Sutureless Biological Aortic Valve Replacement (Su-AVR) in Redo operations: a retrospective real-world experience report of clinical and echocardiographic outcomes.

OBJECTIVE: This retrospective study aimed to compare the outcomes of sutureless aortic valve replacement (su-AVR) and conventional bioprosthetic sutured AVR (cAVR) in high-risk patients undergoing redo surgery. METHODS: A total of 79 patients who underwent redo AVR between 2014 and 2021 were included in the study. Of these, 27 patients underwent su-AVR and 52 underwent cAVR. Patient characteristics and clinical outcomes were analysed using multivariate regression and Kaplan Meier survival test. RESULTS: The groups were similar in terms of age, gender, left ventricular function, and number of previous sternotomies. In cases of isolated AVR, su-AVR had significantly lower cross clamp times than cAVR (71 vs. 86 min, p = 0.03). Postoperatively, 4 cAVR patients required pacemaker compared to zero patients in the su-AVR group. There were no significant differences between the two groups in terms of postoperative complications, intrahospital stay (median 9 days, IQR 7-20), or in-hospital mortality (1 su-AVR; 2 cAVR). The long-term survival rate was similar between the su-AVR (90%) and cAVR (92%) groups (log rank p = 0.8). The transvalvular gradients at follow-up were not affected by the type of valve used, regardless of the valve size (coef 2.68, 95%CI -3.14-8.50, p = 0.36). CONCLUSION: The study suggests that su-AVR is a feasible and safe alternative to cAVR in high-risk patients undergoing redo surgery. The use of su-AVR offers comparable outcomes to cAVR, with reduced cross clamp times and a lower incidence of postoperative pacemaker requirement in isolated AVR cases. The results of this study contribute to the growing body of evidence supporting the use of su-AVR in high-risk patients, highlighting its feasibility and safety in redo surgeries.

Evaluation of metabolic equivalents of task (METs) in the preoperative assessment in aortic repair.

BACKGROUND: Reliable prediction of the preoperative risk is of crucial importance for patients undergoing aortic repair. In this retrospective cohort study, we evaluated the metabolic equivalent of task (MET) in the preoperative risk assessment with clinical outcome in a cohort of consecutive patients. METHODS: Retrospective analysis of prospectively collected data in a single center unit of 296 patients undergoing open or endovascular aortic repair from 2009 to 2016. The patients were divided into four anatomic main groups (infrarenal (endo: n = 94; open: n = 88), juxta- and para-renal (open n = 84), thoraco-abdominal (open n = 13) and thoracic (endo: n = 11; open: n = 6). Out of these, 276 patients had a preoperative statement of their functional capacity in metabolic units and were evaluated concerning their postoperative outcome including survival, in-hospital mortality, postoperative complications, myocardial infarction and stroke, and the need of later cardiovascular interventions. RESULTS: The median follow-up of the cohort was 10.8 months. Patients with < 4MET had a higher incidence of diabetes mellitus (p = 0.0002), peripheral arterial disease (p < 0.0001), history of smoking (p = 0.003), obesity (p = 0.03) and chronic obstructive pulmonary disease (p = 0.05). Overall in-hospital mortality was 4.4% (13 patients). There was no significant difference in the survival between patients with a functional capacity of more than 4 MET (220 patients, mean survival: 74.5 months) and patients with less than 4 MET (56 patients, mean survival: 65.4 months) (p = 0.64). The mean survival of the infrarenal cohort (n = 169) was 74.3 months with no significant differences between both MET groups (> 4 MET: 131 patients, mean survival 75.5 months; < 4 MET: 38 patients, mean survival 63.6 months. p = 0.35). The subgroup after open surgical technique with less than 4 MET had the lowest mean survival of 38.8 months. In 46 patients with > 4MET (20.9%) perioperative complications occurred compared to the group with < 4MET with 18 patients (32.1%) (p = 0.075). There were no significant differences in both groups in the late cardiovascular interventions (p = 0.91) and major events including stroke and myocardial infarction (p = 0.4) monitored during the follow up period. The risk to miss a potential need for cardiac optimization in patients > 4MET was 7%. CONCLUSION: The functional preoperative evaluation by MET in patients undergoing aortic surgery is a useful surrogate marker of perioperative performance but cannot be seen as a substitute for preoperative cardiopulmonary testing in selected individuals. Trial registration clinicaltrials.gov, registration number NCT03617601 (retrospectively registered).

