA+DR has the same prevalence of operative mortality, NE and association of death+PND than MHCA+ACP. However, the data suggests that DHCA+DR when compared with MHCA+ACP provides better renal protection and reduced prevalence of composite endpoint.

Mitral valve (MV) repair for mitral regurgitation (MR) due to posterior leaflet (PL) prolapse is achieved nowadays with a great success rate and a good survival, similar, in certain subgroups. In this paper, Sakaguchi et al describe their results in two groups of patients with PL prolapse. Some patients underwent resection (resection group) and others chordal replacement with/out limited resection (respect group). Results were similar in terms of survival and MR recurrence. Our goal is to eliminate, as much as possible, MR when a patient with degenerative MR is operated on. Reduction of the mitral orifice and consequently an increase of the transmitral gradient is the rule. MV repair for degenerative MR provides great results, but there is not a single surgical technique. A close evaluation of the anatomical findings will allow us to choose the best strategy for the individual patient. An open mind is the most important characteristic that a surgeon should have to repair a prolapsing PL without residual regurgitation and dangerous gradients.

Robotic totally endoscopic techniques to perform the LITA to LAD graft, coupled with PCI, provides the least invasive option to achieve hybrid coronary revascularization (HCR). Shorter hospital stay and reduced need for blood transfusions have been consistently being reported by several studies along with similar long-term outcomes. Considerable variations exist in the definition of HCR which can be single or two-staged with surgical revascularization being carried out after PCI or vice versa. Variations also exist with respect to usage of cardiopulmonary bypass, surgical incisions, and use of minimally invasive robotic techniques. The different strategies of HCR do not lead to similar outcomes and the findings of one strategy cannot be extrapolated to the entire group. Studies reporting different strategies of HCR, should ideally provide more granular data when reporting outcomes.

Caseous liquefaction necrosis of mitral annular calcifications are rare. Rupture of its capsule may lead to systemic embolization. Surgical management entails Incision and Drainage with either mitral valve repair or replacement.

Background. A staged thoracotomy unifocalization approach has not been the dominant option over the past 20 years primarily due to the introduction of midline one-stage complete unifocalization. Methods. In this issue of the Journal of Cardiac Surgery, van de Woestijne and colleagues publish their experience over the past 30 years in 39 consecutive patients with “consistent” staged unifocalization through a lateral thoracotomy in patients with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries (PA/VSD/MAPCA). Results. They report definitive repair completion in 76.3% of the patients and an overall survival after definitive repair of 96% at 20 years despite the study period ranging from 1989 to the present. Conclusion. Given the multiple variations one could have with PA/VSD/MPACA, a midline unifocalization approach may not always be possible. Surgeons should be familiar with the lateral thoracotomy unifocalization staged approach to PA/VSD/MAPCA.

Choosing to perform mitral valve (MV) repair or replacement remains a hot and highly debated topic. The current guidelines seem to be conflicting in this specific field and the evidences at our disposal are scarce, only one small randomized trial and few larger retrospective studies. The meta-analysis by Gamal and coworkers tries to summarize the current evidences, concluding that MV replacement for the treatment of ischemic mitral regurgitation is at least as safe as repair and certainly offers a more stable result over time than the latter. Obviously, the implantation of a prosthesis, especially a mechanical one, brings with it a series of problems, such as anticoagulation and, above all, a possible lack of ventricular remodeling, especially if a chordal sparing replacement is not performed. It must be said, on the other hand, that isolated annuloplasty cannot act as a counterpart to replacement, because ischemic MR cannot be considered only an annular disease. Therefore, wanting to mimic the nature that, after an infarction, enacts a series of changes involving also the mitral leaflets and chordae, the surgeons are called to act also on these two entities and not only to downsize the annulus. In a nutshell, a procedure should not be opposed in a fundamentalist way to another one, but we must accept the concept of armamentarium where both procedures are present and tail on the single patient, and also on the surgeon’s expertise, the technique guaranteeing the best possible result.

