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Herein, we describe the unique interplay among biomedical ethics, principles of distributive justice, and economic theory to highlight the role of health technology assessments to compare therapeutic options for aortic valve replacement. From the perspective of the Canadian health care system, transcatheter aortic-valve implantation is associated with higher costs but also higher incremental health benefits compared with surgical aortic-valve replacement. At current willingness to pay thresholds, transcatheter aortic-valve replacement is likely cost effective across the spectrum of risk, from inoperable patients to those at low surgical risk. However, we highlight the nuances within each subgroup of surgical risk that merit careful consideration by the heart team. Moreover, incorporation of patients and their preferences in decision-making is key. In particular, in young, low-risk patients, there remains uncertainty regarding the optimal treatment, with unique concerns around valve durability, selection of valve prosthesis, and consideration for special procedures such as the Ross procedure. Nonetheless, current research suggests that, universally, patients prefer a less invasive approach compared with a more invasive approach. Finally, we highlight that there remain critical issues around timeliness of access to care and unacceptable geographic inequities across Canada. Further research into alternative funding mechanisms and integrated cross-sector care pathways is necessary to address these issues.

Purpose of review The review summarizes the key parameters that can aid in determining the optimal treatment of ischemic mitral regurgitation (IMR). Recent findings Left ventricular (LV) and mitral valve (MV) parameters are important for surgical planning and risk stratification in IMR. Although LV dimensions is one of the main parameters used in the guidelines, volumes more accurately depict LV remodelling. Furthermore, wall motion abnormalities and wall motion score index can also be useful for surgical planning in treatment of IMR. Viability is best measured with cardiac magnetic resonance, but it is not feasible in certain centres. In contrast, measurement of strain with echocardiography is an emerging and feasible tool for estimating viability. MV leaflet tethering and pattern measured with echocardiography are also useful for MV surgery. Anterior leaflet excursion angle can identify patients in whom undersized ring annuloplasty is potentially unsuitable. Summary Treatment of IMR relies on accurate parameters that can determine the optimal surgical approach. In some patients, lack of viable myocardium suggests inadequacy of revascularization and thus, an adjunctive left ventricular reconstruction may be necessary. Degree and pattern of MV leaflet tethering can indicate whether ring annuloplasty, which is the most common repair technique, is sufficient or an adjunctive sub-valvular intervention is beneficial.

Aortic valve-sparing operations theoretically have fewer stroke and bleeding complications but may increase late reoperation risk versus composite valve grafts.We meta-analyzed all studies comparing aortic valve-sparing (reimplantation and remodelling) and composite valve-grafting (bioprosthetic and mechanical) procedures. Early outcomes were all-cause mortality, reoperation for bleeding, myocardial infarction, and thromboembolism/stroke. Long-term outcomes included all-cause mortality, reintervention, bleeding, and thromboembolism/stroke. Studies exclusively investigating dissection or pediatric populations were excluded.A total of 3794 patients who underwent composite valve grafting and 2424 who underwent aortic valve-sparing procedures were included from 9 adjusted and 17 unadjusted observational studies. Mean follow-up was 5.8 ± 3.0 years. Aortic valve sparing was not associated with any difference in early mortality, bleeding, myocardial infarction, or thromboembolic complications. Late mortality was significantly lower after valve sparing (incident risk ratio, 0.68; 95% confidence interval [CI], 0.54-0.87; P.01). Late thromboembolism/stroke (incident rate ratio, 0.36; 95% CI, 0.22-0.60; P.01) and bleeding (incident rate ratio, 0.21; 95% CI, 0.11-0.42; P .01) risks were lower after valve sparing. Procedure type did not affect late reintervention.Aortic valve sparing appears to be safe and associated with reduced late mortality, thromboembolism/stroke, and bleeding compared with composite valve grafting. Late durability is equivalent. Aortic valve sparing should be considered in patients with favorable aortic valve morphology.