Interdisciplinary approach in emergency revascularization and treatment for acute mesenteric ischemia.

BACKGROUND: Mesenteric ischemia is associated with poor outcome and high overall mortality. The aim was to analyze an interdisciplinary treatment approach of vascular and visceral specialists focusing on the in-hospital outcome and follow-up in patients with acute and acute-on-chronic mesenteric ischemia. METHODS: From 2010 until 2017, 26 consecutive patients with acute or acute on chronic mesenteric ischemia were treated by an interdisciplinary team. Data were prospectively collected and retrospectively evaluated. Throughout the initial examination, the extent of bowel resection was determined by the visceral surgeon and the appropriate mode of revascularization by the vascular surgeon. The routine follow-up included clinical examination and ultrasound- or CT-imaging for patency assessment and overall survival as primary endpoint of the study. RESULTS: Out of 26 patients, 18 (69.2%) were rendered for open repair. Ten patients (38.5%) received reconstruction of the superior mesenteric artery with an iliac-mesenteric bypass. Seven patients (26.9%) underwent thrombembolectomy of the mesenteric artery. One patient received an infra-diaphragmatic aorto-celiac-mesenteric bypass. Out of the 8 patients, who were not suitable for open revascularization, 2 patients (7.7%) were treated endovascularly and 6 (23.1%) underwent explorative laparotomy. The in-hospital mortality was 23% (n = 6). The mean survival of the revascularized group (n = 20) was 51.8 months (95% CI 39.1-64.5) compared to 15.7 months in the non-revascularized group (n = 6) (95% CI - 4.8-36.1; p = 0.08). The median follow-up was 64.6 months. Primary patency in the 16 patients after open and 2 after interventional revascularization was 100% and 89.9% in the follow-up. CONCLUSION: The interdisciplinary treatment of mesenteric ischemia improves survival if carried out in time. Hereby open revascularization measures are advantageous as they allow bowel assessment, resection, and revascularization in a one-stop fashion especially in advanced cases.

Intraoperatively self-made bovine pericardial graft for portomesenteric reconstruction in pancreatic surgery.

PURPOSE: Vascular encasement or infiltration of the portomesenteric veins can compromise resectability and local tumour control in pancreatic resections. So far, there is no consensus on how vascular reconstruction should be performed. Bovine pericardium has shown promising results, particularly in infected arterial vascular reconstructions. The aim of this study is to evaluate the feasibility and technical success of portomesenteric venous vascular reconstruction using bovine pericardium in pancreatic resections. METHODS: Retrospective analysis of portomesenteric reconstruction using bovine pericardium (patches, self-made tube grafts) in pancreatic resections between 2014 and 2019. The primary endpoint examined was the technical success rate and short-term patency of vascular reconstruction. In addition to clinical surveillance and laboratory routine testing, patency was tested with duplex scans (4 h postoperatively) and computed tomography imaging in case of an abnormal clinical course and as part of the oncological follow-up. RESULTS: In 15 surgical procedures (pancreaticoduodenectomy (12, 80%), pancreatic left resection (3, 20%)), vascular reconstruction was performed with superior mesenteric vein (6/15), portal vein (7/15) and the junction between superior mesenteric and splenic vein (2/15). Eighty percent of the reconstructions were tube grafts (12/15), and the remaining were patch plasties. In 13/15 (87%) of the cases, the vascular reconstruction was patent; in 2/15 (13%), there was one stenosis without reintervention need and one graft failure with complete thrombosis. Out of 15 patients, 4 major complications according to Clavien-Dindo classification (IIIa n = 2, 13%; IIIb n = 1, 7%; V n = 1, 7%) were documented. Latest re-imaging after surgery among the 10 patients with imaging follow-up more than 1 month postoperatively was after 6.5 months ((median, interquartile range 4-12 months), and clinical follow-up was at 6.7 months (median, 3.3-13 months)). CONCLUSION: Due to its off-the-shelf availability, portomesenteric reconstruction using bovine pericardium seems to be a feasible and safe method in pancreatic resection with vascular encasement. Xenopericardial grafts can be crafted to any size and are applicable in potentially infected environment.

