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This article is the eighth in an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr Kaplan, and the editorial board for the opportunity to continue this series. In most cases, these will be research articles targeted at the perioperative echocardiographic diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, the articles will target the use of perioperative echocardiography in general., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to report., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Postcardiotomy shock in the cardiac surgical patient is a highly morbid condition characterized by profound myocardial impairment and decreased systemic perfusion inadequate to meet end-organ metabolic demand. Postcardiotomy shock is associated with significant morbidity and mortality. Poor outcomes motivate the increased use of mechanical circulatory support (MCS) to restore perfusion in an effort to prevent multiorgan injury and improve patient survival. Despite growing acceptance and adoption of MCS for postcardiotomy shock, criteria for initiation, clinical management, and future areas of clinical investigation remain a topic of ongoing debate. This article seeks to (1) define critical cardiac dysfunction in the patient after cardiotomy, (2) provide an overview of commonly used MCS devices, and (3) summarize the relevant clinical experience for various MCS devices available in the literature, with additional recognition for the role of MCS as a part of a modified approach to the cardiac arrest algorithm in the cardiac surgical patient., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships, which may be considered as potential competing interests: Glenn JR Whitman reports a relationship with Avania that includes: consulting or advisory. Glenn JR Whitman reports a relationship with GWBN LLC that includes: equity or stocks. Michael C Grant reports a relationship with ERAS Cardiac Society that includes: board membership. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Objectives: To examine trends in the prevalence of multiorgan dysfunction (MODS), utilization of multi-organ support (MOS), and mortality among patients undergoing cardiac surgery with MODS who received MOS in the United States., Design: Retrospective cohort study., Setting: 183 hospitals in the Premier Healthcare Database., Participants: Adults ≥18 years old undergoing high-risk elective or non-elective cardiac surgery., Interventions: none., Measurements and Main Results: The exposure was time (consecutive calendar quarters) January 2008 and June 2018. We analyzed hospital data using day-stamped hospital billing codes and diagnosis and procedure codes to assess MODS prevalence, MOS utilization, and mortality. Among 129,102 elective and 136,190 non-elective high-risk cardiac surgical cases across 183 hospitals, 10,001 (7.7%) and 21,556 (15.8%) of patients developed MODS, respectively. Among patients who experienced MODS, 2,181 (22%) of elective and 5,425 (25%) of non-elective cardiac surgical cases utilized MOS. From 2008-2018, MODS increased in both high-risk elective and non-elective cardiac surgical cases. Similarly, MOS increased in both high-risk elective and non-elective cardiac surgical cases. As a component of MOS, mechanical circulatory support (MCS) increased over time. Over the study period, risk-adjusted mortality, in patients who developed MODS receiving MOS, increased in high-risk non-elective cardiac surgery and decreased in high-risk elective cardiac surgery, despite increasing MODS prevalence and MOS utilization (p<0.001)., Conclusions: Among patients undergoing high-risk cardiac surgery in the United States, MODS prevalence and MOS utilization (including MCS) increased over time. Risk-adjusted mortality trends differed in elective and non-elective cardiac surgery. Further research is necessary to optimize outcomes among patients undergoing high-risk cardiac surgery., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: JC reports consulting fees from Teleflex, but there are no other conflicts of interest to report., (Published by Elsevier Inc.)

Competing Interests: The author has served as a consultant for Starlight Cardiovascular and Autus Valve Technologies.

Based on a voluntary registry, founded by the German Society for Thoracic and Cardiovascular Surgery (DGTHG) in 1980, a well-defined but limited dataset of all cardiac and vascular surgery procedures performed in 77 German heart surgery departments is reported annually. For the year 2023, a total of 168,841 procedures were submitted to the registry. Of these operations, 100,606 are defined as heart surgery procedures in a classical sense. The unadjusted in-hospital survival rate for the 28,996 isolated coronary artery bypass grafting procedures (relationship on-/off-pump 2.8:1) was 97.6%; 97.7% for the 39,859 isolated heart valve procedures (23,727 transcatheter interventions included); and 99.2% for 19,699 pacemaker/implantable cardioverter defibrillator procedures. Concerning short and long-term mechanical circulatory support, a total of 2,982 extracorporeal life support/extracorporeal membrane oxygenation implantations and 772 ventricular assist device implantations (left/right ventricular assist device, BVAD, total artificial heart) were reported. In 2023, 324 isolated heart transplantations, 248 isolated lung transplantations, and 2 combined heart-lung transplantations were performed. This annually updated registry of the DGTHG represents nonrisk adjusted voluntary public reporting and encompasses acute data for nearly all heart surgical procedures in Germany. It constitutes trends in heart medicine and represents a basis for quality management (e.g., benchmark) for all participating institutions., Competing Interests: None declared., (Thieme. All rights reserved.)

