The MitraClip technique has been increasingly used for correction of mitral valve regurgitation in patients in whom surgical mitral repair is considered contraindicated or very risky, but off label use occurs often. Failure of the procedure, translated into moderate to severe rates of residual or recurrent mitral regurgitation, is observed in up to one-third of the patients, and surgery has been used to correct it in a number of cases, in what can be called an “operation for the inoperable”. That is precisely the subtitle of a paper published in this issue of the JOCS by Gerfen and colleagues, who analyse their institutional experience with a series of 17 patients. In this Editorial, I comment on this series and the possible reasons for failure of the MitraClip, and on the indications for reintervention and its constraints, which I hope can contribute to the discussion about “further exploration and refinement of patient selection criteria and identify predictors for MitraClip failure”, as the authors suggest.

This paper, among other findings, affirmed Society of Thoracic Surgeons' published risk model for stroke after isolated CABG, that pre-existing cerebrovascular disease, prior MI, reduced EF and poor renal function as independent risk factors for peri-operative CVA.

Title Page Title: Letter to the Editor: ”Urinary TIMP-2 and IGFBP-7 protein levels as early predictors of acute kidney injury after cardiac surgery”.Article type: Letter to the editor.

Pump thrombosis is a rare and infrequent complication of HeartMate III left ventricular assist device (LVAD). While there are reports of pump thrombosis in the postoperative period, to our knowledge, there have been no prior reports on pump thrombosis in the intraoperative period. Here we present a case of a 24-year-old female who required HeartMate III LVAD implantation for progressive heart failure and the intraoperative period was complicated with pump thrombosis (PT). Managing PT in the intraoperative period is challenging and time-sensitive because of its rare occurrence and paucity of recommendations in diagnosing the PT.

Title: Letter to the Editor: Management of aortic arch hypoplasia in neonates and infantsArticle type : Letter to the Editor.Correspondence: 1. Maida QaziContact: 03332132159 Email: maidaqazi10@gmail.comInstitution: DOW University Of Health SciencesAddress: Bihar Colony, Al-Falah Road, Karachi.Co-authors : 2. Satesh KumarContact: +923325252902 Email: kewlanisatish@gmail.comInstitute: Shaheed Mohtarma Benazir Bhutto Medical College Liyari, KarachiAddress: Parsa citi, Garden East, Karachi

Aortic valve stenosis is the most common adult valve disease in industrialized countries. The ageing population and the increase in comorbidities urge the development of safer alternatives to the current surgical treatment. Sutureless bioprosthesis have shown promising results, especially in complex procedures and in patients requiring concomitant surgeries. Objectives: Assess the clinical and hemodynamic performance, safety, and durability of the Perceval ® prosthetic valve. Methods: This single center retrospective longitudinal cohort study collected data of all adult patients with aortic valve disease who underwent aortic valve replacement with a Perceval ® prosthetic valve between February 2015 and October 2020. Of the 196 patients included (mean age 77.20±5.08 years; 45.4% female; mean EuroSCORE II 2.91±2.20%), the majority had aortic stenosis. Results: Overall mean cross-clamp and cardiopulmonary bypass times were 33.31±14.09 and 45.55±19.04 minutes, respectively. Mean ICU and hospital stay were 3.32±3.24 and 7.70±5.82 days, respectively. Procedural success was 98,99%, as two explants occurred. 4 valves were reimplanted due to intra-operative misplacement. Mean transvalvular gradients were 7.82±3.62 mmHg. Pacemaker implantation occurred in 12.8% of patients, new-onset atrial fibrillation in 21.9% and renal replacement support was necessary in 3.1%. Early mortality was 2.0%.  We report no structural valve deterioration, strokes or endocarditis and one successfully treated valve thrombosis. Conclusions: Our study confirms the excellent clinical and hemodynamic performance and safety of a truly sutureless aortic valve, up to 5-year follow-up. These results were consistent in isolated and concomitant interventions, solidifying this device as a viable option for treatment of isolated aortic valve disease.

