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ABSTRACT Introduction: Pediatric heart transplantation is the definitive therapy for children with end-stage heart failure. This paper describes our initial experience in pediatric heart transplantation in a tertiary center in Brazil Methods: This is a historical prospective descriptive cohort study based on a review of the medical records of children undergoing heart transplantation at Hospital de Base and Hospital da Criança e Maternidade de São José do Rio Preto. Variables were displayed as frequency, mean, or median. Statistical analysis and Kaplan-Meier actuarial curve were obtained with the aid of Microsoft® Excel® 2019 and STATSDirect version 3.3.5. Results: Between January 2010 and December 2020, ten children underwent bicaval orthotopic heart transplantation, 30% of which were under one year of age. Nine patients had end-stage heart failure (International Society for Heart and Lung Transplantation-Heart Failure D) and 50% of the recipients were transplanted under conditions of progressive clinical deterioration (Interagency Registry for Mechanically Assisted Circulatory Support ≤ 2). Forty percent of the recipients had a panel-reactive antibody > 20% on virtual crossmatch. In the postoperative period, 80% of patients required high dose of inotropic support (vasoactive-inotropic score > 10) for > 48 hours. The death-free survival rate at 131 months was 77.1±14.4%. Most patients (88.9%) in late follow-up had an episode of active cytomegalovirus infection. Cellular rejection, with or without clinical repercussion, was present in 44.4% of the patients. Conclusion: Pediatric heart transplantation produces acceptable and feasible outcomes as definitive therapy for children with end-stage heart failure.

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ABSTRACT Introduction: Aortic valve bioprostheses ring fracture in valve-in-valve procedures has shown low complication rates and presents as an option in the treatment of patients at high risk for conventional surgery, avoiding high transvalvular gradients, which are associated with increased mortality. Some prostheses available in the market cannot be fractured. In an ex vivo test, the possibility of ring fracture of aortic valve bioprostheses produced in Brazil when submitted to radial force application using a high-pressure non-compliant balloon was evaluated. Methods: One unit of each aortic valve bioprosthesis model, sizes 19 and 21 mm, produced by Brazilian companies (Braile Biomédica, Cardioprótese, and Labcor), was used. In the experiment, a non-compliant high-pressure balloon (Atlas®-Gold), 1 mm larger than the external diameter of the prosthesis, was positioned inside the valve annulus and inflated gradually aiming to fracture the prosthesis. Fracture pressures and photographic and radiological images of the prostheses before and after test were recorded. Results: All prostheses were fractured. In the models with metal ring, the fracture pressures were between 23 and 25 atm. In the other prostheses, the rupture occurred between 10 and 13 atm. No deformations in the structure were observed, which could potentially damage the aortic root. Conclusion: All the Brazilian prostheses evaluated were fractured, although the presence of a metal ring in the prosthesis framework increases the pressure required for fracture. The information obtained helps in the planning of valve-in-valve procedures in patients with aortic valve bioprostheses.

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ABSTRACT Introduction: Functional tricuspid regurgitation (TR) is known to complicate adult atrial septal defect (ASD), but its management is still under debate. We reviewed our experience in ASD surgery, focusing on associated functional TR and its treatment. Methods: This retrospective study (2005-2019) included 206 consecutive adult ASD surgical cases without associated valve pathology, except functional TR. Variables were statistically compared on TR classes and surgery-defined groups. Results: Mean age of the patients was 40.3±13 years; 19.9% had sinus venosus syndrome. TR severity was directly related to age, pulmonary systolic pressure, right ventricular and tricuspid annulus diameters, and heart failure class. TR ≥ 2 was found in 134 (65%) patients, while TR ≥ 3 in 56 (27.2%) patients. Tricuspid surgery was associated to shunt closure in 66 (32%) patients, almost all through valve repair; indication was directly related to age, right ventricular and tricuspid annulus diameters, and heart failure class ≥ 3. Tricuspid surgery was more efficient than isolated shunt closure in decreasing TR (79±23% vs. 36±26%; P=1.8 E-18). Device closure availability (last four years of the study) was associated with 1/3 reduction of surgical cases but increased the share of cases with TR>2 (> 51% vs. < 31%; P<0.05). Conclusion: In the era of device closure, surgery for adult ASD is less frequent, but the share of significant TR cases is in net increase. To avoid long-term postoperative TR, we plead for valve repair in all patients with severe TR and for considering repair in moderate TR at risk of persistence.

