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ABSTRACT Introduction: Cardiac surgery-associated acute kidney injury (CSA-AKI) is a powerful predictor of perioperative outcomes. We evaluated the burden of CSA-AKI in patients with preserved baseline renal function. Methods: The data of 2,162 adult patients who underwent cardiac surgery from January 2005 to December 2020 were analyzed. Logistic regression models were used to determine predictors of CSA-AKI and their associations with hospital mortality up to 30 days. Results: The prevalence of acute kidney injury was 43.0%, and 2.0% of patients required renal replacement therapy. Hospital mortality rate was 5.6% (non-acute kidney injury = 2.0% vs. CSA-AKI = 10.4%, P<0.001), and any degree of CSA-AKI was associated with a significant increase in death rates (stage 1 = 4.3%, stage 2 = 23.9%, stage 3 = 59.7%). Multivariable logistic regression analysis identified age, obesity, left ventricular dysfunction, previous cardiac surgery, and cardiopulmonary bypass duration as predictors of CSA-AKI. Moreover, CSA-AKI was confirmed as independent predictor of hospital mortality for stage 1 (odds ratio, 2.02; 95% confidence interval, 1.16 to 3.51; P=0.013), stage 2 (odds ratio, 9.18; 95% confidence interval, 4.54 to 18.58; P<0.001), and stage 3 (odds ratio, 37.72; 95% confidence interval, 18.87 to 75.40; P<0.001) patients. Conclusion: Age, obesity, left ventricular dysfunction, previous cardiac surgery, and cardiopulmonary bypass duration are independent predictors of CSA-AKI in patients with preserved baseline renal function. The development of CSA-AKI is significantly associated with worse outcomes, and there is a dose-response relationship between acute kidney injury stages and hospital mortality.

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ABSTRACT Introduction: Although endovascular correction is a promising perspective, the gold-standard treatment for thoracoabdominal aortic aneurisms and type-B dissections with visceral involvement remains open surgery, particularly due to its well-established long-term durability. This study aims to describe and evaluate public data from patients treated for thoracoabdominal aortic aneurism in the Brazilian public health system in a 12-year interval. Methods: Data from procedures performed between 2008 and 2019 were extracted from the national public database (Departamento de Informática do Sistema Único de Saúde, or DATASUS) using web scraping techniques. Procedures were evaluated regarding the yearly frequency of elective or urgency surgeries, in-hospital mortality, and governmental costs. All tests were done with a level of significance P<0.05. Results: A total of 812 procedures were analyzed. Of all surgeries, 67.98% were elective cases. There were 328 in-hospital deaths (mortality of 40.39%). In-hospital mortality was lower in elective procedures (26.92%) than in urgency procedures (46.74%) (P=0.008). Total governmental expenditure was $3.127.051,56 — an average of $3.774,22 for elective surgery and $3.791,93 for emergency surgery (P=0.999). Conclusion: The proportion of urgency procedures is higher than that recommended by international literature. Mortality was higher for urgent admissions, although governmental costs were equal for elective and urgent procedures; specialized referral centers should be considered by health policy makers.

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ABSTRACT Introduction: Most implantations of left ventricular assist devices (LVAD) are performed in low-volume centers. This study aimed to evaluate the procedural learning curve of HeartMate II (HM2) implantations by comparing outcomes between two time periods in a low-volume center. Methods: All 51 consecutive patients undergoing HM2 implantation between January 2009 and December 2017 were reviewed and allocated into 2 groups: early-era group (from 2009 to 2014; n=25) and late-era group (from 2015 to 2017; n=26). The primary outcome was the 90-day mortality rate, and the secondary outcome was a composite of mortality, neurological event, reoperation for bleeding, need for temporary right ventricular assist device, and pump thrombosis at 90 days. Median follow-up time was 51 months (0-136). A cumulative sum (CUSUM) control analysis was used to establish a threshold of implantations that optimizes outcomes. Results: Patients in the early era had a higher rate of diabetes, previous stroke, and inotrope support before HM2 implantation. The 90-day mortality rate was not significantly higher in the early era (24% vs. 15%, P=0.43), but the composite endpoint was significantly higher (76% vs. 42%, P=0.01). The CUSUM analysis found a threshold of 23 operations after which the composite endpoint was optimized. Conclusion: Patients undergoing HM2 implantation in a low-volume center have improving outcomes with number of cases and optimized results after a threshold of 23 cases. Significant changes in patient selection, surgical techniques, and patient management might lead to improved outcomes after LVAD implantation.

