In this paper, the authors describe a simplified technique for concomitant left atrial posterior box isolation for atrial fibrillation using a standard non-irrigated bipolar radiofrequency clamp without opening the left atrium.

Despite the fact that Russia has a long history of cardiac surgery, little is known about how cardiac surgeons are actually trained here. Our aim was to reveal current challenges in cardiac surgical training in Russia by surveying recent residency (ordinatura) graduates. An online survey using Google Forms was conducted among cardiovascular surgical residency graduates who completed their training in 2017–2021. The survey contained 34 questions on demography, workload, technical and non-technical skills, research, mentor–mentee relationship, etc. In addition, room for comments was provided. From February 19, 2022, to March 12, 2022, 69 entries were received. Sixty entries were available for analysis, 14 (23

Central MessageSeagull deformity of a sequential diamond-shaped coronary anastomosis may be easily solved with a patch repair technique. Seagull deformity of a sequential diamond-shaped coronary anastomosis may be easily solved with a patch repair technique. Seagull deformity (Figure 1, A) is the most frequent and feared complication of sequential diamond-shaped coronary anastomoses.1Lemma M.G. Technique for Y and T grafts.in: Gaudino M. Technical Aspects of Modern Coronary Artery Bypass Surgery. 1st ed. Academic Press, 2020: 99-113Google Scholar Its threat is a turbulence flow that may trigger clot formation within the graft. The main cause of the seagull deformity is too-long incision of a target coronary artery, which leads to the transverse tension of the graft with its flattening and kinking at the anastomosis. In addition, the position of the target coronary artery deep in the myocardium and stiffness of its wall may amplify the impact of the excessive incision length. Another cause of the deformity is when some redundant adventitial tissue is dragged to the anastomosis while sewing. Strategies to avoid this complication have been described by numerous authors,1Lemma M.G. Technique for Y and T grafts.in: Gaudino M. Technical Aspects of Modern Coronary Artery Bypass Surgery. 1st ed. Academic Press, 2020: 99-113Google Scholar, 2Grondin C.M. Limet R. Sequential anastomoses in coronary artery grafting: technical aspects and early and late angiographic results.Ann Thorac Surg. 1977; 23: 1-8Abstract Full Text PDF PubMed Scopus (74) Google Scholar, 3Lytle B.W. Anastomotic techniques.Oper Tech Thorac Cardiovasc Surg. 2000; 5: 222-230Abstract Full Text Full Text PDF Scopus (13) Google Scholar, 4Glineur D. Fortier J. Kimmaliardjuk D.M. Segura P. Grau J. Sequential anastomoses: surgical technique, results, grafting strategy in coronary artery revascularization.in: Gaudino M. Technical Aspects of Modern Coronary Artery Bypass Surgery. 1st ed. Academic Press, 2020: 85-97Google Scholar, 5Akhrass R. Bakaeen F.G. Multi-arterial coronary grafting.Oper Tech Thorac Cardiovasc Surg. 2022; 27: 126-146Abstract Full Text Full Text PDF Scopus (2) Google Scholar but little is known about how to address a seagull deformation if it is already occurred. The traditional approach is to redo the anastomosis using a parallel side-to-side or end-to-side technique, which means switching to a completely different graft strategy. Here, we describe an easier way to solve this complication. As we mentioned earlier, the mechanism of the seagull deformity includes transverse tension of the graft. This means a lack of graft tissue to close a large incision of the coronary artery. Hence, one of the ways to address with this complication is to add some extra tissue to the graft. For this purpose, a longitudinal incision is made on the graft just over the anastomosis (Figure 1, B). Then, this incision is closed with a diamond-shaped patch from the same tissue as the graft (Figure 1, C and D). Video 1 shows this technique by means of a high-fidelity simulation model. We used this technique clinically in 2 patients with a good immediate result. Here, we describe a patch repair technique for the seagull deformity of a sequential diamond-shaped coronary anastomosis, which seems to be the easiest way to solve this complication. However, this technique has some limitations. First, it adds an extra suture line at the site of the anastomosis, increasing the risk of technical errors, which may lead to endothelium damage and subsequent clot formation. Second, some grafts may be too fragile for patch repair (however, such grafts are not likely to be used for sequential anastomoses). And, finally, this technique has not been proven with long-term follow-up. Nevertheless, alternatives to the described technique are even more risky, as they mean switching to a new graft configuration in the middle of the procedure. Seagull deformity of a sequential diamond-shaped coronary anastomosis may be easily solved with a patch repair technique.

