Multiple approaches in recent years have been implemented to address the persistent shortage of heart donors, including a recent modification of UNOS heart allocation system, expanding donor acceptance criteria, and adoption of novel techniques to utilize hearts from donors with circulatory death. The opioid epidemic has resulted in an exponential increase in deaths in the United States in recent years, particularly affecting younger adults. A recent analysis of UNOS database by Jenser et al. reveals a relative underutilization of heart donors with cardiovascular mechanism of brain death which provide similar long-term survival as donors with other mechanisms of brain death, highlighting the potential role of these donors to provide life saving cardiac allografts and mitigate the persistent shortage of hearts for transplantation.

Advantages of combined distal-first and visceral branch-first technique: A universal fit for extensive thoracoabdominal aortic aneurysm?Kenji Okada, MD, PhD, Taishi Inoue, MDDivision of Cardiovascular Surgery, Department of Surgery,Kobe University Graduate School of Medicine, Kobe, Japan.Corresponding author: Kenji OkadaDepartment of Cardiovascular Surgery, Kobe University Graduate School of Medicine7-5-2 Kusunoki-cho, Chuo-ku, Kobe , Hyogo 630-0005, JapanTel: +81-78-382-5942;Fax: +81-78-382-5959;E-mail: kokada@ med.kobe-u.ac.jpWord counts; 743 wordsMinimization of end organ ischemia is a key tenet in successful thoracoabdominal aortic aneurysm (TAAA) surgery. In recent years various techniques have been inspired and refined to reduce the duration and risk of visceral ischemia such as mild, moderate, or deep hypothermic repair with left heart bypass, or complete or partial cardiopulmonary bypass combined with selective perfusions to vital viscera, the lower extremities and the spinal cord. (1) (2) (3) Despite advances in surgical technique and organ protection strategies, open surgical repair for TAAA remains associated with considerable levels of morbidity and mortality. Moulakakis and colleagues conducted a meta-analysis which summarized the surgical outcomes of 9963 patients in experienced surgical centers and found that the mortality after repair of extent I-IV TAAA was 11.3%. (4) These results can be attributed to the nature of open surgical repair of TAAA, which represents the pinnacle of invasive cardiovascular surgery and comes with the burden of a relatively high association of comorbidities.Estrera and colleagues reported the “distal first approach” assumes the advantage of providing a distal fenestration and ensuring adequate antegrade blood flow at an early stage for patients with chronic aortic dissection. (5) Previous reports have described the utility of “visceral branch-first techniques” in reducing visceral ischemic time with minimal reperfusion injury. (6) (7) Marchenko and colleagues also successfully devised a novel “iliac branch first” strategy combined with the distal-first approach for Crawford extent II TAAA using a “neo-graft.” (8) A bifurcated graft of the neo-graft was anastomosed to the common iliac arteries first, followed by reattachments of the left renal artery, superior mesenteric artery and celiac axis without aortic cross-clamp. Ischemic time was no longer than 7 minutes for each anastomosis and extremely short compared to previous reports from experienced centers. This may minimize the risk or degree of ischemia-reperfusion injury even if no selective organ perfusion was applied. Since the right renal artery is located on the bottom of the aneurysm, the reconstruction was performed after initiating a left heart bypass (LHB). During these reattachments, antegrade pulsatile blood flow to the spinal cord was guaranteed not only via the Adamkiewicz artery but also the collateral network, which ultimately minimizes spinal cord ischemia. Next, the thoracic intercostal arteries were reimplanted using the island technique followed by proximal anastomosis of the main graft at the aortic isthmus. Overall LHB time was merely 32 minutes. The “iliac branch first” strategy eliminated the need for femoral artery exposure, which is particularly beneficial in obese patients.At a glance, these procedures appear to be a highly promising addition to the existing armamentarium of TAAA surgical techniques; however, the question remains whether they are applicable to all types of aortic pathologies? Starting with the simplest answers, the branch reconstructions prior to aortic decompression made it difficult to adjust the length of the branches, particularly in huge aneurysms. Longer branch grafts—in particular those to the left renal artery—the may cause kinking. Secondly, some iliac arteries are not always healthy and there unsuitable for end-to-side anastomosis, which may obstruct the establishment of the primary inflow source. Third, the current procedure is indeed suitable for chronic dissecting aortic aneurysms. By ligating the visceral branches prior to the aortic procedure, this technique not only reduced visceral ischemic time but also avoided the embolization of debris or thrombi. Therefore the “branch-first” technique appears to be a desirable option in terms of preventing embolic complications in the visceral organs. But let’s suppose that the aortic pathology is an atherothrombotic one (e.g. shaggy aorta). Yokawa and colleagues reported on thoracoabdominal repair in patients with shaggy aorta (atherothrombotic aorta)—a significant risk factor for organ infarction—and showed the relationship with spinal cord injury (SCI), acute kidney injury and perioperative mortality. (9) A shaggy aorta does not always allow segmental aortic cross-clamping such as at the levels of the diaphragm and the middle third of the descending aorta for reimplantation of the intercostal arteries. Furthermore, it may be difficult to reattach the major targeted intercostal arteries if the Adamkiewicz artery exists at lower levels such as Th12 or L1. Marchenko and colleagues used the current approach in 29 patients, but the aortic pathology of the patients is unknown. Therefore, the question remains whether the incidence of spinal cord ischemia in patients with atherothrombotic aorta could be reduced by the current technique.The approach comes with inherent advantages and we eagerly await the next series of evolution along with a report on the long-term results.