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Abstract Introduction: Cryopreserved allograft heart valves (CAHV) show longer event-free survival compared to other types of protheses. However, all patients develop early and/or late allograft failure. Negative predictors are clinical, and there is a lack of evidence whether they correspond with the microscopic structure of CAHV. We assessed histopathological signs of structural degeneration, degree of cellular preservation, and presence of antigen-presenting cells (APC) in CAHV and correlated the changes with donor clinical characteristics, cryopreservation times, and CAHV types and diameters. Methods: Fifty-seven CAHV (48 pulmonary, nine aortic) used for transplantation between November/2017 and May/2019 were included. Donor variables were age, gender, blood group, height, weight, and body surface area (BSA). Types and diameters of CAHV, cold ischemia time, period from decontamination to cryopreservation, and cryopreservation time were recorded. During surgery, arterial wall (n=56) and valvar cusp (n=20) samples were obtained from the CAHV and subjected to microscopy. Microscopic structure was assessed using basic staining methods and immunohistochemistry (IHC). Results: Most of the samples showed signs of degeneration, usually of mild degree, and markedly reduced cellular preservation, more pronounced in aortic CAHV, correlating with arterial APC counts in both basic staining and IHC. There was also a correlation between the degree of degeneration of arterial samples and age, height, weight, and BSA of the donors. These findings were independent of preservation times. Conclusion: CAHV show markedly reduced cellular preservation negatively correlating with the numbers of APC. More preserved CAHV may be therefore prone to stronger immune rejection.

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ABSTRACT Introduction: There is no complete consensus on the three surgical methods and long-term consequences for coexisting coronary and carotid artery disease. We retrospectively evaluated the surgical results in this high-risk group in our clinic for a decade. Methods: Between 2005 and 2015, 196 patients were treated for combined carotid and coronary artery disease. A total of 50 patients were operated on with the staged method, 40 of which had carotid endarterectomy (CEA) priority, and 10 had coronary artery bypass grafting (CABG) priority. CABG and CEA were simultaneously performed in 82 patients; and in 64 asymptomatic patients with unilateral carotid artery lesions and stenosis over 70%, only CABG was done (64 patients). Results were evaluated by uni-/multivariate analyses for perioperative, early, and late postoperative data. Results: In the staged group, interval between the operations was 2.82±0.74 months. Perioperative and early postoperative (30 days) parameters did not differ between groups (P-value < 0.05). Postoperative follow-up time was averaged 94.9±38.3 months. Postoperative events were examined in three groups as (A) deaths (all cause), (B) cardiovascular events (non-fatal myocardial infarction, recurrent angina, congestive heart failure, palpitation), and (C) fatal neurological events (amaurosis fugax, transient ischemic attack, and stroke). When group C events were excluded, event-free actuarial survival rates were similar in all three methods (P=0.740). Actuarial survival rate was significantly different when all events were included (P=0.027). Neurological events increased markedly between months 34 and 66 (P=0.004). Conclusion: Perioperative and early postoperative event-free survival rates were similar in all three methods. By the beginning of the 34th month, the only CABG group has been negatively separated due to neurological events. In the choice of methodology, “most threatened organ priority’’ was considered as clinical parameter.