North America is facing an opioid epidemic and growing illicit drug supply, contributing to growing numbers of injection drug use-related infective endocarditis (IDU-IE). Patients with IDU-IE have high early and late mortality. Patients with IDU-IE more commonly present with right-side IE compared with those with non-IDU IE, and a majority are a result of Streptococcus aureus. Although most patients can be successfully managed with intravenous antibiotic treatment, surgery is often required in part owing to high relapse rates, potential treatment biases, and more aggressive pathophysiology in some. Multidisciplinary management as endocarditis teams, including not only cardiologists and cardiac surgeons, but also infectious disease specialists, drug addiction experts, social workers, neurologists, and neurosurgeons, is essential to best manage substance use disorder and facilitate safe discharge to home and society. Structural and population-level interventions, such as harm-reduction programs, are necessary to reduce IDU-IE relapse rates in the community and other IDU-related health concerns, such as overdoses. In this review, we describe the pathophysiologic, clinical, surgical, social, and ethical characteristics of IDU-IE and their management. We present the most recent clinical guidelines for this condition and discuss existing gaps in knowledge to guide future research, practice changes, and policy interventions.

Summary OBJECTIVES With reductions in training time and intraoperative exposure, there is a need for objective assessments to measure trainee progression. This systematic review focuses on the evaluation of trainee technical skill performance using objective assessments in cardiothoracic surgery and its incorporation into training curricula. METHODS Databases (EBSCOHOST, Scopus and Web of Science) and reference lists of relevant articles for studies that incorporated objective assessment of technical skills of trainees/residents in cardiothoracic surgery were included. Data extraction included task performed; assessment setting and tool used; number/level of assessors; study outcome and whether the assessments were incorporated into training curricula. The methodological rigour of the studies was scored using the Medical Education Research Study Quality Instrument (MERSQI). RESULTS Fifty-four studies were included for quantitative synthesis. Six were randomized-controlled trials. Cardiac surgery was the most common speciality utilizing objective assessment methods with coronary anastomosis the most frequently tested task. Likert-based assessment tools were most commonly used (61%). Eighty-five per cent of studies were simulation-based with the rest being intraoperative. Expert surgeons were primarily used for objective assessments (78%) with 46% using blinding. Thirty (56%) studies explored objective changes in technical performance with 97% demonstrating improvement. The other studies were primarily validating assessment tools. Thirty-nine per cent of studies had established these assessment tools into training curricula. The mean ± standard deviation MERSQI score for all studies was 13.6 ± 1.5 demonstrating high validity. CONCLUSIONS Despite validated technical skill assessment tools being available and demonstrating trainee improvement, their regular adoption into training curricula is lacking. There is a need to incorporate these assessments to increase the efficiency and transparency of training programmes for cardiothoracic surgeons.

Ischemic heart disease is the leading cause of morbidity and mortality worldwide and may require coronary revascularization when more severe or symptomatic. Coronary artery bypass grafting (CABG) is the most common cardiac surgical procedure and can be performed with different bypass conduits and anastomotic techniques. Saphenous vein grafts (SVGs) are the most frequently used conduits for CABG, in addition to the left internal thoracic artery. Outcomes with a single internal thoracic artery and SVGs are favorable, and the long-term patency of SVGs may be improved through novel harvesting techniques, preservation methods, and optimal medical therapy. However, increasing evidence points towards the superiority of arterial grafts, especially in the form of multiple arterial grafting (MAG). Nevertheless, the uptake of MAG remains limited and variable, both as a result of technical complexity and a scarcity of conclusive randomized controlled trial evidence. Here, we present an overview of CABG techniques, harvesting methods, and anastomosis types to achieve total arterial revascularization and adopt MAG. We further narratively summarize the available evidence for MAG versus single arterial grafting to date and highlight remaining gaps and questions that require further study to elucidate the role of MAG in CABG.

Valve-sparing root replacement (VSRR) has excellent outcomes when performed in experienced centers in well-selected patients. It is suggested that reimplantation of the aortic valve may have better durability than remodeling in patients with Marfan syndrome (MFS), although long-term comparative data are limited.Between 1988 and 2018, 194 patients with MFS underwent VSRR at our institution. From these, we derived a propensity-matched cohort of 68 patients (44 who underwent reimplantation and 24 who had remodeling). Early outcomes included death and perioperative complications. Late outcomes were survival, probability of aortic insufficiency, and reintervention up to 20 years of follow-up. Median follow-up was 17.8 years (interquartile range, 12.0-20.6 years) for the entire matched cohort.Baseline variables were similar between reimplantation and remodeling patients after matching: age (39 ± 12 vs 40 ± 13 years, P = .75) and male sex (28 [64%] vs 15 [63%], P = 1.0). Similar 20-year survival was observed after reimplantation compared with remodeling (82% vs 72%, P = .20), whereas the probability of developing greater than mild aortic insufficiency at 20 years was increased after remodeling (5.8% vs 13%, P = .013). More patients underwent reoperation on the aortic valve after a remodeling procedure than after reimplantation of the aortic valve (18% vs 0%, P = .018).VSRR provides excellent long-term survival and freedom from valve-related complications outcomes in patients with MFS. Reimplantation of the aortic valve was associated with a lower risk of aortic valve reoperation and aortic insufficiency than the remodeling procedure after 2 decades of follow-up.

