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Objective: To determine the feasibility of original aortic valve reconstruction, 404 consecutive cases were reviewed.
The early results are reported here.
Methods: Aortic valve reconstruction was performed for 404 patients from April 2007 through September 2011.
The results for all 404 patients were reviewed retrospectively. There were 289 patients with aortic stenosis and
115 patients with aortic regurgitation. One hundred two patients had bicuspid aortic valves, 13 patients had unicuspid
valves, and 2 patients had quadricuspid valves. There were 201 males and 203 females. Mean age was
69.0
12.9 years. Preoperative echocardiography revealed an average peak pressure gradient of 79.6
32.5
mm Hg with aortic stenosis. Surgical annular diameter was 20.3
3.2 mm. The surgical procedure is based
on the independent tricuspid replacement by autologous pericardium. First, the distance between the commissure
is measured with an original sizing apparatus, then the pericardial cusp is trimmed using an original template,
and it is sutured to the annulus.
Results: There were no conversions to prosthetic valve replacement. There were 7 in-hospital mortalities resulting
from a noncardiac cause. Postoperative echocardiography revealed an average peak pressure gradient of
19.8
10.2 mm Hg 1 week after surgery and 13.8
3.7 mm Hg 3.5 years after surgery. Two patients needed
reoperation because of infective endocarditis. The other 402 patients showed less than mild aortic regurgitation.
No thromboembolic events were recorded. The mean follow-up period was 23.7
13.1 months. Freedom from
reoperation was 96.2% at 53 months of follow-up.
Conclusions: Original aortic valve reconstruction was feasible in patients with various aortic valve diseases.
Long-term data will be disclosed in the future. (J Thorac Cardiovasc Surg 2014;147:301-6)

Objectives: Optimal medical therapy in patients with heart failure and coronary
artery disease is associated with improved outcomes. However, whether this association
is influenced by the performance of coronary artery bypass grafting is less
well established. Thus, the aim of this study was to determine the possible relationship
between coronary artery bypass grafting and optimal medical therapy and its
effect on the outcomes of patients with ischemic cardiomyopathy.
Methods: The Surgical Treatment for Ischemic Heart Failure trial randomized 1212
patients with coronary artery disease and left ventricular ejection fraction 35% or
less to coronary artery bypass grafting with medical therapy or medical therapy
alone with a median follow-up over 9.8 years. For the purpose of this study, optimal
medical therapy was collected at baseline and 4 months, and defined as the combination of 4 drugs: angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, beta-blocker, statin, and 1 antiplatelet drug.
Results: At baseline and 4 months, 58.7% and 73.3% of patients were receiving
optimal medical therapy, respectively. These patients had no differences in important parameters such as left ventricular ejection fraction and left ventricular volumes. In a multivariable Cox model, optimal medical therapy at baseline was
associated with a lower all-cause mortality (hazard ratio, 0.78; 95% confidence interval, 0.66-0.91; P¼ .001). When landmarked at 4months, optimal medical therapy was also associated with a lower all-cause mortality (hazard ratio, 0.82; 95%confidence interval, 0.62-0.99; P ¼ .04). There was no interaction between the benefit of optimal medical therapy and treatment allocation.
Conclusions: Optimal medical therapy was associated with improved long-term
survival and lower cardiovascular mortality in patients with ischemic cardiomyopathy and should be strongly recommended. (J Thorac Cardiovasc Surg 2021;-:1-10)

Pedro S. Farsky, MD,a Jennifer White, MS,b Hussein R. Al-Khalidi, PhD,b Carla A. Sueta, MD, PhD,c
Jean L. Rouleau, MD,d Julio A. Panza, MD,e Eric J. Velazquez, MD,f and Christopher M. O’Connor, MD,g
on behalf of the Working Group and Surgical Treatment for IsChemic Heart failure Trial Investigators

