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OBJECTIVES The onset of the coronavirus disease 2019 (COVID-19) pandemic has forced our cardiac surgery programme and hospital to enact drastic measures that has forced us to change how we care for cardiac surgery patients, assist with COVID-19 care and enable support for the hospital in terms of physical resources, providers and resident training. METHODS In this review, we review the cardiovascular manifestations of COVID-19 and describe our system-wide adaptations to the pandemic, including the use of telemedicine, how a severe reduction in operative volume affected our programme, the process of redeployment of staff, repurposing of residents into specific task teams, the creation of operation room intensive care units, and the challenges that we faced in this process. RESULTS We offer a revised set of definitions of surgical priority during this pandemic and how this was applied to our system, followed by specific considerations in coronary/valve, aortic, heart failure and transplant surgery. Finally, we outline a path forward for cardiac surgery for the near future. CONCLUSIONS We recognize that individual programmes around the world will eventually face COVID-19 with varying levels of infection burden and different resources, and we hope this document can assist programmes to plan for the future.

Valve sparing aortic root replacement remains a complex procedure despite various improvements that have been made to this operation. Specifically, a hemostatic proximal anastomosis is one of the most important factors for successful completion of the operation without complication. Here we describe a double mattress suture line technique, which facilitates a secure and hemostatic proximal suture line.

Venoarterial extracorporeal membrane oxygenation is a useful treatment for severe primary graft dysfunction after heart transplant. The ideal timing of initiation is unknown.We retrospectively reviewed 362 adult heart transplant recipients at our center between January 2011 and December 2017. Thirty-eight patients (10.5%) experienced severe primary graft dysfunction treated with venoarterial extracorporeal membrane oxygenation. As our institution adopted a prompt venoarterial extracorporeal membrane oxygenation policy in 2015, patients were stratified into pre-2015 (conservative extracorporeal membrane oxygenation: n = 18) and post-2015 (prompt extracorporeal membrane oxygenation: n = 20) cohorts. Clinical outcomes were compared.Baseline characteristics were similar (conservative vs prompt) except for age (51.82 vs 59.96 years, P = .036), aspartate transaminase (32 vs 21.5 U/L, P = .038), male donor (44.4 vs 80%, P = .042), and donor ejection fraction (60 vs 65%, P = .047). Median ischemic time was significantly longer in the conservative extracorporeal membrane oxygenation cohort (210 vs 148 minutes, P = .005). Median time to initiation of extracorporeal membrane oxygenation was significantly shorter in the prompt extracorporeal membrane oxygenation cohort (7.26 vs 1.95 hours, P .0001). There was no difference in intensive care unit stay or major complications. In-hospital mortality improved from 28% (conservative) to 5% (prompt, P = .083). Post-transplant survival at 1 year was 67% in the conservative extracorporeal membrane oxygenation cohort and 90% in the prompt extracorporeal membrane oxygenation cohort (P = .117). There was no difference in the Kaplan-Meier survival curves (P = .071), although Cox regression suggested, but certainly did not prove, a 74.6% lower risk of mortality in the prompt extracorporeal membrane oxygenation group (P = .094).Prompt venoarterial extracorporeal membrane oxygenation use for primary graft dysfunction after heart transplant results in excellent myocardial recovery and a possible decrease in mortality without increased risk of complications.

Over the past several decades, techniques for surgery of the aortic arch have undergone significant evolution. In addition, there have been refinements in the mechanism of cerebral protection utilized intraoperatively. However, significant practice variations in the strategy of antegrade selective cerebral perfusion continue to persist. Here, we describe a simple and easily reproducible technique for selective antegrade cerebral perfusion, utilizing axillary cannulation and retrograde coronary sinus balloon catheters.

To assess the utility of full bowel preparation with oral nonabsorbable antibiotics in preventing infectious complications after elective colectomy.Bowel preparation before elective colectomy remains controversial. We hypothesize that mechanical bowel preparation with nonabsorbable oral antibiotics is associated with a decreased rate of postoperative infectious complications when compared with no bowel preparation.Patient and clinical data were obtained from the Michigan Surgical Quality Collaborative-Colectomy Best Practices Project. Propensity score analysis was used to match elective colectomy cases based on primary exposure variable-full bowel preparation (mechanical bowel preparation with nonabsorbable oral antibiotics) or no bowel preparation (neither mechanical bowel preparation given nor nonabsorbable oral antibiotic given). The primary outcomes for this study were occurrence of surgical site infection and Clostridium difficile colitis.In total, 2475 cases met the study criteria. Propensity analysis created 957 paired cases (n = 1914) differing only by the type of bowel preparation. Patients receiving full preparation were less likely to have any surgical site infection (5.0% vs 9.7%; P = 0.0001), organ space infection (1.6% vs 3.1%; P = 0.024), and superficial surgical site infection (3.0% vs 6.0%; P = 0.001). Patients receiving full preparation were also less likely to develop postoperative C difficile colitis (0.5% vs 1.8%, P = 0.01).In the state of Michigan, full bowel preparation is associated with decreased infectious complications after elective colectomy. Within this context, the Michigan Surgical Quality Collaborative recommends full bowel preparation before elective colectomy.