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ABSTRACT Introduction: In patients undergoing coronary artery bypass grafting (CABG), stroke is a major complication that increases morbidity and mortality. The presence of carotid stenosis (CS) increases risk of stroke, and the optimal treatment remains uncertain due to the lack of randomized clinical trials. The aim of this study is to compare three management approaches to CS in patients submitted to CABG. Methods: From 2005 to 2015, 79 consecutive patients with significant CS submitted to CABG were retrospectively evaluated. Patients were divided in three groups, according to CS treatment: 17 underwent staged carotid endarterectomy (CEA)-CABG, 26 underwent synchronous CEA-CABG, and 36 underwent isolated CABG without carotid intervention. The primary outcomes were composed by 30-day postoperative acute myocardial infarction (MI), 30-day postoperative stroke, and death due to all causes during the follow-up. Results: Patients were evaluated during an average 2.05 years (95% confidence interval = 1.51-2.60) of follow-up. Major adverse cardiac events, including death, postoperative MI, and postoperative stroke, occurred in 76.5% of the staged group, 34.6% of the synchronous group, and 33.3% of the isolated CABG group (P=0.007). As for MI, the rates were 29.4%, 3.85%, and 11.1% (P=0.045), respectively. There was no statistically significant difference in total mortality rates (35.3%, 30.8%, and 25.0%, respectively; P=0,72) and stroke (29.4%, 7.7%, and 8.3%, respectively; P=0,064) between groups. Conclusion: Staged CEA-CABG is associated with higher major adverse cardiac events and MI rate when compared to the strategy of synchronous and isolated CABG, but without statistically difference in total mortality during the entire follow-up.

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Abstract Introduction: The objective of this study is to evaluate the left ventricular systolic function of patients with coronary microvascular dysfunction (CMD) using the three-dimensional speckle-tracking imaging (3D-STI) technique. Methods: From June 2018 to June 2019,72 subjects from Huzhou Central Hospital were enrolled, including 42 CMD in-patients with typical chest pain or chest tightness and positive treadmill exercise stress test, but without coronary stenosis on coronary angiography, (the CMD group) and another 30 healthy individuals who were undergoing physical examinations in an outpatient clinic (the control group). Using 3D-STI technique, the global longitudinal strain (GLS), global radial strain (GRS), global circumferential strain (GCS), global area strain (GAS), and left ventricle were measured. Results: Compared with the control group, GLS and GAS were significantly reduced in the CMD group (P<0.05), while GRS and GCS were similar in both groups (P>0.05). Univariate logistic regression analysis showed that GLS and GAS were the influencing factors of CMD. For the diagnosis of CMD, the area under the receiver operating characteristic (ROC) curve of GLS was 0.883, and the area under the ROC curve of GAS was 0.875. GAS of -29.3% (log-rank test chi-square=34.245, P<0.001) was a strong predictor of major adverse cardiac events. Conclusion: 3D-STI technique has obvious advantages in the evaluation of the left ventricular systolic function for CMD patients. Moreover, 3D-STI parameters, especially GLS and GAS, can detect the early abnormal changes in the ischaemic myocardium. Being timelier and more sensitive than echocardiography, 3D-STI should be recommended for clinical application.