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ABSTRACT Introduction: Extracorporeal membrane oxygenation (ECMO) for temporary cardiopulmonary support is one of the most intense and technologically complex therapies offered in medicine. It is a high-risk procedure that requires specific knowledge and technical skills to perform it with good results. Objective: The main goal of this study is to describe our extracorporeal membrane oxygenation (ECMO) training program based on the study of specialized nurses and physicians of a simulation teaching experience, conducted in a pediatric cardiac intensive care unit. The program was developed as a theoretical-practical course with final exam and annual maintenance training sessions, caring for ECMO patients, its implementation and results. Methods: A descriptive study for registered nurses, intensivists, and cardiac surgeons. A self-administered, anonymous, and voluntary survey was conducted to assess the long-term perception about the program. Demographic data to describe the population was required, and questions about satisfaction and confidence in acquired skills and competences were asked. A descriptive statistical analysis was performed; patient survival and complications were compared before and after ECMO program using chi-square test, and P<0.05 was considered statistically significant. Results: Twenty-four training courses were performed for 68 professionals. More than 88% of the professionals considered the course components to be adequate and complete; and 94% felt trained to manage the ECMO circuit. Most valued activities were workshops and clinical cases. Since the implementation of the training program, 88 patients were assisted, with a survival rate at discharge of 58%, higher than in the previous period (P=0.03). Conclusion: More than 80% of the professionals considered the workshops and simulations as the most useful components. Reliance on the circuit care was higher than in training problem scenarios. Since 2013 we assisted 88 patients on ECMO, with a survival rate at discharge of 58%, within international standards results.

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ABSTRACT Introduction: The objective of this single-center study it to retrospectively analyze the relationship between transfusion and 30-day postoperative outcomes in patients undergoing isolated off-pump coronary artery bypass grafting. Methods: Perioperative data of 2,178 patients who underwent isolated off-pump coronary artery bypass grafting from 2018 to 2019 were collected. A 1:1 propensity score matching was performed to control for potential biases between patients who received blood transfusion and those who did not. After propensity score matching, we analyzed the clinical outcomes of transfusion and non-transfusion patients. Postoperative complications and the survival of patients within 30 days after surgery in both groups were analyzed. Kaplan-Meier survival curve and log-rank test were used for survival analysis. Results: The total blood transfusion rate of all patients was 29%, including red blood cell (27.6%), plasma (7.3%), and platelet (1.9%). Four hundred and forty patients in each group were compared after propensity score matching. There were no significant differences in the incidence of stroke, myocardial infarction, atrial fibrillation, acute kidney function injury, and sternal wound infection of both groups (P>0.05). However, higher incidence of postoperative pulmonary infection and more mechanical ventilation time and days of stay in the intensive care unit and postoperative in-hospital stay were associated with blood transfusion (P<0.05). The 30-day cumulative survival rate of the transfusion group was lower than that of the control group (P<0.05). Conclusion: Perioperative blood transfusion increases the risks of postoperative pulmonary infection and short-term mortality in off-pump coronary artery bypass grafting patients.

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ABSTRACT Introduction: Prosthetic valve dysfunction is a potentially critical complication of heart valve replacement. An easy and quickly applicable diagnostic procedure is required for recognizing the prosthetic valve dysfunction. The purpose of this study was to prospectively define the diagnostic value of D-dimer and INR level in predicting prosthetic valve dysfunction. Methods: This cross-sectional study was performed in 70 patients suspected to have prosthetic valve dysfunction admitted to Imam Ali Hospital, affiliated with Kermanshah University of Medical Sciences (KUMS), Kermanshah Province, Iran. Cinefluoroscopy, as the gold standard diagnostic test, was used for the diagnosis of prosthetic valve dysfunction in enrolled patients. Two milliliters of blood from each patient were taken into a tube containing sodium citrate anticoagulant. To evaluate D-dimer, the cutoff value was set at 500 ng/ml. Also, to evaluate international normalized ratio (INR), the cutoff value was set at 2. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), and negative likelihood ratio (NLR) of the serum markers were used to describe predictive properties. Results: Of 70 patients, 27 (38.6%) were male and 43 (61.4%) were female, and the mean age was 54.67±15.11 years (range, 18 to 80 years). Of 70 patients, 27 (38.6%) had prosthetic heart valve malfunction demonstrable by fluoroscopy, and 19 patients (27.1%) had D-dimer levels >500 ng/ml. Elevated D-dimer levels (>500 ng/ml) have been indicated to have sensitivity of 70.4%, and hence an NPV of 84.3%, specificity of 100%, PPV of 100%, NLR of 0.3, and the infinity value of PLR for predicting prosthetic valve dysfunction. There was a significant relationship between fluoroscopy and D-dimer test (P=0.001). A kappa coefficient value of 0.745 indicated a substantial agreement between D-dimer and fluoroscopy testing. Mixing test (combination of D-dimer and INR) showed to have 100% sensitivity, and hence a NPV of 69.8%, specificity of 69.8%, PPV of 51.8%, NLR of 1.41, and PLR of 1.44 for predicting prosthetic valve dysfunction. Conclusion: D-dimer with moderate sensitivity and high specificity is an ideal marker for the diagnosis of prosthetic valve dysfunction in suspected patients. Enhanced plasma D-dimer level is not by itself diagnostic of a prosthetic valve dysfunction but may alert physicians to refer the patient for more detailed examination, preferably by fluoroscopy. Mixing test with 100% sensitivity can apply as a rule-out test.

