Impact of transcatheter aortic valve implantation on circulating von Willebrand factor in patients with severe aortic stenosis.

INTRODUCTION: Severe aortic stenosis (AS) can lead to degradation of high molecular weight (HMW) von Willebrand factor (VWF) which can result in haemostatic abnormalities. While studies have explored changes in VWF profiles before and after surgical aortic valve replacement (SAVR), the longer-term changes in VWF profiles pre- and post-transcatheter aortic valve implantation (TAVI) are less understood. AIM: Our primary objective was to identify differences in VWF multimer profiles and VWF function pre-TAVI and 1-month post-TAVI. Our secondary objective was to correlate VWF markers with measures of AS severity. METHODS: Adult patients with severe AS referred for TAVI at our institution were prospectively enrolled in this cohort study. Blood samples were collected for plasma analysis at three time points for all patients: 1 day pre-TAVI, 3 days post-TAVI, and 1-month post-TAVI. VWF antigen, activity, propeptide, collagen binding, multimers, and factor VIII coagulant activity were determined at each time point. Correlations between VWF parameters and severity of AS were assessed. RESULTS: Twenty participants (15 males, five females) with severe AS were recruited for the study. There was a significant increase in HMW VWF between pre-procedure and 1-month post-TAVI (p < .05). There was a transient increase in VWF antigen levels and activity at 3-days post TAVI that decreased to pre-TAVI levels at 1-month. There were no statistically significant correlations between VWF markers and AS severity. CONCLUSIONS: This is the first study to elucidate longer-term (>1 week) improvements in HMW VWF after a TAVI procedure in severe AS patients.

Phosphodiesterase 1C integrates store-operated calcium entry and cAMP signaling in leading-edge protrusions of migrating human arterial myocytes.

In addition to maintaining cellular ER Ca2+ stores, store-operated Ca2+ entry (SOCE) regulates several Ca2+-sensitive cellular enzymes, including certain adenylyl cyclases (ADCYs), enzymes that synthesize the secondary messenger cyclic AMP (cAMP). Ca2+, acting with calmodulin, can also increase the activity of PDE1-family phosphodiesterases (PDEs), which cleave the phosphodiester bond of cAMP. Surprisingly, SOCE-regulated cAMP signaling has not been studied in cells expressing both Ca2+-sensitive enzymes. Here, we report that depletion of ER Ca2+ activates PDE1C in human arterial smooth muscle cells (HASMCs). Inhibiting the activation of PDE1C reduced the magnitude of both SOCE and subsequent Ca2+/calmodulin-mediated activation of ADCY8 in these cells. Because inhibiting or silencing Ca2+-insensitive PDEs had no such effects, these data identify PDE1C-mediated hydrolysis of cAMP as a novel and important link between SOCE and its activation of ADCY8. Functionally, we showed that PDE1C regulated the formation of leading-edge protrusions in HASMCs, a critical early event in cell migration. Indeed, we found that PDE1C populated the tips of newly forming leading-edge protrusions in polarized HASMCs, and co-localized with ADCY8, the Ca2+ release activated Ca2+ channel subunit, Orai1, the cAMP-effector, protein kinase A, and an A-kinase anchoring protein, AKAP79. Because this polarization could allow PDE1C to control cAMP signaling in a hyper-localized manner, we suggest that PDE1C-selective therapeutic agents could offer increased spatial specificity in HASMCs over agents that regulate cAMP globally in cells. Similarly, such agents could also prove useful in regulating crosstalk between Ca2+/cAMP signaling in other cells in which dysregulated migration contributes to human pathology, including certain cancers.

Euglycemic Diabetic Ketoacidosis Associated With Sodium-Glucose Cotransporter-2 Inhibitors After Cardiac Surgery: A Review of Current Literature.

