Tetralogy of Fallot (TOF) is rarely associated with partial anomalous pulmonary venous return (PAPVR). Unidentified PAPVR, however, might increase the risk of pulmonary valve replacement in repaired TOF patients by right ventricular (RV) dilatation and RV dysfunction. Here, we present a case of a 19-year-old male who received a correction of TOF 18 years ago and a rare type of PAPVR was identified during the follow up period. The anomalous pulmonary veins were connected to the left hepatic vein, left superior vena cava, and the right superior vena cava. Performing a pulmonary valve replacement, PAPVR was also corrected by an intra-atrial baffle with a new approach using the venous plexus between the left hepatic vein and the right hepatic vein.

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.

A systematized description of the morphology of congenitally malformed hearts is recognized as essential for the understanding of the important features that will determine the appropriate clinical and surgical approaches.

Cervantes-Salazar and colleagues report the long-term surgical outcomes of 414 patients with total anomalous pulmonary venous connection (TAPVC) from January 2003 to June 2019. With an overall survival rate of 87.2% from 2003 to 2019, the authors found that an increased mortality risk was associated with infra-cardiac TAPVC, pulmonary venous obstruction (PVO), and postoperative mechanical ventilation. Their comprehensive study with a large sample size of varying age groups, and patients with late referrals for surgery, provide valuable insight into TAPVC surgical outcomes. Improved survival for these patients continues to be a major goal of clinical teams striving to transform treatment paradigms. The comprehensive and promising results of the study reported by Cervantes-Salazar and colleagues gives our field hope for a better future for these patients.

Understanding the aortic annulus is important for obtaining reproducible and durable aortic valve repair and allowing advances for TAVR treatment of aortic regurgitation. Significant limitations exist when using echocardiography and CT-based imaging with feature tracking at the aortic annulus. Cardiac Magnetic Resonance is used to obtain Regional Longitudinal Strain (RLS) and can be modified to obtain circumferential annular strain at the fibrous and muscular portions of the aortic valve annulus. Holst and colleagues use a novel method to characterize and prove that adverse annular deformation occurs at the muscular portion of the aortic valve annulus in patients with aortic regurgitation. The direction of muscular annular deformation in patients with aortic regurgitation is opposite to the direction of muscular annular deformation in patients with normal aortic valves.

Background: Left ventricular assist devices have been a significant development in the treatment of patients with advanced heart failure supporting circulation as a bridge to transplant, recovery or long-term destination therapy. When ventricular recovery occurs, there are multiple described ways of proceeding. HM2 decommissions are well described with varying degrees of explant operations, less so in HM3 due to the novelty of the device. In certain situations, invasive surgery can carry high risk and so a minimally invasive decommission, leaving the LVAD essentially intact in situ can be considered. Case report In this report, we describe the case of a 35-year-old male diagnosed with an idiopathic dilated cardiomyopathy requiring an LVAD with subsequent identification of cardiac recovery with the asymptomatic thrombosis of the 2 nd HM3 device. Investigations demonstrated absent flow through the pump whilst the patient-reported NYHA I functional class symptoms. The Driveline was cut with the remaining internal pump components decommissioned and left in situ. At 1 year the patient continues to do well with continued features of cardiac recovery with an LVEF of over 40%. Conclusion LV recovery is well recognized with typical management being LVAD explant surgeries performed. Each case should be analyzed for risks and benefits to the patient and future research showed be directed towards levels of decommissioning surgery and management post-LVAD decommission patient care.

The potential benefit of concomitant surgical revascularization represents a controversial topic of the surgical treatment of post-infarction ventricular septal rupture (VSR). Beliaev and colleagues presented a case series interestingly focusing on this issue and showed how the possibility to perform coronary artery bypass grafting at time of VSR repair was associatd with better early and late mortality and improved cardiac function. However, a few more aspects deserve further comments in this controversial topic, especially considering late survival and postoperative cardiac function, although it seems reasonable to conclude that the presence of coronary artery disease not amenable to revascularization represents a strong negative prognostic factor in surgically treated VSR patients.