ARTIFICIAL CHORDAE FOR ANTERIOR LEAFLET PROLAPSE: ARE ALL THE ROADS LEADING TO ROME?Antonio Maria Calafiore (a), MD, Antonio Totaro (a), MD, Sotirios Prapas (b), MD, Diego Magnano, MD (a), Stefano Guarracini (c), PhD, Massimo Di Marco (d), MD, Michele Di Mauro (c,e), PhDDepartment of Cardiovascular Diseases, Gemelli Molise, Campobasso, ItalyDivision of Cardiac Surgery A, Henry Dunant Hospital, Athens, GreeceDepartment of Cardiology, “Pierangeli” Hospital, Pescara, ItalyDepartment of Cardiology, “S Spirito” Hospital, Pescara, ItalyCardio‐Thoracic Surgery Department, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands

We reported a case of a 53-year-old patient with coarctation of aorta and multiple aneurysmatic changes on aortic arch. Enhanced CT and reconstruction revealed significant coarctation and multiple aneurysmatic dilatation. The patient underwent stent implantation and was discharged with symptoms relived. Follow-up examination progression of aneurysms, however, without symptoms.

Cardiothoracic surgery is facing a multitude of challenges in leadership and training on the global scale, these being a complex and aging patient population, shortage of cardiac surgeons, diminishing student interest and trainee enthusiasm, increasingly challenging training obstacles and work-life imbalances, suboptimal job prospects, reports of discrimination and bullying and lack of diversity as well as gap between innovation and technology, clinical application, and training of future surgeons. The survival of cardiac surgery hinges on the leadership attracting and retaining young surgeons into the specialty. Mentoring, leading through example, recognizing the work-life imbalances, adapting to diverse and modern training models and embracing diversity with respect to gender and race, will ultimately be required to create and cultivate a nurturing environment of training and preparing future leaders. The vision for training future generations of cardiothoracic surgeons must rely heavily on strengthening the unity of the heart team. In doing so we can provide the best possible care for our patients and a most fulfilling career for the future generation of cardiac surgeons.

A general misconception that unicuspid aortic valves (UAV) are just a subtype of bicuspid aortic valves (BAV) has now been perpetuated in the medical and surgical community for nearly two decades[1](#ref-0001), and there is no end in sight.

Introduction The Carpentier-Edwards PERIMOUNT Magna Ease valve is a third-generation bioprosthesis for aortic valve replacement (AVR). This is a postapproval study reporting on its 8‑year outcomes. Methods Adults undergoing AVR with the Magna Ease valve between October 2007 and December 2012 were enrolled for this prospective, nonrandomized, single‑arm, multicenter study. Assessments occurred preoperatively, at hospital discharge, 6 months, 1 year, and annually thereafter up to 8 years. Outcomes included safety endpoints, hemodynamic performance, and New York Heart Association (NYHA) Functional Class. Results Of the 258 study patients, 67.5% were in NYHA Class I or II, and 32.5% were in NYHA Class III or IV at baseline. Concomitant procedures were performed in 44.2%. Total follow-up was 1,597.6 patient-years, median follow‑up was 7 years (interquartile range: 5.5–8.0 years). Eight years following AVR, functional class remained improved from baseline with 93.9% in NYHA Class I/II and 6.1% in NYHA Class III; thirty-eight deaths had occurred, eight of which were valve related; freedom from all‑cause mortality was 80.7% (95% confidence intervals 74.9, 86.4); freedom from valve-related mortality was 95.8% (92.8, 98.8); freedom from reintervention, explant, major bleeding events, and structural valve deterioration were 89.8% (85.1, 94.6), 94.8% (91.7, 97.9), 85.1% (80.0, 90.1), and 90.1% (84.7, 95.4), respectively; effective orifice area was 1.5±0.5 cm 2, mean gradient was 14.8±8.3 mmHg, and 88.6% of patients had no or trivial aortic regurgitation. Conclusions This study demonstrated satisfactory safety and sustained hemodynamic and functional improvements at 8 years following AVR with the Magna Ease valve.