There is growing evidence to support the use of sodium-glucose cotransporter-2 (SGLT2) inhibitors for type 2 diabetes mellitus (T2DM) and the management of heart failure. As such, more patients undergoing cardiac surgery are on SGLT2-inhibitor therapy. Despite the numerous benefits of SGLT2 inhibitors on cardiac health, they can be associated with an increased risk of diabetic ketoacidosis, often with normal glucose levels (euglycemic diabetic ketoacidosis or EDKA), which potentially can be detrimental in this vulnerable patient population. In this narrative review, the authors discuss 17 papers that described EDKA in perioperative cardiac surgical patients. The authors discuss suggested preventative measures and management options, with a particular emphasis on raising the clinical awareness of the care teams toward this complication. SGLT2 inhibitor-induced EDKA is a medical emergency that can be difficult to identify in the postcardiac surgical patient due to the overlap of signs and symptoms with other frequent scenarios in these patients. A reduction in SGLT2 inhibitor-associated EDKA can be mitigated by the appropriate perioperative discontinuation of the medication, clinical awareness, and early investigation to diagnose the condition, with emphasis on serum ß-hydroxybutyrate. Future quality improvement initiatives are needed to assist in reducing EDKA in patients taking SGLT2 inhibitors in the perioperative surgical setting.

The use of sutureless and rapid-deployment aortic valve prosthesis in patients with bicuspid aortic valve: A focused review.

OBJECTIVE: The objective of this scoping review is to describe the postoperative outcomes and complications of patients with bicuspid aortic valve (BAV) treated with sutureless or rapid-deployment prosthesis. BACKGROUND: The use of sutureless and rapid-deployment prostheses is generally avoided in patients with BAV due to anatomical concerns and the elevated risk of para-prosthetic leaks. Multiple studies have reported the use of these prostheses into patients with BAV with varying degrees of success. The focus of this review is to consolidate the current available evidence on this topic. METHODS: A scoping review was conducted using a comprehensive search strategy in multiple databases (Medline, Embase, Cochrane Central Register of Controlled Clinical Trials) for relevant articles. All abstracts and full texts were screened by two independent reviewers according to predefined inclusion and exclusion criteria. Thirteen articles, including case reports and case series were ultimately included for analysis. RESULTS: Of 1052 total citations, 44 underwent full text review and 13 (4 case reports, 6 retrospective analyses, and 3 prospective analyses) were included in the scoping review. Across all 13 studies, a total of 314 patients with BAV were used for data analysis. In sutureless and rapid-deployment prostheses, the mean postoperative aortic valvular gradients were less than 15 mmHg in all studies with mean postoperative aortic valvular areas all greater than 1.3 cm.2 There were 186 total complications for an overall complication rate of 59%. Individual complications included new onset atrial fibrillation (n = 65), required pacemaker insertion (n = 24), intraprosthetic aortic regurgitation (n = 20), new onset atrioventricular block (n = 18), and new onset paravalvular leakage (n = 10). CONCLUSIONS: The use of sutureless and rapid deployment prostheses in patients with BAV showed comparable intraoperative and implantation success rates to patients without BAV. Postoperative complications from using these prostheses in patients with BAV included new onset atrial fibrillation, intraprosthetic aortic regurgitation, new onset atrioventricular block, and required pacemaker insertion. Various techniques have been described to minimize these complications in patients with BAV receiving sutureless or rapid deployment prostheses.

Lung transplantation and concomitant cardiac surgical procedures: A systematic review and meta-analysis.

BACKGROUND: Lung transplantation is an effective treatment option for end-stage lung diseases. In some cases, these patients may also have underlying cardiac disease which may require surgical intervention before or during transplantation. Concomitant cardiac surgery may often be preferred, as reduced lung function precludes these patients from pre-transplant surgery. Our meta-analysis sought to examine the impact of lung transplantation paired with concomitant cardiac surgery on long-term mortality. METHODS: We conducted a systematic review of the MEDLINE, Embase, and Cochrane databases. Our primary outcome was overall mortality. Secondary outcomes included length of stay (LOS) in hospital and serious postoperative complication rates. We used a meta-analytic model to determine the differences in the above outcomes between patients who underwent lung transplantation with or without concomitant cardiac surgery. RESULTS: Out of the 1876 articles screened, 7 met our pre-determined inclusion criteria. Lung transplantation with concomitant cardiac surgery was not associated with increased mortality compared to lung transplantation alone (hazard ratio = 1.02; 95% confidence interval [CI] = 0.80-1.31; I2 = 0%; p = .99). LOS in hospital was not significantly different between groups (standardized mean difference = 0.32; 95% CI = -0.91 to 1.55). Postoperative complication rates were also reported but not analyzed due to missing data. CONCLUSIONS: There was no significant difference in mortality rates in patients undergoing lung transplantation with or without concomitant cardiac surgery at 1, 3, and 5 years. However, postoperative complication rates were higher in the concomitant group. The decision to perform concomitant procedures should be tailored to each patient's clinical condition.