Nasogastric tube (NGT) use has been common in the immediate postoperative period in surgical patients for decades. Potential advantages include the decompression of gastric contents and the early administration of time-sensitive medications. However, its routine use after cardiac surgery has not been established as a gold standard yet. The NGT use for prevention of post-operative nausea and vomiting has been a matter of debate in literature. Also, NGT use has also been associated with the incidence of some respiratory and gastrointestinal complications and it may be a source of significant pain and discomfort to patients. In this article, we review the current available literature regarding the use of NGT during and immediately after cardiac surgery, with particular emphasis on its potential role in enhanced postoperative recovery.

Changes in the heart allocation system have led to transplant programs traveling greater distances for donor organs. At the same time, several new technologies have emerged to provide improvements in donor organ protection when compared with traditional strategies. These new developments have increased the need for a better understanding of risks associated with donor injury related to various types of ischemia.

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.

Title : Submitral Aneurysm: Exploring a Rare PathologyAuthors : Kellen Round BS1, Jake L. Rosen BA1, Colin C. Yost BA1, T. Sloane Guy MD, MBA21Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St #100, Philadelphia, PA 191072Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University, Curtis Bldg, Ste 620, 1015 Walnut St Philadelphia, PA 19107Running Title: Submitral Aneurysm Commentary

Background The decision to conserve or replace the native aortic valve following acute type-A aortic dissection (ATAAD) is an area of cardiac surgery without standardised practice. This single centre retrospective study analysed the long-term performance of the native aortic valve and root following surgery for ATAAD. Methods Between 2009 and 2018 all cases ATAAD treated at Royal Brompton and Harefield NHS Foundation Trust were analysed. Patients were divided into 2 groups: a) ascending aorta (interposition) graft (AAG) without valve replacement; and b) non-valve-sparing aortic root replacement (ARR). Pre-operative covariates were compared, as well as operative characteristics and post-operative complications. Long-term survival and echocardiographic outcomes were analysed using regression analysis. Results In total, 116 patients were included: 63 patients in the AAG group and 53 patients in the ARR group. In patients where the native aortic valve was conserved, 9 developed severe aortic regurgitation and 2 patients developed dilation of the aortic root requiring subsequent replacement during the follow-up period. Aortic regurgitation at presentation was not found to be associated with subsequent risk of developing severe aortic regurgitation or reintervention on the aortic valve. Overall mortality was observed to be significantly lower in patients undergoing AAG (17.5% vs. 41.5%, p=0.004). Conclusions With careful patient selection, the native aortic root shows good long-term durability both in terms of valve competence and stable root dimensions after surgery for ATAAD. This study supports the consideration of conservation of the aortic valve during emergency surgery for type-A dissection, in the absence of a definitive indication for root replacement, including in cases where aortic regurgitation complicates the presentation.

Take the bull by its horn: ‘Prophylactic aortic intervention’ in uncomplicated type B aortic dissectionRunning title: Prophylactic intervention in uncomplicated TBADDr. A. Mohammed Idhrees MCh, FIASORCID ID : 0000-0001-5981-9705Consultant,Institute of Cardiac and Aortic Disorders (ICAD),SRM Institutes for Medical Science (SIMS Hospital), Chennai.