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Abstract Objective: Sutureless aortic valve replacement (Su-AVR) offers an alternative to supra-annular stented biological aortic prostheses. This single-center study aimed to compare early outcomes after aortic valve replacement with sutureless and conventional stented bioprostheses. Methods: In this retrospective study, we analyzed 52 patients who underwent aortic valve replacement with sutureless and stented bioprostheses between January 2013 and October 2017. Sorin Perceval S sutureless valves were implanted in group 1 and Sorin Mitroflow stented bioprosthetic valves were used in group 2. Postoperative outcomes, including demographics, cardiopulmonary bypass (CPB) times, cross-clamp times, morbidity and mortality, as well as echocardiography in the first month, were compared. Results: Mortality occurred in 1 (3.6%) patient in group 1, and in 2 (8.3%) patients in group 2 (P=0.186). Group 1 had significantly shorter CPB (61.6±26.1 min vs. 106.3±32.7 min, P=0.001) and cross-clamp (30.9±13.6 min vs. 73.3±17.3 min, P=0.001) times. The length of stay in the intensive care unit (1.9±1.3 days vs. 2.4±4.9 days, P=0.598) and hospital stay (7.6±2.7 days vs. 7.3±2.6 days, P=0.66) were similar. Postoperatively, there was no statistically significant difference between the two groups in echocardiography results, and morbidities. The mean aortic valve gradient was 13.5±5.8 mmHg in group 1 and 14.5±8.0 mmHg in group 2 (P=0.634). Paravalvular regurgitation was diagnosed in 3 (10.7%) patients in group 1 and in 1 (4.2%) patient in group 2 (P=0.220). Conclusions: Su-AVR resulted in shorter cross-clamp and CPB times. However, early mortality, postoperative morbidity, and echocardiography results were similar between groups.

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Abstract Introduction: The objective of this study is to investigate the protective effect of kaempferol against ischemia/reperfusion (IR) injury and the underlying molecular mechanisms. Methods: H9C2 cells were pretreated with kaempferol for 24 hours and further insulted with IR injury. Cell vitality, reactive oxygen species (ROS) level, glutathione (GSH) level, nicotinamide adenine dinucleotide phosphate (NADPH) oxidase activity, and sirtuin-3 (SIRT3), B-cell lymphoma 2 (Bcl2), and Bcl2-associated X protein (Bax) expressions were evaluated. Moreover, short interfering ribonucleic acid targeting SIRT3 was used to investigate the role of SIRT3 against IR mediated by kaempferol in vitro. IR mice models were also established to confirm the protective effects of kaempferol on IR in vivo. Results: After IR injury, H9C2 cells vitality was reduced, ROS levels, NADPH oxidase activity, and Bax expressions were increased, and GSH levels and Bcl2 expressions were decreased. After kaempferol pretreatment, the vitality of H9C2 cells was increased. The levels of ROS, NADPH oxidase activity, and Bax expression were decreased. In addition, levels of GSH and Bcl2 expression were enhanced. Furthermore, silencing SIRT3 attenuated the protective effect mediated by kaempferol, with increased ROS levels, NADPH oxidase activity, and Bax expression, along with reduced GSH level and Bcl2 expression. In vivo IR model showed that kaempferol could preserve IR-damaged cardiac function. Conclusion: Kaempferol has the capability of attenuating H9C2 cells IR injury through activating SIRT3 to inhibit oxidative stress.

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Abstract Introduction: At present, there are few reports regarding the issue of aortic reoperation due to its complexity and high risk and individual differences among patients. Methods: From November 2016 to December 2017, the data from 35 cases of aortic reoperation at our institution, out of 212 consecutive aortic repairs, were reviewed. We retrospectively summarized and analyzed their surgical indications, operative data, time interval from previous aortic repair, and outcomes. The time intervals until reoperation were analyzed for differences. Results: Patients’ mean age was 40.9±14.5 years, and 25 of them were men (71.4%). The indications for reoperation were aortic valvular problem (14.3%), aneurysmal dilatation (25.7%), pseudoaneurysm formation due to anastomotic leakage (43.2%), and aortic dissection (17.1%). For patients who had underwent primarily emergency operations due to aortic dissection, the time interval until reoperation (4.8±3.2 years) was significantly shorter than that of the whole group (5.5±3.6 years, P<0.01). Among the 35 reoperations, Sun’s procedure was selected for 16 patients (45.7%) with total aortic arch reconstruction. The average follow-up was 12 months (range 9-15 months). Hospital mortality was 5.7% (two patients). Among the hospital survivors there were no cases of death, rupture of residual dissection, paraplegia, or central nervous system complications during the follow-up period. Conclusion: Patients with acute aortic dissection required repeat surgery significantly earlier compared to other diseases. As to reoperation strategy, we recommend Sun’s procedure as the choice for extended arch reconstruction since minimal effect on overall mortality and complication rates were found.