Erector spinae plane block as perioperative analgesia for midline sternotomy in cardiac surgery: A systematic review and meta-analysis.

BACKGROUND: Inadequate analgesia following cardiac surgery increases postoperative complications. Opioid-based analgesia is associated with side effects that may compromise postoperative recovery. Regional anesthetic techniques provide an alternative thereby reducing opioid requirements and potentially enhancing postoperative recovery. The erector spinae plane block has been used in multiple surgical procedures including sternotomy for cardiac surgery. We, therefore, aimed to characterize the impact of this block on post-sternotomy pain and recovery in cardiac surgery patients. METHODS: We conducted an electronic search for studies reporting on the use of the erector spinae plane block in adult cardiac surgery via midline sternotomy. Randomized controlled trials, cohort studies, and case-control studies were considered for inclusion. Outcomes of interest included postoperative pain, time-to-extubation, and intensive care unit length of stay. RESULTS: In total, 498 citations were identified and five were included in the meta-analysis. The erector spinae plane block did not significantly reduce self-reported postoperative pain scores at 4 h (-2.04; 95% confidence interval [CI] -8.15 to 4.07; p = .29) or 12 h (-0.27; 95% CI -2.48 to 1.94; p = .65) postextubation, intraoperative opioid requirements (-3.07; 95% CI -6.25 to 0.11; p = .05], time-to-extubation (-1.17; 95% CI -2.81 to 0.46; p = .12), or intensive care unit (ICU) length of stay (-4.51; 95% CI -14.23 to 5.22; p = .24). CONCLUSIONS: Erector spinae plane block was not associated with significant reduction in postoperative pain, intraoperative opioid requirements, time-to-extubation, and ICU length of stay in patients undergoing cardiac surgery. The paucity of large randomized controlled trials and the high heterogeneity among studies suggest that further studies are required to assess its effectiveness in cardiac surgery patients.

Median sternotomy pain after cardiac surgery: To block, or not? A systematic review and meta-analysis.

BACKGROUND: Inadequate pain control after median sternotomy leads to reduced mobilization, increased respiratory complications, and longer hospital stays. Typically, postoperative pain is controlled by opioid analgesics that may have several adverse effects. Parasternal intercostal block (PSB) has emerged as part of a multimodal strategy to control pain after median sternotomy. However, the effectiveness of this intervention on postoperative pain control and analgesic use has not been fully established. METHODS AND RESULTS: We conducted a meta-analysis to assess the effect of PSB on postoperative pain and analgesic use in adult cardiac surgery patients undergoing median sternotomy. PubMed, Embase, Google Scholar, and the Cochrane database were searched with the following search strategy: ([postoperative pain] or [pain relief] OR [analgesics] or [analgesia] or [nerve block] or [regional block] or [local block] or [regional anesthesia] or [local anesthetic] or [parasternal block] and [sternotomy]) and (humans [filter]). Inclusion criteria were: patients who underwent cardiac surgery via median sternotomy, age >18 and parasternal block (continuous and single dose). Exclusion criteria were: noncardiac surgery, nonparasternal nerve blocks, and the use of NSAIDS in parasternal block. Quality assessment was performed by three independent reviewers via the Cochrane risk of bias assessment tool. Of 1165 total citations, 18 were found to be relevant. Of these 18 citations, 7 citations (N = 2223 patients) reported postoperative pain scores in an extractable format and 11 citations (N = 2155 patients) reported postoperative opioid use in an extractable format. For postoperative opioid use, morphine equivalent doses were calculated for all studies and postoperative pain scores were standardized to a 10-point visual analog scale for comparison between studies; both these were reported as total opioid use or cumulative score ranging from 24 to 72 h postoperative. All data analyses were run using a random effects model, using a restricted maximum likelihood estimator, to obtain summary standardized mean differences with 95% confidence interval (CI's). For studies which only reported median and interquatile range (IQR), the median was standard deviation was estimated by IQR/1.35. Following median sternotomy both postoperative pain (SMD [95% CI] -0.49 [-0.92 to -0.06]) and postoperative morphine equivalent use (SMD [95% CI] -1.68 [-3.11 to -0.25]) were significantly less in the PSB group. CONCLUSION: Our meta-analysis suggests that parasternal nerve block significantly reduces postoperative pain and opioid use.