The Recurring Theme of Gender Difference in Cardiac Surgical OutcomesJohn S. Ikonomidis MD, PhDDivision of Cardiothoracic Surgery, University of North Carolina at Chapel HillWord Count: 1144References: 13Address correspondence to:John S. Ikonomidis MD, PhDProfessor and Chief,Division of Cardiothoracic SurgeryUniversity of North Carolina at Chapel Hill3034 Burnett Womack Building160 Dental Circle,Chapel Hill, NC27599e-mail: [email protected]: (919) 966-3381In this issue of the Journal of Cardiac Surgery,1Newell and colleagues examined contemporary national outcomes following surgical resection of benign primary atrial and ventricular tumors. The 2016-2018 Nationwide Readmissions Database was queried for all patients > 18 years of age with a primary diagnosis of benign neoplasm of the heart who underwent resection of the atria, ventricles, or atrial/ventricular septum. A weighted total of 2,557 patients met inclusion criteria. Mean age was 61 years, 67.9% were female, and patients had relatively low comorbidity burdens. The authors found that while there was no difference in 30-day mortality (2.1% vs 1.3%, p=0.550), 30-day readmission (7.0% vs 9.1%, p=0.222), or 30-day composite morbidity (56.8% vs 53.8%, p=0.369) between females and males respectively, on multivariable analysis, female sex was independently associated with increased risk of 30-day mortality (OR 2.65, p=0.028).Overall, this was a well study which documents a large contemporary cohort of benign cardiac tumor resections. However, perhaps the most interesting feature of this study is the finding of sex as an independent predictor of 30 day mortality after propensity matching. Cardiac surgery suffers from a gender gap in terms of its outcomes. It has been well established that for many procedures such coronary bypass surgery (CABG), aortic valve replacement, mitral valve surgery, and aortic surgery.2 For CABG, women referred for surgery are typically older than men, have a higher comorbidity (hypertension, renal failure, diabetes, peripheral vascular disease) profile, and more often present in urgent or emergent status for surgery.3 Large, risk-adjusted, propensity matched studies have documented increased mortality in women as compared with men.4-7 This difference also extends into the interventional cardiology realm, where mortality and complication rates have been shown to be higher in women following percutaneous interventions for ST-elevation myocardial infarction.8For aortic valve replacement, a Nationwide Inpatient Sample study of 166809 patients with aortic stenosis from 2003 to 2014 found that women experience higher inpatient mortality (5.6% versus 4%, P<0.001) which persisted after propensity matching (3.3% versus 2.9%, P<0.001).9 For mitral valve surgery, a randomized controlled trial of patients with severe ischemic mitral insufficiency undergoing repair versus replacement found that women had higher mortality than men (27.1% versus 17.4%, p<0.03).10 For aortic surgery, female gender was associated with a higher mortality after both aortic dissection and aortic arch repair.11,12 Reduction in surgical stress through application of minimally invasive approaches still resulted in female sex being a risk factor for higher in-hospital mortality.13 The findings of the present study add further support to the above observations, with the potential addition that, in contrast to the other disease processes described, the majority of patients presenting for surgical removal of benign cardiac tumors were likely free of either symptoms or cardiac sequelae due to the disease, but nevertheless still the gender disparity in mortality persisted.While it is obvious that the above disease processes and their related surgical remedies are quite disparate, the association with increased mortality seen in females seems to be constant. Why is this? A considerable amount has been written regarding sex bias in referral patterns for surgery and even decreased functional reserve and health profiles of women when they are referred for surgical intervention compared with men.2 With regard to these referral patterns, published guidelines directing practitioners regarding indications for surgery are, in general, based upon studies in which the majority of patients were male. Interestingly, in the present study, females made up over two thirds of the patient population.1 While this suggests that females carry a disproportionately more benign cardiac tumors amenable to surgery, the post-surgical mortality disparity remained.The exact reasons for the above disparity remain unelucidated and further work is required to eliminate the gender gap in cardiac surgical outcomes. There is considerable focus on the removal of sex bias in animal and human research, as well as the development of disease treatment guidelines that consider gender in the algorithms. Hopefully and these and other sex-balanced approaches will reveal new insights that will allow us to bring equipoise to gender-stratified cardiac surgical outcomes.

We present a case of a 3-year-old child with ventricular septal defect and infective endocarditis with mycotic pulmonary artery aneurysm. The case highlights the role of CT angiography in the diagnosis and characterization of aneurysm and in demonstrating the extent of thrombo-embolic complications in distal pulmonary arteries and lung parenchyma.