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Abstract Objective: To investigate the expression level and significance of T cell immunoglobulin and mucin-domain containing molecules-3 (Tim-3) and interleukin-7 (IL-7) in CD4+ T lymphocytes in peripheral blood of patients with coronary heart disease (CHD). Methods: 75 patients with CHD treated at our hospital were selected and classified as mild group (25 cases), moderate group (25 cases) and severe group (25 cases), according to the severity of illness. Twenty-five healthy volunteers who underwent a physical examination at our hospital during the same period were selected as the control group. The expression level of Tim-3 in CD4+ T lymphocytes in peripheral blood of patients in four groups was detected by flow cytometry and quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR). The expression level of IL-7 in peripheral blood serum was measured by enzyme-linked immunosorbent assay (ELISA). Correlation analyses of Tim-3 and IL-7, Tim-3 and disease severity and IL-7 and disease severity were performed, respectively. Results: Flow cytometry and qRT-PCR demonstrated that the expression of Tim-3 in CD4+ T lymphocytes in peripheral blood of patients with CHD increased with the aggravation of the disease. ELISA showed that the tendency of IL-7 expression in peripheral blood serum was consistent with the expression of Tim-3, and the expression of Tim-3 had a positive correlation with IL-7. The expression levels of both Tim-3 and IL-7 were positively correlated with the Gensini score. Conclusion: The expression of Tim-3 and IL-7 in peripheral blood of patients with CHD was upregulated and increased with the aggravation of CHD.

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ABSTRACT Introduction: Oral anticoagulants are the treatment of choice for diverse types of coagulation disorders. Warfarin is widely used by the Brazilian population, possibly due to its lower cost than other oral anticoagulants. However, it has a high risk of serious adverse effects if used incorrectly. The Anticoagulation Knowledge Tool (AKT) can assess a patient’s knowledge about her/his oral anticoagulant therapy and can assist health professionals in identifying patients with difficulties in adherence. This study aimed to translate, culturally adapt, and validate the AKT into Brazilian Portuguese. Methods: After a standard forward-backward procedure to translate the AKT into Brazilian Portuguese (AKT-Br), a version of the instrument was applied in three groups (patients, pharmacists, and the general population). The reliability of the AKT-Br was tested using an internal consistency measure and test-retest. The validity of the instrument was confirmed with data from the contrasted groups. All statistical analyses were performed with RStudio. Results: The median scores obtained with the AKT-Br were 29.0, 17.0, and 7.5 for pharmacists, patients, and the general population, respectively (maximum score of 35 points). There was moderate internal consistency for the instrument and test-retest reliability was satisfactory. Analysis of variance for validity of the groups revealed a significant relationship between the total score and the evaluated groups. Conclusion: The ATK-Br is a reliable and valid tool to assess knowledge about oral anticoagulants. AKT-Br can be used in clinical practice as an auxiliary tool to improve patient care through personalised educational interventions.

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ABSTRACT Introduction: The objective of this study is to investigate the protective mechanism of dexmedetomidine (Dex) in myocardial ischemia/reperfusion (MIR)-induced acute lung injury (ALI) of diabetic rats by inhibiting hypoxia-inducible factor-1α (HIF-1α). Methods: Initially, healthy male Sprague Dawley rats were treated with streptozocin to induce diabetes. Then, three weeks after the induction, Dex or lentiviral vector (LV)-HIF-1α was injected into the rats 30 minutes prior to the MIR modeling. After four weeks, lung tissues were harvested for pathological changes observation and the wet/dry weight (W/D) ratio determination. Afterwards, oxidative stress indicators and pro-inflammatory factors were measured. In addition, HIF-1α expression was assessed by immunohistochemistry and western blot analysis. Results: Dex could suppress inflammatory cell infiltration, improve lung tissue structure, reduce pathological score and the W/D ratio, and block oxidative stress and inflammatory response in MIR-induced ALI of diabetic rats. Besides, Dex could also inhibit HIF-1α expression. Moreover, Dex + LV-HIF-1α reversed the protective role of Dex on diabetic MIR-induced ALI. Conclusion: Our study has made it clear that Dex inhibited the upregulation of HIF-1α in diabetic MIR-induced ALI, and thus protect lung functions by quenching the accumulation of oxygen radical and reducing lung inflammatory response.