Predicting adverse cardiovascular outcomes in post-coronary artery bypass grafting patients using novel ECG frequency analysis of the QRS complex.

BACKGROUND: A novel metric called Layered Symbolic Decomposition frequency (LSDf) has been shown to be an independent predictor of ventricular arrhythmia and mortality in patients receiving implantable cardioverter-defibrillator (ICD) devices. This novel index studies the fragmentation of the QRS complex. However, its generalizability to predict cardiovascular events for other cardiac procedures is unknown. Herein, we investigated the applicability of LSDf as a predictive measure for major adverse cardiovascular events (MACE) in patients receiving coronary artery bypass grafting (CABG). METHODS AND RESULTS: One hundred ninety-five patients had high-resolution ECG recorded prior to CABG surgery in 2012/2013 and were followed for a mean duration of 7.32 ± 0.32 years for postoperative cardiovascular outcomes. These outcomes were described as a modified composite of MACE defined as hospitalization for heart failure, ventricular tachycardia, ventricular fibrillation, and cardiovascular death including stroke and cardiac arrest. One hundred seventy-two patients were included for analysis and 18 patients experienced a postoperative cardiovascular outcome. These patients had significantly increased age (71.3 vs. 64.6 years, p = .007), prolonged QRS duration (113.22 vs. 97.35 ms, p = .003), reduced left ventricular ejection fraction (42.7% vs. 56.5%, p < .001), and lower LSDf percent (13.5% vs. 16.9%, p = .002). Patients with an LSDf below 13.25% were 4.8 (OR 1.7-13.5, p < .001) times more likely to experience a MACE and up to 19.4 (OR 4.2-90.3, p < .001) times more likely to experience a MACE when older than 70 years and an ejection fraction below 50%. CONCLUSION: Layered Symbolic Decomposition frequency may be an applicable metric to predict long-term cardiovascular outcomes in patients with ischemic heart disease.

Sex-Related Differences in Patients Undergoing Thoracic Aortic Surgery.

BACKGROUND: Contemporary outcomes after surgical management of thoracic aortic disease have improved; however, the impact of sex-related differences is poorly understood. METHODS: A total of 1653 patients (498 [30.1%] female) underwent thoracic aortic surgery with hypothermic circulatory arrest between 2002 and 2017 in 10 institutions of the Canadian Thoracic Aortic Collaborative. Outcomes of interest were in-hospital death, stroke, and a modified Society of Thoracic Surgeons-defined composite for mortality or major morbidity (stroke, renal failure, deep sternal wound infection, reoperation, prolonged ventilation). Multivariable logistic regression was used to determine independent predictors of these outcomes. RESULTS: Women were older (mean±SD, 66±13 years versus 61±13 years; P<0.001), with more hypertension and renal failure, but had less coronary disease, less previous cardiac surgery, and higher ejection fraction than men. Rates of aortic dissection were similar between women and men. Rates of hemiarch, and total arch repair were similar between the sexes; however, women underwent less aortic root reconstruction including aortic root replacement, Ross, or valve-sparing root operations (29% versus 45%; P<0.001). Men experienced longer cross-clamp and cardiopulmonary bypass times, but similar durations of circulatory arrest, methods of cerebral perfusion, and nadir temperatures. Women experienced a higher rate of mortality (11% versus 7.4%; P=0.02), stroke (8.8% versus 5.5%; P=0.01), and Society of Thoracic Surgeons-defined composite end point for mortality or major morbidity (31% versus 27%; P=0.04). On multivariable analyses, female sex was an independent predictor of mortality (odds ratio, 1.81; P<0.001), stroke (odds ratio, 1.90; P<0.001), and Society of Thoracic Surgeons-defined composite end point for mortality or major morbidity (odds ratio, 1.40; P<0.001). CONCLUSIONS: Women experience worse outcomes after thoracic aortic surgery with hypothermic circulatory arrest. Further investigation is required to better delineate which measures may reduce sex-related outcome differences after complex aortic surgery.