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ABSTRACT Introduction: Custodiol (histidine-tryptophan-ketoglutarate) and repetitive blood cardioplegia are the solutions for myocardial protection and cardiac arrest. In this study, we aimed to compare immunohistochemical analysis, clinical outcomes, and cardiac enzyme values of Custodiol and blood cardioplegia groups. Methods: This was a randomized prospective study consisting of 2 groups and 20 patients, 10 patients for each group, who underwent mitral and mitral/tricuspid valve surgery. Group 1 was formed for Custodiol cardioplegia and group 2 for blood cardioplegia. Perioperative and postoperative cardiac events were recorded, cardiac enzymes were analyzed with intervals, and myocardial samples were taken for immunohistochemical analysis. Recorded data were statistically evaluated. Results: There was no significant difference for the Custodiol and blood cardioplegia groups in perioperative and postoperative cardiac performance and adverse events. Cardiac enzyme analysis showed no significant difference between groups. However, two parameters (eNOS, Bcl-2) were in favor of the Custodiol group in immunohistochemical studies. Custodiol performed better in cellular oxidative stress resistance and cellular viability. Conclusion: Clinical outcomes and cardiac enzyme analysis results were similar regarding myocardial protection. However, Custodiol performed better in the immunohistochemical analysis.

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ABSTRACT Introduction: The totally thoracoscopic approach for mitral valve (MV) disease is a minimally invasive method. We investigated the procedure’s feasibility, safety and effectiveness when it was performed by an experienced operator. Methods: We retrospectively analysed 96 consecutive patients with MV disease treated between March 2016 and November 2019 by minimally invasive procedures. The procedures were performed on a femoral artery-vein bypass through two ports, including a main operation port and a thoracoscopic port. The clinical data of patients were collected, including preoperative cardiac function, operative data, postoperative complications, and follow-up. Results: A total of 96 patients (57 male patients; average age, 49.7±14.5 years; left ventricular ejection fraction, 65.6±7.7%) were enrolled in this study. No intraoperative conversion incision or death occurred. The cardiopulmonary bypass and aortic cross-clamp times were 163.8±50.6 minutes and 119.7±38.9 minutes, respectively. Postoperative chest tube drainage in the first 24 hours was 232.8±108.1 ml. The ventilation time and length of intensive care unit stay were 13.2±6.2 hours and 2.9±2.2 days, respectively. One patient died of disseminated intravascular coagulation and prosthesis thrombosis 3 days after the operation, fearing anticoagulant-related hemorrhage. The overall success rate of valve repair during 1-year follow-up was 97.9%. Conclusion: The totally thoracoscopic procedure on mitral valves by an experienced surgeon is technically feasible, safe, effective and worthy of widespread adoption in clinical practice.