81-year-old man with a history of Bio-Bentall surgery presented to the emergency department with fever, chills and back pain. Initial physical examination was inconclusive apart from sudden onset of delirium, and investigation showed elevated WBCs, anemia, and neutrophilia. Further studies revealed gram-positive cocci on the initial blood culture, which was then confirmed to be MSSA bacteremia. Subsequently, a TEE showed a peri-aortic abscess, Moderate AR and severe AS with no evidence of endocarditis. Antibiotics were started and urgent abscess drainage was planned. In a hybrid operative setting, a multidisciplinary team of cardiology, and cardiac surgery managed the periaortic graft abscess drainage through a median sternotomy and TAVR. Post-operatively, the complications included bradycardia, and RHF. Six-week course of IV Rifampin, Probenecid and Cefazolin was initiated, and patient was to remain on lifelong Cefadroxil.

Caseous liquefaction necrosis of mitral annular calcifications are rare. Rupture of its capsule may lead to systemic embolization. Surgical management entails Incision and Drainage with either mitral valve repair or replacement.

A document by Dr. Muhammad Shehryar. Click on the document to view its contents.

Title pageTitle: Reply to Jasinski M et al.: ´Indeed, there is still room for improvement in long‐term durability of BAV repair´Authors: Tomas Holubec, MD, PhD, Mojyan Safari, MD, Arnaud Van Linden, MD, Anton Moritz, MDInstitutions and Affiliations: Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, Frankfurt, GermanyCorresponding author: Assoc. Prof. Tomas Holubec, MD, PhD, Theodor-Stern-Kai 7, 60596 Frankfurt/Main, Germany, Tel.: +49 69 6301 80094, Email: tomasholubec@email.cz

- The Gerbode type of ventricular septal defect is rare and can be congenital or acquired. - The defect can be closed retrograde or through the transvenous approach. - Short term follow-up suggests that transcatheter closure of the Gerbode type defect is feasible, safe, and effective and should be considered an alternative to surgical repair

Significant dilemma exists regarding management of the aortic root pathology in acute aortic dissections. Several strategies for both repair and replacement exist and there is a lack of clarity on the superiority of one over the other. Important factors that influence management strategies include involvement of the sinuses, competence of the aortic valve, presence of Marfan's syndrome and connective tissue disorders, as well as availability of surgical expertise. The wide variability in these factors makes it unlikely for any one technique to be suitable for management of all aortic roots and the root pathology has to be tailored to an individual patient.

Redo cardiac surgery can present a unique set of challenges even to the experienced surgeon. Although outcomes have steadily improved in the modern era; if an intraoperative adverse event occurs, there is a 5% incidence of mortality and 19% incidence of myocardial infarction, stroke or death [(1)](#ref-0001). Overall, the modern incidence of mortality at reoperation varies but be segregated into low and higher risk cohorts depending on the planning computed tomography imaging and risk to substernal structures on re-entry [(2, 3)](#ref-0002). Patients with ascending aortic or root pseudoaneurysms represent a particularly difficult subset of high-risk patients requiring re-operative cardiac surgery due to the danger of exsanguination and air embolization [(4)](#ref-0004). Some surgeons advocate the use of deep hypothermic circulatory arrest (DHCA) to achieve safe re-entry in such cases however this can result in unpredictable DHCA duration depending on the degree of pericardial adhesions [(5)](#ref-0005). We report a case of aortic pseudoaneurysm in a patient with patent coronary grafts managed using an endoballoon precisely positioned relative to the proximal anastomoses resulting in a safe surgical re-entry and shorter DHCA time.