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ABSTRACT Introduction: The current coronavirus pandemic has greatly strained the limited resources that had previously maintained the sustainability of the high-cost cardiothoracic surgeries in low-income countries like Egypt. Methods: Hospital databases and patients’ records were reviewed to evaluate the impact of the pandemic on the workflow and waiting lists. Postoperative patients were contacted by telephone for follow-up, as well as preoperative patients whose operations were cancelled. Regular virtual meetings were held, and residents were asked to discuss the stresses, challenges, and their suggestions for the gradual resumption of services. Residents’ logbooks were evaluated to assess the disruption of the surgical exposure compared to 2019. Results: While thoracic surgeries have continued to thrive, cardiac surgeries have witnessed the worst consequences, including cancellation of all surgeries, expansion of waiting lists, patients’ non-compliance with follow-up, and impaired surgical exposure of junior residents. Conclusion: The gradual recovery of cardiac surgery services in Alexandria (Egypt) is being carefully planned, taking into consideration the backlog of cases and the shortage of screening kits. Careful tiering and triaging of patients by a multidisciplinary team, as well as seeking alternative assessment tools for trainees, are the main lines of our action plan.

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Abstract Introduction: Here we describe our technique and results of beating heart pulmonary thromboendarterectomy (PTE) with cardiopulmonary bypass (CPB) in four patients for treatment of chronic thromboembolic pulmonary hypertension (CTEPH). Methods: Retrospective analysis of data from patients who underwent PTE for CTEPH between January 2019 and September 2020. Patients were followed up with clinical assessment, 2D echocardiography, and computed tomography pulmonary angiogram. Results: Four patients were operated for CTEPH using our technique. Moderate tricuspid regurgitation (TR) and severe TR were found in two patients each. Severe right ventricular (RV) dysfunction was found in all cases. Thrombi were classified as Jamieson type II in three cases and type I in one case. Postoperative median direct manometric pulmonary artery (PA) pressures decreased (from 46.5 mmHg to 23.5 mmHg), median CPB time was 126 minutes, and median temperature was 33.35 °C. Mechanical ventilation was for a median of 19.5 hours. There was one re-exploration. Median intensive care unit stay was 7.5 days. There was no mortality. Postoperative 2D echocardiography revealed decrease in median PA systolic pressures (from 85 mmHg to 33 mmHg), improvement in RV function by tricuspid annular plane systolic excursion (median 14 mm vs. 16 mm), and improved postoperative oxygen saturations (88.5% vs. 99%). In follow-up (ranging between 2-15 months), all patients reported improvement in quality of life and were in New York Heart Association class I. Conclusion: With our described simple modifications, advances in perfusion, and blood conservation technologies, one can avoid the need for deep hypothermic circulatory arrest during PTE.

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Abstract The treatment of valvular endocarditis in patients with cardiac implantable electrophysiological device (CIED) includes valvular surgery and lead extraction. This can be challenging in patients with severely reduced left ventricular ejection fraction (LVEF). Reduced LVEF in combination with sepsis and cardioplegic cardiac arrest can make weaning from cardiopulmonary bypass difficult. Some of these patients require venoarterial extracorporeal membrane oxygenation (VA-ECMO) for postcardiotomy syndrome. Lead extraction by manual traction is often not possible in cases with a long lead dwell time. Therefore, a lead extraction procedure with powered sheaths is required during the VA-ECMO support. We describe our technique for laser lead extraction during VA-ECMO support in a 64-year-old patient with triple valve endocarditis and lead vegetations.

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ABSTRACT Accidental detachment of mechanical valve leaflet during implantation is a rare and potentially serious complication. When the lost leaflet cannot be found by direct visualisation, additional diagnostic procedures are necessary to detect it. Computer tomography is the best detection method, but the patient needs reoperation. We presented a patient in whom the detached leaflet migrated and became trapped into the left inferior pulmonary vein. The computed tomography (CT) scan was used to reveal leaflets, and successful extirpation was performed in the second operation.

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Abstract Introduction: Lymphomas arising from cardiac myxomas represent a particularly rare pathology, with only few cases reported in the literature. Case presentation: We report a complete excision of a malignant lymphoma arising from a cardiac myxoma in a 44-year-old female patient. The myxoma presented like a floating mass within the left atrium with a maximum diameter of 3.5 cm. The clinical post-operative period was uneventful and the patient was dismissed on the 6th post-operative day. Conclusion: This case reinforces the concept of radical excision of cardiac neoplasms.