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Abstract Introduction: Halting ventilation during cardiopulmonary bypass (CPB) is implemented to operate in a less bleeding setting. It sustains a better visualization of the operation area and helps to perform the operation much more comfortably. On the other hand, it may lead to a series of postoperative lung complications such as atelectasis and pleural effusion. In this study, we investigated the effects of low tidal volume ventilation on inflammatory cytokines during CPB. Methods: Twenty-eight patients undergoing cardiovascular surgery were included in the study. Operation standards and ventilation protocols were determined and patients were divided into two groups: patients ventilated with low tidal volume and non-ventilated patients. Plasma samples were taken from patients preoperatively, perioperatively from the coronary sinus and postoperatively after CPB. IL-6, IL-8, TNF-α and C5a levels in serum samples were studied with enzyme-linked immunosorbent assay (ELISA) kits. Results: C5a, IL-6, IL-8 and TNF-α were similar when compared to the low tidal volume ventilated and non-ventilated groups (P>0.05) Comparing the groups by variables, IL-6 levels were increased during CPB in both groups (P=0.021 and P=0.001), and IL-8 levels decreased in the ventilation group during CPB (P=0.018). Conclusion: Our findings suggest that low tidal volume ventilation may reduce the inflammatory response during CPB. Although the benefit of low tidal volume ventilation in CPB has been shown to decrease postoperative lung complications such as pleural effusion, atelectasis and pneumonia, we still lack more definitive and clear proofs of inflammatory cytokines encountered during CPB.

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Abstract Introduction: There is not enough data in the literature regarding the safety and efficiency of del Nido cardioplegia in patients with prolonged cross-clamping time. This study aims to determine the efficacy and safety of del Nido cardioplegia compared to cold blood cardioplegia in patients with prolonged aortic cross-clamping time. Methods: In this retrospective study, patients with an aortic cross-clamping time ≥ 90 minutes were included. One hundred consecutive adult patients undergoing cardiac surgery using del Nido cardioplegia comprised the study group, and 100 consecutive adult patients undergoing cardiac surgical procedures using cold blood cardioplegia comprised the control group. Propensity score matching yielded 88 del Nido cardioplegia and 88 cold blood cardioplegia patients. Results: There were no significant differences when comparing the matched groups regarding the requirement for intraoperative defibrillation, postoperative peak troponin T levels, inotropic support, intra-aortic balloon pump requirement, and left ventricular ejection fraction at discharge and on the sixth postoperative month; also, there were no significant differences when comparing cardiopulmonary bypass time and total operation time. Mean cross-clamping time was significantly shorter in the del Nido group (P<0.001). Conclusion: Del Nido cardioplegia may be a safe alternative to cold blood cardioplegia in adults undergoing cardiac surgical procedures with prolonged aortic cross-clamping time.

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Abstract Introduction: Transcatheter aortic valve-in-valve implantation (TAVI-ViV) can be associated with unfavorable hemodynamic outcomes. This study aimed to estimate the prevalence, identify the risk factors, and evaluate the outcomes and survival of patients with high residual gradients after TAVI-ViV. Methods: A total of 85 patients were included in the study. The cohort was divided into group A, with postprocedural mean pressure gradient (PG) ≥ 20 mmHg, and group B, with mean PG < 20 mmHg. Results: Postprocedural PG ≥ 20 mmHg was observed in 24.7% of the patients. In a univariate analysis, preoperative gradient, pre-existing patient-prosthesis mismatch (PPM), deep valve implantation, small degenerated valves, and an older generation of transcatheter aortic valves were found to be risk factors for high residual gradient. Multivariate analysis showed that preexisting maxPG > 60 mmHg, implantation level of 4 mm below neo-annulus, and degenerated valve size ≤ 23 mm were independent predictors of high residual gradient. There were no differences in early morbidity (myocardial infarction, pacemaker implantation, stroke, acute renal insufficiency) between groups. Kaplan-Meier estimated that the survival rate was comparable at one and five years regardless of postoperative gradient. Survivors with high residual mean gradient were significantly affected by a high New York Heart Association (NYHA) class. Conclusion: High residual transvalvular gradient after TAVI-ViV is not rare, but it does not significantly affect mortality. High residual mean gradient has a negative impact on NYHA functional class improvement after the procedure. High preoperative gradient, implantation level, and small failed bioprosthesis may predispose to increased residual gradient.

