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Current guidelines recommend a target international normalized ratio (INR) range of 2.5 to 3.5 in patients with a mechanical mitral prosthesis. The Prospective Randomized On-X Anticoagulation Clinical Trial (PROACT) Mitral randomized controlled noninferiority trial assessed safety and efficacy of warfarin at doses lower than currently recommended, in patients with an On-X mechanical mitral valve.After On-X mechanical mitral valve replacement followed by at least 3 months of standard anticoagulation, 401 patients at 44 North American centers were randomized to low-dose warfarin (target INR 2.0 to 2.5) or standard-dose warfarin (target INR 2.5 to 3.5). All patients were prescribed aspirin 81 mg daily and encouraged to use home INR testing. The primary endpoint was the sum of the linearized rates of thromboembolism, valve thrombosis, and bleeding events. The design was based on an expected 7.3% event rate and 1.5% noninferiority margin.Mean patient follow-up was 4.1 years. Mean INR was 2.47 and 2.92 (P.001) in the low-dose and standard-dose warfarin groups, respectively. Primary endpoint rates were 11.9%/patient-year in the low-dose group and 12.0%/patient-year in the standard-dose group (difference -0.07, 95% confidence intervals: -3.40, 3.26). The confidence interval exceeded 1.5%, thus noninferiority was not achieved. Rates (%/patient-year) of the individual components of the primary endpoint were 2.3% vs 2.5% for thromboembolism, 0.5% vs 0.5% for valve thrombosis, and 9.13% vs 9.04% for bleeding.Compared to standard-dose warfarin, low-dose warfarin did not achieve noninferiority for the composite primary endpoint. (PROACT Clinicaltrials.gov number, NCT00291525).

Background: to investigate the frequency and distribution of new ischemic brain lesions detected by diffusion-weighted imaging on brain magnetic resonance imaging after aortic arch surgery. Methods: This preplanned secondary analysis of the randomized, controlled ACE (Aortic Surgery Cerebral Protection Evaluation) CardioLink-3 trial compared the safety and efficacy of innominate versus axillary artery cannulation during elective proximal aortic arch surgery. Participants underwent pre and postoperative magnetic resonance imaging. New ischemic lesions were defined as lesions visible on postoperative, but not preoperative diffusion weighted imaging. Results: Of the 111 trial participants, 102 had complete magnetic resonance imaging data. A total of 391 new ischemic lesions were observed on diffusion-weighted imaging in 71 (70%) patients. The average number of lesions in patients with ischemic lesion were 5.5±4.9 with comparable numbers in the right (2.9±2.0) and left (3.0±2.3) hemispheres ( P =0.49). Half the new lesions were in the middle cerebral artery territory; 63% of the cohort had ischemic lesions in the anterior circulation, 49% in the posterior circulation, 42% in both, and 20% in watershed areas. A probability mask of all diffusion-weighted imaging lesions revealed that the cerebellum was commonly involved. More severe white matter hyperintensity on preoperative magnetic resonance imaging (odds ratio, 1.80 [95% CI, 1.10–2.95]; P =0.02) and lower nadir nasopharyngeal temperature during surgery (odds ratio per 1°C decrease, 1.15 [95% CI, 1.00–1.32]; P =0.05) were associated with the presentation of new ischemic lesion; older age (risk ratio per 1-year increase, 1.02 [95% CI, 1.00–1.04]; P =0.03) and lower nadir temperature (risk ratio per 1°C decrease, 1.06 [95% CI, 1.00–1.14]; P =0.06) were associated with greater number of lesions. Conclusions: In patients who underwent elective proximal aortic arch surgery, new ischemic brain lesions were common, and predominantly involved the middle cerebral artery territory or cerebellum. Underlying small vessel disease, lower temperature nadir during surgery, and advanced age were risk factors for perioperative ischemic lesions. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02554032.

BACKGROUND: Coronary artery bypass grafting (CABG) is the most common revascularization approach for the treatment of multi-vessel coronary artery disease. While the internal mammary artery is nearly universally used to bypass the left anterior descending coronary artery, autologous saphenous vein grafts (SVGs) are still the most frequently used conduits to grafts the remaining coronary artery targets Long-term failure of these grafts, however, continues to limit the benefits of surgery. DESIGN: The Cardiothoracic Surgical Trials Network trial of the safety and effectiveness of a Venous External Support (VEST) device is a randomized, multicenter, within-patient trial comparing VEST-supported versus unsupported saphenous vein grafts in patients undergoing CABG. Key inclusion criteria are the need for CABG with a planned internal mammary artery to the left anterior descending and two or more saphenous vein grafts to other coronary arteries. The primary efficacy endpoint of the trial is SVG intimal hyperplasia (plaque + media) area assessed by intravascular ultrasound at 12 months post randomization. Occluded grafts are accounted for in the analysis of the primary endpoint. Secondary confirmatory endpoints are lumen diameter uniformity and graft failure (>50% stenosis) assessed by coronary angiography at 12 months. The safety endpoints are the occurrence of major adverse cardiac and cerebrovascular events and hospitalization within 5 years from randomization. CONCLUSIONS: The results of the VEST trial will determine whether the VEST device can safely limit SVG intimal hyperplasia in patients undergoing CABG as treatment for coronary atherosclerotic disease.

