TITLE: Letter to the Editor: Association between time to therapeutic INR and length of stay following mechanical heart valve surgeryARTICLE TYPE: letter to the editor

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TITLE: Letter to the Editor: The choice of palliative arterial switch operation as an alternative for selected cases in a single center: Experience and midterm resultsARTICLE TYPE: letter to the editorCORRESPONDENCE: 1 . Arun KumarContact: +92 331 3856579 Email: [email protected]: Ghulam Muhammad Mahar Medical College, SukkurAddress: Flat No 108 Columbus Tower Teen Talwar Karachi

The future of CABG can be bright if cardiac surgeons will change the paradigm followed so far and will return in history, abandoning the current comfortable life and accepting the burden represented by the cost of innovation, which has a path already mapped out but not sufficiently trodden for guilty lack of commitment.

Title Page:Title: Letter To The Editor: Gastrointestinal complications after cardiac surgery: Incidence, predictors, and impact on outcomesArticle Type: Letter To The EditorCorrespondence: 1. Sapna goindaniContact no: +971 54 344 9435. Email: [email protected]: Peoples University of Medical and Health Sciences For Women (PUMHSW)Address: Flat no 9, building no 10 bastakia building, Al hamriya bur dubai, dubaiORCID: 0000-0003-4906-8463Co-Authors: 2. Roomi rajaContact No: +92-3342946940. Email: [email protected]: Ziauddin University KarachiAddress: Hemilton Courts Block G-1 Flat 408 Near Teen Talwar Clifton KarachiORCID: 0000-0001-9104-3644Co-Authors: 3. Satesh KumarContact No: +92-3325252902. Email: [email protected]: Shaheed Mohtarma Benazir Bhutto Medical College Liyari, KarachiAddress: Parsa Citi Garden East, KarachiORCID: 0000-0001-7975-6297Word Count: 340Conflict of interest : NoneAcknowledgment : NoneDeclaration: NoneDisclosure : NoneFunding : None

Title pageTitle : Letter to the Editor: What are the factors affecting the progression of kidney failure mortality and morbidity after cardiac surgery in patients with chronic kidney disease”.Article type: Letter to the editorCorrespondence: 1. Hafsa ArifContact: +923092446917 Email : [email protected]: Jinnah Sindh medical university.Address: R141 salman garden malir, karachi.

Background: We aimed to determine the relationship between HbA1c levels and the development of postoperative atrial fibrillation (PoAF) . Methods: 288 patients diagnosed with diabet and undergoing on-pump coronary bypass were included in the study. Those with serum HbA1c levels between 5.5-7.0% were defined as Group 1, those with serum HbA1c levels between 7.1-8.9% were defined as group 2, while those with serum HbA1c levels 9.0% and above formed Group 3. Data between groups were compared. The predictive values of the independent variables for the development of PoAF were measured. Results: We did not found difference between groups in terms of development PoAF (p=0.170). Presence of hypertension was determined as an independent predictor for the development of PoAF (p=0.003) but not HbA1c levels (p=0.134). There was 50.5% sensitivity and 61.1% specificity for HbA1c values of 9.06% and above to predict PoAF (AUC: 0.571, p=0.049) Conclusions: HbA1c levels were not an independent predictor of PoAF development. However, we think that high HbA1c levels may be a risk factor for the development of PoAF.

Title Page:Title: Letter to the Editor: Intraoperative renal hypoxia and risk of cardiac surgery-associated acute kidney injuryArticle Type: Letter to the EditorCorrespondence: 1. Roomi RajaContact No: +92-3342946940. Email: [email protected]: Ziauddin University KarachiAddress: Hemilton Courts Block G-1 Flat 408 Near Teen Talwar Clifton KarachiORCID: 0000-0001-9104-3644Co-Authors: 2. Muhammad fahad AminContact No: +92-3408056755. Email: [email protected]: Ziauddin university karachiAddress: 128/2 14th street off khayaban e muhafiz phase 6 defence housing authority karachiORCID: 0000-0003-1861-5313Co-Authors: 3. Satesh KumarContact No: +92-3325252902. Email: [email protected]: Shaheed Mohtarma Benazir Bhutto Medical College Liyari, KarachiAddress: Parsa Citi Garden East, KarachiORCID: 0000-0001-7975-6297Word Count: 302

ECMO is a selectively available therapeutic option, generally at a large-size referral healthcare system. In a single-center experience of use of veno-venous ECMO for COVID-19 ARDS in a medium-size healthcare system during the pandemic, West and colleagues in their study have convincingly demonstrated that ECMO can become a broadly available therapeutic option without compromising quality.

