Response to Letter to Editor Regarding: Equivalent outcomes with minimally invasive and sternotomy mitral valve repair for degenerative mitral valve disease. J Card Surg. 2021; 36:2636-43.Authors: Ramsey S. Elsayed, MD MS1, Brittany Abt, MD1, and Michael E. Bowdish, MD MS1,2Institutions and Affiliations: 1Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA2Department of Preventive Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USAAddress for Correspondence: Dr. Michael E. Bowdish, Associate Professor of Surgery and Preventive Medicine; Department of Surgery, Keck School of Medicine of USC; University of Southern California; 1520 San Pablo Street, HCC II Suite 4300; Los Angeles, CA 90033; Phone: (323)-442-5849; Email: Michael.Bowdish@med.usc.eduConflicts of Interest/Competing Interests: NoneFunding: Research reported in this publication was supported by the Department of Surgery of the Keck School of Medicine of USC. MEB is partially supported by UM1-HL11794 from the National Heart Lung and Blood Institute of the National Institutes of Health.To the editor,We would like to thank Song et. al. for their letter regarding our recent publication in the Journal of Cardiac Surgery titled “Equivalent outcomes with minimally invasive and sternotomy mitral valve repair for degenerative mitral valve disease”1. They asked some important questions and brought up valuable points that are worthy of discussion.Regarding the selection criteria we use for operative approach for mitral valve repair operations, it is primarily based on collective surgeon-patient decision making. However, patients with a previous history of cardiac surgery or peripheral vascular disease (which would render peripheral cannulation difficult), and those in need of concomitant cardiac procedures such as coronary artery bypass grafting, aortic replacement, or biatrial ablation, are not offered a minimally invasive approach. Regarding the role of artificial chordae (neochordae) in mitral valvuloplasty, we use elongated polytetrafluorethylene made of interrupted GoreTex (Gore-Tex, WL Gore and Associates, Inc., Flagstaff, AZ) sutures placed in a horizontal mattress fashion. These neochordae are routinely used to repair elongated or ruptured chordae causing mitral valve prolapse or regurgitation.2 Typically, the neochordae are used in the anterior leaflet of the mitral valve. The etiologies of degenerative mitral valve disease are comprised of myxomatous degeneration of the MV, fibroelastic deficiency including so called Barlow’s valves, and dystrophic calcification of the mitral annulus.3 While the etiologies are not mutually exclusive and may overlap, myxomatous degeneration and fibroelastic deficiencies resulting in severe, symptomatic MR were the most common indications for operation in our patient population. As mentioned by Song and colleagues, the success and durability of MVr can vary depending on etiology, particularly on how much of the valve apparatus is affected by pathology. While not examined in this paper specifically, previous papers (including Tatum et al. conducted at our institution), have demonstrated that anterior leaflet repair is significantly associated with recurrence and progression of MR after surgery, whereas isolated posterior repair is protective.3,4The operative team was similar in all cases, whereas the senior author (VAS) performed over 85% of the total procedures and nearly 100% of the minimally invasive procedures. The success rate of the minimally invasive cohort was 100% (as defined by the Society of Thoracic Surgeons). There was one conversion to conventional sternotomy in the minimally invasive cohort (.003%) for bleeding control.Finally, Song and colleagues are to be congratulated on their robotic and thoracoscopic mitral valvuloplasty results. Their 10-year total robotic mitral valve valvuloplasty results showing excellent cardiac function with 93% of patients in NYHA classes I and II.5 Furthermore, their early thoracoscopic results were very good with one operative mortality and only two reoperations demonstrating thoracoscopic mitral valvuloplasty is a technically feasible, safe, effective, and reproducible technique.6References:Bowdish ME, Elsayed RS, Tatum JM, Cohen RG, Mack WJ, Abt B, Yin V, Barr ML, Starnes VA. Equivalent outcomes with minimally invasive and sternotomy mitral valve repair for degenerative mitral valve disease. J Card Surg. 2021 Aug;36(8):2636-2643. PMID: 33908645.Bortolotti U, Milano AD, Frater RW. Mitral valve repair with artificial chordae: a review of its history, technical details, long-term results, and pathology. Ann Thorac Surg. 2012 Feb;93(2):684-91. PMID: 22153050.David, Tirone E. ”Durability of mitral valve repair for mitral regurgitation due to degenerative mitral valve disease.” Annals of cardiothoracic surgery 4.5 (2015): 417.Tatum, James M., et al. ”Outcomes after mitral valve repair: a single-center 16-year experience.” The Journal of thoracic and cardiovascular surgery 154.3 (2017): 822-830.Zhao H, Gao C, Yang M, Wang Y, Kang W, Wang R, Zhang H. Surgical effect and long-term clinical outcomes of robotic mitral valve replacement: 10-year follow-up study. J Cardiovasc Surg (Torino). 2021 Apr;62(2):162-168. PMID: 33302613.Cui H, Zhang L, Wei S, Li L, Ren T, Wang Y, Jiang S. Early clinical outcomes of thoracoscopic mitral valvuloplasty: a clinical experience of 100 consecutive cases. Cardiovasc Diagn Ther. 2020 Aug;10(4):841-848. PMCID: PMC7487400.