Objectives: To evaluate the impact of acute kidney injury on transition to chronic kidney disease (CKD) after cardiac surgery and to determine frequency of incident CKD in these patients., Design: A systematic review and meta-analysis of observational studies., Setting: Electronic databases Medline and Embase were systematically searched from 1974 to February 6, 2023., Participants: Eligible studies were original observational studies on adult cardiac surgery patients, written in the English language, and with clear kidney disease definitions. Exclusion criteria were studies with previously transplanted populations, populations with preoperative kidney impairment, ventricular assist device procedures, endovascular procedures, a kidney follow-up period of <90 days, and studies not presenting necessary data for effect size calculations., Interventions: Patients developing postoperative acute kidney injury after cardiac surgery were compared with patients who did not develop acute kidney injury., Measurements and Main Results: The search identified 4,329 unique studies, 87 underwent full-text review, and 12 were included for analysis. Mean acute kidney injury occurrence across studies was 16% (minimum-maximum: 8-50), while mean occurrence of CKD was 24% (minimum-maximum: 3-35), with high variability depending on definitions and follow-up time. Acute kidney injury was associated with increased odds of CKD in all individual studies. The pooled odds ratio across studies was 5.67 (95% confidence interval, 3.34-9.64; p < 0.0001)., Conclusions: Acute kidney injury after cardiac surgery was associated with a more than 5-fold increased odds of developing CKD. New-onset CKD occurred in almost 1 in 4 patients in the years after surgery., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: Hypertrophic obstructive cardiomyopathy (HOCM) may be treated by septal myectomy. Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common complication, but little is known about its incidence after septal myectomy. The objectives of this work were to evaluate the prevalence of CSA-AKI after septal myectomy and identify potential perioperative and phenotype-related factors contributing to CSA-AKI., Design: This was a retrospective database analysis with new data analysis., Setting: The study occurred in a single university academic expertise center for septal myectomy HOCM patients., Participants: Data from 238 HOCM patients with septal myectomy operated on between 2005 and 2022 were collected., Interventions: CSA-AKI was stratified according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines using measurement of creatinine and urine production. Important HOCM phenotype-related and perioperative factors were analyzed for their possible associations with CSA-AKI., Measurements and Main Results: CSA-AKI occurred in 45% of patients; of these, 55% were classified as KDIGO stage I and the remaining 45% as stage II, with no chronic kidney damage observed. Moreover, there were no phenotypical or perioperative characteristics that were more prevalent in the CSA-AKI cohort. However, the use of beta-blockers and coronary artery disease were more prevalent in the CSA-AKI cohort., Conclusions: CSA-AKI is a common complication after septal myectomy but was transient, and kidney function recovered in all patients., Competing Interests: Declaration of competing interest M. Michels reports speaker and consultant honoraria supported by BMS/Myokardia, Cytokinetics, and Pfizer, outside the submitted work. All other authors declare no relevant conflict of interests., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of competing interest None.

Objectives: Optimal perioperative success in cardiac surgery requires precise management of drug treatment. This study aimed to determine the prevalence, types and associated factors of drug-related problems (DRPs) during the entire hospital stay., Methods: A prospective observational study was conducted at the department of cardiovascular surgery in a university hospital between November 2019 and March 2020. Patients with planned elective cardiac surgery, aged ≥18 years, were included. A clinical pharmacist collaboratively reviewed medications on a daily basis and identified DRPs., Results: A total of 100 patients (60 male) were included; median (range) age was 62 (19-86) years, and median (IQR) length of stay in hospital was 15 (9) days. A total of 275 DRPs were identified (median (IQR) 3 (2-4)). The number of patients who had at least one DRP was 47 preoperatively, 55 in the postoperative intensive care unit, 100 in the postoperative ward, and 16 at discharge. In order to reduce bias because of the small sample size, Firth's logistic regression analysis was conducted. Statistically significant variables according to univariate analysis were included into a logistic regression model. Therefore the length of hospital stay (OR 1.14, 95% CI 1.03 to 1.26, p=0.008), living arrangements (living alone) (OR 4.24, 95% CI 1.41 to 12.73, p=0.009), number of medications at admission (OR 1.32, 95% CI 1.09 to 1.59, p=0.002), and having coronary artery bypass graft surgery (OR 2.87, 95% CI 1.07 to 7.70, p=0.03) were associated with an increased risk for DRPs in the final model., Conclusion: Hospital stay carries an increased risk for DRPs, especially at the postoperative stage. Modifiable risk factors for DRPs can be managed by required interventions performed by a multidisciplinary healthcare team., Competing Interests: Competing interests: None declared., (© European Association of Hospital Pharmacists 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Autonomic neuromodulation therapies (ANMTs) (ie, ganglionated plexus ablation, epicardial injections for temporary neurotoxicity, low-level vagus nerve stimulation [LL-VNS], stellate ganglion block, baroreceptor stimulation, spinal cord stimulation, and renal nerve denervation) constitute an emerging therapeutic approach for arrhythmias. Very little is known about ANMTs' preventive potential for postoperative atrial fibrillation (POAF) after cardiac surgery. The purpose of this review is to summarize and critically appraise the currently available evidence. Herein, the authors conducted a systematic review of 922 articles that yielded 7 randomized controlled trials. In the meta-analysis, ANMTs reduced POAF incidence (OR: 0.37; 95% CI: 0.25 to 0.55) and burden (mean difference [MD]: -3.51 hours; 95% CI: -6.64 to -0.38 hours), length of stay (MD: -0.82 days; 95% CI: -1.59 to -0.04 days), and interleukin-6 (MD: -79.92 pg/mL; 95% CI: -151.12 to -8.33 pg/mL), mainly attributed to LL-VNS and epicardial injections. Moving forward, these findings establish a base for future larger and comparative trials with ANMTs, to optimize and expand their use., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the trends in hospitalizations for children with trisomy 18 over time and to determine the rate of invasive procedures on these children, using a large inpatient database., Study Design: A retrospective analysis using the Kids' Inpatient Database from 1997 to 2016 was performed for trisomy 18. We evaluated survival to discharge as well as the presence of pulmonary, skeletal, neurologic, gastrointestinal, renal, and hematologic/bleeding problems. We also searched for the following interventions, if performed: gastrostomy tube placement, tracheostomy, or cardiac procedure., Results: Over this period 10 151 admissions occurred in children with a diagnosis of trisomy 18. Between 1997 and 2016, the number of children admitted annually with trisomy 18 increased 74% from 1036 to 1798. The proportion of patients born prematurely remained stable at 14%-16% throughout the study. Gastrostomy tube placement increased 12-fold during the study period, tracheostomy increased 11-fold, and cardiac intervention increased 5-fold. The overall mortality rate decreased in those with trisomy 18 from 32% in 1997 to 21% in 2016., Conclusions: We highlight a decreased inpatient mortality rate during the study period. The number of children undergoing interventions such as gastrostomy tube and tracheostomy increased, as did the number of children undergoing cardiac intervention. Although the number of procedures has increased with the mortality rate decreasing, it is unclear at present whether the 2 are related., (Copyright © 2021 Elsevier Inc. All rights reserved.)