Title Page:Title: Letter to the Editor: Longer-Term Outcomes after Bicuspid Aortic Valve Repair In 142 Patients.Article Type: Letter to the EditorCorrespondence: 1. Roomi RajaContact No: +92-3342946940. Email: [email protected]: Ziauddin University KarachiAddress: Hemilton Courts Block G-1 Flat 408 Near Teen Talwar Clifton KarachiCo-Authors: 2. Satesh KumarContact No: +92-3325252902. Email: [email protected]: Shaheed Mohtarma Benazir Bhutto Medical College Liyari, KarachiAddress: Parsa Citi Garden East, KarachiWord Count: 335

Title Page:Title: Letter To The Editor: Long-Term Renal Function After Venoarterial Extracorporeal Membrane Oxygenation.Article Type: Letter To The EditorCorrespondence: 1. Sapna GoindaniContact No: +971 54 344 9435. Email: [email protected]: Peoples University Of Medical And Health Sciences For Women (Pumhsw)Address: Flat No 9, Building No 10 Bastakia Building, Al Hamriya Bur Dubai, DubaiOrcid: 0000-0003-4906-8463Co-Authors: 2. Muhammad Abdullah KhanContact No: +923032992689. Email: [email protected]: Ziauddin University KarachiAddress: House No R 133 Block 11 Gulshan E Iqbal KarachiOrcid: 0000-0002-0653-5060Co-Authors: 3. Satesh KumarContact No: +92-3325252902. Email: [email protected]: Shaheed Mohtarma Benazir Bhutto Medical College Liyari, KarachiAddress: Parsa Citi Garden East, KarachiORCID: 0000-0001-7975-6297Word Count: 354Conflict of interest : NoneAcknowledgment : NoneDeclaration: NoneDisclosure : NoneFunding : None

Background: Atrial fibrillation (AF) is common in patients with reduced left ventricle ejection fraction (RLVEF). The impact of concomitant surgical atrial fibrillation ablation (SAFA) in patients with RLVEF is uncertain. The purpose of this study was to assess the outcomes of concomitant SAFA in patients with RLVEF undergoing heart surgery on heart failure (HF) rehospitalization and mortality. Methods: Using a local registry and electronic health records linked with provincial civil register survival data from July 2002 to April 2019, we analyzed treatment and outcomes in a cohort of patients with AF and HF defined by left ventricle ejection fraction (LVEF) ≤ 40%. Health records were used to collect treatment and International Classification of Diseases (ICD 10) codes to determine outcomes. A negative binomial model was used to compare outcomes such as all-cause mortality and rehospitalization for heart failure. Results: The cohort included 682 patients with RLVEF and AF who underwent coronary artery bypass graft and/or valve surgery. A total of 196 patients (29%) underwent concomitant SAFA. After matching, 132 patients with concomitant SAFA were compared to 159 patients who did not undergo concomitant SAFA. At 6.0±3.7 years of follow-up, concomitant SAFA was not associated with lower all-cause mortality (P=0.9861) and reduction in rehospitalizations for heart failure decompensation (P=0.31) compared to patients who did not have concomitant SAFA performed. Post-operatively, concomitant SAFA might be associated with less vasopressor and mechanical support use (p=0.01). Conclusions: Concomitant SAFA during index cardiac surgery is safe but does not reduce mortality or rehospitalizations for HF. The effects of concomitant SAFA in the context of RLVEF needs to be better studied with prospective trials.

Patients suffering retrograde type A dissection after TEVAR for type B dissection are at a higher risk of mortality than their spontanous counterparts and the kind of optimal therapy remains obscure. We present a rare case of successful open surgical repair where distal open anastomosis was accomplished cutting off the un-covered stent portion and suturing a vascular prosthesis to the dissected distal aortic arch including the covered stent part. The clinical course was regular. Immediate and radical repair in the aortic arch may be the adequate response in such instances.

Background: Acute type B aortic dissection (TBAD) is a rare condition that can be divided into complicated (CoTBAD) and uncomplicated (UnCoTBAD) based on certain presenting clinical and radiological features, with UnCoTBAD constituting the majority of TBAD cases. The classification of TBAD directly affects the treatment pathway taken, however, there remains confusion as to exactly what differentiates complicated from uncomplicated TBAD. Aims: The scope of this review is to delineate the literature defining the intervention parameters for UnCoTBAD. Methods: A comprehensive literature search was conducted using multiple electronic databases including PubMed, Scopus, and EMBASE to collate and summarize all research evidence on intervention parameters and protocols for UnCoTBAD. Results: A TBAD without evidence of malperfusion or rupture might be classified as uncomplicated but there remains a subgroup who might exhibit high-risk features. Two clinical features representative of “high risk” are refractory pain and persistent hypertension. First line treatment for CoTBAD is TEVAR, and whilst this has also proven its safety and effectiveness in UnCoTBAD, it is still being managed conservatively. However, TBAD is a dynamic pathology and a significant proportion of UnCoTBADs can progress to become complicated, thus necessitating more complex intervention. While the “high risk” UnCoTBAD do benefit the most from TEVAR, yet, the defining parameters are still debatable as this benefit can be extended to a wider UnCoTBAD population. Conclusion: Uncomplicated TBAD remains a misnomer as it is frequently representative of a complex ongoing disease process requiring very close monitoring in a critical care setting. A clear diagnostic pathway may improve decision making following a diagnosis of UnCoTBAD. Choice of treatment still predominantly depends on when an equilibrium might be reached where the risks of TEVAR outweigh the natural history of the dissection in both the short- and long-term.