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ABSTRACT Introduction: The aim of this study was to present the mid-term results of patients who had undergone a carotid-subclavian bypass surgery after a thoracic endovascular aortic repair (TEVAR) stent-graft implantation with proximal landing at zone 2 of the aorta. Methods: A total of 66 patients had undergone TEVAR and carotid-subclavian bypass between January 2015 and May 2020 at our clinic. Five of these patients were lost to follow-up, so 61 patients were included in this retrospective study. At follow-up visits, patency of the carotid-subclavian bypass grafts was evaluated with physical examination and radiological imaging. Results: The mean follow-up time was 15.11±12.29 months (ranging from 1 to 56 months). There were 3 (4.91%) in-hospital deaths of patients admitted with bilateral lower limb and visceral malperfusion. There were also 2 (3.27%) deaths unrelated to the procedure. Carotid-subclavian graft occlusion occurred in 3 (4.91%) patients. The occlusion was detected with radiological imaging within a period of 12 to 24 months. The graft patency rate was 100% in the first 12 months. The mean graft patency time (survival) was 52.56±2.10 months. Conclusion: Periprocedural carotid-subclavian bypass surgery with synthetic grafts is a recommended procedure with high patency and acceptably low mortality and morbidity rates in TEVAR.

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ABSTRACT Introduction: Coronary heart disease (CHD) is a dynamic process in which there are interactions between endothelial dysfunction, oxidative stress, and inflammatory responses. The aim of the present study was to investigate the function and mechanism of HSCARG in the treatment of CHD. Methods: Male apolipoprotein E/low-density lipoprotein receptor-deficient mice were given a high-fat diet with 21% fat and 0.15% cholesterol for the in vivo model. Human umbilical vein endothelial cells were incubated with angiotensin II for the in vitro model. HSCARG expression was inhibited in patients or mice with CHD. Results: HSCARG reduced oxidative stress in mice with CHD. HSCARG also reduced reactive oxygen species (ROS)-oxidative stress in the in vitro model. HSCARG induced p47phox expression in the in vitro model by NF-κB activity. The regulation of nuclear factor kappa B (NF-κB) activity or p47phox expression participates in the effects of HSCARG in CHD. Conclusion: Altogether, our data indicate that HSCARG reduced ROS-oxidative stress in in vivo and in vitro models of CHD via p47phox by NF-κB activity and may be a clinical target for CHD.

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ABSTRACT Introduction: Heart transplantation is the recommended treatment method for patients with advanced heart failure that is refractory to clinical treatment. Due to the progressive severity of these patients and the impossibility of performing the transplant in a short term, there are mechanical circulatory assist devices that can offer necessary hemodynamic support and clinical stability in the period preceding the heart transplant surgery. The present study aims to address and describe the main devices used as bridges for heart transplantation, as well as to analyze their advantages and disadvantages. Methods: This work is a literature review, developed with scientific production in the period from 2010 to 2020, that focus on circulatory assist devices as a bridge for heart transplantation. Results: These devices are characterized as a bridge for transplantation. Short-term or temporary devices are those used for hemodynamic support to stabilize the individual clinically in the presence of refractory cardiogenic shock. And long-term devices are indicated for stable patients with long-term strategic planning. Conclusion: According to the present study, it is possible to observe that there is a wide variety of devices available on the market, enabling the most appropriate choice according to the patient’s need.

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Abstract There remains a significant paucity of information evaluating the effect of glycated HbA1c levels and its theorized effect on mortality and morbidity rates following cardiac surgery. Diabetes is a very common comorbidity in patients undergoing open heart surgery, as there is a shift in patient characteristics and greater risk. Currently, there is no clear consensus that an increase in HbA1c level is associated with increased perioperative mortality rate. However, the reported literature is more commonly able to demonstrate that elevated HbA1c levels is associated with increased rates of wound infection, cardiovascular events and renal failure, and thus, higher post-operative morbidities. This review aims to examine and synthesis the evidence behind each of the morbidities and mortalities associated with open heart surgery and the impact of high HbA1c on the reported outcomes.

