René Prêtre

Background and Clinical Significance: Revascularization of the circumflex territory remains technically challenging because of its anatomical position and the frequent need for distal branch grafting. Case presentation: We report the case of a 76-year-old man in whom the proximal circumflex trunk was used as the target for an in situ right internal thoracic artery routed through the transverse sinus during combined coronary and ascending aortic surgery. This approach allowed antegrade perfusion of the circumflex territory while avoiding multiple distal anastomoses. In this selected anatomical setting, the technique proved feasible and was associated with excellent intraoperative flow and 1-year radiological patency. Conclusions: Direct grafting of the circumflex trunk is not a new concept, but this case revisits it using a contemporary total arterial revascularization strategy. This approach may represent a useful adjunctive option in carefully selected patients with favorable circumflex anatomy.

Objectives: Patients with congenitally corrected transposition of the great arteries (ccTGA) may undergo physiologic repair, leaving the right ventricle systemic, or anatomic repair, correcting the double discordance. We compared both strategies in an international study using propensity-score matching. Methods: Patients from 12 European centres, aged <18 years, who underwent either physiologic or anatomic repair between 1990 and 2010 were included (n = 266). Patients were matched by optimal pair matching on ventricular septal defect, subpulmonary left ventricular outflow tract obstruction, ≥mild systemic tricuspid valve regurgitation, age, and gender, resulting in a 1:1 matched cohort of 162 patients. The resulting groups were compared for long-term survival, reoperations, and function of the systemic ventricle and atrioventricular valve. Results: Transplant-free survival at 10 and 15 years was 87 ± 4%, 95% confidence interval (CI) [79%-95%] and 80 ± 6% [68%-93%] for the physiologic group and 85 ± 5% [78%-96%] and 85 ± 5% [78%-96%] for the anatomic group (P = .568). Freedom from cardiac reoperation at 10 and 15 years was 73 ± 6% [62%-85%] and 56 ± 8% [41%-75%] for the physiologic group and 61 ± 8% [47%-76%] and 36 ± 9% [26%-62%] for the anatomic group (P = .279). Tricuspid valve regurgitation at final follow-up was present in 57% (27/47) vs 17% (12/72), respectively (P < .001). Conclusions: Long-term survival and reoperation rates are similar in comparable patients following physiologic and anatomic repair of ccTGA in childhood. Tricuspid valve function may deteriorate when left in the systemic position following physiologic repair. In contrast, patients with tricuspid regurgitation may benefit from anatomic repair, with improved function in the subpulmonary position.

Revascularization of the circumflex artery territory is challenging due to its anatomical position and technical complexity. We present a novel approach using the proximal circumflex trunk for arterial bypass, ensuring natural antegrade blood flow and avoiding multiple distal anastomoses. This streamlined technique minimizes grafting complications and achieves efficient revascularization in complex left main disease.

OBJECTIVES: This study aims to explore the potential efficacy of the Freestyle Medtronic bioroot in the treatment of aortic endocarditis, based on our single-centre experience. METHODS: In this retrospective study conducted between 2015 and 2023, adult patients who underwent aortic root replacement with coronary arteries reimplantation using the modified Bentall technique with a Medtronic Freestyle bioroot in our centre for infective endocarditis were included. RESULTS: Thirty patients, with five deaths, no cases of relapse and two cases of reinfection, were included, and prosthetic valve endocarditis represented 73.3% of cases. The median age was 66 years (IQR 14.5 years), and 24/30 (80%) were male. Median EuroSCORE II was 12.2% (IQR 13.9%). The most commonly identified pathogen was Staphylococcus aureus (eight cases; 23.3%). Fourteen additional procedures were performed on 12 patients. Annular abscess was present in 73.3% of cases and required annulus patch repair in 13/22 (59%). Early reoperation rate was 20%, mostly for surgical bleeding. One- and 5-year actuarial survival rates were 90.0 and 82.2%, respectively. There were no cases of relapse, and reinfection-free survival was 86.7% at 1 year and 75.5% at 5 years. Postoperative mean and maximal transvalvular gradients were 7 (IQR 3.3 mmHg) and 14.6 mmHg (IQR 4.6 mmHg), respectively. CONCLUSIONS: The Medtronic Freestyle bioroot could be a valid alternative to homografts for the treatment of infective endocarditis, particularly in cases necessitating aortic root reconstruction after extensive debridement of annular abscesses, with comparable outcomes and potential advantages in terms of durability and availability.