Purpose of review Mechanical complications of myocardial infarction are a group of postischemic events and include papillary muscle rupture resulting in ischemic mitral regurgitation, ventricular septal defect, left ventricle free wall rupture, pseudoaneurysm, and true aneurysm. Advances made in management strategies, such as the institution of 'Code STEMI' and percutaneous interventions, have lowered the incidence of these complications. However, their presentation is still associated with increased morbidity and mortality. Early diagnosis and appropriate management is crucial for facilitating better clinical outcomes. Recent findings Although the exact timing of a curative intervention is not known, emerging percutaneous and transcatheter approaches and improving mechanical circulatory support (MCS) devices have greatly enhanced our ability to manage and treat some of the complications postinfarct. Summary Although the incidence of mechanical complications of myocardial infarction has decreased over the past few decades, these complications are still associated with high rates of morbidity and mortality. The combination of early and accurate diagnosis and subsequent appropriate management are imperative for optimizing clinical outcomes. Although more randomized clinical trials are needed, mechanical circulatory support devices and emerging therapeutic strategies can be offered to carefully selected patients.

Background People who inject drugs (PWID) represent a high-risk subgroup of endocarditis patients. This is highlighted by poorer post-operative outcomes in injection drug use-related infective endocarditis (IDU-IE), which is largely attributable to the increased vulnerability of prosthetic valves to re-infection. Consequently, many centres do not perform valve replacement on these patients. A parallel, but often underrecognized, component of care is the role of multidisciplinary management for individuals with IDU-IE, including perioperative addictions and psychiatric care. Consequently, surgical management options in IDU-IE remain a controversial topic. Objectives To determine the characteristics of optimal surgical and psychiatric care for individuals with IDU-IE. Methods We conducted a narrative synthesis of the findings of literature retrieved from searches of computerized databases, hand searches, and authoritative text, organizing the findings into several key themes: clinical characteristics and factors associated with mortality in IDU-IE, alternative surgical management options, perioperative risk stratification techniques, principles of psychiatric and addictions management in IDU-IE, ethical considerations and controversies, and future research directions. Results/conclusions Managing IDU-IE involves the treatment of two comorbidities: the intra-cardiac infection and the underlying substance use disorder. Cardiac surgery represents a high-intensity intervention with appreciable risk, and the benefit it is not always clear. As patients often present acutely, it is not feasible to use drug abstinence as a prerequisite to surgery. Involvement of inpatient psychiatry and addictions teams, however, appears to be an evidence-based approach that can bridge IDU-IE patients with opioid agonist therapy in hospital and adequate outpatient treatment options for their underlying addiction upon their discharge from hospital. It is likely that a majority of these patients are not receiving optimal psychiatric management despite increasing recognition of efficacy. Further interdisciplinary studies are needed to elucidate optimal surgical and multidisciplinary protocols. Background Infective endocarditis (IE) is an infection of the innermost lining of the heart often affecting the heart valves. Over the last few decades, the epidemiology of IE has shifted in the developed world and while it continues to be a significant cause of morbidity and mortality, there has been a significant increased incidence among persons who inject drugs (PWID). To date, well-conducted epidemiologic studies of IE among PWID have been sparse, which has limited our ability to fully characterize this disease phenomenon. To address this knowledge deficit, we conducted a narrative synthesis of the findings of literature retrieved from searches of computerized databases, hand searches, and authoritative text, and organized our findings into six key themes: clinical characteristics and factors associated with mortality in IDU-IE, alternative surgical management options, perioperative risk stratification techniques, principles of psychiatric and addictions management in IDU-IE, ethical considerations and controversies, and future research directions.