Introduction - The impact of manufacturer labelled prosthesis size and predicted effective orifice area (EOA) on long term survival after aortic valve replacement is not clear although indexed effective orifice area (iEOA) has been associated with worse survival. Methods - Data was retrospectively collected from Jan 2000 – Dec 2019 for prosthesis type, model and size for isolated aortic valve replacements. Stratified survival was compared between groups and subgroups for labelled valve size, EOA and predicted PPM. Results – Total of 3444 patients were included. Moderate and severe PPM was 15.6% and 1.6% respectively. Cumulative life time hazard was worse for biological valves (mortality: biological 77.7% vs mechanical 64.8%, p=0.001). Mean survival was 132.7 months for biological versus 191.3 months for mechanical valves (p=0.001). Moderate prosthetic AS (EOA = 1-1.5 cm2) was12.1% and severe prosthetic AS (EOA≤1 cm2) was 0.8% respectively. Worse survival in the presence of moderate-severe prosthetic AS was seen in biological valves (115.2 months versus 133.7 months, p=0.001 for EOA≤1.5cm2 and >1.5cm2 respectively). There was a statistically significant correlation between survival and iEOA (Spearman’s rho=0.084, p=0.001, BCa bootstrap 95% CI;0.050, 0.120). Moderate to severe PPM (iEOA≤0.85cm2/m2) was a predictor of worse long term survival (HR 3.56; 95% CI: 1.37 - 9.25; p=0.009). Conclusion - Predicted prosthetic moderate to severe AS and moderate to severe PPM adversely affect long term survival. Smaller valves are associated with reduced survival in all groups.

Dear Editor, With great interest, I read the article by Flécher et al1 and congratulate them on the quality of the review carried out on the history of surgical treatment of cardiac wounds. It is an exciting topic, so I would like to briefly comment on some facts narrated in this work.The well-known surgical approach to the heart, described by Larrey in the subxiphoid region, should not be placed in a close historical relationship with the pericardiotomy he performed in 1810 through a thoracotomy. It was not until 1824 that, after treating a soldier who had suffered a penetrating wound between the xiphoid appendix and the 7th costal cartilage, the French surgeon began experimenting on cadavers in search of a faster route to the heart. In 1829 he proposed his oblique subcostal incision which is currently practically not used.2During Milton’s service in Egypt, he surely performed several thoracic surgeries in extremis situation, but there is no evidence to support the claim that median longitudinal sternotomy (MLS) was created during an emergency approach3 or that has been designed for this type of procedure. When he decided to operate on a living human being on January 25, 1897, he used it for an elective total sternectomy in a patient with sternal tuberculosis and ruled out its use in patients with true mediastinal tumors, who needed more urgent surgeries.On the other hand, it can hardly be said that MLS is currently the gold standard for cardiac surgeons to safely and quickly manage a cardiac stab wound. In patients such as those shown in the article,1 an approach using a MLS would be very difficult since lateral mobilization of the costal wall during the necessary separation of the two halves of the sternum would displace the knife, causing probably fatal bleeding.In the emergency room, the gold standard for quickly managing a penetrating cardiac injury is anterolateral thoracotomy in the fifth intercostal space. A 1906 article on experimental surgery in dogs has led some authors to mistakenly consider Spangaro to be the creator of this incision.4 They forget that in 1893 Daniel Hale William performed his famous pericardioraphy (the second in history) precisely using that approach.5References1. Flécher E, Leguerrier A, Nesseler N. An odyssey of suturing cardiac wounds: Lessons from the past. J Card Surg. 2020;35(7):1597-9.2. López de la Cruz Y, Quintero Fleites YF. Modifications to the classic simple-longitudinal inferior pericardiotomy (Sauerbruch technique). CorSalud. 2019;11(3):225-32.3. Milton H. Mediastinal Surgery. Lancet. 1897;1:872 - 5.4. Pust GD, Namias N. Resuscitative thoracotomy. International Journal of Surgery. 2016;33:202-8.5. Buckler H. Doctor Dan. Pioneer in American surgery. Boston: Little, Brown and Company; 1954.Correspondence: “July 26” Ave., No. 306, Apt. 18. Santa Clara. Villa Clara. Cuba. Postal code: 50 200. E-mail: yoandylc@infomed.sld.cu