MMCTS brings online training for cardio-thoracic surgeons to an entirely new level with step-by-step video demonstrations of surgical procedures, supported by succinct text and clear graphics. It is published as a free service by the European Association for Cardio-Thoracic Surgery.

Background: To compare mid-term clinical outcomes and hemodynamic performance of the stented pericardial Trifecta bioprosthesis for surgical aortic valve replacement (AVR) with a technically comparable commonly used surgical bioprosthesis. Methods: Data from consecutive patients implanted with the TF or the Carpentier Edwards Magna Ease valve were retrospectively analyzed. Primary analysis was performed on a propensity score–matched cohort. Primary endpoints included the composite of death or reoperation and structural valve deterioration. The comparison also included echocardiographic assessments at one-week post-AVR and at the last documented follow-up. Results: Two propensity score–matched groups of 170 patients each were identified from the overall population ( n = 486). Incidence of postoperative mortality (2.9% vs. 7.1%, respectively, p = 0.08), and patient prosthesis mismatch (1.2% and 2.4%, p = 0.41) were similar. At mean follow-up of 5.84 (Trifecta) and 6.1 (Carpentier Edwards) years, the incidence of all-cause death/reoperation (15.3% vs. 15.9%, p = 0.88 for Trifecta and Carpentier Edwards, respectively) and structural valve disease (1.8% vs. 2.9%, p = 0.47) were similar. Overall, postoperative mean transvalvular pressure gradients were significantly lower in the Trifecta group than in the Carpentier Edwards group (7.7 ± 3.3 vs. 11.3 ± 3.6 mmHg, p < 0.01). Mean transvalvular gradient remained significantly lower through the last follow-up for small-sized Trifecta valves (19/21 mm; 10.5 ± 4.2 vs. 13.8 ± 5.9 mmHg, p = 0.039) but not for larger valves (10.3 ± 4.8 vs. 9.4 ± 3.5 mmHg, p = 0.31). Conclusion: The Trifecta valve is a valuable alternative to the Carpentier Edwards valve in terms of safety, hemodynamic performance, and mid-term durability. Smaller-sized valves provide additional clinical benefits, given their persistent hemodynamic advantages through mid-term follow-up.

Complete atrioventricular septal defect is a common congenital malformation. Various surgical corrections coexist. This video tutorial describes a correction that preserves the height of the leaflets by splitting both the anterior and the posterior bridging leaflets and using two patches to close the ventricular septal defect and the atrial septal defect separately.

René Prêtre, MD; Two good and one bad news, European Journal of Cardio-Thoracic Surgery, , ezac343, https://doi.org/10.1093/ejcts/ezac343

We describe a classic trapdoor technique to correct a late presenting, rare congenital heart condition and explain its relative merits.

Background and aim of the study Guidelines indicate for type 5 myocardial infarction (MI) that postoperative troponin need not be exclusively ischemic but may also be caused by epicardial injury. Complexity arises from the introduction of high-sensitive troponin. This study attempts to contribute to the understanding of postoperative high-sensitive cardiac troponin T (hs-cTnT) increase. Methods The median enzyme increase of different cardiac operations was compared. Linear regression analyses were used to determine correlations between enzyme rise and independent parameters. Receiver-operating characteristics (ROC) served to evaluate the discriminatory power of enzyme rise in detecting ischemia and to determine possible thresholds. Results Among 400 patients, 2.8% had intervention-related ischemia analogous to type 5 MI definition. The median postoperative hs-cTnT/creatine kinase myocardial band (CK-MB) increase varied according to types of surgery, with highest increase after mitral valve and lowest after off-pump coronary surgery. After ruling out patients with preoperatively elevated hs-cTnT, regression analysis confirmed Maze procedure (p < .001), intra-pericardial defibrillation (p = .002), emergency intervention (p = .01), blood transfusions (p = .02), and cardiopulmonary bypass time (p = .03) as significant factors associated with hs-cTnT increase. In addition, CK-MB increase was associated with mortality (p = .002). ROC confirmed good discriminatory power for hs-cTnT and CK-MB with ischemia-indicating thresholds of 1705.5 ng/L (hs-cTnT) and 113 U/L (CK-MB) considering different types of operations. Conclusions The Influence of the type of surgery and intervention-related parameters on hs-cTnT increase was confirmed. Potential thresholds indicating perioperative ischemia appear to be significantly elevated for high sensitive markers.