Quantified pre-operative neurological dysfunction predicts outcome after coronary artery bypass surgery.

AIMS: Patients undergoing coronary artery bypass grafting (CABG) surgery may experience neurological impairment. We examined whether intraoperative regional cerebral oxygen saturation (rSO2) and neurological dysfunction prior to surgery, measured by robotic technology, are important predictors of post-operative performance following CABG surgery. METHODS: Adult patients undergoing CABG surgery were recruited for this single-center prospective observational study. Intraoperative rSO2 was captured using the FORESIGHT cerebral oximeter. Neurological assessment was performed pre-operatively and 3 months following surgery using robotic technology and a standardized pen-and-paper assessment. Linear regression models were generated to determine the predictive ability of both intraoperative rSO2 and pre-operative performance on post-operative neurological outcome. RESULTS: Forty patients had complete data available for analysis. Quantified pre-operative performance accounted for a significantly larger amount of variance in post-operative outcome compared to intraoperative rSO2. In particular, pre-operative scoring on a cognitive visuospatial task accounted for 82.2% of variance in post-operative performance (b = 0.937, t(37) = 12.98, p = 1.28e-5). DISCUSSION: Our results suggest that pre-operative performance is a stronger indicator of post-operative neurological outcome than intraoperative rSO2, and should be included as an important variable when elucidating the relationship between cerebral oxygen levels and post-operative neurological impairment. Rigorous neurological assessment prior to surgery can provide valuable information about each individual patient's path to recovery. CONCLUSION: Using robotic technology, quantified neurological impairment prior to CABG surgery may better predict post-operative neurological outcomes, compared to intraoperative rSO2 values.

Aortic valve rupture during isometric muscle contraction.

Aortic valve rupture has been previously reported in association with blunt chest trauma as well as spontaneously in the setting of abnormal valves. We present a case of a patient who required emergent aortic valve replacement following rupture of his aortic valve during an isometric muscle contraction.

Huge Morgagni Hernia, a Rare Criterion to Favor TAVI Against SAVR.

Transcatheter aortic valve implantation is now a validated treatment option for severe aortic stenosis in patients in whom surgical aortic valve replacement is recommended, especially those associated with an elevated surgical risk. Here, we discuss the surgical management of a case of severe aortic stenosis in a patient with huge Morgagni hernia. (Level of Difficulty: Beginner.).

Retraction speed and chronic poststernotomy pain: A randomized controlled trial.

OBJECTIVES: Approximately 30% of patients develop chronic poststernotomy pain (CPSP) following cardiac surgery with sternal retraction. Risk factors have been described but no causal determinants identified. Investigators hypothesized that opening the sternum slowly would impart less force (and thereby less nerve/tissue damage) and translate to a reduced incidence of CPSP. The main objectives were to determine whether or not slower sternal retraction would reduce the incidence of CPSP and improve health-related quality of life. METHODS: Patients undergoing coronary artery bypass graft surgery were recruited to this randomized controlled trial. Patients were randomized to slow or standard retraction (ie, sternum opened over 15 minutes vs 30 seconds, respectively). Although the anesthesiologist and surgeon were aware of the randomization, the patients, assessors, and postoperative nursing staff remained blinded. Sternotomy pain and analgesics were measured in hospital. At 3, 6, and 12 months postoperatively, all patients completed the Medical Outcomes Survey Short Form and reported on CPSP and complications requiring rehospitalization. Thirty-day rehospitalizations and mortality were recorded. RESULTS: In total, 326 patients consented to participate and 313 were randomized to slow (n = 159) versus standard retraction (n = 154). No clinically relevant differences were detected in acute pain, analgesic consumption, or the incidence of CPSP or health-related quality of life. Although the slow group had significantly more hospitalizations at 3 and 12 months postoperatively, the reasons were unrelated to retraction speed. No differences were observed in 30-day rehospitalizations or mortality. CONCLUSIONS: All outcomes were consistent with previous reports, but no clinically significant differences were observed with retraction speed.