Background: Surgical management of coexisting cardiac disease and extra-cranial carotid artery disease is a controversial area of debate. Thus, in this challenging scenario, risk stratification may play a key role in surgical decision making. Aim: To report the results of single stage coronary/valve surgery (CVS) and carotid endarterectomy (CEA), and to identify predictive factors associated with 30-day mortality. Methods: This was a multicenter, retrospective study of prospectively maintained data from three academic tertiary referral hospitals. For this study, only patients treated with single stage CVS, meaning coronary artery bypass surgery or valve surgery, and CEA between March 1, 2000 and March 30 , 2020, were included. Primary outcome measure of interest was 30-day mortality. Secondary outcomes were neurologic events rate, and a composite endpoint of postoperative stroke/death rate. Results: During the study period, there were 386 patients who underwent the following procedures: CEA with isolated coronary-artery bypass graft in 243 (63%) cases, with isolated valve surgery in 40 (10.4%), and combination of coronary artery bypass grafting and valve surgery in 103 (26.7%). Postoperative neurologic event rate was 2.6% (n = 10) which includes 5 (1.3%) TIAs and 5 (1.3%) strokes (major n = 3, minor n = 2). The 30-day mortality rate was 3.9% (n = 15). Predictors of 30-day mortality included preoperative left heart insufficiency (OR: 5.44, 95%CI: 1.63-18.17, p = 0.006), and postoperative stroke (OR: 197.11, 95%CI: 18.28-2124.93, p < 0.001). No predictor for postoperative stroke and for composite endpoint was identified. Conclusions: Considering that postoperative stroke rate and mortality was acceptably low, single stage approach is an effective option in such selected high-risk patients.

Background: Chest X-rays are routinely obtained after removal of chest drains in patients undergoing cardiac and thoracic surgical procedures. However, a lack of guidelines and evidence could question the practice. Routine chest X-rays increase exposure to ionising radiation, increase healthcare costs and lead to overutilisation of available resources. This review aims to explore the evidence in the literature regarding the routine use of chest X-rays following the removal of chest drains. Materials & Method: A systematic literature search was conducted in PubMed, Medline via Ovid, Cochrane central register of control trials (CENTRAL) and ClinicalTrials.gov without any limit on the publication year. The references of the included studies are manually screened to identify potentially eligible studies. Results: A total of 375 studies were retrieved through the search and 18 studies were included in the review. Incidence of pneumothorax remains less than 10% across adult cardiac, and paediatric cardiac and thoracic surgical populations. The incidence may be as high as 50% in adult thoracic surgical patients. However, the re-intervention rate remains less than 2% across the populations. Development of respiratory and cardiovascular symptoms can adequately guide for a chest X-ray following the drain removal. As an alternative, bedside ultrasound can be used to detect pneumothorax in the thorax after the removal of a chest drain without the need for ionising radiation. Conclusion: A routine chest X-ray following chest drain removal in adult and paediatric patients undergoing cardiac and thoracic surgery is not necessary. It can be omitted without compromising patient safety. Obtaining a chest X-ray should be clinically guided. Alternatively, bedside ultrasound can be used for the same purpose without the need for radiation exposure.

A 63-year-old male, with a history of coronary artery bypass grafting using bilateral internal thoracic artery grafts, underwent surgical aortic valve replacement. Avoiding the graft injury, we selected the right anterior mini-thoracotomy approach under cardiac arrest with systemic hyperkalemia with remaining bilateral internal thoracic artery grafts open. Deep hypothermia was induced to obtain more reliable myocardial protection. We believe this strategy can be considered as a therapeutic option in patients requiring aortic valve replacement but unsuitable for transcatheter aortic valve replacement.

A 57-year-old man suffered chest pain during the COVID-19 pandemic, but he delayed medical treatment due to fear of infection. Four months later, symptoms chest tightness and shortness of breath appeared. Electrocardiogram (ECG) revealed old myocardial infarction; color sonography and myocardial CT revealed apical myocardial defect. He refused surgery and percutaneous transcatheter closure, and follow-up observation. After 22 months, the symptoms of chest tightness and shortness of breath aggravated. He recovered after percutaneous transcatheter closure, and was discharged. This case shows delayed closure is one of the possible options for the patients without severe organ dysfunction or hemodynamic disturbance.

