The surgical ventricular restoration is an evolution of treatment of left ventricle aneurysm. The aetioloy of left ventricle aneurysm and the dilated post AMI cardiomiopaty is the same; the difference is in the extension of scarred tissue and in the quality of remote zone. Because in this anatomical situation the geometry of left left ventricle can be deeply affected, it can very difficult to have point of reference as position of apex or papillary mussles. Using a sizer and combine different surgical thecniques allow to rebuilt a ventricle with appropriate volume and shape.

We have reported a case of trans-cuff leakage that occurred in a composite graft of bio-Bentall operation. The leakage resolved several months after surgery, similar to the trans-cuff leakage seen in simple aortic valve replacement. We have proposed hypotheses on the mechanism of trans-cuff leakage during a bio-Bentall operation and suggested ways to prevent it from occurring.

Title pageTitle : Letter to the editor: Septal myectomy in the era of genetic testingArticle type : Letter to the editor

Redo aortic valve surgery for failure of a previously implanted valve is always challenging. In case of small-sized implanted valves, the use of a balloon-expanding Sapien-3 valve can enhance the final effective orifice area, avoid complex annulus enlargement techniques, and can reduce operative time and morbidities. We describe a case where after explanting a failed 19mm St. Jude mechanical aortic valve and further deployment of a 23mm Sapien-3 valve, the left coronary ostia was obstructed by the skirt of the transcatheter prosthesis. After careful removal of a little part of the skirt, we were able to restore the coronary flow and the patient had a favorable outcome.

The authors report an exceptionally rare patient with findings of a bicuspid aortic valve in conjunction with a mature cystic teratoma in a middle-aged male presenting for symptomatic chest pain. Surgical resection and valve replacement were performed, confirming the rare cardiac tumor. While certainly interesting, this case highlights the importance of maintaining a broad differential diagnosis and the appropriate work-up, treatment and considerations for such rare pathology.

Objective: To assess the impact of surgeon experience on the outcomes of degenerative mitral valve disease. Methods: We reviewed all patients who had surgery for degenerative mitral valve disease between 2011-2016. Experienced surgeon was defined as performing  25 mitral valve operations/year. Patient characteristics and outcomes were compared. Multivariable analysis was performed to identify factors associated with MR recurrence. Survival analysis for mortality was done using Kaplan Meier curve and Cox proportional Hazard method. Results: There were 575 patients treated by 9 surgeons for severe mitral regurgitation caused by degenerative mitral valve disease between 2011-2016. Three experienced surgeons performed 77.2% of the operations. Patients treated by less experienced surgeons had worse comorbidity profile and were more likely to have an urgent or emergent operation (P=0.001). Experienced surgeons were more likely to attempt repair (P=0.024), to succeed in repair (94.7% vs 87%, P=0.001), had shorter cross-clamp times (P=0.001), and achieved higher repair rate (81.3% vs 69.7%, P=0.005). Experienced surgeons were more likely to use neochordae (P=0.001) and less likely to use chordae transfer (P=0.001). Surgeon experience was not associated with recurrence (moderate or higher MR) within the first two years after surgery but was an independent risk factor for mortality (HR= 2.64, P=0.002). Conclusions: Techniques of degenerative mitral valve surgery differ with surgeon experience, with higher rates of repair and better outcomes associated with more experienced surgeons.

Response to Letter to the Editor: “Impact of preoperative troponin levels on cardiac function following coronary surgery for myocardial infarction”Nicholas Hess MD1, Arman Kilic MD2

I read with interest the manuscript by Masroor and co-authors on the strategy of surgical repair for left atrial appendage perforation following implantation of Watchman device. The authors present the successful management of this complications and they comment on the preferred therapeutic strategy. This is a particular sensitive subject nowadays, since the widespread use and the constant growth of a variety of transcatheter cardiac interventions has inevitably increased the number of patients who are exposed to this type of complication.

Deep sternal wound infection (DSWI) with prosthetic graft infection is a rare, though lethal, complication after cardiovascular surgery via median sternotomy. This commentary is a review of a report by Takagi et al. published in the Journal of Cardiac Surgery that reported favorable outcomes in patients with DWSI with prosthetic graft infection treated with an enhanced strategy consisting of hydro-debridement with pulsed lavage and negative pressure wound therapies.

Management of aortic arch pathologies remains challenging. Open total arch replacements have been associated with significant morbidity and mortality owing to the need for cardiopulmonary bypass and circulatory arrest. On the other hand, aortic arch branched stent grafts are not widely available. In this context, hybrid techniques combining open arch debranching with endovascular graft placement have been identified as an attractive option in select patients. However, there still is a paucity of literature on their application and outcomes. A case is presented of an elderly frail patient diagnosed with a pseudoaneurysm of the aortic arch and who was successfully treated by an off-pump arch debranching followed by endovascular arch repair. This case highlights (i) the feasibility of hybrid debranching techniques, (ii) their technical challenges, and (iii) the need for long-term follow-up data.

In this case report, we describe a rare large right ventricular fibroma with sudden chest pain in a 9 year old child. The tumor was successfully surgical removed under cardiopulmonary bypass, but there was only a small remnant of the tumor to avoid rupture of the right ventricle and injury to the tricuspid valve. Pathological examination confirmed that the tumor was fibrous borderline tumor. The patient's heart function and the size of atrium and ventricles were normal, and there was no tricuspid regurgitation at 3-months follow-up. It was reported that the age less than 17 years old at time of diagnosis are associated with a poor prognosis, the long term outcome for this children patient needs further follow-up.