The evidence for use of direct oral anticoagulants (DOACs) in the management of post-operative cardiac surgery atrial fibrillation is limited and mostly founded on clinical trials that excluded this patient population. We performed a systematic review and meta-analysis of clinical trials and observational studies to evaluate the hypothesis that DOACs are safe compared to warfarin for the anticoagulation of patients with post-operative cardiac surgery atrial fibrillation. We searched PubMed, EMBASE, Web of Science, clinicaltrials.gov, and the Cochrane Library for clinical trials and observational studies comparing DOAC with warfarin in patients ≥18 years old who had post-cardiac surgery atrial fibrillation. Primary outcomes included stroke, systemic embolization, bleeding, and mortality. We performed a random-effects meta-analysis of all outcomes. The meta-analysis for the primary outcomes showed significantly lower risk of stroke with DOAC use (6 studies, 7143 patients, RR 0.64; 95% CI 0.50–0.81, I2: 0.0%) compared to warfarin, a trend towards lower risk of systemic embolization (4 studies, 7289 patients, RR 0.64, 95% CI 0.41–1.01, I2: 31.99%) and similar risks of bleeding (14 studies, 10182 patients, RR 0.91; 95% CI 0.74–1.10, I2: 26.6%) and mortality (12 studies, 9843 patients, relative risk [RR] 1.01; 95% CI 0.74–1.37, I2: 26.5%). Current evidence suggests that DOACs, compared to warfarin, in the management of atrial fibrillation after cardiac surgery is associated with lower risk of stroke and a strong trend for lower risk of systemic embolization, and no evidence of increased risk for hospital readmission, bleeding and mortality.

The frozen elephant trunk technique has revolutionized aortic arch repair to enable more extensive arch and descending thoracic aortic treatment in a single setting. We review the current evidence supporting the use of the Thoraflex Hybrid (Terumo Aortic, FL, USA) device and discuss advantages, pitfalls and future design considerations.Lay abstract Disease of the aorta, the biggest blood vessel in the body, is challenging. In recent years, new technologies such as the frozen elephant trunk (FET) have improved the treatment of patients with these complicated diseases. The FET is a hybrid device, made of medical fabrics and a covered metal stent (a tube inserted into the blood vessel to keep it open). In this paper, we provide an in-depth review of a FET device known as Thoraflex Hybrid (Terumo Aortic, FL, USA). We discuss its advantages and pitfalls as well as future areas of research.

Background: To explore evolving surgical techniques and outcomes for aortic arch surgery. Methods: A total of 2435 consecutive patients underwent aortic arch repair with hypothermic circulatory arrest between 2008 and 2018 in 12 institutions across Canada. Trends in patient characteristics, surgical techniques, and in-hospital outcomes, including major morbidity or mortality, were examined. Results: From 2008 to 2018, the age of patients (62.3 ± 13.2 years) and the proportion of women (30.2%) undergoing arch surgery did not change significantly. Aortic diameters at operation decreased (2008: 58 ± 13 mm; 2018: 53 ± 11 mm; P < 0.01). Surgeons performed more valve-sparing root replacements (2008: 0%; 2018: 15%; P < 0.001) and fewer Bentall procedures (2008: 27%; 2018: 20%; P < 0.01). Total arch replacement rates were similar (P = 0.18); however, elephant trunk (2008: 9.5%; 2018: 19%; P < 0.001) and frozen elephant trunk (2008: 3.1%; 2018: 15%; P < 0.001) repair rates have increased. Over time, higher nadir temperatures (2008: 18 [17-21]°C; 2018: 25 [23-28]°C; P < 0.001), and more frequent antegrade cerebral perfusion (2008: 61%; 2018: 83%; P < 0.001) were used. For elective cases, in-hospital mortality rates declined (2008: 6.8%; 2018: 1.2%; P = < 0.01), as did major morbidity or mortality (2008: 24%; 2018: 13%; P < 0.001) and transfusion rates (2008: 61%; 2018: 41%; P < 0.001), but stroke rates remained constant (2008: 6.8%; 2018: 5.3%; P = 0.12). Outcomes remained the same over time for urgent or emergent cases. Conclusions: Outcomes have improved over the past decade in Canada for elective aortic arch surgery, in the context of operating on smaller aortas, and more frequent use of moderate hypothermia and antegrade cerebral perfusion. Further research is needed to improve stroke rates and outcomes in the emergency setting. Résumé: Introduction: Examiner l’évolution des techniques chirurgicales et les résultats de l'intervention chirurgicale de l'arc aortique. Méthodes: Un total de 2 435 patients consécutifs ont subi une réparation de l'arc aortique en arrêt circulatoire en hypothermie entre 2008 et 2018 dans 12 établissements du Canada. Nous avons examiné les tendances en ce qui concerne les caractéristiques des patients, les techniques chirurgicales et les résultats cliniques intrahospitaliers, y compris les principales causes de morbidité ou de mortalité. Résultats: De 2008 à 2018, l’âge des patients (62,3 ± 13,2 ans) et la proportion de femmes (30,2 %) subissant l'intervention chirurgicale de l'arc n'a pas montré de changement significatif. Les diamètres aortiques à l'opération ont diminué (2008 : 58 ± 13 mm; 2018 : 53 ± 11 mm; P

