Background: The purpose of this study was to investigate the incidence, predictors, and long-term impact of gastrointestinal (GI) complications following adult cardiac surgery. Methods: Index Society of Thoracic Surgeons (STS) adult cardiac operations performed between January 2010 and February 2018 at a single institution were included. Patients were stratified by the occurrence of postoperative GI complications. Outcomes included early and late survival as well as other associated major postoperative complications. A sub-analysis of propensity score matched patients was also performed. Results: 10,285 patients were included, and the overall rate of GI complications was 2.4% (n=246). Predictors of GI complications included dialysis dependency, intra-aortic balloon pump, congestive heart failure, chronic obstructive pulmonary disease, and longer aortic cross-clamp times. Thirty-day (2.6% vs 24.8%), one- (6.3% vs 41.9%), and three-year (11.1% vs 48.4%) mortality were substantially higher in patients who experienced GI complications (all P<0.001). GI complication was associated with a three-fold increased hazard for mortality (HR 3.1, 95% CI 2.6-3.7) after risk adjustment, and there was an association between the occurrence of GI complications and increased rates of renal failure (39.4% vs 2.5%), new dialysis dependency (31.3% vs 1.5%), multisystem organ failure (21.5% vs 1.0%), and deep sternal wound infections (2.6% vs 0.2%)(all P<0.001). These results persisted in propensity-matched analysis. Conclusions: GI complications are infrequent but have a profound impact on early and late survival, and often occur in association with other major complications. Risk factor modification, heightened awareness, and early detection and management of GI complications appears warranted.

At a time where delivering the best quality of care is the raison d’être of the health service, outliers can pose a serious challenge to both clinicians and policy makers. Methods of outlier detection are highly variable. The collection and assimilation of outcome variables can also be very challenging. Despite this, the publication of surgeon specific data has brought the concept of outliers into the public eye and the consequent punitive action affected upon surgeons can be deleterious to clinician psychology and patient perception. Simultaneously, positive outliers are rarely mentioned and never rewarded. Moving forward, the use of more objective outcomes, including novel biomarkers and patient-centred data, as well as innovative statistical strategies and management cultures, can positively evolve the healthcare paradigm for the future.

Objective: The arterial switch operation is the standard treatment for the transposition of the great arteries. The timely variation in the residual pressure gradient across the pulmonary arteries is ill-defined. This work is aimed to study the progressive changes in the pressure gradient across the pulmonary valve and pulmonary arteries after arterial switch operation (ASO). Methods: All eligible patients for this study who underwent arterial switch operation between 2000 and 2019 were reviewed. Transthoracic echocardiography (TTE), was used to estimate the peak pressure gradient across the pulmonary artery and its branches. The primary outcome was the total peak pressure gradient (TPG) which is the sum of peak pressure gradients across the main pulmonary artery and pulmonary artery branches. Furthermore, a longitudinal data analyses with mixed effect modeling were used to determine the independent predictors for the changes in pressure gradient. Results: 309 patients were included in the study. Over 17-year follow up, the freedom from pulmonary stenosis reintervention was 95% (16 out of the 309 patients underwent reintervention = 5%). the Longitudinal data analyses of serial 1844 echocardiographic studies for the included patients revealed that the TPG recorded in the first postoperative echocardiogram across pulmonary valve, right and left pulmonary artery branches was the most significant predictor for reintervention. Conclusion: The total peak gradient measured in the first postoperative echocardiogram is the most important predictor for reintervention. We propose that a total peak gradient in the first postoperative echocardiography of 55 mmHg or more is a predictor for reintervention

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.

Title: “Close But No Cigar”: Successful Aortic Valve Repair Using Autologous Pericardium

We present a case of a young patient who presented with unstable angina due to coronary-pulmonary fistula caused by a nail-gun injury that stayed asymptomatic for 3 years. The patient has a successful surgical resection of the fistula and removal of the foreign body.

WeChat and access to wireless communication may offer a continuum of care following medical and surgical intervention. This cardiac surgery research study evaluates the process of parental education and social support following pediatric cardiac surgery utilizing standard of care compared to telehealth.

