A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Which cannulation (ascending aortic cannulation or peripheral arterial cannulation) is better for acute type A aortic dissection surgery?' Altogether 393 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Femoral artery cannulation has the highest rate of mortality, stroke rate and other complications including retrograde cerebral embolization, organ malperfusion and perfusion of the false lumen. Five out of 14 papers were found to be reporting in favour of axillary (or subclavian) artery cannulation over femoral artery cannulation. In a total of 1829 patients evaluated in these studies, 1068 patients demonstrated a significantly lower complication rate with axillary artery cannulation than femoral artery cannulation. Some of the larger studies showed femoral artery cannulation has higher mortality and stroke rates ranging from 6.5% to 40% and 3% to 17%, respectively. Meanwhile, mortality and stroke rates were ranging from 3% to 8.6% and 1.75% to 4%, respectively, in the favour of axillary artery cannulation. A total of seven studies evaluated direct aortic cannulation for the establishment of cardiopulmonary bypass (CPB). They demonstrated mortality and stroke rates from 0% to 15% and 3.8% to 21%, respectively. Central cannulation has promising results with a lower mortality rate but a higher stroke rate. Direct cannulation of the true lumen is a promising method for quick and easy establishment of CPB. Axillary artery cannulation with a side graft, although it takes more time to construct, is proven to be safe and straightforward, with fewer local and systemic complications including lower mortality and neurological complications.

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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients with an acute type A dissection (TAAD) is a frozen elephant trunk in addition to standard aortic dissection repair advantageous in terms of improved long-term mortality and closure of the distal false lumen? Altogether more than 138 papers were found using the reported search, of which six represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Jakob et al. (23 patients stented vs. 22 patients non-stented), showed similar early outcome but lower false lumen patency rate and lower need of reintervention in the stented group. Pochettino et al. (36 patients stented vs. 42 patients non-stented) reported higher circulatory arrest time and higher incidence of spinal cord and bowel ischemia but a lower false lumen patency rate in stented group. Uchida and co-workers (65 patients stented vs. 55 patients non-stented) reported similar early outcome but better long-term survival and freedom from aortic events in the stented group. Consecutively, Uchida et al. reported the follow-up of the stented group demonstring false lumen thrombosis in all patients one month postoperatively, and complete after three years. Sun and co-workers (107 patients operated with an hybrid approach) showed a hospital mortality of 4.67% and neurological complications rate of 5.6%. At follow-up (35+/-14 months), 95% of the patients had false lumen thrombosis and no distal reoperations were needed. We conclude that the frozen elephant trunk is still rarely adopted during TAAD repair. However, this procedure can be performed safely without increase the operative mortality and morbidity but with an overall higher cardiopulmonary bypass and circulatory arrest time. Spinal cord ischemia and malperfusion syndrome represents the main complications associated with this procedure. Despite few studies, this procedure seems to allow early thrombosis of the false lumen and a reduction of late thoraco-abdominal aneurysm formation and reoperations rate.

Background & Objectives:Vascular injury diagnosis and management can be challenging and need expert clinical judgments. The current study aims to present diagnostic methods and management outcome in vascular injury patients attending our centre.Materials & Methods: The study  is a prospective study conducted during the study period of one and half years (From January 2015 to June 2016). Diagnosis of vascular injury was done by clinical examination, hand Doppler or in conjugation with duplex scan/CT Angiography. Primary vascular repair with end to end anastomosis was carried out whenever technically feasible; however, if it was not possible interposition reversed saphenous graft (SVG) was used to complete the repair.Results:Out of hundred cases of vascular injury, 77% were male and 23% female with a mean age of 35.18± 16.93 years. The majority of the cases 53% were diagnosed by duplex study followed by additional imaging by CT angiography in 30% cases and 17% cases were diagnosed only on clinical judgment. The main type of vascular injury was a complete transaction in 62% of cases followed by complex wall defect in 22%. The most common type of vascular reconstruction was end-end anastomosis in 76% of cases followed by ligation and haemostasis in 13% and reverse SVG graft repair in six percent of cases.Conclusion:The study concluded with the observation that early presentation, diagnosis and management including initial resuscitation and definitive multi-specialist surgical approach are paramount for excellent outcome after vascular injury.

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We report our institutional experience, with 25 consecutive patients with patent coronary artery bypass grafts (71.8+/-12.7 years), who underwent video-assisted minithoracotomic approach for mitral valve surgery. The surgical technique includes: right minithoracotomy, femoral cannulation and hypothermic ventricular fibrillation. Mean preoperative EuroSCORE was 10.2+/-2.4 and mean ejection fraction was 45+/-9%. Operative mortality was 4% (1/25). No patient required a conversion to sternotomy. Procedures performed were: mitral valve repair in 15 patients (60%), replacement in 10 (40%) and associated tricuspid repair in seven (28%). Mean blood transfusion was 1.2 package/patient. No cardiological, neurological, vascular and wound complications were observed. Postoperative major morbidity includes: severe pulmonary dysfunction in two patients (8%) and acute renal failure in one (4%). Mean ICU and hospital stay were 3.4+/-2.9 and 10.6+/-7.9 days. Echocardiographic follow-up (22.8+/-14.9 months) revealed trace or mild mitral valve regurgitation in all the mitral repair patients. When interrogated, all the surviving patients preferred the minithoracotomic approach rather than the sternotomy. In conclusion, minimally invasive right thoracotomy can be safely performed in patients with functioning coronary bypass grafts requiring mitral valve operation. Low blood transfusion, the avoidance of deep wound infection and the high patient satisfaction are the main advantages of this approach.

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Background Destination left ventricular assist device placement is increasing as a result of donor shortages and changing patient attitudes. As organ shortages become critical, LVAD programs become fundamental even in more remote regions of the world including island states. Here, we provide a look into the current state and availability of LVAD programs in island states. Main body A narrative review was performed using the World Health Organization Global Index Medicus and PubMed/MEDLINE databases to identify articles describing the island states having reported LVAD placements and programs. Additionally, INTERMACS reports were used. Data were retrieved and a review is presented describing the current state of LVADs in island states. The Caribbean region as a whole has a heart failure (HF) prevalence of 814 per 100,000 and Oceania 667 per 100,000 people. We estimate that over 3000 people in these islands need either a heart transplant or an LVAD. Short conclusion For HF patients living in island regions, special attention should be paid to the inability of having access to specialized mainland medical care. The continuous quest for a solution to HF in island regions should include the establishing of high-quality LVAD programs in a transfer-network centralized/regionalized system to care for those patients not candidates for long-distance air-bridging.