Objectives The aim of this study was to evaluate clinical characteristics, mechanisms of failure, and outcomes of transcatheter aortic valve replacement (TAVR) explantation. Background Surgical explantation following TAVR may be required for structural valve degeneration, paravalvular leak, infection, or other reasons. However, in-depth data on indications and outcomes are lacking. Methods Data from a multicenter, international registry (EXPLANT-TAVR) of patients who underwent TAVR explantation were reviewed retrospectively. Explantations performed during the same admission as initial TAVR were excluded. Clinical and echocardiographic outcomes were evaluated. Median follow-up duration was 6.7 months (interquartile range [IQR]: 1.0-18.8 months) after TAVR explantation and was 97.7% complete at 30 days and 86.1% complete at 1 year. Results From November 2009 to September 2020, 269 patients across 42 centers with a mean age of 72.7 ± 10.4 years underwent TAVR explantation. About one quarter (25.9%) were deemed low surgical risk at index TAVR, and median Society of Thoracic Surgeons risk at TAVR explantation was 5.6% (IQR: 3.2%-9.6%). The median time to explantation was 11.5 months (IQR: 4.0-32.4 months). Balloon-expandable and self-expanding or mechanically expandable valves accounted for 50.9% and 49.1%, respectively. Indications for explantation included endocarditis (43.1%), structural valve degeneration (20.1%), paravalvular leak (18.2%), and prosthesis-patient mismatch (10.8%). Redo TAVR was not feasible because of unfavorable anatomy in 26.8% of patients. Urgent or emergency cases were performed in 53.1% of patients, aortic root replacement in 13.4%, and 54.6% had concomitant cardiac procedures. Overall survival at last follow-up was 76.1%. In-hospital, 30-day, and 1-year mortality rates were 11.9%, 13.1%, and 28.5%, respectively, and stroke rates were 5.9%, 8.6%, and 18.7%, respectively. Conclusions The EXPLANT-TAVR registry reveals that surgical risks associated with TAVR explantation are not negligible and should be taken into consideration in the lifetime management of aortic stenosis.

Objectives The aim of this study was to determine clinical and echocardiographic characteristics, mechanisms of failure, and outcomes of mitral valve (MV) surgery after transcatheter edge-to-edge repair (TEER). Background Although >100,000 mitral TEER procedures have been performed worldwide, longitudinal data on MV surgery after TEER are lacking. Methods Data from the multicenter, international CUTTING-EDGE registry were retrospectively analyzed. Clinical and echocardiographic outcomes were evaluated. Median follow-up duration was 9.0 months (interquartile range [IQR]: 1.2-25.7 months) after MV surgery, and follow-up was 96.1% complete at 30 days and 81.1% complete at 1 year. Results From July 2009 to July 2020, 332 patients across 34 centers underwent MV surgery after TEER. The mean age was 73.8 ± 10.1 years, median Society of Thoracic Surgeons risk for MV repair at initial TEER was 4.0 (IQR: 2.3-7.3), and primary/mixed and secondary mitral regurgitation were present in 59.0% and 38.5%, respectively. The median interval from TEER to surgery was 3.5 months (IQR: 0.5-11.9 months), with overall median Society of Thoracic Surgeons risk of 4.8% for MV replacement (IQR: 2.8%-8.4%). The primary indication for surgery was recurrent mitral regurgitation (33.5%), and MV replacement and concomitant tricuspid surgery were performed in 92.5% and 42.2% of patients, respectively. The 30-day and 1-year mortality rates were 16.6% and 31.3%, respectively. On Kaplan-Meier analysis, the actuarial estimates of mortality were 24.1% at 1 year and 31.7% at 3 years after MV surgery. Conclusions In this first report of the CUTTING-EDGE registry, the mortality and morbidity risks of MV surgery after TEER were not negligible, and only

The study objective was to evaluate the clinical and radiographic outcomes of the Ascyrus Medical Dissection Stent in a prospective, nonrandomized, international study (Dissected Aorta Repair Through Stent Implantation) of patients with acute DeBakey type I aortic dissection.The Ascyrus Medical Dissection Stent was used in combination with the standard surgical management of acute DeBakey type I aortic dissection I to treat patients with (56.5%, 26/46) and without (43.5%, 20/46) preoperative clinical and radiographic malperfusion. All patients had a primary entry tear in the ascending aorta, and 97.8% (45/46) were treated with a hemiarch repair. Median follow-up was 3 years.All 47 patients underwent emergency surgical repair with successful Ascyrus Medical Dissection Stent implantation. One patient was excluded from analysis due to use in iatrogenic dissection. Overall mortality at 30 days and 3 years was 13.0% (6/46) and 21.7% (10/46), respectively. Overall new stroke rate at 30 days was 15.2% (7/46). No devices were explanted at any time during the 3-year median follow-up. At 3 years, the total aortic diameter in zones 0, 1, and 2 decreased or remained stable in 91.7%, 72.7%, and 75.0%, respectively. The false lumen was completely or partially thrombosed in 90.5% in zone 0, 60.0% in zone 1, and 68.2% in zone 2 at 3 years.The use of the Ascyrus Medical Dissection Stent in the treatment of acute DeBakey type I aortic dissection I holds promise as a simple technology that enables repair of the aortic arch and proximal descending aorta, while promoting positive aortic remodeling. Ongoing follow-up of the Dissected Aorta Repair Through Stent Implantation trial will provide long-term, prospective, clinical outcomes and radiographic data on positive remodeling of the aortic arch.