Fast-Track Management in Off-Pump Coronary Artery Bypass Grafting: Dexmedetomidine Provides Rapid Extubation and Effective Pain Modulation.

BACKGROUND: Dexmedetomidine (DEX) is a highly selective α-2 agonist with many desirable effects including analgesia, improvement of hemodynamic stability, and potential myocardial and renal protection. The aim of this study was to investigate the effect of DEX on patients undergoing off-pump coronary artery bypass (OPCAB) grafting with regard to less pain medication, earlier extubation, faster transfer to normal ward, and cardiac protection. PATIENTS AND METHODS: From January 2012 to March 2015, 464 patients receiving OPCAB were included for retrospective analysis. After propensity matching (1:1), two groups (DEX vs. propofol, n = 129) could be compared. Continuous and categorical variables were reported as mean ± standard deviation or percentages, and compared with the chi-square test and the Mann-Whitney's test, respectively. RESULTS: In the DEX group, less use of pain medication in the initial phase at intensive care unit was observed. During the first 2 hours, DEX patients received more nicomorphine (DEX 8 ± 3.2 mg vs. propofol 6 ± 4 mg, p < 0.001), while in the following 2 hours, the pain medication was significantly reduced (DEX 3.2 ± 2.8 mg vs. propofol 4.7 ± 3.3 mg, p < 0.001). Remifentanil was stopped considerably earlier (DEX 238 ± 209 minutes vs. propofol 353 ± 266 minutes, p < 0.001). DEX led to earlier extubation (DEX 208 ± 106 minutes vs. propofol 307 ± 230 minutes, p < 0.001) and less postoperative atrial fibrillation (AF) (p = 0.01). CONCLUSION: Early postoperative DEX application supports the fast-track strategy in patients after OPCAB through enabling rapid extubation, effective pain control, and reduced occurrence of new-onset AF. We are confident to give precedence to DEX over propofol as the new routine medication during postoperative patient transfer.

Tricuspid Valve Repair for the Poor Right Ventricle: Tricuspid Valve Repair in Patients with Mild-to-Moderate Tricuspid Regurgitation Undergoing Mitral Valve Repair Improves In-Hospital Outcome.