Prominent septal hypertrophy: a contra-indication for transapical aortic valve implantation?

We report a case of transapical aortic valve implantation in a patient with severe left ventricular hypertrophy. The valve was deployed but failed to attain stable seating because of a hypertrophied septal ridge encroaching on the landing zone. Moderate perivalvar insufficiency was also noted. A second valve was deployed in an attempt to achieve stable seating and correct the perivalvar leak. This was unsuccessful and the two-valve complex embolized into the ascending aorta. The valves were moved and seated in the proximal descending thoracic aorta. The technical issues of transapical aortic valve implantation in patients with severe left ventricular hypertrophy are reviewed.

Long-term impact of permanent cardiac pacing after surgical aortic valve replacement: systematic review and meta-analysis.

OBJECTIVES: Permanent pacemaker (PPM) implantation after surgical aortic valve (SAVR) is associated with short- and long-term complications. However, the impact of PPM implantation on long-term mortality has not been fully established. The aim of this meta-analysis was to determine whether PPM post-SAVR increases the risk of mortality. METHODS: We searched Cochrane, MEDLINE, and EMBASE from inception to December 2020 for studies comparing mortality between patients who received PPM post-SAVR and those who did not. Random effects meta-analysis was performed to determine the effect of PPM on early and late mortality. The effect sizes were reported as hazard ratio (HR) with 95% confidence intervals. RESULTS: Three studies met criteria, which yielded a total of 9,105 patients. The most common indication was post-operative complete atrioventricular block. While there was no difference in early mortality between the PPM and no PPM groups (RR 1.19; 95%CI 0.20-7.08; I2 = 23%), PPM implantation was shown to significantly increase late mortality (RR 1.49; 95%CI 1.25-1.77; I2 = 0%). CONCLUSION: The need for permanent pacemaker after surgically isolated aortic valve replacement is associated with increased risk of long-term mortality. This warrants further exploration on the effect of PPM on long-term mortality in patients receiving sutureless prostheses or transcatheter aortic valve implants.AbbreviationsPPM Permanent PacemakerSAVR Surgical Aortic Valve Replacement.

Does Pacemaker Implantation After Surgical Aortic Valve Replacement Impact Long-Term Morbidity and Mortality? A Focused Review.

Permanent pacing remains a serious complication that can occur in the postoperative period of surgical aortic valve replacement. The reported incidence is variable, and there are many perioperative factors that have been linked with a greater need for permanent pacing. Permanent pacing can also be associated with late lead-related and cardiac complications that can affect late outcome. However, the degree of late dependence on pacemakers is varied, and some studies have shown that a substantial proportion of patients do not need long-term pacing. Some groups have found that permanent pacing was associated with a negative impact on long-term survival in these patients. A common finding among these studies is that the groups of patients with pacemakers had higher preoperative surgical risk and comorbidity status. This makes it difficult to establish whether permanent pacing on its own represents a risk factor for late mortality or whether it is simply a marker that reflects the higher complexity and comorbidities in this group of patients.

Galectin-3 as a Predictor of Post Cardiac Surgery Atrial Fibrillation: A Scoping Review.