Background The coronavirus disease 2019 (COVID‐19) pandemic has had an unprecedented impact on health care and cardiac surgery. We report cardiac surgeons' concerns, perceptions, and responses during the COVID‐19 pandemic. Methods A detailed survey was sent to recruit participating adult cardiac surgery centers in North America. Data regarding cardiac surgeons' perceptions and changes in practice were analyzed. Results Our study comprises 67 institutions with diverse geographic distribution across North America. Nurses were most likely to be redeployed (88%), followed by advanced care practitioners (69%), trainees (28%), and surgeons (25%). Examining surgeon concerns in regard to COVID‐19, they were most worried with exposing their family to COVID‐19 (81%), followed by contracting COVID‐19 (68%), running out of personal protective equipment (PPE) (28%), and hospital resources (28%). In terms of PPE conservation strategies among users of N95 respirators, nearly half were recycling via decontamination with ultraviolet light (49%), followed by sterilization with heat (13%) and at home or with other modalities (13%). Reuse of N95 respirators for 1 day (22%), 1 week (21%) or 1 month (6%) was reported. There were differences in adoption of methods to conserve N95 respirators based on institutional pandemic phase and COVID‐19 burden, with higher COVID‐19 burden institutions more likely to resort to PPE conservation strategies. Conclusions The present study demonstrates the impact of COVID‐19 on North American cardiac surgeons. Our study should stimulate further discussions to identify optimal solutions to improve workforce preparedness for subsequent surges, as well as facilitate the navigation of future healthcare crises.

Background Advancements in technology have changed the treatment of aortic arch pathologies. Specifically, the introduction of the frozen elephant trunk technique has allowed one-stage treatment of pathologies that would have otherwise required a two-stage procedure. We present the early outcomes of a novel frozen elephant hybrid stent graft. Methods Between August 2015 and July 2019, 39 patients (56% male; mean age 67 ± 11years) underwent an arch reconstruction with a novel hybrid stent graft in four different Canadian centers. The most common indication for surgery was arch aneurysm (31%) followed by acute dissection (28%). All patients were prospectively followed with clinical and imaging assessments. Results The device was successfully implanted in all patients. There were 3 perioperative deaths (8%). Transient spinal cord injury occurred in 5 patients (13%); all had complete neurologic recovery before discharge. Seven patients had a perioperative stroke/transient ischemic attack; 3 of them initially presented with cerebral malperfusion caused by acute dissection. One patient died during the study follow-up. Survival at 30 days and at 1 and 3 years was 92% ± 5%, 89% ± 5%, and 89% ± 5%, respectively. At a median follow-up of 16 months, 3 patients required a reintervention to address a type I distal endoleak and 1 patient was treated for a type II endoleak. There was no arch anastomosis complications. Conclusions The Cook hybrid stent graft device provides encouraging midterm results in a high-risk cohort. This novel graft is simple to deploy, may be customized to patients’ anatomy in elective cases, eases arch reconstruction, and allows versatility in the choice of arch grafts.

A 75-year-old male with severe symptomatic aortic stenosis underwent transcatheter aortic valve implantation with a Large (27-mm) ACURATE-neo transcatheter aortic valve, complicated by severe paravalvular leak. He developed rapid and progressive worsening heart failure. Reanalysis of the computed tomography images suggested evidence of prosthesis–annulus mismatch. Therefore, a redo transcatheter aortic valve implantation utilizing a 29-mm SAPIEN 3 transcatheter aortic valve was performed. This case illustrates the importance of proper valve sizing to avoid paravalvular leak, and how to safely cross an ACURATE-neo valve to avoid catheter entangling. Résumé: Un homme de 75 ans présentant une sténose aortique symptomatique sévère a subi l'implantation d'une valve aortique par cathéter, dont une ACURATE neo de 27-mm compliquée par une fuite paravalvulaire sévère. Par la suite, le patient a présenté une insuffisance cardiaque sévère . Une nouvelle analyse de ses examens tomodensitométriques a indiqué des signes d'incompatibilité entre la prothèse et l'anneau mitral. Il a donc fallu réaliser une nouvelle implantation valvulaire aortique par cathéter avec une valve SAPIEN 3 de 29 mm. Ce cas illustre l'importance d'une bonne évaluation de l'anneau valvulaire pour éviter les fuites paravalvulaires, et décrit comment traverser une valve ACURATE neo pour éviter l'enchevêtrement du cathéter.

Objective The safety of minimally invasive mitral valve surgery (MIMVS) in elderly patients is still debated. Our objective was to perform a systematic review and meta-analysis of studies comparing MIMVS with conventional sternotomy (CS) in elderly patients (≥65 years old). Methods We searched PubMed, EMBASE, Web of Science, clinicaltrials.gov, and Cochrane Central Register of Controlled Trials for trials and observational studies comparing MIMVS with CS in patients ≥65 years old presenting for mitral valve surgery. We performed a random-effects meta-analysis of all outcomes. Results The MIMVS group had lower odds of acute renal failure (odds ratio [OR] 0.27; 95% CI 0.10 to 0.78), prolonged intubation (>48 h; OR 0.47; 95% CI 0.31 to 0.70), less blood product transfusion (weighted mean difference [WMD] −0.82 units; 95% CI −1.29 to −0.34 units), shorter ICU length of stay (LOS; WMD −2.57 days; 95% CI −3.24 to −1.90 days) and hospital LOS (WMD −4.06 days; 95% CI −5.19 to −2.94 days). There were no significant differences in the odds of mortality, stroke, respiratory infection, reoperation for bleeding, and postoperative atrial fibrillation. MIMVS was associated with longer cross-clamp (WMD 11.8 min; 95% CI 3.5 to 20.1 min) and cardiopulmonary bypass times (WMD 23.0 min; 95% CI 10.4 to 35.6 min). Conclusions MIMVS in elderly patients is associated with lower postoperative complications, blood transfusion, shorter ICU, and hospital LOS, and longer cross-clamp and bypass times.