Objectives: Female sex is considered a risk factor for mortality and morbidity following cardiac surgery. This study is the first to review the UK adult cardiac surgery national database to compare outcomes following surgical coronary revascularisation and valvular procedures between females and males. Methods: Using data from National Adult Cardiac Surgery Audit (NACSA), we identified all elective and urgent, isolated coronary artery by-pass grafting (CABG), aortic valve replacement (AVR) and mitral valve replacement/repair (MVR) procedures from 2010-2018. We compared baseline data, operative data and outcomes of mortality, stroke, renal failure, deep sternal wound infection, return to theatre for bleeding and length of hospital stay. Multivariable mixed-effect logistical/linear regression models were used to assess relationships between sex and outcomes, adjusting for baseline characteristics. Results: Females, compared to males, had greater odds of experiencing 30-day mortality (CABG OR 1.76, CI 1.47-2.09, p<0.001; AVR OR 1.59, CI 1.27-1.99, p<0.001; MVR OR 1.37, CI 1.09-1.71, p=0.006). After CABG, females also had higher rates of post-operative dialysis (OR 1.31, CI 1.12-1.52, p<0.001), deep sternal wound infections (OR 1.43, CI 1.11-1.83, p=0.005) and longer length of hospital stay (Beta 1.2, CI 1.0-1.4, p<0.001) compared to males. Female sex was protective against returning to theatre for post-operative bleeding following CABG (OR 0.76, CI 0.65-0.87, p<0.001) and AVR (OR 0.72, CI 0.61-0.84, p<0.001). Conclusion: Females in the UK have an increased risk of short-term mortality after cardiac surgery compared to males. This highlights the need to focus on the understanding of the causes behind these disparities and implementation of strategies to improve outcomes in females.

Introduction Anomalous aortic origin of coronary artery (AAOCA) is the second leading cause of sudden cardiac death in children and young adults. Intramural-interarterial course is the most frequent anatomic variation and coronary unroofing is widest adopted for surgical management. Symptoms recurrence is described regardless of the technique used. This study aims to describe how an anatomic patient-centered approach aimed to restore a normal coronary artery take-off is associated with symptoms resolution. Methods From 2008 to 2021, 25 patients were operated on for an AAOCA at a median age of 20 years. Nineteen patients had a right AAOCA and six had left AAOCA. Intramural course was present in 18 patients. Seventy-six percent were symptomatic. No episodes of aborted sudden cardiac death before surgery was described in the population. Surgical technique used were coronary unroofing in 18 patients, coronary neo-ostioplasty in 3, coronary re-implantation in 3 and main pulmonary artery re-location in one. Results No hospital mortality or re-operation was observed in our experience as well as major complications related to surgery. Mean hospital length of stay was 8.5 days. None of patients reported symptoms recurrence at follow-up. Young athletes returned to play competitive sport. Postoperative computed-tomography scan evaluation showed a general improvement of the take-off angle. Conclusions AAOCA requires a patient anatomic-based surgical management. There is not a single surgical technique that can fits all anatomic subtype of AAOCA. Surgical techniques may be selected on the base of the preoperative images and intraoperative findings. In our experience this policy is associated with no symptoms recurrence.

Background and Aim: To review the anatomical details, diagnostic challenges, associated cardiovascular anomalies, and techniques and outcomes of management, including re-interventions, for the rare instances of transposition physiology with concordant ventriculo-arterial connections. Methods: We reviewed clinical and necropsy studies on diagnosis and surgical treatment of individuals with transposition physiology and concordant ventriculo-arterial connections, analyzing also individuals with comparable flow patterns in the setting of isomerism. Results: Among reported cases, just over two-thirds were diagnosed during surgery, after initial palliation, or after necropsy. Of the patients, four-fifths presented in infancy with either cyanosis or congestive cardiac failure, with complex associated cardiac malformations. Nearly half had ventricular septal defects, and one-fifth had abnormalities of the tricuspid valve, including hypoplasia of the morphologically right ventricle. A small minority had common atrioventricular junctions We included cases reported with isomerism when the flow patterns were comparable, although the atrioventricular connections are mixed in this setting. Management mostly involved construction of intraatrial baffles, along with correction of coexisting anomalies, either together or multi-staged. Overall mortality was 25%, with one-fifth of patients requiring pacemakers for surgically-induced heart block. The majority of survivors were in good functional state. Conclusions: The flow patterns produced by discordant atrioventricular and concordant ventriculo-arterial connections remain an important, albeit rare, indication for atrial redirection. The procedure recruits the morphologically left ventricle in the systemic circuit, producing good long-term functional results. The approach can also be used for those with isomeric atrial appendages and comparable hemodynamic circuits.

Severe shortage of donor hearts has increased the mortality of patients on the transplant waiting list. However, donor hearts with valvular dysfunction are rarely used. Utilizing donor hearts with valvular lesions that can be repaired or replaced at the time of transplant will decrease waitlist mortality and offer many patients a second chance in life.