We thank Shixiong Wei et al for their interest in our technical paper on Robotic Septal myectomy for HOCM and their letter to the editor. Their technique of using the Computed Tomography Angiography (CTA) along with 3D Printing technology for the better delineation of the anatomy of HOCM has been an evolving way to approach the problem. As they have mentioned in their letter, we used cardiac magnetic resonance imaging (MRI) predominantly for all our patients who undergo septal myectomy. Using 3D printing technology augmenting CTA or MRI can certainly augment the surgical planning in complex patients. In their case report, Wei et al have shaved off most of the subvalvular tissue along with the mitral valve. Removal of the entire mitral valve definitely would have enhanced the exposure to the mid-ventricular cavity and the apex for their thoracoscopic approach. It will be interesting to know whether they tried to repair the valve before replacement. Our technique of Robotic mitral valve repair, septal myectomy, and particularly papillary muscle re-orientation tries to preserve the sub-valvular apparatus even after completely relieving the mid-cavitary obstruction and this may provide better ventricular re-modeling. We congratulate them on providing a successful surgical option to this complex subset of patients using novel evolving technology and meticulous surgical planning.

Letter to the editor

Title: The Time May Soon Be At HandRunning Head: Time May Soon Be At HandAuthors: Saqib Masroor, MD1 and Donald B. Glower MD21. University of Toledo College of Medicine and Life Sciences, Department of Surgery, Division of Cardiothoracic Surgery2. Duke University Medical Center, Department of Surgery, Division of Cardiothoracic SurgeryMeeting Presentation: NoneDisclosure: NoneWord Count: 1213

Although a Kommerell diverticulum (KD) and aberrant subclavian artery (ASA) are a common congenital anomaly, a KD and ASA with two thoracic aortic aneurysms are rarely reported. We describe a case of a KD with a right ASA and two thoracic saccular aortic aneurysms, which were treated with a total arch replacement, frozen elephant trunk technique, and thoracic endovascular aortic repair.

t’s time for a fivesome. Commentary to: “The predictive value of five glomerular filtration rate formulas for long-term mortality in patients undergoing coronary artery bypass grafting” Coronary artery disease is an extremely common condition and coronary artery bypass-grafting is still one of the most important therapeutic strategy to treat it. Chronic kidney disease is often affecting patients with CAD. Nevertheless, the literature is still debating what formula estimate the best the glomerular filtration rate in patients undergoing CABG. Indeed, the formulas used in clinical practice have some differences some are more accurate in patients with diabetes, while there are some bias given by age and body mass index. In cardiac surgery, the choice of the most fitting formula to evaluate GFR has important clinical implication and, up to now, three formulas have been compared at most. Eilon Ram et al. present a retrospective study which compares the 5 most used formulas (CG, MDRD, CKD-EPI, Mayo, and IB) to derive GFR to evaluate the one with the best accuracy in predicting long-term mortality. In order to do so, they divided 3744 patients in three groups according to the estimated GFR by means of all 5 formulas: significant CKD according to all formulas, non-significant CKD according to all formulas and discordant results (meaning that at least one formula gave normal GFR and at least one formula gave abnormal GFR). Patients with the highest mortality were the ones with significant CKD according to all formulas.

Introduction Thoracic endovascular aortic repair (TEVAR) became the standard of care for treating type B aortic dissections and descending thoracic aortic aneurysms. We aimed to describe the racial/ethnic differences in TEVAR utilization and outcomes. Methods The National Inpatient Sample was reviewed for all TEVARs performed between 2010 and 2017 for Type B aortic dissection and descending thoracic aortic aneurysm (DTAA). We compared groups stratifying by their racial/ethnicity background in whites, black, Hispanic, and others. A mixed-effects logistic regression was performed to assess the relationship between race/ethnicity and the primary outcome, in-hospital mortality. Results A total of 25,260 admissions for TEVAR during 2010–2017 were identified. Of those, 52.74% (n= 13,322) were performed for aneurysm and 47.2% (n= 11,938) were performed for type B dissection. 68.1% were white, 19.6% were black, 5.7% Hispanic, and 6.5% were classified as others. White patients were the oldest (median age 71 years; <0.001), with TEVAR being performed electively more often for aortic aneurysm (58.8% vs. 34% vs. 48.3% vs. 48.2%; p<0.001). In contrast, TEVAR was more likely urgent or emergent for type B dissection in black patients (65.6% vs 41.1% vs 51.6% vs 51.7%; p<0.001). Finally, the black population showed a relative increase in the incidence rate of TEVAR over time. The adjusted multivariable model showed that race/ethnicity was not associated with in-hospital mortality. Conclusion Although there is a differential distribution of thoracic indication and comorbidities between race/ethnicity in TEVAR, racial disparities do not appear to be associated with in-hospital mortality after adjusting for covariates.

Expanding the armamentarium for reoperative coronary artery bypass graftingShort title : Expanding the armamentarium for redo CABGMaria Currie, MD PhD11 Department of Cardiothoracic Surgery, Stanford University School of Medicine