Background We evaluated a novel formula using preoperative transesophageal echocardiographic measurements to determine neochordae length for repair of degenerative mitral regurgitation (MR). Methods The formula is based on measuring the distance from the adjacent papillary head to the intended coaptation zone of the flail/prolapsing leaflet segment and subtracting the redundant leaflet length. Between 2008 and 2017, 264 consecutive patients underwent mitral valve repair (82.2% endoscopic, minimally invasive approach and 17.8% sternotomy) with neochordae loop reconstruction (68.6% posterior, 6.4% anterior, and 25% bileaflet repair). Mean patient age was 63 ± 13.6 years, 73.5% were men, and mean left ventricular ejection fraction was 63.1% ± 6.7%. Results Mitral valve repair was successful in 100% of patients, with no patient requiring conversion to replacement. Neochordae length measurement was accurate in 259 patients (98%), with 4 patients requiring conversion to resection and 1 patient requiring longer anterior leaflet neochordae. Median anterior and posterior neochordae lengths were 27 mm (range, 18-32) and 17 mm (range, 9-27), respectively. Intraoperative transesophageal echocardiography demonstrated no or trace residual MR in 254 patients and mild residual MR in 10 patients. In-hospital mortality occurred in 1 patient, and complications included respiratory failure (2.7%) and renal failure (1.8%). At the median follow-up of 12.6 months (interquartile range, 11.1), 98.9% of patients remained free from ≥2+ MR, whereas freedom from reoperation was 100%. Conclusions Preoperative transesophageal echocardiographic measurements can accurately and reproducibly predict the required length of neochordae loop reconstruction for degenerative mitral valve repair with good results. Longer-term follow-up is necessary.

Background The intimal flap at the distal aortic anastomosis after standard aortic dissection repair creates distal anastomotic new entry, leading to false lumen (FL) pressurization and true lumen (TL) collapse and resulting in increased mortality, malperfusion, aortic growth, and reinterventions. The Ascyrus Medical Dissection Stent (AMDS; Ascyrus Medical, Boca Raton, FL) is a hybrid prosthesis that seals and depressurizes the FL at the distal anastomosis while expanding and pressurizing the TL. Methods The Dissected Aorta Repair Through Stent Implantation trial is a prospective, nonrandomized, international type A dissection trial where patients with acute DeBakey I dissections were enrolled between March 2017 and January 2019. Forty-seven patients were enrolled (median age, 62.5; 67.4% men) with a median follow-up of 631 days. Results All patients underwent emergent surgical repair with successful AMDS implantation. One patient was excluded because of use in iatrogenic dissection. Overall mortality at 30 days and 1 year was 13.0% (6/46) and 19.6% (9/46), whereas new strokes occurred in 6.5% (3/46). Over 95% of vessel malperfusions resolved because of AMDS-induced TL expansion, including 3 patients with preoperative paralysis. Positive remodeling of the aortic arch occurred in 100% of cases with complete obliteration or thrombosis of the FL in 74%. In the proximal descending thoracic aorta positive remodeling occurred in 77% and complete obliteration or FL thrombosis in 53% of cases. Conclusions AMDS facilitates single-stage management of malperfusion and induces positive remodeling of the aortic arch through effective sealing of the distal anastomotic FL, depressurization of the FL with expansion, and pressurization of the TL. Importantly the use of AMDS is safe and reproducible.

Academic productivity, as measured by number and impact of publications, is central to the career advancement and promotion of academic surgeons. We compared research productivity metrics among specialties and sought factors associated with increased productivity.Academic surgeons were identified through departmental webpages and their scholarly metrics were collected through Scopus in a standardized fashion. We collected total number of documents, h-index, and average number of publications per year in the preceding 5 years. We explored whether presence of a training program, graduate degree, academic rank and size of the clinical group affected productivity metrics. Linear regression was used for multivariable analysis.We collected data on 2172 surgeons from 15 separate academic centres across Canada. Wide variability existed in metrics among specialties, with cardiac and neurosurgery being the most productive, and vascular surgery and plastic surgery being the least productive. The average number of publications was 71, and the average h-index was 18.7. The average h-index for cardiac surgery was 25.7 compared with 8.3 for vascular surgery (p0.001). Our multivariable model identified academic rank, surgical specialty, graduate degree, presence of a training program, and larger clinical group as being associated with increased academic productivity.There is variability in research productivity among Canadian surgical specialties. Cardiac surgery and neurosurgery are productive, whereas vascular surgery and plastic surgery are less productive than other surgical disciplines. Obtaining a research-oriented graduate degree, being part of a larger clinical group, and presence of a training program were all associated with higher productivity, even after adjusting for academic rank and specialty.La productivité universitaire, évaluée selon le nombre de publications et leurs retombées, est déterminante pour la carrière et l’avancement des professeurs de chirurgie. Nous avons comparé des indicateurs de la productivité en recherche de diverses spécialités et cherché les facteurs liés à une productivité accrue.Nous avons identifié les professeurs de chirurgie dans les pages Web de départements, et recueilli dans Scopus, de manière normalisée, les données : nombre total de documents, indice h et nombre moyen de publications par année dans les 5 dernières années. Nous avons cherché à savoir si l’existence d’un programme de formation, le diplôme d’études supérieures, le rang professoral et la taille du groupe clinique avaient une incidence sur les indicateurs de productivité. L’analyse multivariable a été faite au moyen d’une régression linéaire.Nous avons recueilli des données sur 2172 chirurgiens de 15 différents centres universitaires du Canada. Les indicateurs variaient grandement selon la spécialité. La productivité la plus élevée était associée à la chirurgie cardiaque et à la neurochirurgie, et la productivité la moins élevée, à la chirurgie vasculaire et à la chirurgie plastique. Le nombre moyen de publications était de 71 et l’indice h moyen, de 18,7. L’indice h moyen pour la chirurgie cardiaque était de 25,7, comparativement à 8,3 pour la chirurgie vasculaire (p0,001). Notre modèle multivariable a montré que le rang professoral, la spécialité chirurgicale, le diplôme d’études supérieures, l’existence d’un programme de formation et un grand groupe clinique sont liés à une productivité universitaire accrue.La productivité en recherche varie en fonction de la spécialité chirurgicale au Canada. La chirurgie cardiaque et la neurochirurgie sont productives, tandis que la chirurgie vasculaire et la chirurgie plastique le sont moins que d’autres spécialités. L’obtention d’un diplôme d’études supérieures axées sur la recherche, l’appartenance à un grand groupe clinique et l’existence d’un programme de formation étaient toutes associées à une productivité supérieure, même après correction pour tenir compte du rang professoral et de la spécialité.