Background: Remote ischemic preconditioning (rIPC) has been applied to attenuate tissue injury. We tested the hypothesis that rIPC applied to fetal lambs undergoing cardiac bypass (CB) reduces fetal systemic inflammation and placental dysfunction. Methods: Eighteen fetal lambs were divided into 3 groups: sham, CB control, and CB rIPC. CB rIPC fetuses had a hindlimb tourniquet applied to occlude blood flow for 4 cycles of a 5-minute period, followed by a 2-minute reperfusion period. Both study groups underwent 30 minutes of normothermic CB. Fetal inflammatory markers, gas exchange, and placental and fetal lung morphological changes were assessed. Results: The CB rIPC group achieved higher bypass flow rates (p<.001). After CB start, both study groups developed significant decreases in PaO2, mixed acidosis and increased lactate levels (p<.0004). No significant differences on tissular edema were observed on fetal lungs and placenta (p>.391). Expression of toll-like receptor-4 and ICAM-1 in the placenta and fetal lungs did not differ among the 3 groups, as well as with VCAM-1 of fetal lungs (p>.225). Placental VCAM-1 expression was lower in the rIPC group (p<.05). Fetal interleukin-1 (IL-1) and thromboxane A2 (TXA2) levels were lower at 60 minutes post-CB in the CB rIPC group (p<.05). There was no significant differences in TNF-α, PGE2, IL-6 and IL-10 plasma levels of the three groups at 60-minute post-bypass (p>.133). Conclusion: Although rIPC allowed for increased blood flow during fetal CB and decreased in IL-1 and TXA2 levels and placental VCAM-1, it did not prevent placental dysfunction in fetal lambs undergoing CB.

Objectives Redo sternotomy and explantation of left ventricular assist devices (LVAD) for heart transplantation (HT) involve prolonged dissection, potential injury to mediastinal structures and/or bleeding. Our study compared a complete expanded polytetrafluoroethylene (ePTFE) wrap versus minimal or no ePTFE during LVAD implantation, on outcomes of subsequent HT. Methods Between July 2005 and July 2018, 84 patients underwent a LVAD implant and later underwent HT. Thirty patients received a complete ePTFE wrap during LVAD implantation (Group 1), and 54 patients received either a sheet of ePTFE placed in the anterior mediastinum or no ePTFE (Group 2). Results Baseline characteristics were similar between Groups 1 and 2. Surgeons reported subjective improvements in speed, predictability and safety of dissection with complete ePTFE compared with minimal or no ePTFE. Time from incision to initiation of cardiopulmonary bypass (CPB) were similar between groups (97±38 min vs 89±29 min, p=0.3). Injury to mediastinal structures during the dissection was similar between groups (10% vs 11%, p>0.9). While surgeons reported less intraoperative bleeding in Group 1 (43% vs 61%), this trend did not reach significance (p=0.1). In-hospital mortality, ICU length of stay and hospital length of stay were similar between both groups. Conclusions In patients undergoing LVAD explant-HT, there was a trend towards reduced surgeon reported intraoperative bleeding with ePTFE placement. Despite qualitatively reported greater ease and speed of mediastinal dissection with ePTFE membrane placement, time to initiation of CPB did not differ, likely because surgeons remained cautious, allowing extra time for unanticipated difficulties.

BACKGROUND Postoperative pain after cardiac surgery is a very important issue and affects recovery, risk of postoperative complications and quality of life. The pain management has been traditionally based on intravenous opioids with growing evidence suggesting the use of opioid-free and opioid-sparing techniques to reduce its adverse effects. CASE PRESENTATION We report the case of a 75-years-old frail patient underwent awake mediastinal revision with subxiphoid access due to deep sternal wound infection using a Pectoralis-Intercostal Rectus Sheath (PIRS) plane block. During the procedure the patient never reported pain receiving acetaminophen 1 g every 8 hours for postoperative pain management without others pain relievers. CONCLUSION Ultrasound guided PIRS block could be an effective and safe analgesic technique to manage sternal and subxiphoid drainage pain in patients undergoing cardiac surgery via subxiphoid approach.