Background:The advent of TAVR changed the practice for treating patients with severe aortic stenosis. Heart-Teams improved their decision-making process to refer patients to the best and safest treatment. Evidence allowed centers to increase funding and TAVR volume and extend indications to different risk category of patients. This study evaluates the outcomes of intermediate-risk patients treated for severe aortic stenosis in an academic center. Methods:Between 2012 and 2019, 812 patients with aortic stenosis underwent TAVR or SAVR. A propensity score-matching analytic strategy was used to balance groups and adjust for time periods. Outcomes were recorded according to the Society of Thoracic Surgeons Guidelines; primary outcome being 30-day mortality and secondary outcomes being perioperative course and complications. Results:No difference in mortality was seen but complications differed: more postoperative transient ischemic attacks, permanent pacemaker implantations and perivalvular leaks in the transcatheter group, while more acute kidney injuries, atrial fibrillation, delirium, postoperative infections and bleeding, tamponade and need for reoperation in the surgical group as well as longer hospital length-of-stay. However, over the years, morbidities/mortality decreased for all patients treated for aortic stenosis. Conclusions:Data showed an improvement in morbidities/mortality for intermediate risk patients treated with SAVR or TAVR. Increased funding allowed for higher TAVR volume by increasing access to this technology. Also, the difference in complications could impact healthcare cost. By incorporating important metrics such as length-of-stay, readmission rates and complications into decision-making, the Heart-Team can improve clinical outcomes, healthcare economics and resource utilization.

Background: Infective endocarditis (IE) remains an expressive health problem with high morbimortali-ty rates. Despite its importance, epidemiological and microbiological data remain scarce, especially in developing countries. Aim: This study aims to describe IE epidemiological, clinical, and microbiological profile in a tertiary university center in South America, and to identify in-hospital mortality rate and predictors. Methods: Observational, retrospective study of 167 patients, who fulfilled modified Duke’s criteria during a six-year enrollment period, from January 2010 to December 2015. Primary outcome was de-fined as in-hospital mortality analyzed according to treatment received (clinical vs. surgical). Multivari-ate analysis identified mortality predictors. Results: Median age was 60years (Q1-Q3 50-71), and 66% were male. Echocardiogram demonstrated vegetations in 90.4%. An infective agent was identified in 76.6%, being Staphylococcus aureus (19%), Enterococcus (12%), Coagulase-negative staphylococci (10%), and Streptococcus viridans (9.6%) the most prevalent. Overall in-hospital mortality was 41.9%, varying from 49.4% to 34.1%, in clinical and surgical patients, respectively (p=0.047). On multivariate analysis, diabetes mellitus (OR 2.5), previous structural heart disease (OR 3.1), and mitral valve infection (OR 2.1) were all-cause death predictors. Surgical treatment was the only variable related to better outcome (OR 0.45; 95%IC 0.2-0.9). Conclusion: This study presents IE profile and all-cause mortality in a large patient’s cohort, compris-ing a 6-years’ time window, a rare initiative in developing countries. Elderly and male patients predom-inated, while Staphylococcus aureus was the main microbiological agent. Patients conservatively treated presented higher mortality than surgically managed ones. Epidemiological studies from developing countries are essential to increase IE understanding.

This program director survey attempts to determine how coronavirus 2019 (COVID-19) pandemic is impacting current training in cardiothoracic surgery. A transition to virtual didactic sessions may prove beneficial with increasing attendance. On the other hand, decreasing live simulation and case volumes may jeopardize achieving competency in surgical skills.

This is a response to the Letter to Editor received regarding the article “Outcomes of Non-Cardiotomy Patients Requiring Postoperative Extracorporeal Membrane Oxygenation.”

Background and Aims- A fracture and retention of guidewire after cardiac resynchronization therapy device implant has not been reported so far, although it is an uncommon but known complication during cardiac interventions like percutaneous coronary interventions and other cardiac catheterization procedures. Methods- A 53 years old female patient presented to us, who had been diagnosed as a case of dilated cardiomyopathy with severe left ventricular dysfunction and underwent cardiac resynchronization therapy (CRT-D) device implant three years back and subsequently underwent lead replacement 6 months back due to lead dysfunction, with severe pain over the left arm and shoulder for last 1-2 days. On evaluation, it was found that she had a coronary guidewire which might have fractured and retained inadvertently in previous surgical procedure and has caused her symptoms that might have been aggravated by the movements of her arm. Emergency surgical exploration was done and the guidewire which was impacted in deltoid muscle was removed. Results, and Conclusion- We are reporting the case due to a very unlikely and unusual delayed presentation of retained intervention guide-wire post cardiac resynchronization therapy, retrieved from left deltoid muscle.