There is continued interest in surgical repair of both the congenitally malformed aortic valve, and the valve with acquired dysfunction. Aortic valvar repair based on a geometric approach has demonstrated improved durability and outcomes. Such an approach requires a thorough comprehension of the complex 3-dimensional anatomy of both the normal and congenitally malformed aortic root. In this review, we provide an understanding of this anatomy based on the features that can accurately be revealed by contrast-enhanced computed tomographic imaging. We highlight the complimentary role that such imaging, with multiplanar reformatting and 3-dimensional reconstructions, can play in selection of patients, and subsequent presurgical planning for valvar repair. The technique compliments other established techniques for perioperative imaging, with echocardiography maintaining its central role in assessment, and enhances direct surgical evaluation. This additive morphological and functional information holds the potential for improving selection of patients, surgical planning, subsequent surgical repair, and hopefully the subsequent outcomes.

Background: Mediastinitis is a serious complication of open heart surgery associated with high mortality, considerable health care costs, and prolonged hospital stay. We examined characteristics and incidence of mediastinitis during 29 years when indications and patient material have been in a process of change., Methods: This was a retrospective population-based study comprising all mediastinitis patients more than 16 years of age after open heart surgery between 1990 and 2018 from a population of 1.7 million. Patient records of 50 mediastinitis patients from 2004 to 2014 were reviewed and compared with 120 patients from 1990 to 1999., Results: Annual mediastinitis rate varied 0% to 1.5% with a decreasing trend-from a level exceeding 1.2% to approximately 0.3%-over the study period. In 2004 to 2014 patients with mediastinitis were older, more often smokers, and more often had diabetes mellitus and renal insufficiency than in 1990 to 1999. No difference in length of hospital treatment, antibiotic prophylaxis or treatment, intensive care unit treatment, or mortality was observed between 1990 to 1999 and 2004 to 2014. Coronary artery bypass graft surgery became less common and valve replacement and hybrid operations more common among operations leading to mediastinitis. Staphylococcus aureus increased (from 25% to 56%, p = .005) whereas coagulase-negative staphylococci (46% to 23%, P < .001) and gram-negative bacteria (18% to 12%, P = .033) decreased as causative agents. Surgery for mediastinitis remained similar except introduction of vacuum-assisted closure treatment., Conclusions: The rate of mediastinitis decreased during these 29 years. No difference in 30-day mortality in mediastinitis was seen: 0.9% in 1990 to 1999 and 2% in 2004 to 2014., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The coronavirus disease 2019 (COVID-19) pandemic has potentiated the need for implementation of strict safety measures in the medical care of surgical patients - and especially in cardiac surgery patients, who are at a higher risk of COVID-19-associated morbidity and mortality. Such measures not only require minimization of patients' exposure to COVID-19 but also careful balancing of the risks of postponing nonemergent surgical procedures and providing appropriate and timely surgical care. We provide an overview of current evidence for preoperative strategies used in cardiac surgery patients, including risk stratification, telemedicine, logistical challenges during inpatient care, appropriate screening capacity, and decision-making on when to safely operate on COVID-19 patients. Further, we focus on perioperative measures such as safe operating room management and address the dilemma over when to perform cardiovascular surgical procedures in patients at risk., Competing Interests: Declaration of competing interest J. C. Schefold declares that the Department of Intensive Care Medicine, Inselspital, Bern, has received research or other grants from (full departmental disclosure): Orion Pharma, Abbott Nutrition International, B. Braun Medical, CSEM, Edwards Lifesciences Services, Kenta Biotech, Maquet, Nestle, Pierre Fabre Pharma, Pfizer, Bard Medica, Abbott, Anandic Medical Systems, Pan Gas Healthcare, Bracco, Hamilton Medical, Fresenius Kabi, Getinge Group Maquet, Dräger, Teleflex Medical, GlaxoSmithKline, Merck Sharp and Dohme, Eli Lilly and Company, Baxter, Astellas, AstraZeneca, CSL Behring, Novartis, Covidien, Hemotune, Phagenesis, and Nycomed outside the submitted work. The money was paid into departmental funds; and all other authors reported no conflicts of interest., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

A 60-year old male with paroxysmal atrial fibrillation underwent a combined procedure of left atrial appendage occlusion and pulmonary vein isolation. However, an acute intraprocedural 24-mm Watchman device dislodgement occurred, and thus a decision for urgent surgery was made. However, it was noted during the surgery that the device had migrated further to the descending aorta, just distal to the left subclavian artery. Since a right sternotomy access for retrieval was not feasible, a percutaneous approach was justified. A homemade snare was created using a combination of a long sheath, J-wire, and a regular snare, and the device was successfully retrieved without significant difficulty.

Background: The coronavirus-disease 2019 (COVID-19) pandemic imposed an unprecedented burden on the provision of cardiac surgical services. The reallocation of workforce and resources necessitated the postponement of elective operations in this cohort of high-risk patients. We investigated the impact of this outbreak on the aortic valve surgery activity at a single two-site centre in the United Kingdom., Methods: Data were extracted from the local surgical database, including the demographics, clinical characteristics, and outcomes of patients operated on from March 2020 to May 2020 with only one of the two sites resuming operative activity and compared with the respective 2019 period. A similar comparison was conducted with the period between June 2020 and August 2020, when operative activity was restored at both institutional sites. The experience of centres world-wide was invoked to assess the efficiency of our services., Results: There was an initial 38.2% reduction in the total number of operations with a 70% reduction in elective cases, compared with a 159% increase in urgent and emergency operations. The attendant surgical risk was significantly higher [median Euroscore II was 2.7 [1.9-5.2] in 2020 versus 2.1 [0.9-3.7] in 2019 (p = 0.005)] but neither 30-day survival nor freedom from major post-operative complications (re-sternotomy for bleeding/tamponade, transient ischemic attack/stroke, renal replacement therapy) was compromised (p > 0.05 for all comparisons). Recommencement of activity at both institutional sites conferred a surgical volume within 17% of the pre-COVID-19 era., Conclusions: Our institution managed to offer a considerable volume of aortic valve surgical activity over the first COVID-19 outbreak to a cohort of higher-risk patients, without compromising post-operative outcomes. A backlog of elective cases is expected to develop, the accommodation of which after surgical activity normalisation will be crucial to monitor., (© 2021. The Author(s).)