The morphological variations when one, or both, of the atrial chambers is subdivided, are many and varied. We present a synthesis of 198 published investigations of this “family” of uncommon lesions. Almost three-quarters of patients with divided atrial chambers present during infancy with severe pulmonary hypertension and cardiac failure. Associated cardiac and extra-cardiac defects are present in between half and nine-tenths of cases. Acquired division of the left atrium has been reported after the Fontan operation, orthotopic cardiac transplantation, and complicated aortic valvar infective endocarditis. Surgery under cardiopulmonary bypass remains the definitive treatment. Balloon dilation may be considered in anatomically compatible variants in the setting of cardiac failure and pregnancy as a bridge to definitive treatment. Overall, mortality has been cited between nil to 29%. Presentation during infancy, associated congenital anomalies, pulmonary hypertension, and surgery in the previous era, have been the reported causes of death. The operative survivors have long-term favourable outcomes, with near normal cardiac dimensions and low risk of recurrence. While asymptomatic patients with division of the right atrium do not need treatment, surgical resection of the dividing partition under cardiopulmonary bypass is recommended in symptomatic patients with complex anatomy, the spinnaker malformation, or associated cardiac anomalies. Balloon dilation may be considered in uncomplicated patients with less obstructive lesions. Hybrid intervention and endoscopic robotic correction also have been performed. We submit that an increased appreciation of the anatomic background to division of the atrial chambers will contribute to improved surgical management.

Coronavirus 2019 (COVID 19) captured worldwide attention as the virus spread from initial detection as a pneumonia of unknown cause in Wuhan, China in December 2019 to the declaration of a pandemic by the World Health Organization only three months later. This paper describes the impact of COVID 19 on cardiac surgery services in the greater Los Angeles area. Discussion includes public health response to the pandemic, how local hospitals reacted to the expected surge in COVID patients, establishment of telemedicine services, and the projected future impact on California healthcare as a result of the COVID 19 pandemic.

Background: Minimally invasive mitral valve(MV) surgery(MIVT) is increasingly performed with excellent clinical outcome, despite longer procedural times. This study analyzes clinical outcome and secondary organ function effects in a propensity-matched comparison with conventional MV surgery. Methods and Results: Out of 439 patients undergoing MV surgery from January 2005 to May 2017, 345 patients were included after propensity-matching: 95 sternotomy patients and 250 MIVT patients. Endpoints focused on survival, quality of MV repair and organ function effects through analysis of biomarkers and functional parameters. Despite longer cardiopulmonary bypass(sternotomy: 96.0(IQR34)min – MIVT:134.0(IQR42)min, p<0.001) and cardioplegic arrest times(sternotomy: 61.0(IQR26)min – MIVT:87.0(IQR34)min, p<0.001), no differences in survival nor complication rate were found. Effect on renal function(creatinine, p=0.751 – ureum, p=0.538 - glomerular filtration, p=0.848), myocardial damage by troponine I level (sternotomy:1.8±3.9ng/ml – MIVT:1.2±1.3ng/ml, p=0.438) and ventilatory support > 24 hours(sternotomy:5.5% - MIVT:9.5%, p=0.240) were comparable. Systemic inflammatory reaction by postoperative CRP count was markedly lower for MIVT(p<0.001). Increased rhadomyolysis was found after MIVT surgery, based on significant elevation of creatinine-kinase levels(sternotomy: 431±237U/L – MIVT: 701±595U/L, p<0.001). Conclusion: Despite an inherent learning curve, minimally invasive MV surgery guarantees a clinical outcome and MV repair quality, at least non-inferior to those of MV surgery via sternotomy. Notwithstanding longer cardiopulmonary bypass and cardiac arrest times, the impact on secondary organ function is negligible, excepted for a lower systemic inflammatory response. The postoperative increase of CK-enzymes suggestive for enhanced rhabdomyolysis needs to be accounted when procedural times tend to exceed the critical time threshold for severe limb ischemia.

A document by Abdullah Nasif. Click on the document to view its contents.

Reimplantation of the supra-aortic vessels can be challenging with Thoraflex Hybrid. A device modification made the vessel lengths more appropriate and the position of the neo-vessels in the chest avoided malpositioning and kinking and facilitated sternum closure; this may improve operating times as well as allowing complete and continuous cerebral trivascular perfusion and corrects positioning of the intrathoracic vessels.