Diffuse intimal hyperplasia and graft irregularity adversely affect the long-term patency of saphenous vein grafts (SVGs) and clinical outcomes of patients undergoing coronary artery bypass grafting (CABG). The VEST trial evaluated the efficacy of external graft support in limiting the development of intimal hyperplasia (IH) at 1 year postsurgery. In the present secondary analysis, we explored the associations between graft disease and IH and clinical events. We also examined risk factors for early graft occlusion.VEST is a within-patient randomized, multicenter trial that enrolled 224 patients with multivessel coronary disease undergoing CABG surgery, of whom 203 were evaluated by 1 year postsurgery. Intimal hyperplasia, lumen uniformity, graft stenosis, and graft perfusion were measured by intravascular ultrasound and angiography. Major cardiac and cerebrovascular events (MACCE; including death, myocardial infarction, stroke, and revascularization) were recorded over a median follow-up of 3 years.Worse lumen uniformity, greater stenosis, and worse graft perfusion were associated with higher IH values and an increased incidence of clinical events. Consistent with previous findings, we identified endoscopic vein harvesting, female sex, and transit time flow measurement of pulsatility index and flow as risk factors for SVG occlusion during the first year postsurgery.In this secondary analysis of the VEST trial, we observed an association between intimal hyperplasia area and clinical measures of SVG disease at 1 year postsurgery. More severe SVG disease and larger areas of IH were associated with a higher incidence of 3-year MACCE. Ongoing follow-up to 5 years will further elucidate the impact of SVG disease on long-term clinical outcomes of CABG.

This study evaluated the frequency and clinical impact of thromboembolic complications after frozen elephant trunk aortic arch repair using the Thoraflex device (Terumo Aortic).A total of 128 consecutive patients (mean age 67.9 ± 13.7 years, 31.0% female) underwent frozen elephant trunk aortic arch repair using the Thoraflex device between September 2014 and May 2021 in 4 Canadian centers. Patient baseline characteristics, intraoperative details, and frozen elephant trunk thromboembolic complications were collected retrospectively and analyzed.Fifteen patients (11.7%) had thrombus visualized within the frozen elephant trunk stent graft on imaging (n = 8; 53.3%) or had a thromboembolic event (n = 9; 60.0%) before hospital discharge. Sites of embolism were mesenteric (n = 8; 88.9%), renal (n = 4; 44.4%), and iliofemoral (n = 1; 11.1%). Patients who experienced thromboembolic complications were more likely to have a history of autoimmune disease (n = 3; 20.0% vs n = 2; 1.8%; P = .01) and implantation of a longer frozen elephant trunk stent graft (150 mm vs 100 mm) (n = 13; 86.7% vs n = 45; 39.8%; P .001). All patients with thromboembolic complications received therapeutic anticoagulation, and a smaller proportion required an open surgical (n = 5; 33.3%) or an endovascular (n = 2; 13.3%) intervention. Radiographic resolution of thromboembolic complications was observed in 86.7% of patients (n = 13). In-hospital mortality occurred in 1 patient, stroke occurred in 1 patient, and transient spinal cord injury occurred in 1 patient.Thromboembolic complications occur more often than previously recognized after frozen elephant trunk aortic arch repair using the Thoraflex device and are associated with increased rates of surgical and endovascular reintervention. Prevention and management of these complications require further study.

