A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether posterior pericardiotomy (PP) reduces the incidence of atrial fibrillation (AF) after coronary artery bypass grafting surgery. Twelve papers were found using the reported search, of which seven 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 were tabulated. One non-randomized prospective cohort controlled study generated early evidence that PP reduced the rate of postoperative AF and pericardial effusion. The operative details of PP were clearly explained in this paper. The efficacy of this procedure was subsequently examined in five prospective randomized controlled trials performed with some limitations, listed in the table. Meta-analysis of the randomized control trials examined a group of 763 patients (PP = 389, control = 374). It revealed a highly significant reduction in total arrhythmias and AF in the PP group (odds ratio 0.31 and 0.33, respectively). There was a 10.8% AF rate in the PP group (41/379) and a 28.1% AF rate in the control group (108/384). Furthermore, the PP group had a significant reduction in the rate of early and late pericardial effusion (P < 0.001). Moreover, the reduction in the incidence of arrhythmias was significantly associated with the reduction in the incidence of pericardial effusion. Referring to these studies, two guidelines recommend PP to reduce postoperative AF with grade B strength of recommendation. We conclude that PP significantly reduces the incidence of postoperative AF. The number needed to treat to prevent one case of AF is six.

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Avulsion of a graft after coronary artery bypass grafting surgery is a rare but very serious complication which leads to massive bleeding and possible life-threatening cardiac tamponade. In this paper we report a very rare case of a left internal mammary artery graft avulsion on the day of surgery in a patient with syphilis.

A 58-year-old woman presented with decompensated rheumatic mitral valve stenosis and was evaluated for surgery. Preoperative chest radiography revealed a circumscribed mass shadow in the right upper lobe area ( Figure 1A). Computed tomography angiography showed multiple pulmonary arteriovenous malformations between the right upper lobe artery and the left atrium ( Figure 1B). Pulmonary arteriography revealed a massive right-to-left shunt through the malformations (Video 1). The patient underwent uneventful mitral valve replacement and a right upper lobectomy.

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<p><strong>Aim.</strong> Postoperative atrial fibrillation is one of the most frequent complications in cardiac surgery. The aim of this trial was to evaluate the effectiveness of posterior pericardiotomy in the prevention of postoperative atrial fibrillation and pericardial effusion in patients undergoing isolated primary aortic valve replacement.<br /><strong>Methods.</strong> The trial was approved by the local ethics committee. It included adult patients under 70 y.o. who had signed the informed consent for participation in the study and who were planned to undergo isolated primary aortic valve replacement. Exclusion criteria were a history of atrial fibrillation, hyperthyroidism, amiodarone intake, severe chronic obstructive pulmonary disease, left ventricle ejection fraction less than 30%, the size of the left atrium exceeding 50 mm, active infective endocarditis, the presence of adhesions in the pericardium and/or left pleural cavity and mini-sternotomy. From October 2013 to April 2015 607 patients in our clinic underwent different aortic valve procedures. 507 patients were excluded from the study because of the inclusion and exclusion criteria. The remaining 100 patients were randomized into two groups: 49 patients underwent posterior pericardiotomy and 51 patients made up the control group. In both groups the frequency of postoperative atrial fibrillation, pericardial effusion greater than 5 mm, surgery-discharge time, as well as posterior-pericardiotomy-related complications were studied. Trial number: ISRCTN11129539.<br /><strong>Results.</strong> There were no deaths, stroke or cardiac tamponade during the postoperative stay. Neither were there any complications associated with the performance of posterior pericardiotomy. The incidence of atrial fibrillation, pericardial effusion and average duration of the postoperative stay were similar in both groups: 16% in posterior pericardiotomy group vs 14% in the control group (p=0.71), 10% in posterior pericardiotomy group vs 12% in the control group (p=0.80) and 12.4±4.3 days in posterior pericardiotomy group vs 11.9±4.1 days in the control group (p=0.27), respectively.<br /><strong>Conclusion.</strong> The trial did not confirm the effectiveness of posterior pericardiotomy in preventing postoperative atrial fibrillation and pericardial effusion during the in-hospital period after isolated primary aortic valve replacement in low risk patients. However, further investigations are needed.</p><p>Received 1 December 2016. Accepted 14 February 2017.</p><p><strong>Funding:</strong> The trial was carried out within the dissertation research and according to the research calendar of Kuban State Medical University. There was no additional funding except for the resources allocated for postgraduate scholarships.</p><p><strong>Conflict of interest:</strong> The authors declare no conflict of interest.</p><p><strong>Author contributions</strong><br />Conception and study design: V.I. Kaleda, K.O. Barbuhatti.<br />Data collection and analysis: V.I. Kaleda, S.Yu. Boldyrev, S.A. Belash, I.I. Yakuba, S.S. Babeshko, I.A. Belan. <br />Drafting the article: V.I. Kaleda.<br />Critical revision of the article: V.I. Kaleda.<br />Final approval of the version to be published: V.I. Kaleda, S.Yu. Boldyrev, S.A. Belash, I.I. Yakuba, S.S. Babeshko, I.A. Belan, K.O. Barbuhatti.</p><p><strong>Acknowledgements:</strong> The authors would like to express their gratitude to Cand. Sci. (Engineering) V.P. Leonov (“Biometrika”) for assistance in statistical data processing.</p>