Galectin-3 is associated with myocardial fibrosis, a known risk factor for developing re-entrant circuits associated with atrial fibrillation (AF). Previous studies have demonstrated increased galectin levels in AF patients. Whether preoperative galectin-3 levels can predict the incidence of postoperative atrial fibrillation (POAF) remains unknown.This scoping review was conducted in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Electronic searches were conducted in Medline, EMBASE, Cochrane, and Google Scholar databases using a predetermined strategy. Methodological variables, demographics and operative data were extracted. Data extraction was performed manually by 3 reviewers.The search yielded 620 citations, of which 74 underwent full text review, and 3 citations with 3 independent samples (n=1812) met full inclusion/exclusion criteria and were included. Of the 3 studies that reported on the association between preoperative galectin-3 levels and POAF, 2 studies compared median galectin levels in patients who developed POAF and those who did not. While Alexandre et al. reported a significant difference (P=0.002), Bening et al did not find a significant difference between POAF and non-POAF groups (P=0.3). A third study reporting on the association between galectin-3 and atrial fibrillation comparing third and first tercile galectin-3 levels found a significant association between preoperative galectin levels and POAF on univariate analysis (OR 1.54; 95% CI 1.14-2.09).Galectin-3 is an emerging biomarker that has been associated with the development of AF. However, there is currently not enough evidence to establish its prognostic role in postcardiac surgery atrial fibrillation.

The use of FEIBA for refractory bleeding in cardiac surgery - a systematic review.

INTRODUCTION: Significant blood loss during cardiac surgery is associated with a dramatic increase in morbidity and mortality. Factor Eight Inhibitor Bypassing Activity (FEIBA), a hemostatic bypassing agent mainly used in hemophiliac patients, has also been used for intractable bleeding during cardiac surgical procedures in non-hemophiliac patients. However, concerns exist that its use may be linked to increased incidence of perioperative adverse effects including thrombotic complications. AREAS COVERED: A systematic literature search was performed on MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases for all studies that reported the administration of FEIBA for treatment of bleeding during adult cardiac surgery in non-hemophiliac patients. After selecting the title and abstracts, two authors assessed the methodological quality of the full-text articles prior to final inclusion in the manuscript. EXPERT OPINION: The safety profile of FEIBA was determined through an aggregate count of adverse events. Major complications included renal failure, re-operation for unresolved bleeding, postoperative mortality, and thromboembolic events. Overall, there is insufficient robust evidence to make a definitive conclusion about the safety or efficacy of using of FEIBA as a hemostatic agent in the setting of cardiac surgery.

Is It Feasible to Implant Sutureless Valves in Presence of Diseased Aortic Root and Aortic Aneurysm?

Sutureless bioprosthetic valves are typically used in patients with a normal-sized aortic root and annulus because of concerns that the stent portion of the valve will not be properly anchored. This report describes an initial case series of sutureless valve implantation in the setting of a diseased aortic root and ascending aortic aneurysm, and it shows that the use of the Perceval valve (LivaNova PLC, London, UK) is feasible in these complex situations.

CABG in patients with liver cirrhosis: to pump or not to pump?

INTRODUCTION: Coronary artery bypass grafting in patients with established liver cirrhosis is generally associated with poor outcomes. Avoiding cardiopulmonary bypass (CPB) in these patients has not demonstrated any advantage over the use of CPB. We review the current available literature that compared the outcome of both on-pump (ONCABG) and off-pump (OPCAB) techniques in cirrhotic patients in terms of morbidity and mortality. AREAS COVERED: A comprehensive search was conducted in the PubMed/MEDLINE and EMBASE databases in January 2021. Articles that reported outcomes of OPCAB and/or ONCABG in cirrhotic patients with no concomitant surgical procedures were included. 829 unique abstracts were retrieved with title and abstract screening completed independently by two reviewers. Two case studies and six retrospective cohort studies were included. The largest study comprised more than 98% of the total population, showing some survival benefit for OPCAB over ONCABG. However, it was population-based and did not report the severity of liver. The remaining studies reported no clear difference in outcome between the two techniques. EXPERT OPINION: Surgical myocardial revascularisation carries high perioperative risk in patients with liver cirrhosis irrespective of the surgical technique. There is a lack of evidence to suggest that avoiding CPB in these patients may be beneficial.