Abstract: Heparin-induced thrombocytopenia (HIT) is a major issue in cardiac surgery requiring cardiopulmonary bypass (CPB). HIT represents a severe adverse drug reaction after heparin administration.
It consists of immune-mediated thrombocytopenia paradoxically leading to thrombotic events. Detection of antibodies against platelets factor 4/heparin (anti-PF4/H) and aggregation of platelets in the presence of heparin in functional in vitro tests confirm the diagnosis. Patients suffering from HIT and requiring cardiac surgery are at high risk of lethal complications and present specific challenges. Four distinct phases are described in the usual HIT timeline, and the anticoagulation strategy chosen for CPB depends on the phase in which the patient is categorized. In this sense, we developed an institutional protocol covering each phase. It consisted of the use of a non-heparin anticoagulant such as bivalirudin, or the association of unfractionated heparin (UFH) with a potent antiplatelet drug such as tirofiban or cangrelor. Temporary reduction of anti-PF4 with intravenous immunoglobulins (IvIg) has recently been described as a complementary strategy. In this article, we briefly described the pathophysiology of HIT and focused on the various strategies that can be
applied to safely manage CPB in these patients.

Citation: Revelly, E.; Scala, E.; Rosner,
L.; Rancati, V.; Gunga, Z.; Kirsch, M.;
Ltaief, Z.; Rusca, M.; Bechtold, X.;
Alberio, L.; et al. How to Solve the
Conundrum of Heparin-Induced
Thrombocytopenia during
Cardiopulmonary Bypass. J. Clin.
Med. 2023, 12, 786. https://doi.org/
10.3390/jcm12030786

BACKGROUND Positive T wave in lead aVR (TaVR) has been associated
with increased risk of adverse events in patients with various
cardiovascular diseases.
OBJECTIVE The purpose of this study was to investigate the prevalence
and prognostic significance of positive TaVR in patients with
hypertrophic cardiomyopathy (HCM).
METHODS This study investigated 421 consecutive patients with
HCM (177 women; age 51.1614.9 years). Admission electrocardiogram
was examined for the presence of a positive TaVR. The primary
endpoint was defined as a composite of major arrhythmic events
(MAEs), which included sudden cardiac death, sustained ventricular
tachycardia or fibrillation, or appropriate implantable cardioverter–
defibrillator therapy. Cardiovascular mortality and all-cause death
were evaluated as secondary endpoints.
RESULTS During median follow-up period of 6.0 years (interquartile
range 4.0–11.6 years), 53 patients (12.6%) experienced the
primary endpoint. On multivariable competing analysis, after adjusting
for other confounding factors, the presence of positive
TaVR was found to be an independent and strong predictor of the
primary composite endpoint. Time-dependent receiver operating
characteristic analysis, net reclassification index, and integrated
discrimination improvement showed that the addition of positive
TaVR to conventional HCM risk factors improved prediction of
arrhythmic events. However, in subgroup analysis, a positive TaVR
lost statistical significance in patients with apical HCM but remained
significant in patients with all other hypertrophy patterns.
CONCLUSION Positive TaVR is associated with MAE in HCM patients,
independent of and incremental to traditional risk factors.

Abstract:
In critically ill patients, fluid infusion is aimed at increasing cardiac output and tissue perfusion. However, it may contribute
to fluid overload which may be harmful. Thus, volume status, risks and potential efficacy of fluid administration
and/or removal should be carefully evaluated, and monitoring techniques help for this purpose. Central venous
pressure is a marker of right ventricular preload. Very low values indicate hypovolemia, while extremely high values
suggest fluid harmfulness. The pulmonary artery catheter enables a comprehensive assessment of the hemodynamic
profile and is particularly useful for indicating the risk of pulmonary oedema through the pulmonary artery occlusion
pressure. Besides cardiac output and preload, transpulmonary thermodilution measures extravascular lung water,
which reflects the extent of lung flooding and assesses the risk of fluid infusion. Echocardiography estimates the
volume status through intravascular volumes and pressures. Finally, lung ultrasound estimates lung edema. Guided by
these variables, the decision to infuse fluid should first consider specific triggers, such as signs of tissue hypoperfusion.
Second, benefits and risks of fluid infusion should be weighted. Thereafter, fluid responsiveness should be assessed.
Monitoring techniques help for this purpose, especially by providing real time and precise measurements of cardiac
output. When decided, fluid resuscitation should be performed through fluid challenges, the effects of which should
be assessed through critical endpoints including cardiac output. This comprehensive evaluation of the risk, benefits
and efficacy of fluid infusion helps to individualize fluid management, which should be preferred over a fixed restrictive
or liberal strategy.