Objectives:Surgical management of aortic arch hypoplasia with associated intra-cardiac anomalies is a challenge in newborns.We reviewed the characteristics and outcomes of neonates and infants who underwent pulmonary artery banding concomitant to arch repair and single-stage total repair at our institution. Methods:Medical records of 60 patients undergoing aortic arch reconstruction for aortic arch hypoplasia between 2014 to 2019 were retrospectively reviewed.Twenty-five patients were female (41.6%), and the age of the patients ranged from 4 to 120 days (median 19.5 days).The patients were divided into two groups;Group 1 (23 patients) underwent pulmonary artery banding concomitant to arch repair, Group 2 (37 patients) underwent single-stage total repair in addition to arch repair.All arch repair procedures consisted of an extended (to the midportion of the ascending aorta)patch aortoplasty. Results:Postoperative early mortality occurred in 12 patients, 8 in Group 1(34.8%), and 4 in Group 2 (10.8%).There was an early survival advantage in group 2 (p=0.019).Recoarctation was occurred in 13 cases (21.6%), and 11 (18.3%) of them required reintervention (balloon angioplasty:7, re-operation:4).On univariate analysis, risk factors associated with death were pulmonary artery banding (HR,0.44;CI,0.09-2;p=0.019),prematurity (HR,4,67;CI,1.34-16.18;p=<0.001),preoperative mechanical ventilation support requirement (HR,0.048;CI, 0.52-6.39;p=0.048),and functional single ventricle (HR,0.43;CI,0.1-1.86;p=0.006).The mean duration of follow-up was 21.9±15.1 months, and there was no late death in each group. Conclusion:Single-stage repair of aortic arch hypoplasia with intracardiac pathologies has better results than palliation, according to survival rates and postoperative results.The use of patch augmentation technique in aortic arch hypoplasia is valid and associated with an acceptable incidence of recurrent arch obstruction.

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Machine learning and artificial intelligence (AI) in medicine has arrived in medicine and the healthcare community is experiencing significant growth in its adoption across numerous patient care settings. There are countless applications for machine learning and AI in medicine ranging from patient outcome prediction, to clinical decision support, to predicting future patient therapeutic setpoints. This commentary discusses a recent application leveraging machine learning to predict one year patient survival following orthotopic heart transplantation. This modeling approach has significant implications in terms of improving clinical decision making, patient counseling, and ultimately organ allocation and has been shown to significantly outperform preexisting algorithms. This commentary also discusses how adoption and advancement of this modeling approach in the future can provide increased personalization of patient care. The continued expansion of information systems and growth of electronic patient data sources in healthcare will continue to pave the way for increased use and adoption of data science in medicine. Personalized medicine has been a long-standing goal of the healthcare community and with machine learning and AI now being continually incorporated into clinical settings and practice, this technology is well on the pathway to make a considerable impact to greatly improve patient care in the near future.

In recent years, the use of bioprosthetic valve (BPV) has increased significantly with both surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) due to reasons such as the advantage of not using anticoagulants. Nevertheless major disadvantage of all BPV is the risk of early structural valve deterioration, leading to valve dysfunction, and requires reoperation, which significantly increases the risk of mortality or major morbidity especially after SAVR. There are a limited number of TAV-in-TAV case reports due to TAVI BPV degeneration. In our knowledge this is the second report of TAV-in-TAV implantation wherein a previously implanted transfemoral 25-mm nonmetallic Direct Flow SVD valve treated with ViV TAVI via Edwards Sapien XT.