Objective: The coronavirus disease 2019 (COVID-19) pandemic has resulted in an increase in hospital resource utilization and the need to defer nonurgent cardiac surgery procedures. The present study aims to report the regional variations of North American adult cardiac surgical case volume and case mix through the first wave of the COVID-19 pandemic., Methods: A survey was sent to recruit participating adult cardiac surgery centers in North America. Data in regard to changes in institutional and regional cardiac surgical case volume and mix were analyzed., Results: Our study comprises 67 adult cardiac surgery institutions with diverse geographic distribution across North America, representing annualized case volumes of 60,452 in 2019. Nonurgent surgery was stopped during the month of March 2020 in the majority of centers (96%), resulting in a decline to 45% of baseline with significant regional variation. Hospitals with a high burden of hospitalized patients with COVID-19 demonstrated similar trends of decline in total volume as centers in low burden areas. As a proportion of total surgical volume, there was a relative increase of coronary artery bypass grafting surgery (high +7.2% vs low +4.2%, P = .550), extracorporeal membrane oxygenation (high +2.5% vs low 0.4%, P = .328), and heart transplantation (high +2.7% vs low 0.4%, P = .090), and decline in valvular cases (high -7.6% vs low -2.6%, P = .195)., Conclusions: The present study demonstrates the impact of COVID-19 on North American cardiac surgery institutions as well as helps associate region and COVID-19 burden with the impact on cardiac surgery volumes and case mix., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Cryoprecipitate has been the gold standard for treating acquired hypofibrinogenemia in cardiac surgery for nearly 50 years. More recently, fibrinogen concentrate has been used off-label in the United States and is the standard in European countries and Canada to treat the acquired hypofibrinogenemia during cardiac surgery. Fibrinogen concentrate has multiple potential advantages including rapid reconstitution, greater dose predictability, viral inactivation during processing, and reduced transfusion-related adverse events. However, because fibrinogen concentrate lacks the other components contained in the cryoprecipitate, it may not be the "ideal" product for replacing fibrinogen in all cardiac surgical patients, particularly those with longer cardiopulmonary bypass duration. In this Pro-Con commentary article, we discuss the advantages and disadvantages of using fibrinogen concentrate and cryoprecipitate to treat acquired hypofibrinogenemia in cardiac surgical patients., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2021 International Anesthesia Research Society.)

The thromboembolic complications of Atrial fibrillation (AF) remain a major problem in contemporary clinical practice. Despite advances and developments in anticoagulation strategies, therapy is complicated by the high risk of bleeding complications and need for meticulous medication compliance. Over the past few decades, the left atrial appendage has emerged as a promising therapeutic target to prevent thromboembolic events while mitigating bleeding complications and compliance issues. Emerging data indicates that it is a safe, effective and feasible alternative to systemic anticoagulation in patients with non-valvular AF. A number of devices have been developed for endocardial or epicardial based isolation of the left atrial appendage. Increasing experience has improved overall procedural safety and ease while simultaneously reducing device related complication rates. Furthermore, increasing recognition of the non-mechanical advantages of this procedure has led to further interest in its utility for further indications beyond the prevention of thromboembolic complications. In this review, we present a comprehensive overview of the evolution of left atrial appendage occlusion, commercially available devices and the role of this modality in the current management of AF. We also provide a brief outline of the landmark trials supporting this approach as well as the ongoing research and future prospects of left atrial appendage occlusion., (© 2021 Wiley Periodicals LLC.)

Background: Cardiac surgery with cardiopulmonary bypass (CPB) is associated with a high risk of postoperative acute kidney injury (AKI). Due to limitations of current diagnostic strategies, we sought to determine whether free hemoglobin (fHb) ratio (ie, levels of fHb at the end of CPB divided by baseline fHb) could predict AKI after on-pump cardiac surgery., Methods: This is a secondary analysis of a randomized controlled trial comparing the effect of nitric oxide (intervention) versus nitrogen (control) on AKI after cardiac surgery (NCT01802619). A total of 110 adult patients in the control arm were included. First, we determined whether fHb ratio was associated with AKI via multivariable analysis. Second, we verified whether fHb ratio could predict AKI and incorporation of fHb ratio could improve predictive performance at an early stage, compared with prediction using urinary biomarkers alone. We conducted restricted cubic spline in logistic regression for model development. We determined the predictive performance, including area under the receiver-operating-characteristics curve (AUC) and calibration (calibration plot and accuracy, ie, number of correct predictions divided by total number of predictions). We also used AUC test, likelihood ratio test, and net reclassification index (NRI) to compare the predictive performance between competing models (ie, fHb ratio versus neutrophil gelatinase-associated lipocalin [NGAL], N-acetyl-β-d-glucosaminidase [NAG], and kidney injury molecule-1 [KIM-1], respectively, and incorporation of fHb ratio with NGAL, NAG, and KIM-1 versus urinary biomarkers alone), if applicable., Results: Data stratified by median fHb ratio showed that subjects with an fHb ratio >2.23 presented higher incidence of AKI (80.0% vs 49.1%; P = .001), more need of renal replacement therapy (10.9% vs 0%; P = .036), and higher in-hospital mortality (10.9% vs 0%; P = .036) than subjects with an fHb ratio ≤2.23. fHb ratio was associated with AKI after adjustment for preestablished factors. fHb ratio outperformed urinary biomarkers with the highest AUC of 0.704 (95% confidence interval [CI], 0.592-0.804) and accuracy of 0.714 (95% CI, 0.579-0.804). Incorporation of fHb ratio achieved better discrimination (AUC test, P = .012), calibration (likelihood ratio test, P < .001; accuracy, 0.740 [95% CI, 0.617-0.832] vs 0.632 [95% CI, 0.477-0.748]), and significant prediction increment (NRI, 0.638; 95% CI, 0.269-1.008; P < .001) at an early stage, compared with prediction using urinary biomarkers alone., Conclusions: Results from this exploratory, hypothesis-generating retrospective, observational study shows that fHb ratio at the end of CPB might be used as a novel, widely applicable biomarker for AKI. The use of fHb ratio might help for an early detection of AKI, compared with prediction based only on urinary biomarkers., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2021 International Anesthesia Research Society.)