Background. The study sought to identify the optimal
aortic root replacement (ARR) strategy for pediatric patients,
and a single-center experience was analyzed.
Methods. Retrospective review of patients undergoing
ARR from 1995 to 2018 was performed. Patients were
stratified by surgical strategy (pulmonary autograft [Ross
procedure], aortic homograft, mechanical valve conduit
[Bentall procedure], or porcine xenograft [Freestyle bioprosthesis])
and aortic annulus size.
Results. ARR was performed in 206 patients with a
median follow-up of 5.0 (interquartile range, 1.4-11.4)
years. Root replacements included Ross procedure (n [
98), homograft (n [ 83), Bentall procedure (n [ 18), and
Freestyle bioprosthesis (n[7). Overall survival was 92%,
and freedom from reoperation or death was 81%.
Reoperation-free survival was superior in the Ross group
when compared with other groups. Because surgical options
differ based on the size of the aortic annulus, the
analysis was arbitrarily stratified. When the aortic
annulus diameter was greater than 19 mm (n [ 74),
procedures included Ross procedure (n [ 23), homograft
(n [ 29), Bentall procedure (n [ 17), and Freestyle bioprosthesis
(n [ 5). Reoperation-free survival at median
follow-up (5 years) was 86%, 58%, 100%, and 100%,
respectively. The Bentall procedure offered the longest
freedom from reoperation. In the subset with aortic
annulus diameter less than 19 mm and a pulmonary valve
suitable for a Ross procedure, patients underwent the
Ross procedure (n [ 75) or homograft ARR (n [ 36). At
median follow-up (3.8 years), reoperation-free survival
was longer after the Ross procedure than after homograft
ARR (88% vs 46%; P < .001).
Conclusions. In patients with a large aortic annulus, a
Bentall ARR offers the longest reoperation-free survival.
For patients with small aortic roots, a Ross procedure
provides better a reoperation-free survival than does
homograft ARR.
(Ann Thorac Surg 2020;110:189-97)

2020 by The Society of Thoracic Surgeons

Ziyad M. Binsalamah, MD, Christopher Ibarra, MD, Zachary Spigel, MD,
Rodrigo Zea-Vera, MD, Jessica Zink, PA, Jeffrey S. Heinle, MD, and
Christopher A. Caldarone, MD
Division of Congenital Heart Surgery, Texas Children’s Hospital, Department of Surgery, Baylor College of Medicine, Houston, Texas

This keynote lecture and corresponding presentation discuss the anatomy and pathophysiology surrounding spinal cord injury in aortic surgery. This article will discuss risk factors and mechanisms for spinal cord injury, including loss of direct and collateral spinal cord perfusion and ischemia-reperfusion injury. This review will examine these elements in both the laboratory and clinical setting, in addition to other neuroprotective strategies applied in clinical practice. Addressing spinal cord injury requires an integrated and considerate approach to simultaneously optimize spinal cord blood flow, promote collateralization and improve ischemic tolerance. Given the catastrophic clinical consequences for both the patient and their caregivers, continuing to investigate and examine spinal cord injury is of the utmost importance.

Submitted Feb 14, 2023. Accepted for publication Mar 29, 2023. Published online May 15, 2023.
doi: 10.21037/acs-2023-scp-08
View this article at: https://dx.doi.org/10.21037/acs-2023-scp-08

Spinal cord deficit (SCD) is a feared complication after thoracoabdominal aortic aneurysm repair. Vigilant management throughout the perioperative period is necessary to reduce the risk of SCD. Measures for preventing SCD during the intraoperative period include preoperative optimization and recognizing patients at a higher risk of SCD. In this manuscript, we discuss intraoperative adjuncts including utilization of cerebrospinal fluid drainage, left heart bypass, mild hypothermia, selective reimplantation of intercostal and lumbar arteries, and renal and visceral vessel perfusion. From the operative to the postoperative period, careful attention to avoiding hypotension and anemia is important. If SCD is recognized early, therapeutic intervention may be implemented to mitigate injury.