We sought to compare the long-term outcomes of multiarterial graft (MAG) coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DES) to treat stable multivessel coronary artery disease.This study was a multicenter population-based retrospective analysis of all residents of Ontario, Canada, from January 1, 2011, to December 31, 2019. We identified 3600 cases of elective primary isolated CABG with MAG and 2187 cases of PCI with second-generation DES.After the application of propensity score-weighting using overlap weights, MAG was associated with better survival over 5 years compared with DES (96.8% vs 94.5%; hazard ratio [HR], 0.56; 95% CI, 0.37-0.85). MAG was also associated with better secondary outcomes including a composite of death, myocardial infarction, and stroke (94.3% vs 88.5%; HR, 0.49; 95% CI, 0.36-0.65). The rate of death, stroke, myocardial infarction, and repeat revascularization (91.2% vs 70.7%; HR, 0.24; 95% CI, 0.20-0.30), and the individual end points of myocardial infarction (1.4% vs 6.9%; HR, 0.22; 95% CI, 0.13-0.35), and repeat revascularization (4.1% vs 24.2%; HR, 0.14; 95% CI, 0.10-0.18) were lower with MAG. PCI with second-generation DES was associated with a lower rate of stroke up to 5 years (0.6% vs 1.8%; HR, 3.97; 95% CI, 1.45-10.88).CABG with MAG was associated with better survival and fewer major cardiac adverse events compared with second-generation DES and might be considered the treatment of choice for patients with stable multivessel coronary artery disease. Further randomized controlled trials are needed to confirm this hypothesis.

BACKGROUND We aimed to examine the rationale and assess risk of additional cardiopulmonary bypass (CPB) episodes, and specifically, re-institution of CPB for reintervention, in congenital heart surgery. METHODS AND RESULTS We retrospectively reviewed all children undergoing cardiac surgery with CPB at one institution (2014-2016). Tetralogy of Fallot was excluded as the annulus-sparing surgical strategy involves planned intraoperative revision. The final cohort of 922 patients was stratified: single CPB run (CPB=1, n=771); >1CPB without revisions (CPB>1NR, n=77) for reperfusion, bleeding, or intractable arrhythmias; and >1CPB with revision (CPB>1R, n=74). Successful revisions were defined as: those resulting in at most mild residual lesions, did not induce new lesions, did not require postoperative revision, and did not result in mortality prior to discharge. Forced revisions were defined as revisions for unacceptable hemodynamics or failure to wean from CPB. Outcomes of interest were in-hospital mortality, complications, need for postoperative revision, and a composite (death, stroke, ECMO, arrest, and leaving OR with open chest). Predictors of the composite outcome were assessed by logistic regression. Mean age was 2.9±4.5 years, 54% were male and mean RACHS was 2.5±0.8. In CPB>1R, 18 (24%) required 2 or 3 revisions. Revisions were valvular in 34 (46%) and forced in 51 (69%) patients. Success with a single revision occurred in 22 (30%) and by the final attempt in 32 (43%) patients. One patient's lesion worsened as a result of the revision. When comparing CPB=1 vs CPB>1NR vs CPB>1R, outcomes with significant differences included: stroke, arrest, postoperative revision, open chest upon leaving OR, and the composite outcome (Table 1). In-hospital death, re-exploration, need for ECMO, and hospital stay were similar (Table 1). Among CPB>1R patients, 12 (16%) required postoperative revision. Logistic regression identified revision as a predictor of the composite outcome with greatest effect seen in 2 revisions: 1: OR=2.39 (95% CI: 1.35, 4.21) p=0.002, 2: OR=3.68 (95% CI: 1.26, 10.74) p=0.02, 3: OR=1.23 (95% CI: 0.25, 12.23) p=0.8. Additionally, CPB runs=3 was associated with the composite outcome: OR=2.25 (95% CI: 1.00, 5.05) p=0.048. A trend towards CPB runs = 4 was seen while CPB runs=2 was not correlated with the composite outcome. CONCLUSION Revisions are uncommon, and most are forced. Revisions frequently do not eliminate residual lesions, occasionally require additional postoperative revisions, but are not associated with increased early mortality. Revisions and >2 CPB runs were associated with greater risk of the composite outcome. Those for non-forced reasons should likely be considered with caution.