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients undergoing valve-sparing aortic root replacement, is reimplantation superior to remodelling? The purpose of this best evidence topic was to re-review the updated evidence that has become available in the near decade since the previous review published in 2011. Altogether more than 300 papers were found using the reported search, of which 8 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The included studies have significant limitations relating to low-level evidence study design, variable outcome collection and limited significance testing with direct comparison. Long-term outcomes such as survival, recurrence of aortic regurgitation and valve reintervention were largely equal between the two procedures across the studies. This review, updated from the previous best evidence topic, continues to suggest that there are no clear recommendations or even consensus to guide clinical decision-making when choosing between remodelling or reimplantation approaches to valve-sparing aortic root replacement. To date, no study provides strong clinical benefit to favour either procedure in terms of perioperative outcomes, medium-long term survival or reintervention of the aortic valve. As such, procedure selection should be based upon patient factors and valve evaluation, combined with surgeon preference and experience., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: To compare patient-reported outcome measures of minimally invasive (MI) to sternotomy (ST) mitral valve repair., Methods: We included all patients undergoing isolated mitral valve surgery via either a right mini-thoracotomy (MI) or ST over a 36-month period. Patients were asked to complete a modified Composite Physical Function questionnaire. Intraoperative and postoperative outcomes, and patient-reported outcome measures were compared between 2 propensity-matched groups (n = 47/group), assessing 3 domains: 'Recovery Time', 'Postoperative Pain' (at day 2 and 1, 3, 6 and 12 weeks) and 'Treatment Satisfaction'. Composite scores for each domain were subsequently constructed and multivariable analysis was used to determine whether surgical approach was associated with domain scores., Results: The response rate was 79%. There was no mortality in either group. In the matched groups, operative times were longer in the MI group (P < 0.001), but postoperative outcomes were similar. Composite scores for Recovery Time [ST 51.7 (31.8-62.1) vs MI 61.7 (43.1-73.9), P = 0.03] and Pain [ST 65.7 (40.1-83.1) vs MI 79.1 (65.5-89.5), P = 0.02] significantly favoured the MI group. Scores in the Treatment Satisfaction domain were high for both surgical approaches [ST 100 (82.5-100) vs MI 100 (95.0-100), P = 0.15]. The strongest independent predictor of both faster recovery parameter estimate 12.0 [95% confidence interval (CI) 5.7-18.3, P < 0.001] and less pain parameter estimate 7.6 (95% CI 0.7-14.5, P = 0.03) was MI surgery., Conclusions: MI surgery was associated with faster recovery and less pain; treatment satisfaction and safety profiles were similar., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The field of transcatheter mitral valve repair (TMVr) for mitral regurgitation (MR) is rapidly evolving. Besides the well-established transcatheter mitral edge-to-edge repair approach, there is also growing evidence for therapeutic strategies targeting the mitral annulus and mitral valve chordae. A patient-tailored approach, careful patient selection and an experienced interventional team is crucial in order to optimise procedural and clinical outcomes. With further data from ongoing clinical trials to be expected, consensus in the Heart Team is needed to address these complexities and determine the most appropriate TMVr therapy, either single or combined, for patients with severe MR., Competing Interests: Competing interests: ODB received institutional research grants and consulting fees from Abbott and Boston Scientific. MT is a consultant for Abbott Vascular, Boston Scientific and 4tech; received personal fees from Edwards Lifesciences, Mitraltech, CoreMedic and Swissvortex; and is a shareholder of 4Tech. FM obtained grant and/or research institutional support from Abbott, Medtronic, Edwards Lifesciences, Biotronik, Boston Scientific Corporation, NVT, Terumo, Consulting fees, Honoraria personal and institutional from Abbott, Medtronic, Edwards Lifesciences, Xeltis, Cardiovalve, Occlufit, Simulands, Occlufit; has Royalty Income/IP Rights Edwards Lifesciences; and is shareholder (including share options) of Cardiogard, Magenta, SwissVortex, Transseptal solutions, Occlufit, 4Tech, Perifect. LS received institutional research grants and consulting fees from Abbott, Boston Scientific, Medtronic and Edwards Lifesciences. All other coauthors have no conflict of interest to disclose concerning this manuscript., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

THIS SPECIAL article is the 13th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr Kaplan, and the editorial board for the opportunity to continue this series; namely, the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology. 1 The major themes selected for 2020 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights in the specialty for 2020 begin with an update on valvular disease, with a focus on updates in management of aortic and mitral valve disorders. The second major theme is an update on coronary artery disease, with discussion of both medical and surgical management. The third major theme is focused on the perioperative management of patients with coronavirus disease 2019 (COVID-19), with the authors highlighting literature discussing medical, surgical, and anesthetic considerations for their cardiac care. The fourth major theme is an update in heart failure, with discussion of medical, psychosocial, and procedural aspects of this complicated disease process. The fifth and final theme focuses on the latest analyses regarding survival in heart transplantation. The themes selected for this 13th special article are only a few of the diverse advances in the specialty during 2020. These highlights will inform the reader of key updates on a variety of topics, leading to improvement of perioperative outcomes for patients with cardiothoracic and vascular disease., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to report., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Competing Interests: None declared.