Background: We developed an integrated triple-branched stent to treat acute DeBakey type I aortic dissection and modified it to enhance its adaptability. However, whether the patients treated by the modified stent would achieve better long-term prognosis is unknown. Methods: This study enrolled 147 patients with acute DeBakey type I aortic dissection. The original integrated triple-branched stents were used in 57 patients (group A) between July 2012 and August 2013, and the modified stents in 90 patients (group B) between September 2013 and March 2015. Clinical characteristics, surgical data, postoperative complications, mortality, and follow-up data of the two groups were analyzed. Results: The two groups presented comparable early death rate (group A=7.0%, group B=5.9%, p=0.719). The incidence of postoperative acute kidney injury was lower in group B (10.0%) vs group A (24.6%) (p=0.018). Compared with the original integrated triple-branched stent graft, the modified stent could reduce the risk of early postoperative acute kidney injury [OR (95%CI)=0.36(0.14, 0.94)]. Early endoleak rate was lower in group B (1.0%) vs group A (9.4%) (p=0.004). During follow-up, there were five deaths in group A (9.4%) and six deaths in group B (7.2%) (p=0.646). Chronic kidney injury (7.5% vs 3.6%, p=0.311), delayed endoleak (11.3% vs 4.8%, p=0.157), and late reinterventions (7.5% vs 2.4%, p=0.155) in the two groups were similar. Conclusions: In patients with acute DeBakey type I aortic dissection, the modified stent could provide feasible and safe treatment outcomes, with better protection of kidney function and reduced early endoleak. However, they had similar long-term effects.

We report a case of acute right ventricular failure in a patient with cardiogenic shock on left-sided mechanical circulatory support with Impella 5.0. The patient was successfully bridged to heart transplantation using additional right-sided support with ProtekDuo. Key learning points of the case include prompt recognition of right ventricular failure in patients on left-sided support, early consideration of right-ventricular mechanical support platforms, and timely deployment of right-sided mechanical support.

Objectives: Female sex is considered a risk factor for mortality and morbidity following cardiac surgery. This study is the first to review the UK adult cardiac surgery national database to compare outcomes following surgical coronary revascularisation and valvular procedures between females and males. Methods: Using data from National Adult Cardiac Surgery Audit (NACSA), we identified all elective and urgent, isolated coronary artery by-pass grafting (CABG), aortic valve replacement (AVR) and mitral valve replacement/repair (MVR) procedures from 2010-2018. We compared baseline data, operative data and outcomes of mortality, stroke, renal failure, deep sternal wound infection, return to theatre for bleeding and length of hospital stay. Multivariable mixed-effect logistical/linear regression models were used to assess relationships between sex and outcomes, adjusting for baseline characteristics. Results: Females, compared to males, had greater odds of experiencing 30-day mortality (CABG OR 1.76, CI 1.47-2.09, p<0.001; AVR OR 1.59, CI 1.27-1.99, p<0.001; MVR OR 1.37, CI 1.09-1.71, p=0.006). After CABG, females also had higher rates of post-operative dialysis (OR 1.31, CI 1.12-1.52, p<0.001), deep sternal wound infections (OR 1.43, CI 1.11-1.83, p=0.005) and longer length of hospital stay (Beta 1.2, CI 1.0-1.4, p<0.001) compared to males. Female sex was protective against returning to theatre for post-operative bleeding following CABG (OR 0.76, CI 0.65-0.87, p<0.001) and AVR (OR 0.72, CI 0.61-0.84, p<0.001). Conclusion: Females in the UK have an increased risk of short-term mortality after cardiac surgery compared to males. This highlights the need to focus on the understanding of the causes behind these disparities and implementation of strategies to improve outcomes in females.

Background and aim: On the basis of previously published accounts, coupled with our own experience, we have assessed the surgical approaches to patients with isomeric atrial appendages. Methods: We reviewed pertinent published studies on surgical treatment of individuals with isomeric atrial appendages, with the pertinent surgical details provided by most of the manuscripts. Results: Half of patients with right isomerism, and two-thirds of those with left isomerism have bilateral superior caval veins. Azygos extension of the inferior caval vein is reported in three-quarters of those with left isomerism. The coronary sinus is universally absent in right isomerism, along with totally anomalous pulmonary venous connection, and is absent in two-fifths of those with left isomerism.. Univentricular atrioventricular connections are expected in up to three-quarters of those with right isomerism. Atrioventricular septal defect is reported in up to four-fifths, more frequently in right isomerism, with such patients typically having discordant ventriculoatrial connections or double outlet right ventricle. Reported mortalities extend to 85% for those with right, and 50% for those with left isomerism. In right isomerism, mortality is up to 54% for systemic-to-pulmonary arterial shunting, up to 75% for univentricular repair, and up to 95% for repair of totally anomalous pulmonary venous connection itself. No more than one-quarter had undergone Fontan completion, with reported mortalities of 21%. Conclusion: Early surgical results are satisfactory in patients with left isomerism, but disappointing for those with right. Recent advances in cardiac and liver transplantation may offer improved survival.