Purpose of review To provide a critical review of the application and outcomes of surgical edge-to-edge (E2E) or Alfieri repair for mitral valvulopathy. Recent findings The E2E repair is a surgical technique to address mitral regurgitation, particularly suited when the responsible mechanism is bileaflet prolapse combined with enlarged annular area. It can also be used for a range of mitral valve pathologies. Surgically, the technique has been employed as a bailout for unsuccessful repair including residual mitral regurgitation because of systolic anterior motion (SAM). E2E repair should be accompanied by a ring annuloplasty for long-term repair durability. The simplicity of this approach makes it an ideal strategy during minimally-invasive mitral valve repair. It may also be performed via a transaortic approach at the time of aortic valve surgery to address less-than-severe mitral regurgitation or to address residual SAM following myectomy for hypertrophic obstructive cardiomyopathy. We review the surgical indication, potential complications including risk of mitral stenosis and the long-term outcomes of E2E repair. Summary The E2E surgical repair is a simple and effective surgical strategy to address a wide range of mitral regurgitation. This is an important technique in the surgical armamentarium especially in cases of minimally-invasive mitral valve surgery.

Left ventricular assist device (LVAD) implantation via lateral thoracotomy can offer similar effectiveness to conventional approaches with less perioperative adverse events. We performed a systematic review and meta-analysis to determine the potential benefits of lateral thoracotomy (LT) for LVAD implantation compared to median sternotomy.We searched MEDLINE and Embase databases for studies comparing continuous-flow LVAD implantation using LT with conventional sternotomy. Main outcomes were perioperative mortality and complications.Twenty-five observational studies enrolling 3072 patients were included with a median follow-up of 10 months. Perioperative mortality (30 day or in-hospital) was 7% (LT) and 14% (sternotomy); however, mortality differences were no longer statistically significant in matched/adjusted studies (RR:0.86; 95%CI:0.52-1.44; p = 0.58). LT was associated with decreased need for blood product transfusions (mean difference[MD]: -4.7; 95%CI: -7.2 to -2.3 units; p0.001), reoperation for bleeding (RR:0.34; 95%CI:0.22-0.54; p0.001), postoperative RVAD implantation (RR:0.53; 95%CI:0.36-0.77; p0.001), days requiring inotropes (MD: -1.1; 95%CI: -2.1 to -0.03 inotrope days; p = 0.04), ICU (MD: -3.3; 95%CI: -6.0 to -0.7 ICU days; p = 0.01), and hospital length of stay (MD: -5.1; 95%CI: -10.1 to -0.1 hospital days; p = 0.04) in matched/adjusted studies. Overall mortality during follow-up was significantly lower for LT in unmatched/unadjusted studies but not statistically significantly lower in matched/adjusted studies (Hazard Ratio:0.82; 95%CI:0.59-1.14; p = 0.24).LVAD implantation via LT was associated with significantly decreased need for blood products, reoperation for bleeding, and postoperative RVAD implantation. Furthermore, days on inotropic support were also lower, likely contributing to the shorter length of stay. These findings support greater use of a LT approach for carefully selected patients.

Each bypass graft requires an inflow to supply arterial blood to the myocardial territory distal to the bypassed lesion, during coronary artery bypass surgery. These inflows may be the conduit’s own native blood supply (i.e., with in situ internal mammary artery or gastroepiploic artery), or in the case of saphenous venous grafts and radial artery grafts, the bypass will require construction of a proximal anastomosis. We describe the technical aspects of a proximal aortocoronary anastomosis.

Acute type A aortic dissection remains a high-risk surgical condition, and mortality among those presenting with malperfusion is up to 3-fold higher. Despite the added technical challenge of distal aortic arch interventions in the acute setting, it may be necessary to resolve distal malperfusion in patients with this disorder. The ideal arch intervention to address acute type A aortic dissection complicated by malperfusion should address the following objectives: (1) to relieve distal malperfusion by expanding the distal true lumen and depressurizing the false lumen; (2) to avoid compromising arch branches without requiring additional arch branch interventions; (3) to minimize the risk of spinal cord ischemia; and (4) to minimize the operative duration and circulatory arrest time. The use of an uncovered aortic arch stent that is delivered in an antegrade manner during circulatory arrest, concomitantly with hemiarch replacement, therefore represents an attractive solution in the management of acute type A aortic dissection complicated by malperfusion. This strategy does not require complex arch reconstruction and may thus be a feasible option among cardiac and vascular surgeons in lower volume aortic centers. Here we present a step-by-step approach to acute type A aortic dissection repair with hemiarch repair and delivery of an uncovered arch stent for a patient presenting with malperfusion.