Background: Increased attention has been dedicated to gender inequity at scientific meetings. This study evaluated the gender distribution of session leaders at cardiothoracic surgery national and regional meetings., Methods: This is a descriptive study of the gender of peer-selected session leaders at 4 cardiothoracic surgery organizations' annual meetings from 2015 to 2019. Session leaders included moderators, panelists, and invited discussants. Data from publicly available programs were used to generate a list of session leaders and organization leaders. The primary outcome measure was the proportion of female session leaders at annual meetings. Descriptive analyses were performed, including the Cochran-Armitage trend test for linear trends of proportions., Results: A total of 679 sessions over 20 meetings were examined. Of the 3662 session leaders, 480 (13.1%) were women. The proportion of total female session leaders trended positively over time from 9.6% (56 of 581) in 2015 to 15.9% (169 of 1060) in 2019 (P = .001). Among specialty topic sessions, female session leaders were distributed as follows: adult cardiac, 6.9% (81 of 1172); congenital cardiac, 10.8% (47 of 437); and thoracic, 23.2% (155 of 668). The proportion of female session leaders trended significantly only for thoracic sessions (20.6% [21 of 102] in 2015 to 29.2% [58 of 199] in 2019; P = .02). More than one-half of the sessions (57.4%; 390 of 679) featured all-male session leadership., Conclusions: Women remain underrepresented in leadership roles at cardiothoracic surgery organizational meetings. This may deter female applicants and has implications for female surgeons' career trajectories; therefore, attention must be given to the potential for unconscious bias in leadership in cardiothoracic surgery., (Copyright © 2021. Published by Elsevier Inc.)

Introduction : During the past five years the approach to procedural planning, operative techniques and perfusion strategies for minimally invasive mitral valve surgery (MIMVS) has evolved. With the goal to provide a maximum of patient safety the procedure has been modified according to individual patient characteristics and is largely based on preoperative imaging. Areas covered : In this review article we describe the important factors in image based therapy planning and simulation, different access strategies, the operative key-steps, a rationale use of devices, and highlight a few future developments in the field of MIMVS. Published studies were identified through pearl growing, citation chasing, a search of PubMed using the systematic review methods filter, and the authors' topic knowledge. Expert opinion : With the help of expert teams including surgeons specialized in mitral repair, anesthesiologists and perfusionists a broad spectrum of mitral valve pathologies and related pathologies can be treated with excellent functional outcomes. Avoiding procedure related complications is the key for success for any MIMVS program.

Background: Irish health services have been repurposed in response to the COVID-19 pandemic. Critical care services have been re-focused on the management of COVID-19 patients. This presents a major challenge for specialities such as cardiothoracic surgery that are reliant on intensive care unit (ICU) resources., Aim: The aim of this study was to evaluate the impact of the COVID-19 pandemic on activity at the cardiothoracic surgical care at the National Cardiothoracic Surgery and Transplant Centre., Methods: A comparison was performed of cardiac surgery and transplant caseload for the first 4 months of 2019 and 2020 using data collected prospectively on a customised digital database., Results: Cardiac surgery activity fell over the study period but was most impacted in March and April 2020. Operative activity fell to 49% of the previous years' activity for March and April 2020. Surgical acuity changed with 61% of all cases performed as inpatient transfers after cardiology admission in contrast with a 40% rate in 2019. Valve surgery continued at 89% of the expected rate; coronary artery bypass surgery was performed at 61% of the expected rate and major aortic surgery at 22%. Adult congenital heart cases were not performed in March or April 2020. One heart and one lung transplant were performed in this period., Conclusions: In March and April of 2020, the spread of COVID-19 and the resultant focus on its management resulted in a reduction in cardiothoracic surgery service delivery.

Background: Retrograde autologous priming (RAP) before cardiopulmonary bypass (CPB) may minimize allogeneic red cell transfusion. We conducted a systematic review of the literature to examine the impact of RAP on perioperative allogeneic red cell transfusions in cardiac surgical patients., Methods: This study involved a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies evaluating the use of RAP in cardiac surgery involving CPB. The primary outcome was intraoperative allogeneic red cell transfusion. Secondary outcomes included whole hospital allogeneic transfusions and adverse events such as acute kidney injury (AKI) and stroke., Results: A total of 11 RCTs (n = 1337 patients) were included, comparing RAP patients (n = 674) to control (n = 663). In addition, 10 observational studies (n = 2327) were included, comparing RAP patients (n = 1257) to control (n = 1070). Overall, RAP was associated with a significantly reduced incidence of intraoperative red cell transfusion (n = 18 studies; odds ratio [OR] = 0.34; 95% confidence interval [CI], 0.22-0.55, P < .001) compared to controls. This effect was seen among RCTs (n = 10 studies; OR = 0.19; 95% CI, 0.08-0.45, P < .001) and observational studies (n = 8 studies; OR = 0.66; 95% CI, 0.50-0.87, P = .004) in isolation. RAP was also associated with a significantly reduced incidence of whole hospital red cell transfusion (n = 5 studies; OR = 0.28; 95% CI, 0.19-0.41, P < .001). Among the studies that reported AKI and stroke outcomes, there was no statistically significant increased odds of AKI or stroke in either RAP or control patients., Conclusions: Based on the pooled results of the available literature, RAP is associated with a significant reduction in intraoperative and whole hospital allogeneic red cell transfusion. Use of RAP may prevent hemodilution of cardiac surgical patients and thus, lessen transfusions. Additional high-quality prospective studies are necessary to determine the ideal priming volume necessary to confer the greatest benefit without incurring organ injury.