Background Tricuspid regurgitation (TR) in patients undergoing surgery for mitral valve (MV) increases morbidity and mortality, especially in case of a poor right ventricle. Does repair of mild-to-moderate insufficiency of the tricuspid valve (TV) in patients undergoing MV surgery lead to a benefit in early postoperative outcome? Methods A total of 22 patients with mild-to-moderate TR underwent MV repair and concomitant TV repair with Tri-Ad (Medtronic ATS Medical Inc., Minneapolis, Minnesota, United States) and Edwards Cosgrove (Edwards Lifesciences Irvine, California, United States) rings. The severity of TR was assessed echocardiographically by using color-Doppler flow images. The tricuspid annular plane systolic excursion (TAPSE) was under 1.7 cm. Additional procedures included coronary artery bypass (n = 9) and maze procedure (n = 15). The following parameters were compared: postoperative and peak dose of noradrenaline (NA), pre/postoperative systolic pulmonary pressure (sPAP), extubation time, operation time, cross-clamp time, cardiopulmonary bypass (CPB) time, pre/postoperative ejection fraction (EF), intensive care unit (ICU)-stay, hospital stay, cell saver blood transfusion, intra/postoperative blood transfusion, and postoperative TR. Results The mean age was 67 ± 14.8 years, 45% were male. Mean EF was 47 ± 16.2%, postoperative 52 ± 12.4%. sPAP was 46 ± 20.1 mm Hg preoperatively, sPAP was 40.6 ± 9.4 mm Hg postoperatively, NA postoperatively was 12 ± 10 µg/min, NA peak was 18 ± 11 µg/min, operation time was 275 ± 92 minutes, CPB was 145 ± 49 minutes, ICU stay was 2.4 ± 2.4 days, hospital stay was 10.8 ± 3.5 days, cell saver blood transfusion was 736 ± 346 mL, intraoperative transfusions were 2.5 ± 1.6. Two patients needed postoperative transfusions. A total of 19 patients were extubated at the 1st postoperative day, 2 patients at the 2nd day, and 1 at the 4th postoperative day. Two patients required a pacemaker. No reintubation, no in-hospital mortality, and one reoperation because of bleeding complications. Conclusion Correction of mild-to-moderate TR at the time of MV repair does maintain TV function and avoid right ventricular dysfunction in the early postoperative period improving the clinical outcome.

Xenopericardial self-made tube grafts in infectious vascular reconstructions: Preliminary results of an easy and ready to use surgical approach.

PURPOSE: Infections are a major setback of vascular reconstruction and associated with considerable morbidity and mortality. We evaluated retrospectively our results with self-made bovine pericardial grafts in infected vessel revascularization versus standard graft material. BASIC METHODS: Retrospective analysis of 9 patients with bovine reconstruction and 10 patients with miscellaneous grafts (vein, homograft) for vascular infections. PRINCIPAL FINDINGS: Infection-free rate of the pericardial group was 100% in 17 months. For patients after reconstructions with miscellaneous grafts, the infection-free rate was 82% in 45 months. Overall in-hospital mortality was 10.5%. There were no in-hospital deaths in the pericardial group. Graft patency of the whole cohort was 100%. The median follow up was 11.74 months. CONCLUSION: Self-made bovine pericardial tube grafts can be crafted to almost any size and adjusted to complex anatomic requirements. The use was feasible in various situations and was associated with good preliminary results concerning patency and reinfection.

Development and validation of a macroarray system--MutaCHIP ARTERO--for the detection of genetic variants involved in the pathogenesis of atherosclerosis.

BACKGROUND: Cardiovascular diseases are the leading cause of death in developed countries. The underlying mechanism is often atherosclerotic remodeling of blood vessels in organs such as heart, kidney, brain, and large arteries in case of peripheral arterial disease. Beside environmental and behavioral factors such as smoking or lack of physical activity, genetic variants in genes involved in lipid metabolism, blood pressure regulation, oxidative stress, and coagulation play a prominent role in the pathogenesis of atherosclerosis. METHODS: Thus, we developed and validated for clinical use and research a macroarray system for the simultaneous detection of key genetic variants in genes involved in lipid metabolism, blood pressure regulation, oxidative stress, and coagulation. RESULTS: When compared with standard PCR technologies to determine all these genetic variants in parallel, the macroarray system (MutaCHIP ARTERO) was as accurate but faster, cheaper, and easier to handle compared to classical real time PCR based technologies. CONCLUSIONS: MutaCHIP ARTERO is a gene chip for diagnostics of a complex genetic panel involved in the pathogenesis of atherosclerosis. This method is as sensitive and precise as real time PCR and is able to replicate real time PCR data previously validated in evaluation studies.

Perceval sutureless bioprosthesis versus Perimount sutured bioprosthesis for aortic valve replacement in patients with aortic stenosis: a retrospective, propensity-matched study.