Risk models were developed to provide clinicians and hospitals with a tool to evaluate risk-adjusted outcomes and to guide quality improvement. The Society of Thoracic Surgeons (STS) Predicted Risk of Mortality (PROM) is the most commonly used risk algorithm, others being the EuroSCORE logistic and additive algorithm and the Ambler Risk Score. These models utilize pre-operative patient characteristics to predict operative risk and early outcomes. Although a great deal of effort has gone into models to predict short-term patient outcomes after common cardiac operations, there has been relatively little effort to develop a statistical algorithm to predict long-term outcomes. Moreover, no risk model takes into account early post-operative complications to construct an algorithm to predict long-term outcomes. The formulation of a risk stratification score based on post-operative complications following common cardiac surgical procedures may be used to estimate the likelihood of long-term survival for individual complications, as well as various permutations and combinations of complications. This may have profound implications in devising strategies to prevent the most devastating combination of complications. Also, this may assist in informing patients and families of the predicted survival after a particular complication or a combination of complications. As Dokollari et all pointed out, there is impetus towards the direction of formulating a risk stratification score, and this may indeed be the need of the hour.

Title Page:Title : Letter To the Editor: Outcomes of Preoperative Antiplatelet Therapy in Patients With Acute Type A Aortic DissectionArticle Type : Letter To The EditorCorrespondence : 1. Sandhya KumariContact no: +92-3321346164 Email: ssdsandhyajiwan@gmail.comInstitute: Ziauddin University KarachiAddress: Bungalow Number 7/2, 26th Street, Tauheed Commercial Area, Phase 5 Defence Karachi.ORCID: 0000-0001-8842-8738Co-Author : 2. Roomi RajaContact No: +92-3342946940 Email: Romirajagoindani@yahoo.comInstitution: Ziauddin University KarachiAddress: Hemilton Courts Block G-1 Flat 408 Near Teen Talwar Clifton KarachiORCID: 0000-0001-9104-3644Word Count : 340Conflict of interest : NoneAcknowledgement : NoneDeclaration : NoneDisclosure : NoneFunding : NoneDear Editor,We have, in recent times, read with great interest the article entitled “ Outcomes of Preoperative Antiplatelet Therapy in Patients With Acute Type A Aortic Dissection” by Xuan Jiang MD et al.1 We highly appreciate the author’s efforts towards this highly sensitive topic and it needs to be applauded by the readers.We acknowledge the primary conclusion of the article that patients receiving antiplatelet therapy before having surgery for acute type A aortic dissection is associated with increased mortality and increased need for blood transfusions. However, some concerns appear, disturbing the validity of the study.Even though the authors have highlighted the use of multiple different antiplatelet drugs before the surgery such as ticagrelor, clopidogrel and aspirin, there remains some factors that made an impact on the findings. Firstly, the authors should have considered the patients who are on Dual antiplatelet therapy because mortality and blood transfusion rate in patients using dual antiplatelet therapy is higher as compared to a single antiplatelet drug user.2 Secondly, the authors should have widened their inclusion criteria and could have included patients with preoperative characteristic such as cardiac tamponade and lower systolic blood pressure, like the study of 2014 included these two as variables and found increased prevalence of mortality associated with these variables.3Thirdly, the authors should have classified the patients using Debakey class 1,2 and Penn class A,B,C classifications. For example, a study in 2019 stated that the patients who experienced major bleeding were associated with Debakey class 1 and higher Penn class.4 Lastly, the authors should have taken into consideration some measures while transferring a patient to the ICU to minimize the mortality rate. For example, a study of 2022 stated that patients on new oral anticoagulants required norepinephrine and other inotropic agents while transferring to ICU as compared to patients taking warfarin (Coumadin).5In last, additional new studies should be conducted on patients receiving antiplatelet therapy before undergoing mitral valve surgery so that incidents leading to mortality goes down and prognosis becomes better.References:1- Jiang X, Khan F, Shi E, Fan R, Qian X, Zhang H, Gu T. Outcomes of preoperativeantiplatelet therapy in patients with acute type A aortic dissection. J Card Surg. 2022Jan;37(1):53-61. doi: 10.1111/jocs.16080. Epub 2021 Oct 17. PMID: 34657299.2- Chemtob RA, Moeller-Soerensen H, Holmvang L, Olsen PS, Ravn HB. OutcomeAfter Surgery for Acute Aortic Dissection: Influence of Preoperative AntiplateletTherapy on Prognosis. J Cardiothorac Vasc Anesth. 2017 Apr;31(2):569-574. doi:10.1053/j.jvca.2016.10.007. Epub 2016 Oct 11. PMID: 28017673.3- Hansson EC, Dellborg M, Lepore V, Jeppsson A. Prevalence, indications andappropriateness of antiplatelet therapy in patients operated for acute aortic dissection:associations with bleeding complications and mortality. Heart. 2013 Jan;99(2):116-21. doi: 10.1136/heartjnl-2012-302717. Epub 2012 Oct 9. PMID: 23048167.4- Hansson EC, Geirsson A, Hjortdal V, Mennander A, Olsson C, Gunn J, et al.Preoperative dual antiplatelet therapy increases bleeding and transfusions but notmortality in acute aortic dissection type a repair [Internet]. OUP Academic. OxfordUniversity Press; 2019: doi: org/10.1093/ejctz/ezy469. Epub 2019 january 16.5- Sromicki J, Van Hemelrijck M, Schmiady MO, Krüger B, Morjan M, Bettex D, VogtPR, Carrel TP, Mestres CA. Prior intake of new oral anticoagulants adversely affectsoutcome following surgery for acute type A aortic dissection. Interact CardiovascThorac Surg. 2022 Jun 15;35(1):ivac037. doi: 10.1093/icvts/ivac037. PMID:35258082; PMCID: PMC9252133.