Background: We set out to compare in a prospective cohort study the mid-term clinical and echocardiographic outcomes of mini-mitral repair for simple (posterior prolapse) vs complex regurgitation (anterior/bileaflet prolapse). Methods: A total of 245 consecutive patients underwent mini-mitral repair for severe degenerative mitral regurgitation through a right, endoscopic approach (n = 145 simple, n = 100 complex). The most common repair technique was annuloplasty + artificial chordae (84%, n = 121 for simple vs 88%, n = 88 for complex, P = 0.3). Patients were prospectively followed for a maximal duration of 9 years. Patients’ characteristics were well balanced between groups. Results: The 30-day/in-hospital mortality was similar (0%, n = 0 simple vs 1%, n = 1 complex, P = 0.2). Both groups had similar rates of early postoperative complications: myocardial infarction (1.4%, n = 2 vs 0%, n = 0, P = 0.2), neurologic complications (1.4%, n = 2 vs 0%, n = 0, P = 0.2), reoperation for bleeding (0.7%, n = 1 vs 3%, n = 3, P = 0.2), intensive care unit length of stay (1 interquartile range, 1-1 days vs 1 interquartile range, 1-1 days, P = 0.7). Late survival (88% for simple vs 92% for complex, P = 0.4) was similar between groups. Cumulative incidence of late reoperation at 6 years is 0% for both groups (subdistribution hazard ratio = 1, P = 1). There was no difference in recurrent mitral regurgitation greater than 2+ at each year after surgery up to 6 years postoperatively. Conclusion: Mitral repair using an endoscopic, minimally invasive approach yields excellent mid-term outcomes regardless of disease complexity. Résumé: Contexte: Dans le cadre d’une étude de cohorte prospective, on a comparé les résultats cliniques et échocardiographiques que la réparation mitrale mini-invasive procurait à moyen terme selon que cette dernière était pratiquée dans un contexte de régurgitation simple (prolapsus postérieur) ou de régurgitation complexe (prolapsus antérieur/bivalvulaire). Méthodologie: Au total, 245 patients consécutifs qui présentaient une régurgitation mitrale dégénérative sévère ont subi une réparation mitrale mini-invasive par abord endoscopique droit (n = 145 cas de régurgitation simple et n = 100 cas de régurgitation complexe). La technique de réparation la plus courante était l’annuloplastie avec implantation de cordages artificiels (84 %, n = 121 cas de régurgitation simple vs 88 %, n = 88 cas de régurgitation complexe, p = 0,3). Les patients ont été l’objet d’un suivi prospectif d’une durée maximale de 9 ans. Il y avait une répartition équilibrée des caractéristiques des patients entre les groupes. Résultats: Les taux de mortalité à 30 jours et de mortalité hospitalière se sont avérés semblables (0 %, n = 0 cas chez les patients qui présentaient une régurgitation simple vs 1 %, n = 1 cas chez les patients qui présentaient une régurgitation complexe, p = 0,2). Les taux de complications postopératoires précoces se sont également révélés semblables chez les patients des deux groupes, notamment en ce qui concerne l’infarctus du myocarde (1,4 %, n = 2 vs 0 %, n = 0, p = 0,2), les complications neurologiques (1,4 %, n = 2 vs 0 %, n = 0, p = 0,2), les nouvelles interventions chirurgicales en raison d’une hémorragie (0,7 %, n = 1 vs 3 %, n = 3, p = 0,2) et la durée de l’hospitalisation à l’unité de soins intensifs (1 intervalle interquartile, 1-1 jour vs 1 intervalle interquartile, 1-1 jour, p = 0,7). De même, des taux de survie tardive similaires ont été notés chez les patients des deux groupes (88 % chez les patients qui présentaient une régurgitation simple vs 92 % chez les patients qui présentaient une régurgitation complexe, p = 0,4). L’incidence cumulative de nouvelles interventions chirurgicales tardives à 6 ans s’est établie à 0 % dans les deux groupes (rapport des risques instantanés de sous-distribution = 1, p = 1). Aucune différence quant à la récidive de régurgitation mitrale de grade supérieur à 2 n’a été relevée au cours de chacune des 6 années suivant l’intervention chirurgicale. Conclusions: La réparation mitrale minimalement invasive par abord endoscopique permet d’obtenir d’excellents résultats à moyen terme, indépendamment de la complexité de la maladie.

Aortic valve-sparing operations theoretically have fewer stroke and bleeding complications but may increase late reoperation risk versus composite valve grafts.We meta-analyzed all studies comparing aortic valve-sparing (reimplantation and remodelling) and composite valve-grafting (bioprosthetic and mechanical) procedures. Early outcomes were all-cause mortality, reoperation for bleeding, myocardial infarction, and thromboembolism/stroke. Long-term outcomes included all-cause mortality, reintervention, bleeding, and thromboembolism/stroke. Studies exclusively investigating dissection or pediatric populations were excluded.A total of 3794 patients who underwent composite valve grafting and 2424 who underwent aortic valve-sparing procedures were included from 9 adjusted and 17 unadjusted observational studies. Mean follow-up was 5.8 ± 3.0 years. Aortic valve sparing was not associated with any difference in early mortality, bleeding, myocardial infarction, or thromboembolic complications. Late mortality was significantly lower after valve sparing (incident risk ratio, 0.68; 95% confidence interval [CI], 0.54-0.87; P.01). Late thromboembolism/stroke (incident rate ratio, 0.36; 95% CI, 0.22-0.60; P.01) and bleeding (incident rate ratio, 0.21; 95% CI, 0.11-0.42; P .01) risks were lower after valve sparing. Procedure type did not affect late reintervention.Aortic valve sparing appears to be safe and associated with reduced late mortality, thromboembolism/stroke, and bleeding compared with composite valve grafting. Late durability is equivalent. Aortic valve sparing should be considered in patients with favorable aortic valve morphology.