BACKGROUND: Rapid-deployment aortic valve replacement (RDAVR) is an alternative to conventional AVR (cAVR) for aortic stenosis. Benefits include a reduction in operative times, facilitation of minimal access surgery and superior haemodynamics compared to conventional valves. However, further evidence is required to inform guidelines, preferably in the form of propensity-matched studies that include mid-term follow-up data. METHODS: This was a single-centre, retrospective, propensity-matched cohort study comparing the Perceval and conventional Perimount Magna Ease valve for short- and mid-term clinical parameters and size-matched mid-term echocardiographic parameters (n = 102 in both groups) from 2014 to 2020. Data were extracted from a nationally managed dataset. RESULTS: There were no demographic differences between the matched groups. The Perceval group had shorter cross-clamp time (Perceval 62 [49-81] minutes; Perimount 79 [63-102] minutes, P < 0.001), shorter bypass time (Perceval 89 [74-114] minutes; Perimount 104 [84-137] minutes, P < 0.001), and more frequent minimally-invasive approaches (Perceval 28%; Perimount 5%, P < 0.001). Size-matched haemodynamics showed initially higher gradients in the Perceval group, but haemodynamics equalised at 12 + months. The Perceval group had a more favourable % change in the left ventricular posterior wall dimension at 2 + years (Perceval - 4.8 ± 18; Perimount 17 ± 2). CONCLUSIONS: The Perceval facilitated shorter operations, which may benefit intermediate-high-risk, elderly patients with comorbidities requiring concomitant procedures. It also facilitated minimally invasive surgery. Size-matched haemodynamic performance was similar at mid-term follow-up, with the Perceval possibly better facilitating regression of left ventricular hypertrophy.

Anatomical evaluation of a novel echocardiography based tricuspid valve classification in 60 hearts from body donors.

OBJECTIVES: This study aimed at providing comprehensive morphological descriptions of the morphology of the tricuspid valve and to evaluate if a novel echocardiography based tricuspid valve nomenclature can also be understood anatomically. MATERIAL AND METHODS: Tricuspid valves of 60 non-embalmed human body donors without a medical history of pathologies or macroscopic malformations of the heart were included. Length, height and surface area of leaflets were measured. The valves were morphologically classified according to a novel echocardiography-based classification, in which 6 types are distinguished: classic three-leaflet configuration, bicuspid valves, valves with one leaflet split into two scallops or leaflets and valves with two leaflets divided into two scallops or leaflets. RESULTS: We found a true three leaflet configuration in only 19 (31.7%) of valves. 5 (8.3%) had a two leaflet configuration with a fused anterior and posterior leaflet. Of those 3 had a divided septal leaflet. 4 valves (6.7%) with a divided anterior leaflet, 17 (28.3%) with a divided posterior leaflet, 6 (10%) with a divided septal leaflet and 9 (15.0%) with two leaflets divided. Overall 39 (65%) of valves have at least one leaflet that is divided. In 22 (36.7%) specimens the leaflet was divided into true leaflets and in 17 (28.3%) into scallops. In addition, we could identify 9 (15%) valves having one leaflet divided not only in two but three scallops or leaflets. CONCLUSIONS: This study provides further anatomical insight for the significant variability in the morphology of the tricuspid valve. By updating the understanding of its morphological characteristics, this study equips clinicians with valuable insights to effectively advance surgical and interventional treatment of tricuspid valves.

Thrombocytopenia after sutureless and standard stented aortic valve replacement: a retrospective analysis of risk factors, clinical course, and early outcome.