There are several approaches to venous cannulation in minimally invasive aortic valve surgery. Frequently used options include central dual-stage right atrial cannulation, or peripheral femoral venous cannulation. During minimally invasive aortic surgery via an upper hemisternotomy, central venous cannulas may obstruct the surgeon’s visualization of the aortic valve and root, or require extension of the skin incision, while femoral venous cannulation requires an additional incision, time and resources. Here we describe a technique for central venous cannulation during minimally invasive aortic surgery, utilizing a novel device, to facilitate simple, convenient, and expedient central cannulation with a cannula-free surgical working space.

Аномалии развития коронарных артерий довольно редки. Они встречаются примерно у 0,2-1,3% больных, которым вы-полняют коронарографию [1]. Отхождение огибающей артерии (ОА) от правой коронарной артерии (ПКА) или правого коронар-ного синуса Вальсальвы с последующим ходом позади аорты (рис. 1) -самая частая аномалия, доля которой составляет около 60% от всех аномалий коронарных артерий [4]. Сама по себе эта аномалия имеет доброкачественное течение, однако при проте-зировании аортального клапана (АК) в силу анатомических осо-бенностей существует риск ишемии миокарда вследствие недо-статочной защиты миокарда, повреждения (прошивания) ано-мальной артерии или сдавления манжетой протеза клапана, а также перианнулярной гематомой [2,15]. В статье представлено наблю дение окклюзии аномальной ОА из-за сдавления манже-той протеза АК. Участок окклюзии успешно стентирован. Клиническое наблюдениеБольной Н., 61 года, поступил с клиникой аортального сте-ноза (одышка, приступы стенокардии при умеренной физиче-ской нагрузке) для хирургического лечения. При эхокардиогра-фии выявили двустворчатый АК со средним градиентом давле-ния 62 мм рт.ст., незначительной регургитацией и фиброзным кольцом диаметром 25 мм. Фракция выброса левого желудочка сохранена. При коронарографии выявили стеноз 75% в передней нисходящей артерии, а также аномальное отхождение ОА от пра-вого коронарного синуса с ретроаортальным ходом при выражен-ном левом типе кровоснабжения миокарда (рис. 2, а). Расчетная площадь поверхности тела больного составила 2,1 м 2 . Выполнили операции: коронарное шунтирование передней нисходящей ар-терии левой внутренней грудной артерией, протезирование АК протезом Carbomedics 25 мм. Применили антеградную неселек-тивную кардиоплегию. После снятия зажима с аорты на кардио-мониторе наблюдали широкие желудочковые комплексы с пере-ходом в узловой ритм. Подшиты временные электроды, начата электрокардиостимуляция (ЭКС). Больного перевели в реанима-цию с инотропной поддержкой адреналином в дозе 0,2 мкг/кг/ мин. В реанимации ритм ЭКС, без ЭКС -узловой ритм, эпизод желудочковой тахикардии, подъем сегмента ST в отведениях II, III, aVF, в боковых грудных отведениях. Установили внутриаор-тальный баллон для контрпульсации, больного транспортирова-ли в рентгенооперационную. При контрольной коронарошунто-графии выявили окклюзию аномальной ОА в области фиброзно-го кольца АК (см. рис. 2, б). Реканализацию со стентированием участка окклюзии ОА провели успешно, получили кровоток TIMI 3 (см. рис. 2, в). Последующий послеоперационный период протекал без особенностей: быстрая нормализация гемодинами-ки, в реанимации больной провел 2 сут, выписан на 20-е сутки после операции в удовлетворительном состоянии. При эхокарди-ографии перед выпиской отмечали снижение фракции выброса левого желудочка до 45%. Рецидивов стенокардии не наблюдали. ОбсуждениеПредставленный клинический случай иллюстрирует необ-ходимость знания вариантной анатомии коронарных артерий, так как наличие аномальной ОА при проведении кардиохирурги-ческих операций вносит свои особенности в их такт...