We present the case of a middle-aged man who developed an infective endocarditis of the tricuspid valve caused by methicillin-sensitive Staphylococcus aureus and associated with a very large vegetation (nearly 5 cm). Besides the quite unusual size of the vegetation, this report highlights that severe right-sided endocarditis can occur in the absence of classical risk factors (intravenous drug abuse, presence of a cardiac implantable electronic device or other intravascular device, and underlying right-sided cardiac anomaly) and that some cases of severe tricuspid endocarditis can be successfully treated by partial excision and patch repair.

Spinal cord ischemia remains a dreadful complication after thoracoabdominal aortic aneurysm repair. The role of cerebrospinal fluid drain in such patients needs further clarifications. Tam and colleagues carried out an interesting decision analysis study that supports the routine use of the cerebrospinal fluid drain after thoracoabdominal aneurysm repair. They also demonstrated that the use of the cerebrospinal drain was safe. Here, we firstly discuss the paper's finding and methodology and, secondly, we try to simply explain what a decision analysis study is and, broadly, and how to construct a Markov model.

Background and Aim: We showed in our anatomical review, ventricular septal defects existing as multiple entities can be considered in terms of three major subsets. We address here the diagnostic challenges, associated anomalies, the role and techniques of surgical instead of interventional closure, and the outcomes. including reinterventions, for each subset. Methods: We reviewed 80 published investigations, noting radiographic findings, and the results of clinical imaging elucidating the location, number, size of septal defects, and associated anomalies, and the effect of severe pulmonary hypertension. Results: Overall, perioperative mortality for treatment of residual multiple defects has been cited to be between zero and 14.2%, with morbidity estimated between 6% to 13%. Perioperative mortality is twice as high for perimembranous compared to muscular defects, with need for reoperation is over four times higher. Perventricular hybrid approaches are useful for closure of high anterior or apical defects. Overall, results have been unsatisfactory. Pooled data reveals incidences between 2.8% and 45% for device-related adverse events. Currently, however, outcomes cannot be assessed on the basis of the different anatomical sub-sets. Conclusions: We have addressed the approaches, and the results, of therapeutic treatment in terms of co-existing discrete defects, the Swiss-cheese septum, and the arrangement in which a solitary apical muscular defect gives the impression of multiple defects when viewed from the right ventricular aspect. Treatment should vary according to the specific combination of defects.

Over the course of time, new developments associated with embryogenesis of the murine heart have served to clarify the developmental processes observed in the human heart. This evidence allows for creation of a developmental framework for many congenital cardiac defects. Here, we aim to solidify the framework related to the categorization of both solitary and multiple ventricular septal defects. Mice having genetic perturbation of the Furin enzyme have demonstrated perimembranous and juxta-arterial ventricular septal defects, permitting the inference to be made that these defects can co-exist with defects occurring within the apical muscular septum. Based on developmental evidence, furthermore, all interventricular communications can be placed into one of three groups, namely, those which are perimembranous, juxta-arterial, and muscular. All of the defects are described based on their borders as seen from the morphologically right ventricle. Our focus here will be on those defects within the muscular ventricular septum, recognizing that such defects can co-exist with those that are perimembranous. We discuss the differentiation of multiple discrete defects from those referred to as the ‘Swiss cheese’ variant. As we show, appropriate surgical management requires understanding of the specific terminology, as the surgical approach may differ depending on the combination of the individual defects. Data from the Society for Thoracic Surgeons revealed that both mortality and morbidity were increased in the setting of multiple as opposed to solitary ventricular septal defects.

Surgical checklists such as ‘World Health Organization (WHO) Surgical Safety Checklist’ are made to make surgery safer, simple and to reduce human errors. Similar to this concept, Ali M et al and others have implemented the ‘haemostasis checklist’ and it had shown reduction in incidence of re-exploration in patients who underwent surgery using cardiopulmonary bypass (CPB). However, there is still scarcity of literature about the effect of these checklists on re-exploration after off-pump coronary artery bypass grafting (OPCABG).