Background The fate of unrepaired tricuspid regurgitation (TR) after mitral valve repair for degenerative mitral regurgitation remains highly debated. The objective of this study was to examine the progress of unrepaired TR after mitral valve repair for degenerative mitral regurgitation, with a particular focus on comparing patients with moderate preoperative TR with those having none or mild preoperative TR. Methods Between 2008 and 2018, 183 consecutive patients (mean age, 61 years [SD, 14]) with severe degenerative mitral regurgitation and less-than-severe TR underwent mitral valve repair alone without concomitant TR repair. They were prospectively followed for a median duration of 3.1 years (interquartile range, 1.6-5.5; maximal duration of 9.4 years). Results At baseline 146 patients (80%) had none or mild TR; 37 patients (20%) had moderate TR. At follow-up 51 patients (30%) had improved TR compared with 28 patients (17%) who had worse TR. At 3 years postoperatively echocardiographic data were available for 82 of 183 patients: 70 (85%) had none or mild TR, 11 (13%) had moderate TR, and 1 (1.2%) had moderate to severe TR. In an exploratory multivariable analysis with limited statistical power, patients with moderate preoperative TR (vs those with none or mild TR) had an association with higher mortality (hazard ratio, 2.8; 95% confidence interval, 0.81-9.4; P = .11). Conclusions After mitral valve repair but without concomitant tricuspid valve repair, a number of patients had progression in their TR. There was a signal of harm in patients having moderate preoperative TR in terms of mortality, but this finding is exploratory and requires investigation.

Background and aim Atrial septal defects with anomalous venous connections are commonly repaired via sternotomy, requiring careful baffle reconstruction to redirect pulmonary venous return and ensure a durable result. The cosmetically appealing periareolar incision may provide an esthetically superior alternative to the anterolateral minithoracotomy incision used in minimally invasive cardiac surgery. Methods We describe a patient with a sinus venosus atrial septal defect and partial anomalous pulmonary venous connection who underwent successful minimally invasive, endoscopic repair with apical vein translocation and autologous pericardial baffle reconstruction through a periareolar approach. Results Post-operative echocardiography demonstrated excellent results with no residual shunt and a widely patent baffle and preserved biventricular function. At 1-year post-op, our patient has had a greatly improved quality of life and an excellent cosmetic result with normal nipple-areolar sensation. Conclusions We believe that periareolar approaches should be considered for all adult patients with simple and complex atrial septal defects.

OBJECTIVES Surgical treatment of infective endocarditis (IE) remains a challenge. The Ross procedure offers the benefit of a living substitute in the aortic position but it is a more complex operation which may lead to increased operative risk. The aim of this study was to assess the safety and late outcomes of the Ross procedure for the treatment of active IE. METHODS From 2000 to 2019, a total of 31 consecutive patients underwent a Ross procedure to treat active IE (mean age 43 ± 12 years, 84% male). All patients were followed up prospectively. Four patients (13%) were intravenous (IV) drug users and 6 patients (19%) had prosthetic IE. The most common infective organism was Streptococcus (58%). Median follow-up was 3.5 (0.9–4.5) years and 100% complete. RESULTS There were no in-hospital deaths. One patient suffered a postoperative stroke (3%) and 1 patient (3%) required reintervention for bleeding. Three patients had a new occurrence endocarditis: 2 patients were limited to the pulmonary homograft and successfully managed with IV antibiotics, whereas 1 IV drug user patient developed concomitant autograft and homograft endocarditis. Overall, cumulative incidence of IE recurrence was 13 ± 8% at 8 years. The cumulative incidence for autograft endocarditis was 5 ± 4% at 8 years. Two patients (6%) died during follow-up, both from drug overdoses. At 8 years, actuarial survival was 88 ± 8%. CONCLUSIONS In selected patients with IE, the Ross procedure is a safe and reasonable alternative with good mid-term outcomes. Freedom from recurrent infection on the pulmonary autograft is excellent, labelporting the notion that a living valve in the aortic position provides good resistance to infection. Nevertheless, in IV drug user patients, pulmonary homograft endocarditis remains a challenge. Continued follow-up is needed to ascertain the long-term benefits of this approach.

Iatrogenic coronary injury after mitral repair is related to blind annuloplasty suture ligation or kinking of the circumflex artery (CxA) and can present with early ST segment changes, malignant ventricular arrhythmias, and segmental wall motion abnormalities. Corrective treatment is imperative to avoid myocardial infarction and can include removal of the annuloplasty ring or CxA bypass. We present a novel hybrid approach for the rapid diagnosis and management of iatrogenic CxA injury after mitral repair.

We sought to determine outcomes of aortic valve replacement (AVR) versus root replacement after transcatheter AVR (TAVR) explantation because they remain unknown.From November 2009 to September 2020, data from the EXPLANT-TAVR International Registry of patients who underwent TAVR explant were retrospectively reviewed, divided by AVR versus root replacement. After excluding explants performed during the same admission as the initial TAVR and concomitant procedures involving the other valves, 168 AVR cases were compared with 28 root replacements, and outcomes were reported at 30 days and 1 year.Among 196 patients (mean age, 73.5 ± 9.9 years) who had primary aortic valve intervention at TAVR explant, the median time from TAVR to surgical explant was 11.2 months (interquartile range, 4.4-32.9 months). Indications for explant were similar between the 2 groups. Compared with AVR, patients requiring root replacement had fewer comorbidities but more unfavorable anatomy for redo TAVR (52.6% vs 26.4%; P = .032), fewer urgent/emergency cases (32.1% vs 58.3%; P = .013), longer median interval from index TAVR to TAVR explant (17.6 vs 9.9 months; P = .047), and more concomitant ascending aortic replacement (58.8% vs 14.0%; P .001). Median follow-up was 6.9 months (interquartile range, 1.4-21.6 months) after TAVR explant and 97.4% complete. Overall survival at follow-up was 81.2% with no differences between groups (log rank P = .54). In-hospital, 30-day, and 1-year mortality rates and stroke rates were not different between the 2 groups.In the EXPLANT-TAVR Registry, AVR and root replacement groups had different clinical characteristics, but no differences in short-term mortality and morbidities. Further investigations are necessary to identify patients at risk of root replacement in TAVR explant.