Objective: Although elderly patients undergoing surgery for acute type A aortic dissection (ATAAD) is increasing, their physical activities are not fully understood. We report the physical activities and surgical outcomes in the elderly patients who underwent ATAAD. Methods: From 2009 to 2019, 103 consecutive patients underwent surgery for ATAAD at our institution. Surgical outcomes along with pre- and postoperative physical activities in 52 elderly patients (≥70 years old) were compared with those in 51 younger patients (<70 years old). Postoperative walking difficulty was defined as taking ≥30 days to regain the ability to walk 200 m postoperatively or as the inability to walk at discharge. Results: It took longer for elderly patients to regain the ability to walk 100 or 200 m postoperatively. ROC analysis revealed the AUC of the duration for walking 200 m postoperatively as a prognostic indicator for late deaths was 0.878, with the highest accuracy at 30 days (sensitivity = 83.3%, specificity = 91.8%). Hospital mortality within 30 days was 3.8%, and 1-, 3-, and 5-years survival rates were 92%, 84.7%, 84.7%, respectively, for elderly patients, with no significant differences between groups. Cox proportional hazard analysis showed postoperative walking difficulty was an independent risk factor for late mortality in all cohorts (P = 0.017). Conclusions: Elderly patients undergoing surgical ATAAD repair showed acceptable surgical outcomes. However, they were more likely to decrease their physical activities postoperatively. Postoperative difficulty in walking was an independent risk factor for the late mortality in patients with ATAAD.

Background and Aim: The P2Y12 platelet receptor inhibitor ticagrelor is widely used in patients following acute coronary syndromes or in those who have received coronary stents. Bentracimab is a monoclonal antibody-based reversal agent that is being formally evaluated in a Phase 3 clinical trial. Here, we probe the knowledge, attitudes, and practice patterns of cardiac surgeons regarding their perioperative management of ticagrelor and potential application of a ticagrelor reversal agent. Methods: A questionnaire was developed by a working group of cardiac surgeons to inquire into participants’ practices and beliefs regarding ticagrelor and disseminated to practicing Canadian cardiac surgeons. Results: A total of 70 Canadian cardiac surgeons participated. Bleeding risk was identified as the most significant consideration when surgically revascularizing ticagrelor-treated patients (90%). There is variability in the duration of withholding ticagrelor prior to coronary artery bypass graft procedure in a stable patient; 44.3% wait 3 days and 32.9% wait 4 days or longer. Currently, 14.3% of cardiac surgeons prophylactically give platelet transfusions and/or fresh frozen plasma intraoperatively following protamine infusion in patients who have recently received ticagrelor. Interestingly, 47.1% of surveyed surgeons were aware of a reversal agent for ticagrelor, 91.4% of cardiac surgeons would consider utilizing a ticagrelor reversal agent if available, and 51.4% acknowledged that the introduction of such an agent would be a major advance in clinical practice. Conclusions: The present survey identified ticagrelor-related bleeding as a major concern for cardiac surgeons. Surgeons recognized the significant unmet need that a ticagrelor reversal agent would address.

Background: Transplant patients are known to be at increased risk of developing de novo malignancies (DNM). As heart transplant survival has increased, DNM represent an obstacle to further improving survival. We sought to examine the incidence, risk factors, and prognostic factors of post-transplant DNM. Methods: We studied adult heart transplant recipients from the Organ Procurement and Transplantation Network database (1987-2018). Kaplan-Meier survival analysis was performed to determine annual probabilities of developing DNM, excluding squamous and basal cell carcinoma. Rates were compared to the general population in the Surveillance, Epidemiology, and End Results database. Cox proportional hazards regression was performed to calculate hazard ratios for risk factors of DNM development, all-cause, and cancer-specific mortality. Results: Over median follow-up of 6.9 years, 18% of the 49,361 patients developed DNM, which correlated with an incidence rate 3.8 times that of the general population. The most common malignancies were lung, post-transplant lymphoproliferative disorder, and prostate. Risk was most increased for female genital, tongue/throat, and renal cancers. Male gender, older age, smoking history, and impaired renal function were risk factors for developing DNM, whereas the use of MMF for immunosuppression was protective. Cigarette use, increasing age, the use of ATG for induction and calcineurin inhibitors for maintenance were risk factors for cancer-specific mortality. The development of a DNM increased the risk of death by 40% (p<0.001). Conclusions: Heart transplant patients are at increased risk of malignancy post-transplant, particularly rare cancers. Strict cancer surveillance and attention to immunosuppressive regimens are critical for further prolonging post-transplant survival.