Currently available evidence supports the safety and efficacy of rapid deployment and sutureless prostheses for aortic valve replacement (AVR) in aortic stenosis as suggested by the International Expert Consensus in 2016. Following the increasing experience and the good results obtained in AVR, the use of sutureless and rapid deployment prostheses in peculiar situations, at times as an ‘off-label’ indication, has been reported demonstrating to represent an effective solution to challenging surgical problems, such as described by Piperata et al. in a recent issue of the Journal of Cardiac Surgery for the treatment of active infective endocarditis complicated by an extensive aortic annulus abscess. The considerable experience acquired so far with rapid deployment and sutureless valves has stimulated many surgeons to use such devices in patients in whom limiting the overall ischemic time is felt to be of paramount importance, but also in different surgical scenarios. Therefore, we believe the time has come to strongly support the unusual or even ‘off label’ employment of these devices by including them in future recommendations.

The impact of the COVID-19 pandemic in New York City (NYC) is dramatic. COVID-19 cases surged, hospitals expanded to meet capacity, and NYC remains the global epicenter of this pandemic. During this unprecedented time, a young woman with known Marfan syndrome presented with an acute complicated type B aortic dissection to our Aortic Center. Using the Provisional Extension to Induce Complete Attachment technique, we treated this patient and quickly discharged her the next day to decrease the risk of COVID-19 infection. Her progress was monitored using frequent phone calls and one office visit at two weeks.

Journal of Cardiac SurgeryEditorial

Objective: Re-exploration after cardiac surgery still remained a troublesome complication. There is still scarcity of data about the effect of re-exploration after off-pump coronary arterial bypass grafting (OPCABG). We here represent our experience of re-exploration following OPCABG. Method: Total 5990 OPCABG were performed at our center, out-off these 132 (2.2%) patients were re-explored in the OR and were included in this study. The medical records of these patients were retrospectively reviewed. Results: The most common cause of re-exploration was bleeding (83.3%) and most common site of bleeding was from graft/anastomosis (53.8%). Mean time to re-exploration was 9.75±8.65 hours. 30-day mortality was 1.41%.On univariate and multiple regression analysis, emergency surgery, preoperative low platelet count, and number of grafts were found to be an independent risk factor for re-exploration. On multiple regression, emergency surgery, euroscoreII, low platelet count, low ejection fraction, re-exploration, time to re-exploration, blood products used, high post-op serum creatinine and bilirubin, were found to be an independent factor (p<0.001) for mortality. On receiver-operating characteristic analysis, optimum cut off for time to re-exploration was 14 hours with sensitivity 81.3%, specificity of 80% and area under curve of 0.798. Patients who re-explored late (>14 hour) had significantly high mortality (30.55%vs7.3%) and morbidity. Conclusion: Delaying the re-exploration is associated with three-fold increase in mortality and morbidity. So strategy of minimizing the incidence of re-exploration like use of minimally invasive surgery and early re-exploration with judicial use of products should be use to improve outcome after re-exploration following off-pump CABG.