Background: This study was designed to evaluate the publication performance of management teams consisting of chief and senior physicians in German university cardiac surgery units over a 10-year period and to facilitate benchmarking., Methods: The cutoff date for consideration of staffing from the unit Web site and publications was July 1, 2017. The literature search was based on an evaluation of the PubMed database. The 5-year impact factor (IF) from 2016 was assigned to each journal., Results: Two thousand five hundred thirty-five publications (average IF 3.02) were registered, published in 323 journals. Of a total of 341 management team members, 235 (68.9%) published as first or last author over the 10-year period. The number of publications from the units divided into quintiles varied considerably with the first six units contributing 39.0% of all publications and the last nine units 9.4%. With a cumulative IF total of 3265, the publications of the first six units accounted for 42.7% of the cumulative IF, the last unit quintile amounted to 621 (8.1%) of the cumulative IF. When considering publications per managing member, the first quintile averaged 11.9 publications (29.6 IF) per managing member, the last quintile 3.3 publications (8.0 IF) per member., Conclusions: The six units of the first quintile published on average 3.6 times more per managing member than the nine units in the last quintile and the average cumulative IF per member in the first quintile was almost five times higher. Further investigation must show whether this considerable difference in publication activity between the university units is also observed in other operative fields., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Complete handover of anesthesia care to a second anesthesiologist has been demonstrated to be associated with worse short-term adverse outcomes among cardiac surgery patients, but little information from multi-institutional studies is available., Methods: New York's cardiac surgery registry was used to identify patients who underwent cardiac surgery in New York between 2010 and 2016 with and without complete handovers of anesthesia care. A retrospective observational study with inverse probability treatment weighting (IPTW) based on the propensity score was used to adjust for differences in preoperative patient characteristics while comparing differences in the primary outcome (in-hospital/30 day mortality), major complications in the index admission or within 30 days of the index surgery, readmissions within 30 days, and length of stay., Results: A total of 8.5% of the 103,102 cardiac surgery procedures involved complete handovers. After adjustment, there was a difference between patients with and without handovers in the primary outcome (2.86% vs 2.48%, adjusted risk ratio [ARR] = 1.15 [1.01-1.31]). There was no difference in readmissions within 30 days (13.7% vs 14.4%, ARR = 0.95 [0.90-1.00]), and the differences in complications and length of stay were not clinically meaningful (adjusted differences of <10%)., Conclusions: Cardiac surgery patients in New York who had complete anesthesia handovers experienced higher short-term mortality rates, but there were no meaningful differences in other outcomes. Unnecessary handovers should be carefully monitored.

Background: Cardiac anesthetics rely heavily on opioids, with the standard patient receiving between 70 and 105 morphine sulfate equivalents (MSE; 10-15 µg/kg of fentanyl). A central tenet of Enhanced Recovery Programs (ERP) is the use of multimodal analgesia. This study was performed to assess the association between nonopioid interventions employed as part of an ERP for cardiac surgery and intraoperative opioid administration., Methods: This study represents a post hoc secondary analysis of data obtained from an institutional ERP for cardiac surgery. Consecutive patients undergoing cardiac surgery received 5 nonopioid interventions, including preoperative gabapentin and acetaminophen, intraoperative dexmedetomidine and ketamine infusions, and regional analgesia via serratus anterior plane block. The primary objective, the association between intraoperative opioid administration and the number of interventions provided, was assessed via a linear mixed-effects regression model. To assess the association between intraoperative opioid administration and postoperative outcomes, patients were stratified into high (>50 MSE) and low (≤50 MSE) opioids, 1:1 propensity matched based on 15 patients and procedure covariables and assessed for associations with postoperative outcomes of interest. To investigate the impact of further opioid restriction, ultralow (≤25 MSE) opioid participants were then identified, 1:3 propensity matched to high opioid patients, and similarly compared., Results: A total of 451 patients were included in the overall analysis. Analysis of the primary objective revealed that intraoperative opioid administration was inversely related to the number of interventions employed (estimated -7.96 MSE per intervention, 95% confidence interval [CI], -9.82 to -6.10, P < .001). No differences were detected between low (n = 136) and high (n = 136) opioid patients in postoperative complications, postoperative pain scores, time to extubation, or length of stay. No differences were found in outcomes between ultralow (n = 63) and high (n = 132) opioid participants., Conclusions: Nonopioid interventions employed as part of an ERP for cardiac surgery were associated with a reduction of intraoperative opioid administration. Low and ultralow opioid use was not associated with significant differences in postoperative outcomes. These findings are hypothesis-generating, and future prospective studies are necessary to establish the role of opioid-sparing strategies in the setting of cardiac surgery.

Congenital heart disease, particularly cyanotic congenital heart disease (CCHD), may lead to a neurodevelopmental delay through central nervous system injury, more unstable central nervous system development, and increased vulnerability of the nervous system. Neurodevelopmental disease is the most serious disorder of childhood, affecting the quality of life of children and their families. Therefore, the monitoring and optimization of nerve damage treatments are important. The factors contributing to neurodevelopmental disease are primarily related to preoperative, intraoperative, postoperative, genetic, and environmental causes, with intraoperative causes being the most influential. Nevertheless, few studies have examined these factors, particularly the influencing factors during early postoperative care. Children with congenital heart disease may experience brain damage during early heart intensive care due to unstable haemodynamics and total body oxygen transfer, particularly early postoperative inflammatory reactions in the brain, blood glucose levels, and other factors that potentially influence long-term neural development. This study analyses the forms of structural and functional brain damage in the early postoperative period, along with the recent evolution of research on its contributing factors., (Copyright © 2020 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.)