OBJECTIVES: Thrombocytopenia following Perceval aortic valve replacement has been described previously with variable outcome. Studies have lacked a robust analysis of platelet fluctuation and factors affecting it. We aimed to statistically describe the trend in thrombocyte variability as compared with conventional aortic valve replacement, and to assess predictors as well as impact on associated outcomes. METHODS: One hundred consecutive patients with first-time Perceval were retrospectively compared to 219 patients after Perimount Magna Ease valve replacement. The primary outcome was the serial thrombocyte count on day 0-6. Generalized estimating equations were used to analyse the data using fixed-effect models: for the effect of the post-operative day on platelet count, and random-effect models estimating both time-variant (platelets) and time in-variant variables (valve type, age, LV function, pre-op platelet level). RESULTS: Perceval patients were older (72 ± 1 vs 68 ± 1 years, p < 0.01) with higher NYHA status (3(2-3) vs 2(1-2), p < 0.001). Mean platelet count in the sutureless group was lowest on day 2 (91.9 ± 31.6 vs 121.7 ± 53.8 × 103 µl-1), and lower on day 4 (97.9 ± 44) and 6 (110.6 ± 61) compared to the conventional group (157.2 ± 60 and 181.7 ± 79) but did not result in a higher number of transfusions, bleeding or longer hospital stay (p > 0.05). Reduced platelet count was a strong predictor of red cell transfusion in the conventional (p = 0.016), but not in the sutureless group (p = 0.457). Age (Coef -1.025, 95%CI-1.649--0.401, p < 0.001) and CPB-time (Coef 0.186, 95%CI-0.371--0.001, p = 0.048) were predictors for lower platelet levels. CONCLUSION: Considering the older patient profile treated with Perceval, postoperative thrombocytopenia does not impact on outcome in terms of transfusions, complications or hospital stay.

Uncommon cause of ventricular tachycardia in a patient with a giant pseudoaneurysm of the ascending aorta.

Ventricular arrhythmias occur predominantly in patients with structural heart disease. The most common substrate is scarring due to ischemic heart disease. We present an uncommon cause of ventricular tachycardia due to excessive right coronary artery stretch in a patient with a giant pseudoaneurysm of the ascending aorta years after aortic root repair.

Concomitant Transapical Aortic/Mitral Transcatheter Valve Replacement for Severe Aortic Stenosis and Mitral Annular Calcification.

Mitral regurgitation (MR) associated with mitral annular calcification (MAC) is surgically challenging, and valve-in-MAC procedures using transcatheter aortic valve replacement (TAVR) devices have poor outcomes. Transcatheter mitral valve replacement (TMVR) may be an option. Concomitant TAVR and TMVR are limited to 2 reports. We describe the first case of concomitant TAVR and TMVR-in-MAC procedures. (Level of Difficulty: Advanced.).

How to test adhesive strength: a biomechanical testing for aortic glue used in type a dissection repair.

OBJECTIVES: The aim of this study was to develop a method to quantify the peel force in an in vitro model simulating repair of ascending aortic dissections with tissue glue (Bioglue). METHODS: This study adapted an adhesive T-Peel test for the determination of the peel strength of adhesives by measuring the peeling force of a T-shaped bonded tissue. Measurements were performed on iatrogenic dissected ascending porcine aorta, which has been repaired with Bioglue using different pressure levels. Four conditions were tested: zero sample pressure according to the manufacturer's recommendation (n = 10), low (504 Pa; n = 11), moderate pressure (1711 Pa; n = 24) and pressure applied by a round shaped vascular 'Borst clamp' (1764 Pa; n = 23). Non-parametric one-way analysis of variance was applied for statistical significance. RESULTS: The median peel force (lower quartile, upper quartile) of aortic samples increased depending on the applied pressure: [no pressure 0.030 N/mm (0.016, 0.057), low pressure 0.040 N/mm (0.032, 0.070) and moderate pressure 0.214 N/mm (0.050, 0.304)]. Samples pressurized with the Borst clamp reached 0.078 N/mm (0.046, 0.152), which was comparable to the peel force of the unpeeled controls [0.107 N/mm (0.087, 0.124)]. Compared to samples without pressure, Bioglue with the application of the Borst clamp (P = 0.021) and with moderate pressure (P = 0.0007) performed significantly better. CONCLUSIONS: The novel T-Peel test offers an attractive method to test tissue glues in defined in vitro environments. Bioglue peel force increased with pressure on the aortic sample in contrast to low or no pressure as per the manufacturer's recommendation. Modifying current recommended use may aid in increasing effectiveness of this approach.