Background Injection drug use–associated infective endocarditis (IDU-IE) is a growing epidemic. The objective of this survey was to identify the beliefs and practice patterns of Canadian cardiac surgeons regarding surgical management of IDU-IE. Methods A 30-question survey was developed by a working group and distributed to all practicing adult cardiac surgeons in Canada. Data were analyzed using descriptive statistics. Results Of 146 surgeons, 94 completed the survey (64%). Half of surgeons (49%) would be less likely to operate on patients with IE if associated with IDU. In the case of prosthetic valve IE owing to continued IDU, 36% were willing to reoperate once and 14% were willing to reoperate twice or more. Most surgeons required commitments from patients before surgery (73%), and most referred patients to addiction services (81%). Some surgeons would offer a Ross procedure (10%) or homograft (8%) for aortic valve IE, and 47% would consider temporary mechanical circulatory support. Whereas only 17% of surgeons worked at an institution with an endocarditis team, 71% agreed that there was a need for one at each institution. Most surgeons supported the development of IDU-IE–specific guidelines (80%). Conclusions Practice patterns and surgical management of IDU-IE vary considerably across Canada. Areas of clinical unmet needs include the development of a formal addiction services referral protocol for patients, the development of an interdisciplinary endocarditis team, as well as the creation of IDU-IE clinical practice guidelines.

Purpose of review Left main coronary artery disease (LMCAD) represents a high-risk subset of coronary artery disease with significant morbidity and mortality if not treated in a timely manner. In this review, we survey the contemporary evidence on the management of LMCAD, highlight advances, and provide in-depth review of data comparing surgical and percutaneous approaches. Recent findings LMCAD represents a heterogeneous condition and management should be guided by key clinical and anatomic factors. In recent years, there has been a wealth of published prospective data including results of the EXCEL and NOBLE trials. Coronary artery bypass graft (CABG), remains the gold standard for optimal long-term outcomes and the greatest benefit seen in patients with higher anatomic complexity and longer life expectancy. Percutaneous coronary intervention (PCI) offers a less-invasive approach with rapid recovery. PCI is optimal in situations when surgery cannot be offered in a timely manner due to hemodynamic instability, for high-risk surgical patients, or those with limited life expectancy, if LMCAD is anatomically simple. As a result of continued technological and procedural improvements in both PCI and CABG, cardiovascular specialists possess a growing armamentarium of approaches to treat LMCAD. Thus, center specialization and use of a heart team approach are increasingly vital, though barriers remain. Summary Emerging evidence continues to support CABG as the gold standard for achieving optimal long-term outcomes in patients with LMCAD. PCI offers a more expeditious approach with rapid recovery and is a safe and effective alternative in appropriately selected candidates.

Long-standing persistent atrial fibrillation remains a significant therapeutic challenge, often proving to be resistant to treatment with antiarrhythmic medications and transcatheter ablation. Hybrid ablation, which combines a minimally invasive surgical and transcatheter approach, is emerging as a promising treatment option. In this video tutorial, we demonstrate our method of hybrid ablation for long-standing persistent atrial fibrillation using advanced 3D electro-anatomical voltage mapping to guide the ablation process and thereby improve the ultimate effectiveness of the procedure.

Objective The objective of this study was to compare the early results of endovascular vs open thoracoabdominal aortic aneurysm (TAAA) repair. Methods MEDLINE and Embase were searched for studies from January 2006 to March 2018 that compared endovascular vs open repair of TAAA using branched or fenestrated endografts. Data were subjected to a meta-analysis using a random-effects model. The outcomes of interest included early mortality, spinal cord injury, renal failure requiring dialysis, stroke, and hospital length of stay. Results Eight comparative studies met inclusion criteria. There were two retrospective propensity-matched studies, two unadjusted single-center retrospective studies, and four unadjusted national population-based studies. Mortality in the matched studies was equivalent in both groups. Pooled analysis of all unmatched observational studies revealed a survival benefit for endovascular over open repair (relative risk [RR], 0.63; 95% confidence interval [CI],0.45-0.87); P Conclusions There are few reports comparing endovascular vs open repair of TAAAs. Short-term outcomes may be improved in patients undergoing endovascular treatment of TAAA on the basis of a limited number of studies with high risk of bias. These findings highlight the need for larger comparative studies with standardization of reporting.