Title Page:Title: Letter To The Editor: Long-Term Renal Function After Venoarterial Extracorporeal Membrane Oxygenation.Article Type: Letter To The EditorCorrespondence: 1. Rohit KumarContact No: +923332669103 Email: rohitkella001@gmail.comInstitute: Dow Medical CollegeAddress: Baba-e-urdu road, KarachiCo-Authors: 2. Sunil KumarContact No: +923008088669. Email: dr.sunilkumar@hotmail.comInstitute: Liaquat University of Medical and Health Sciences.Word Count: 476Conflict of interest : NoneAcknowledgment : NoneDeclaration: NoneDisclosure : NoneFunding : None

Management of aortic arch pathologies remains challenging. Open total arch replacements have been associated with significant morbidity and mortality owing to the need for cardiopulmonary bypass and circulatory arrest. On the other hand, aortic arch branched stent grafts are not widely available. In this context, hybrid techniques combining open arch debranching with endovascular graft placement have been identified as an attractive option in select patients. However, there still is a paucity of literature on their application and outcomes. A case is presented of an elderly frail patient diagnosed with a pseudoaneurysm of the aortic arch and who was successfully treated by an off-pump arch debranching followed by endovascular arch repair. This case highlights (i) the feasibility of hybrid debranching techniques, (ii) their technical challenges, and (iii) the need for long-term follow-up data.

Although mid- and long-term outcomes after the Ross procedure for aortic valve disease have been increasingly improving over the years, this is still a rather challenging operation in neonates and small children. This is particularly true for patients with associated congenital heart defects and critical clinical conditions. Herein we describe the application of this procedure as a rescue operation in emergency circumstances in a low-birth-weight neonate with severe aortic stenosis, aortic regurgitation and mitral regurgitation after a previous aortic coartectomy.

Background and Aim: We assessed the anatomical variations in coronary arterial patterns relative to the techniques of reimplantation in the setting of the arterial switch operation, relating the variations to influences on outcomes. Methods: We reviewed pertinent published investigations, assessing events reported following varied surgical techniques for reimplantation of the coronary arteries in the setting of the arterial switch procedure. Results: The prevalence of reported adverse events, subsequent to reimplantation, varied from 2% to 11%, with a bimodal presentation of high early and low late incidence. The intramural pattern continues to contribute to mortality, with some reports of 28% fatality. The presence of abnormal course relative to the arterial pedicles in the setting of single sinus origin was associated with a three-fold increase in mortality. Abnormal looping with bisinusal origin of arteries was not associated with increased risk. Conclusion: The techniques of transfer of the coronary arteries can be individually adapted to cater for the anatomical variations. Cardiac surgeons, therefore, need to be familiar with the myriad creative options available to achieve successful repair when there is challenging anatomy. Long-term follow-up will be required to affirm the superiority of any specific individual technique. Detailed multiplanar computed-tomographic scanning can now reveal all the variants, and elucidate the mechanisms of late complications. Coronary angioplasty or surgical revascularization may be considered in selected cases subsequent to the switch procedure.

Background We evaluated short- and mid-term outcomes with use of aortic valve-sparing root replacement to treat bicuspid aortic valves. Methods From December 2007 to January 2022, all patients with bicuspid aortic valves who underwent aortic root replacement using Tirone’s procedure were included. This study based on department database information for retrospective and follow-up data. Results Among 51 adults undergoing aortic root replacement using Tirone’s procedure, the mean age was 47.4±12.5 years, and most were men (92.2%). Three presented with a dysmorphic syndrome and one had Marfan’s syndrome. All patients were alive at 30 days, and as of January 2022, 45 were alive, two were lost to follow-up, and there were four noncardiac deaths. Two patients had infectious endocarditis and needed a Bentall’s procedure. One patient had a double biologic valve replacement in the context of severe mitral insufficiency with moderate aortic stenosis at 4.5 years post-procedure. Echocardiographic follow-up showed a left ventricular ejection fraction of 63±7% (n=36), V max 2±0.6 m/s (n=17), and a mean gradient of 9.4±5.4 mmHg (n=27). No patients had grade 3 or 4 aortic regurgitation, one patient had grade 2, and four had grade 1. Conclusion Tirone’s procedure is an option for bicuspid aortic valve surgery, with good safety and outcomes, especially in younger patients.