Objectives: Italy has been one of the countries most severely affected by the coronavirus disease 2019 (COVID-19). The Italian government was forced to introduce quarantine measures quickly, and all elective health services were stopped or postponed. This emergency has dramatically changed the management of paediatric and adult patients with congenital heart disease. We analysed data from 14 Italian congenital cardiac surgery centres during lockdown, focusing on the impact of the pandemic on surgical activity, patients and healthcare providers and resource allocation., Methods: Fourteen centres participated in this study. The period analysed was from 9 March to 4 May. We collected data on the involvement of the hospitals in the treatment of patients with COVID-19 and on limitations on regular activity and on the contagion among patients and healthcare providers., Results: Four hospitals (29%) remained COVID-19 free, whereas 10 had a 39% reduction in the number of beds for surgical patients, especially in the northern area. Two hundred sixty-three surgical procedures were performed: 20% elective, 62% urgent, 10% emergency and 3% life-saving. Hospital mortality was 0.4%. Compared to 2019, the reduction in surgical activity was 52%. No patients operated on had positive test results before surgery for severe acute respiratory syndrome coronavirus 2, the virus responsible for COVID-19. Three patients were infected during the postoperative period. Twenty-nine nurses and 12 doctors were infected. Overall, 80% of our infected healthcare providers were in northern centres., Conclusions: Our study shows that the pandemic had a different impact on the various Italian congenital cardiac surgery centres based on the different patterns of spread of the virus across the country. During the lockdown, the system was able to satisfy all emergency clinical needs with excellent results., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The onset of the coronavirus disease 2019 (COVID-19) pandemic has forced our cardiac surgery program and hospital to enact drastic measures that has forced us to change how we care for cardiac surgery patients, assist with COVID-19 care, and enable support for the hospital in terms of physical resources, providers, and resident training., Methods: In this review, we review the cardiovascular manifestations of COVID-19 and describe our system-wide adaptations to the pandemic, including the use of telemedicine, how a severe reduction in operative volume affected our program, the process of redeployment of staff, repurposing of residents into specific task teams, the creation of operation room intensive care units, and the challenges that we faced in this process., Results: We offer a revised set of definitions of surgical priority during this pandemic and how this was applied to our system, followed by specific considerations in coronary/valve, aortic, heart failure and transplant surgery. Finally, we outline a path forward for cardiac surgery for the near future., Conclusions: We recognize that individual programs around the world will eventually face COVID-19 with varying levels of infection burden and different resources, and we hope this document can assist programs to plan for the future., (Copyright © 2020 Jointly between The American Association for Thoracic Surgery, The Society of Thoracic Surgeons, and the European Association for Cardio-Thoracic Surgery. Published by Elsevier Inc. Published by Elsevier Inc. All rights reserved.)

The tremendous and rapid technological advances that humans have achieved in the last decade have definitely impacted how surgical tasks are performed in the operating room (OR). As a high-tech work environment, the contemporary OR has incorporated novel computational systems into the clinical workflow, aiming to optimize processes and support the surgical team. Artificial intelligence (AI) is increasingly important for surgical decision making to help address diverse sources of information, such as patient risk factors, anatomy, disease natural history, patient values and cost, and assist surgeons and patients to make better predictions regarding the consequences of surgical decisions. In this review, we discuss the current initiatives that are using AI in cardiothoracic surgery and surgical care in general. We also address the future of AI and how high-tech ORs will leverage human-machine teaming to optimize performance and enhance patient safety.

This review summarizes a systematic analysis of 216 randomized trials of cardiovascular interventions performed during 2008-2019, according to the source of trial funding. The systematic analysis showed that on average the results of each trial would change significance if only 5 patients experienced different outcomes. Industry-sponsored trials were more likely to use composite endpoints, noninferiority designs, and twice as likely as nonindustry trials to report results favoring the device arm. Over 80% of industry trials used reporting strategies or "spin" suggesting the device arm was advantageous versus fewer than half of non-industry trials. The review discusses the implications of these findings.

Background: This report summarizes the results of a voluntary survey designed to assess the current situation of cardiac surgical intensive care medicine in Germany in 2018., Methods: A standardized questionnaire concerning detailed information about structural characteristics of cardiac surgical intensive care units (ICUs) was sent to all German departments performing cardiac surgery., Results: Response rate was 93% ( n  = 75/81). Compared with previous surveys since 1998, the median number of intensive care beds for patients after cardiac surgery increased from 15 in 2013 to 16 in 2018. The proportion of cardiac surgical ICUs decreased to 51% with a simultaneous increase of interdisciplinary ICUs. The proportion of cardiac surgeons acting as director of an ICU increased to 43%. The physicians' teams were mostly interdisciplinary (57%). More than half of the directors were board-certified intensivists (62%) with a peak of 100% in ICUs run by cardiac surgeons. Human resources development in the ICU showed similar trends with an increase of physicians and nurses. More than half of all ICUs (61%) and the vast majority of cardiac surgical ICUs (82%) offer an accredited training program for intensive care medicine., Conclusion: The results of this survey corroborate once again that intensive care medicine represents a substantial and important part of cardiac surgery. However, efforts are necessary to keep this attitude alive for the future., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Resectional and artificial cordal repair techniques are effective strategies for degenerative mitral valve (MV) repair. However, resectional repair requires a tailored approach using various techniques, whereas cordal repair offers a simpler, easily reproducible repair. The approach described in this study approach has evolved from resectional to cordal over time, and outcomes are compared between the eras., Methods: Clinical and echocardiographic outcomes of all patients undergoing MV repair for degenerative mitral regurgitation (MR) from January 2004 to September 2017 were reviewed. Patients were stratified by era: from January 2004 to June 2011 (era 1; n = 405), resectional techniques were used in 62% and artificial cordal techniques were used in 38%. From July 2011 to September 2017 (era 2; n = 438), artificial cordal repair was used in 98% of patients. The primary outcome was repair failure, defined as greater than moderate MR or MV reoperation., Results: Of 847 patients with degenerative MR, successful repair was achieved in 843 patients (99.5% repair rate). Leaflet prolapse was posterior in 66%, anterior in 8%, and bileaflet in 26%. Cardiopulmonary bypass time and cross-clamp times were shorter in era 2 (CPB: 109 [IQR, 92-128] minutes vs 97 [IQR, 76-121] minutes; P < .001; cross-clamp: 88 [IQR, 73-106] minutes vs. 79 [IQR, 61-99] minutes; P < .001). Predismissal echocardiography demonstrated no MR or trace MR in 95%, mild MR in 4.7%, and moderate MR in 0.3% of patients. Operative mortality was similar in the eras (0.5% vs 0.5%; P > .999). The rates of 5-year freedom from repair failure (95.1% vs 95.5%; P = .707), stroke (96.8% vs 95.3%; P = .538), and endocarditis (99.3% vs 99.7%; P = .604) were similar between the eras., Conclusions: Artificial cordal repair for all patients with degenerative MR simplifies MV repair and yields equivalent, excellent outcomes compared with a tailored resectional approach., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)