Introduction. In this prospective multicenter analysis, we aimed to investigate the predictive role of neutrophil/lymphocyte ratio (NLR) in permanent pacemaker implantation (PPI) in patients undergoing transcatheter aortic valve replacement (TAVR). Material and methods. 179 consecutive patients without previous PPI underwent TAVR from February 2017 to September 2021. Patients were further divided based on presence (n=48) and absence of conduction abnormalities (CAs) at hospital admission (n=131). Results . In patients with previous CAs, NLR values did not differ significantly between patients requiring PPI (n=16, 33%) and those not requiring it. In contrast, in patients with no CAs at hospital admission, NLR values measured at admission and on TAVR day were significantly higher in patients requiring PPI (n=17, 13%) (4.07±3.22 vs 3.01±1.47, p=0.025, and 10.81±7.81 vs 5.84±3.78, p=0.000, respectively). Multivariable analysis showed that NLR at TAVR day was an independent predictor of PPI in patients without CAs (OR 1.294; 95% CI 1.028-1.630; p=0.028), but not in those with previous CAs. ROC curve analysis showed that the cut point was a NLR value of >7.25. Time to PPI was delayed till 21 days in patients without CAs. Conclusions. In this prospective study, higher NLR values on the day of TAVR day were associated with an increased PPI rate in patients undergoing TAVR with no previous CAs. It is advisable, being inflammation part of the process, to prolong the time of observation for all patients without CAs till at least 21 days not to miss any new CA necessitating PPI.

Title pageTitle : Letter to the Editor: Percardiac closure of large apical ventricular septal defects in infants: Novel modifications and mid-term results

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Current classifications of Cor Triatriatum Sinister (CTS) do not address the associated heart defects or single ventricle pathology. Therefore, these classifications are not prognostic classifications and only describe the anatomy and the pulmonary venous drainage. The proposed classification considered the associated congenital cardiac lesions and the single ventricle pathology, therefore, it could have prognostic value. Future multicenter studies are required to measure the performance of this classification and its prognostic value in patients with CTS.

The authors conducted a prospective, observational study to evaluate the correlation of fluid responsiveness with commonly used carotid doppler-derived indices like carotid artery blood flow (CBF), carotid corrected flow time (FTc), respirophasic variation in carotid artery blood flow peak velocity (ΔVpeak) in patients undergoing CABG. They claimed that altough only ΔVpeak demonstrated some predictive power with areas under receiver operating characteristic (AUROC) of 0.671, carotid doppler ultrasound indices were found to be not dependable as a substitute for invasive methods to assess fluid responsiveness. The presence of studies advocating quite different sentiments in the literature regarding feasibility and reliability show that there is a long way gone and a long way to go.

Background The Organ Care System (OCS) is a revolutionary ex vivo organ perfusion technology that can potentially expand the organ retrieval range. The OCS Lung device uses packed red blood cells (pRBC) with a proprietary solution. We report the ability to reduce blood waste during this procedure by using a thermal packaging solution in conjunction with the OCS platform. Methods We retrospectively reviewed all OCS Lung recoveries performed by our recovery team, using packed red blood cells (pRBC) from May 2019 to January 2021. Initially, units were stored using passive refrigeration with the Performance cooler at a temperature range of 1 to 6 °C for 4 hours. Subsequently, thermal control technology with the ProMed cooler was utilized to maintain the same temperature range for 72 hours. Results Twenty-three recoveries were initiated with 63 pRBC. The Performance cooler was used for eight while the ProMed cooler for thirteen. 37.5% of pRBC transported with the Performance cooler was used within the validated time range, while 25.0% were used beyond the validated time range based on clinical judgment. In addition, 37.5% of pRBC transported with the Performance cooler were returned to the institution after canceled recoveries with an estimated loss of $1,800; the ProMed cooler had no wastage. Conclusions This study showed that using an advanced thermal packaging solution facilitates proper storage of pRBC and represents an advancement for extended donor lung preservation. The elimination of blood wastage in this initial study portends ongoing benefits for the limited blood supply and reduced cost.

Coronavirus (COVID-19) infection exposes patients with heart failure to a higher risk of morbidity and mortality. In LVAD patients, one of the key problems that can lead to life-threatening low-flow or pump malfunction due to thrombus development in the inflow cannula, device body, or outflow graft, implicating hemodynamic instability, hemolysis, renal or hepatic failure, or cerebral or peripheral thromboembolism. [Endothelial protein C receptor and thrombomodulin levels are elevated along with procoagulants such as factor VIII, P-selectin, and von Willebrand factor and downregulated along with thrombomodulin as a result of the cytokine storm released by endothelial and immune cells. In general ,](#ref-0013) LVAD thrombosis has been found to occur in 2–13% of adult patients who use current continuous-flow devices. However, LVAD thrombosis due to COVID-19 is underreported and a few cases presented. We present a case of accelerated LVAD outflow thrombosis in the setting of COVID-19 infection with multiorgan failure.