Digital communication platforms in cardiothoracic surgery during COVID-19 pandemic: keeping us connected or isolated?

During the COVID-19 pandemic, performing a surgeon's duties has become challenging while adhering to social distancing mandates. To aid in the continuity of healthcare services, rapid implementation of digital communication tools became a necessity. This is an account of experiences using digital communication platforms, namely Microsoft Teams and Zoom, for clinical and educative purposes in the field of Cardiothoracic Surgery in the UK. While enabling ongoing virtual clinical meetings, conferences and learning opportunities for residents with little face-to-face contact, are these digital communication platforms keeping us connected or isolated?

Is it time to incorporate hands-on simulation into the cardiothoracic surgery curriculum?

The COVID pandemic has had huge implications for training in cardiothoracic surgery. The reduction in training opportunities has led to concerns from trainees globally regarding the impact on their learning and their training progression. Surgical simulation is effective in the development of technical skills in cardiothoracic surgery with numerous examples of low and high-fidelity simulators. Despite this the incorporation of such methods into training curricula worldwide is seldom. Core fundamentals are required to successfully implement surgical simulation into training programmes, which includes; commitment from trainers, regular sessions and structured feedback. Few programmes have demonstrated the successful incorporation of surgical simulation and there is a growing acceptance of its place in the speciality. As we recover from this challenging period it may be the right opportunity to evolve how we train our current and future trainees by incorporating hands-on simulation as a fundamental part of the cardiothoracic curriculum.

Basic principles of cardiothoracic surgery training: a position paper by the European Association for Cardiothoracic Surgery Residents Committee.

OBJECTIVES: Across Europe there are significant variations in the fundamental structure and content of cardiothoracic surgery (CTS) training programmes. Previous efforts have been made to introduce a Unified European Training System, which outlined the fundamentals of the ideal programme and supported a paradigm shift from an apprenticeship to a competency-based model. This article's goal was to define key structural, administrative and executive details of such a programme to lay the foundations for the standardization of cardiothoracic surgical training across Europe. METHODS: The European Association for Cardiothoracic Surgery Residents Committee had previously conducted a residents' training survey across Europe in 2020. Training curricula from the twelve most represented countries across Europe were either searched online or obtained from the countries' national trainee representative and reviewed by the committee. Information was collated and placed into one of the following categories to develop the position paper: (i) selection of eligible candidates, (ii) guidance for an outcome-based syllabus, (iii) documentation and evaluation of training progress, (iv) mandatory rotations and training courses, (v) number of independent or assisted cases and (vi) requirements and quality assurance of teachers. RESULTS: An independent professional body should promote an outcome-based syllabus and take responsibility for the training programme's quality assurance. Trainees should be selected on merit by an open and transparent process. Training should be delivered within a defined period and supervised by an appointed training committee to ensure its implementation. This committee should review the trainees progression regularly, provide feedback and offer trainees the opportunity to experience various training environments and trainers. A common electronic portal be used by trainees to record their agreed objectives and to evidence their completion. Trainees should regularly attend specialty-relevant courses and conferences to promote professional and academic development. The end of training is reached when the formal requirements of the training programme are met and the trainee is able to perform at the level expected of a day-1 independent surgeon. CONCLUSIONS: This article defines the key structural, administrative, and executive principles for CTS training. Programmes are encouraged to review and modify their training curricula, if necessary, to ensure the delivery of high-quality, standardized, outcome-orientated CTS training across Europe.

Continuing Education through COVID-19 Crisis in the United Kingdom: A Swiss Trainee Abroad.

The work has been awarded in July 2020 with the "Special Swiss Young Cardiac Surgeon Award 2020" by the Swiss Society of Cardiac Surgery (Schweizerische Gesellschaft für Herz- und thorakale Gefässchirurgie [SGHC-SSCC]) and reflects a personal perspective from a Swiss trainee experiencing the novel coronavirus disease 2019 (COVID-19) pandemic during her fellowship in London.