Comment on: Virtual Reality, e-Learning, and Global Cardiac Surgical Capacity-Building

Title page:Title : Letter to the editor: Mitral valve repair with the edge‐to‐edge technique: A 20 years single‐center experienceArticle type : Letter to the editorCorrespondence : 1. Syed HussainContact : +923323230575 Email : syedhussainar2002@gmail.comInstitute : Shaheed Mohtarma Benazir Bhutto Medical College Liyari KarachiAddress : R-75 Railway Housing Society, 13-D1, Gulshan-e-Iqbal, Karachi, 75300Co-authors : 2.Muhammad MaazContact : +923032194036 Email : maaz.27d3@gmail.comInstitute : Shaheed Mohtarma Benazir Bhutto Medical College Liyari KarachiAddress : Flat No. B-16, Hasham Apartment, Rafa-e-aam, Malir Halt, Karachi, 752103. Dr. Sumeet KumarContact : +92-3337351513Email :Dr.sumeetchhabra@gmail.comInstitute : Dow University of Health Sciences, KarachiAddress : Mission Rd, New Labour Colony Nanakwara, Karachi, Karachi City, Sindh 74200Word count : 482Conflict of interest : NoneDeclaration : NoneAcknowledgment : None

Background. We sought to determine the relationship between tricuspid right ventricular (RV) and tricuspid valve (TV) remodeling and late failure of tricuspid annuloplasty. Methods. From May 2009 to December 2015, 423 patients undergoing tricuspid annuloplasty (TA) for functional TR at a single were analyzed. Residual TR was defined TR moderate-or-more at discharge. Recurrent TR was defined TR-moderate-or-more at follow up. RV remodeling was defined RV dysfunction and/or dilatation. Results. Residual TR after TA was recorded in 54. Five-year freedom from TR recurrence was 86.3±2.3% for patients without residual TR vs 57.6±7.6% for patients with residual TR, p<0.001. Evaluating late results of 369 patients without residual TR, following risk factors were identified: preoperative pulmonary pressure, pre RV remodeling, pre TR and TV remodeling, functional mitral regurgitation. Conclusions. Prophylactic tricuspid annuloplasty should be encouraged among surgeons. TA at the time of left-sided valve surgery should take into consideration not only annular size, but also tethering severity and RV remodeling.

Multi-disciplinary teams present the framework in the increasingly challenging care provided for patients. Wang et al. present a 37 year old female who is 35 weeks pregnant when a rare cardiac angiosarcoma is diagnosed.

BACKGROUND: COVID-19 has significantly impacted the healthcare landscape in the United States in a variety of ways including a nation-wide reduction in operative volume. The impact of COVID-19 on the availability of donor organs and the impact on solid organ transplant remains unclear. We examine the impact of COVID-19 on a single, large-volume heart transplant program. METHODS: A retrospective chart review was performed examining all adult heart transplants performed at a single institution between March 2020 and June 2020. This was compared to the same time frame in 2019. We examined incidence of primary graft dysfunction (PGD), continuous renal replacement therapy (CRRT) and 30-day survival. RESULTS: From March-June 2020, 43 orthotopic heart transplants were performed compared to 31 performed during 2019. Donor and recipient demographics demonstrated no differences. There was no difference in 30-day survival. There was a statistically significant difference in incidence of post-operative CRRT (9/31 v. 3/43; p = .01). There was a statistically significant difference in race (23W/8B/1AA v. 30W/13B; P=.029). CONCLUSION: We demonstrate that a single, large-volume transplant program was able to grow volume with little difference in donor variables and clinical outcomes following transplant. While multiple reasons are possible, most likely the reduction of volume at other programs allowed us to utilize organs to which we would not have previously had access. More significantly, our growth in volume was coupled with no instances of COVID-19 infection or transmission amongst patients or staff due to an aggressive testing and surveillance program.

Risk of permanent pacemaker implantation after transcatheter aortic valve replacement: How do we manage beyond risk assessment?