Recent years have shown increasing interest in the use of thromboelastography (TEG) (Haemonetics, Braintree, MA) and thromboelastometry (ROTEM; Munich, Germany). These are established point‐of‐care global viscoelastic hemostatic techniques with several advantages. They use whole blood samples, which are more physiological compared with conventional plasma‐based tests, require small volumes, and provide comprehensive and real‐time data on coagulation/fibrinolysis. Many successful applications have been reported, including hepatobiliary/cardiovascular surgeries, transfusion therapy, and trauma; however, the routine use of these tests remains surprisingly low in relation to pregnancy and puerperium. [...]

Background This meta-analysis compares the early and late outcomes of valve repair versus replacement, the primary surgical strategies for tricuspid valve infective endocarditis (IE). Methods We searched MEDLINE and EMBASE databases until 2016 for studies comparing tricuspid valve repair and replacement. Results The main outcomes were mortality, recurrent IE, and need for reoperation. There were 12 unmatched retrospective observational studies with 1,165 patients (median follow-up 3.8 years, interquartile range: 2.1 to 5.0). The most common indications for surgery were septic pulmonary embolism, left-sided IE, right-side heart failure, and persistent bacteremia. Median repair proportion was 59% and replacement was 41% among studies. The primary repair strategies are vegetectomy, De Vega procedure, annuloplasty ring, bicuspidization, and leaflet patch augmentation. Of valve replacements, 83% were bioprosthetic and 17% mechanical prostheses. There were no differences in perioperative mortality between tricuspid valve repair versus replacement (relative risk [RR] 0.62, 95% confidence interval [CI]: 0.26 to 1.46, p = 0.3). Long-term all-cause mortality was not different (RR 0.61, 95% CI: 0.22 to 1.72, p = 0.4). Valve repair was associated with lower recurrent IE (RR 0.17, 95% CI: 0.05 to 0.57, p = 0.004) and need for reoperation (RR 0.26, 95% CI: 0.07 to 0.92, p = 0.04) but a trend toward greater risk of moderate to severe tricuspid regurgitation (RR 4.14, 95% CI: 0.80 to 21.34, p = 0.09). Furthermore, tricuspid valve repair is associated with lower need for permanent pacemaker (RR 0.20, 95% CI: 0.11 to 0.35, p Conclusions Tricuspid valve repair and replacement offer similar long-term survival. Valve repair may offer greater freedom from recurrent IE and reoperation as well as freedom from pacemaker and should be the preferred approach for patients with tricuspid valve IE.

Nitric Oxide (NO) is a well-known potent and rapid vasodilator and inhibitor of coagulation. Synthesized from an L-arginine precursor, NO is produced via the Nitric Oxide Synthase enzyme which is expressed constitutively in endothelial cells. Nitric oxide has a wide range of biological properties that maintain vascular homeostasis and protection of the vessel from injurious consequences. The decreased production of NO in pathological states causes deleterious effects, creating an endothelial dysfunction state with a wide variety of subsequent diverse biological effects. There is now evidence of the link between hypoxia and/or reduction of NO availability and coagulopathies. NO is also a modulator of various cancer-related events and has anti-tumor properties. Cancer is a known hypercoagulable state and hypoxia is a typical feature of the tumor micro-environment. Cancer patients—particularly those with advanced or metastatic states—are at higher risk of developing venous and arterial thromboembolic events. The dichotomous nature of nitric oxide with regard to its tumorigenic and tumoricidal properties are at present under intense investigation. The transcendent field of nanotechnology has moved into the realm of NO donor therapy, though currently there are no commercially available carriers of NO. While nanotechnology is not quite at the translational research stage, it poses the greatest potential for storage and site-specific delivery of high concentrations of NO to tumors. In this chapter, we review the effects of NO on various hemostatic elements, the pro-tumoral and anti-tumoral effects of NO and finally shed some light on the link between NO, cancer and coagulopathies.