Freestyle aortic root prosthesis in combination with aortic replacement and open anastomosis: a retrospective analysis.

BACKGROUND: The Freestyle® bioprosthesis is used for pathologies of the aortic root. Additional resection of the ascending aorta and the proximal arch in dissections or aneurysms might be indicated. The aim was to assess mid-term outcome regarding prosthetic performance, stroke, reoperations, and survival in various pathologies comparing patients with and without additional procedures on the ascending aorta and proximal arch focusing on the standardised technique of unilateral antegrade cerebral perfusion under moderate hypothermia. METHODS: Retrospective data analysis of 278 consecutive patients after Freestyle® root replacement between September 2007 and March 2017. Patients were divided in three categories due to the pathology of the aortic root (re-operation vs endocarditis vs dissection). Two groups based on the aortic anastomosis technique (open arch anastomosis (OA) versus non-open arch anastomosis (non-OA) were compared (119 OA vs 159 non-OA). Cardiovascular risk, previous cardiac events, intra- and postoperative data were evaluated. Inferential statistics were performed with Mann-Whitney U-test. Nominal and categorical variables were tested with Fisher-Freeman-Halton exact test. Kaplan-Meier estimate was used to assess survival. RESULTS: The follow-up rate was 90% (median follow-up: 39.5 months). There were differences in the indication (endocarditis: OA 5 (4.2%) vs non-OA 36 (24%), p < 0.0001; dissection: OA 13 (10.9%) vs non-OA 2 (1.3%); p = 0.0007). OA patients had less perioperative stroke (1 (1%) vs 15 (10%), p = 0.001) and shorter hospital stay (9 vs 12 days, p = 0.0004). There were no differences in the mortality (in-hospital: OA 8 (7%) vs non-OA 8 (5%); p = 0.6; death at follow-up: OA 5 (5%) vs non-OA 15 (11%); p = 0.1). Overall valve performance showed a well-functioning valve in 97.3% at follow-up. CONCLUSION: The valve performance showed excellent results regardless of the initial indication. The incidence of stroke was lower in patients receiving an open arch anastomosis using unilateral antegrade cerebral perfusion without elevated mortality or prolonged hospital stay.

Converging rapid deployment prostheses with minimal access surgery: analysis of early outcomes.

BACKGROUND: Sutureless prostheses may have added benefit when combined with minimal access surgery, although this has not been fully assessed in the literature. This study aims to provide a comparative analysis of the Perceval valve comparing median sternotomy (MS) with mini-sternotomy (MIS). METHODS: A retrospective analysis of prospectively collected data was conducted for all isolated aortic valve replacement (AVR), using the Perceval valve, for severe aortic stenosis cases in the period 2014 to 2019. Patients undergoing concomitant valve or revascularisation surgery were excluded. RESULTS: A total of 78 patients were included: MS group 41; MIS group 37. Operatively, bypass times were comparable between MS and MIS groups (mean 89.3 vs 83.4, p = 0.307), as were aortic cross clamp times (58.4 vs 55.9, p = 0.434). There were no operative deaths or new onset post-operative neurology. MIS was a predictor of reduced stay in the intensive care unit (coef - 3.25, 95% CI [- 4.93, - 0.59], p = 0.036) and hospital stay overall (p = 0.004). Blood transfusion units were comparable as were the incidence of heart block (n = 5 vs n = 3, p = 0.429) and new onset atrial fibrillation (n = 15 vs n = 9, p = 0.250). Follow-up echocardiography found a significant improvement in effective orifice area, left ventricular dimension and volume indices, and LVEF (p > 0.05) for all patients. Multivariate analysis found mini-sternotomy to be a predictor for reduced LV diastolic volume (coef - 0.35, 95% CI [- 1.02, - 0.05], p = 0.05). CONCLUSIONS: The combination of minimal access surgery and sutureless AVR may enhance patient recovery and provide early LV remodelling.