Submitted Feb 14, 2023. Accepted for publication Mar 29, 2023. Published online May 04, 2023.
doi: 10.21037/acs-2023-scp-10
View this article at: https://dx.doi.org/10.21037/acs-2023-scp-10

A b s t r a c t
Introduction: Transcatheter aortic valve implantation (TAVI) is an alternative
to surgical aortic valve replacement (SAVR) in patients with increased
comorbidity. Lead aVR in surface ECG has valuable information about prediction
of mortality in many cardiovascular diseases. Our aim was to determine
the relationship between ischemic changes in lead aVR and mortality in TAVI
patients.
Material and methods: We retrospectively examined 86 patients with TAVI.
The ST segment deviation in lead aVR (STaVR) and T wave polarity (TPaVR)
on surface ECG were measured. The absolute values of TPaVR and STaVR
were calculated. A ratio (TP/STaVR or vice versa) was obtained from the
division of the larger absolute value by the smaller one.
Results: The patients were divided into two groups as living and deceased.
The living group had 68 patients, and the deceased group had 18 patients.
The number of positive TPaVR patients after TAVI, TPaVR after TAVI, and TP/
STaVR ratio after TAVI were significantly higher in the deceased group. The
deceased group had a significantly shorter aortic annulus-LMCA distance.
Presence of positive TPaVR (OR = 8.765, 95% CI: 1.088–70.618, p = 0.041),
aortic annulus-LMCA distance (for each 1 mm increase, OR = 0.306,
95% CI: 0.158–0.595, p < 0.001) and TP/STaVR ratio (for each 0.1 increase,
OR = 1.966, 95% CI: 1.276–3.024, p = 0.002) were determined as independent
predictors for mortality.
Conclusions: Ischemic changes in lead aVR may provide valuable information
about mortality after TAVI.

Abstract
Background: Myocardial bridging (MB) is commonly treated in patients with hypertrophic cardiomyopathy. However, whether and how MB should be treated in patients with hypertrophic obstructive cardiomyopathy (HOCM) who underwent septal myectomy remain unclear.
Methods: A total of 823 adults with HOCM who underwent septal myectomy at the Fuwai Hospital from 2011 to 2017 were retrospectively studied.
Results: Overall, 31 events occurred: 24 patients died and 7 had nonfatal myocardial infarction (MI). The 3‐year cumulative event‐free survival of all‐cause death
(97.9% vs. 100% vs. 100% vs. 98.4%, p = .89) and cardiovascular death (98.3% vs. 100% vs. 100% vs. 98.4%, p = .63) were similar among the four groups (non MB,
coronary artery bypass grafting [CABG], unroofing, untreated, respectively).
However, the 3‐year cumulative event‐free survival of nonfatal MI (100% vs. 97.5% vs. 98.0% vs. 89.9%, p < .001) and combined endpoints (97.9% vs. 97.5% vs. 98.0% vs. 88.4%, p = .02) were significantly lowest in untreated MB (non‐MB, CABG,
unroofing, untreated, respectively). Cox regression analysis indicated that untreated MB was a significant independent predictor of combined endpoints (hazard ratio: 4.06, 95% confidence interval: 1.60–10.32, p < .001). Moreover, 49 patients underwent coronary artery computed tomography 1 year after surgery. The patency
rate of the saphenous vein graft was significantly higher than that of the left internal mammary artery (13.3% vs. 84.2%, p < .001). No MB was detected in the unroofing
group.
Conclusions: Surgical MB treatment could be beneficial and performed safely during septal myectomy. Myocardial unroofing is the recommended treatment for MB, and unroofing when technically possible may be preferable for long‐term outcomes