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ABSTRACT Introduction: Since the coronavirus disease 2019 (COVID-19) pandemic, cardiac surgeries in patients with previous infection by COVID-19 were suspended or postponed, which led to surgeries performed in patients with an advanced stage of their disease and an increase in the waiting list. There is a heterogeneous attitude in Latin America on the optimal timing to cardiac surgery in patients with previous COVID-19 infection due to scarce data on its outcome. Two Latin American associations joined to establish common suggestions on the optimal timing of surgery in patients with previous COVID-19 infection. Methods: Data collection was performed using a pre-established form, which included year of publication, objective, type of study (prospective/retrospective, descriptive/analytical), number of patients, year of study, waiting time between infection and surgery, type of surgery, morbidity, mortality, and conclusions regarding the association between mortality and morbidity. Final recommendations were approved by the board of directors of Latin American Association of Cardiac and Endovascular Surgery (LACES) and Latin American Confederation of Anesthesia Societies (CLASA). Results: Of the initial 1,016 articles, 11 comprised the final selection. Only six of them included patients who underwent cardiac surgery. According to the analyzed literature, optimal timing for cardiac surgery needs to consider the following aspects: deferable surgery, symptomatic COVID-19 infection, completeness of COVID-19 vaccination. Conclusion: These recommendations derive from the analysis of the scarce literature published at present on outcomes after cardiac surgery in patients with previous COVID-19 infection. These are to be taken as a dynamic recommendation in which Latin American reality was taken into consideration.

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ABSTRACT Transfemoral transcatheter aortic valve replacement (TAVR) is currently the standard catheter-based treatment of severe aortic stenosis patients. Being the transfemoral route not feasible, other access sites could be chosen. Transaortic TAVR via either a J mini-sternotomy or a right anterolateral mini-thoracotomy is a good option for patients having tricky thoracoabdominal aorta. Some tips and tricks may help in getting a fast and safe transaortic procedure.

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ABSTRACT Aortic valve repair combined with root stabilization procedures have been reported to have reliable mid to long-term outcomes, and this is one of the reasons that various surgical units are accepting these techniques as an option in selected cases. Aortic valve replacement is a standard procedure with established results, but to master its techniques there is a major uphill learning curve. A brief communication is presented on the aortic valve repair focusing on the lesser discussed aspects like global variability of the pathology and outcomes, variable referral patterns, and effect of ethnicity.

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ABSTRACT Coronary artery fistula draining into the coronary sinus is a rare vascular malformation, and its diagnosis and clinical manifestations usually occur late. We describe the case of a 72-year-old female patient with dyspnea on exertion (New York Heart Association Class III) associated with palpitations. The transthoracic echocardiogram showed significant tricuspid insufficiency. Cardiac catheterization showed aneurysm of the circumflex coronary artery and fistula of this artery draining into the coronary sinus. The patient underwent fistula ligation and tricuspid valve repair, with excellent surgical results.

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Abstract Coronary subclavian steal syndrome is an uncommon cause of angina in patients with a previous coronary artery bypass graft procedure. The patient had chest pain with the exertion of the left upper limb, difference in blood pressure between the left and right arm, occlusion at the ostium of the left subclavian artery. He underwent carotid subclavian bypass surgery that was successful in relieving symptoms. On the other hand, the patient had an embolic stroke related to the procedure and further assessment may be necessary.

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Abstract Kawasaki disease was first reported in 1967, and it was classified as an autoimmune vasculitis of the small and medium arteries. It is a self-limiting condition that occurs mostly in childhood, but it may involve complications — such as coronary artery aneurysms, myocardial ischemia, and arrhythmias — with significant morbidity and mortality that occur later in life. In this article, we present the association of an ascending aortic aneurysm with bicuspid aortic disease in addition to coronary aneurysm in a 55-year-old patient diagnosed with Kawasaki disease.

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ABSTRACT Cannulation through the femoral artery is the preferred method of establishing peripheral cardiopulmonary bypass in minimally invasive totally thoracoscopic cardiac surgery. However, faced with the contraindication of femoral artery cannulation, modified ascending aortic cannulation is an alternative approach to minimally invasive totally thoracoscopic cardiac surgery.