Bleeding Assessment Tools (BATs) have been developed to aid in the standardized evaluation of bleeding symptoms. The Vicenza Bleeding Questionnaire (BQ), published in 2005, established a common framework and scoring key that has undergone subsequent modification over the years, culminating in the publication of the ISTH-BAT in 2010. Understanding the normal range of bleeding scores is critical when assessing the utility of a BAT. Within the context of The Merging Project, a bioinformatics system was created to facilitate the merging of legacy data derived from four different (but all Vicenza-based) BATs; the MCMDM1-VWD BQ, the Condensed MCMDM-1VWD BQ, the Pediatric Bleeding Questionnaire and the ISTH-BAT. Data from 1040 normal adults and 328 children were included in the final analysis, which showed that the normal range is 0–3 for adult males, 0–5 for adult females and 0–2 in children for both males and females. Therefore, the cut-off for a positive or abnormal BS is ≥4 in adult males, ≥6 in adult females and ≥3 in children. This information can now be used to objectively assess bleeding symptoms as normal or abnormal in future studies.

Background Challenges in reporting subjective hemorrhagic symptoms consistently has led to the need for standardized, quantitative Bleeding Assessment Tools (BATs), some of which assign Bleeding Scores (BSs). The ISTH-BAT (International Society on Thrombosis and Hemostasis – Bleeding Assessment Tool (Rodeghiero et al JTH 2010; 8:2063)) aimed to consolidate and optimize advances made by its predecessors, which were based on the 2005 “Vicenza Bleeding Questionnaire”. It is important to note, however, that the scoring systems differ among the BATs, with each bleeding symptom scored from 0 to +3 for the original Vicenza, -1 to +4 for the MCMDM-1VWD and Condensed MCMDM-1VWD Bleeding Questionnaires and the PBQ (Pediatric Bleeding Questionnaire), and 0 to +4 for the ISTH-BAT. As a result, the normal ranges of BSs vary among questionnaires. To date, the normal range for the ISTH-BAT has not been established; the objective of this study was to determine the normal range of bleeding scores for the ISTH-BAT for both adults and pediatric patients. Patients and Methods BS data from different studies, originally generated using 4 different Vicenza-based BATs, were compiled using a bioinformatics system created to facilitate the collation and analysis using different scoring systems. Demographic and BS data, along with blood group, VWF:Ag/VWF:RCo/FVIII:C (when available) were collected from all enrolled subjects. Data were derived from multiple studies; all defined normal subjects as those without a known problem with bleeding or bruising. All BATs were expert-administered. The normal range for both adults and pediatrics was determined by: 1) removing outliers > 3 SD away from the mean and then, 2) selecting the mid-95th %ile. Results 1,422 normal subjects were included (adult: n=1,079, pediatric: n=343). Adult data were collected using MCMDM-1VWD (n=294), Condensed MCMDM-1VWD (n=660), and ISTH-BAT (n=125), while pediatric data were collected using PBQ (n=324) and ISTH-BAT (n=19). 48 adults were removed from the analysis because they had BSs > 6.3, (i.e., >3 SD away from the mean), leaving n=1,031 for determination of the normal range. For children, BSs > 3.5 were judged to be outliers and therefore 18 children were removed, leaving n=325 children for determination of the normal range. The remaining adults had a mean age of 43 yrs (range 18 – 88) with 695 females and 336 males. The remaining children had a mean age of 9 yrs (range 0.4 – 17 yrs), with 169 females and 156 males. The relationship between BSs and demographic and lab data are given in Table 1. For the ISTH-BAT, the normal range of BSs was 0 - 4 in adults (meaning that for individuals 18 yrs or older, a BS 5 or greater is positive or abnormal) and 0 - 2 in children (meaning that for individuals < 18 yrs, a BS 3 or greater is positive or abnormal). Conclusion The newly established normal BS ranges can now be used to objectively assess the bleeding symptoms of individuals by administration of the ISTH-BAT. They also highlight the strength of merging existing datasets to generate meaningful results. By making these data accessible to all investigators using the web-based ISTH-BAT system housed at Rockefeller University we hope to aid investigators initiating new studies and facilitate correlating bleeding symptoms with genotypic, molecular, and environmental data. Disclosures: Mauer: CSL Behring: Honoraria. James:CSL Behring: Honoraria, Research Funding; Octapharma: Honoraria, Research Funding; Baxter: Honoraria; Bayer: Honoraria.