Central MessagePosterior pericardiotomy is a safe and simple procedure that may prevent not only postoperative atrial fibrillation, but also pericardial effusion and tamponade.See Commentary on page 117. Posterior pericardiotomy is a safe and simple procedure that may prevent not only postoperative atrial fibrillation, but also pericardial effusion and tamponade. See Commentary on page 117. During the American Heart Association Scientific Sessions 2021, Dr Mario Gaudino presented the results of the PALACS (Posterior Left pericardiotomy for the prevention of postoperative Atrial fibrillation after Cardiac Surgery) trial, which were simultaneously published in The Lancet.1Gaudino M. Sanna T. Ballman K.V. Robinson N.B. Hameed I. Audisio K. et al.Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery: an adaptive, single-centre, single-blind, randomised, controlled trial.Lancet. 2021; 398: 2075-2083Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar This trial attracted attention to posterior pericardiotomy (PP)—an intervention first applied in cardiac surgery a quarter-century ago,2Mulay A. Kirk A.J.B. Angelini G.D. Wisheart J.D. Hutter J.A. Posterior pericardiotomy reduces the incidence of supra-ventricular arrhythmias following coronary artery bypass surgery.Eur J Cardiothorac Surg. 1995; 9: 150-152Crossref PubMed Scopus (48) Google Scholar whose mechanism of action is linked to the elimination of pericardial effusion—a known trigger of atrial fibrillation.3St-Onge S. Perrault L.P. Demers P. Boyle E.M. Gillinov A.M. Cox J. et al.Pericardial blood as a trigger for postoperative atrial fibrillation after cardiac surgery.Ann Thorac Surg. 2018; 105: 321-328Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar So, the question is raised: should this prophylactic intervention be applied in cardiac surgery routinely? To answer this question, we would like to briefly review the results of the PALACS trial and some earlier studies and our trial. The authors of the PALACS trial conducted a perfectly designed and powered randomized controlled trial that has shown a beneficial effect of PP on preventing postoperative atrial fibrillation (POAF) in cardiac surgery. This trial included adult patients undergoing primary, elective coronary artery bypass grafting, aortic valve or ascending aortic procedures, or a combination of these, who had no previous history of arrhythmia. Patients undergoing mitral or tricuspid valve surgery were excluded from the study because, the authors stated, they had different pathophysiology and risk of POAF. However, whether patients undergoing isolated interventions on the coronary arteries have the same pathophysiology of POAF as do patients undergoing aortic valve or ascending aortic procedures is unknown. From several meta-analyses, we already know that PP is effective in patients undergoing isolated coronary artery bypass grafting.4Xiong T. Pu L. Ma Y.F. Zhu Y.L. Li H. Cui X. et al.Posterior pericardiotomy to prevent new-onset atrial fibrillation after coronary artery bypass grafting: a systematic review and meta-analysis of 10 randomized controlled trials.J Cardiothorac Surg. 2021; 16: 233Crossref PubMed Scopus (2) Google Scholar,5Hu X.L. Chen Y. Zhou Z.D. Ying J. Hu Y.H. Xu G.H. Posterior pericardiotomy for the prevention of atrial fibrillation after coronary artery bypass grafting: a meta-analysis of randomized controlled trials.Int J Cardiol. 2016; 215: 252-256Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Now, from a prespecified subgroup analysis of the PALACS trial, we have learned that PP is also effective in aortic valve and ascending aortic procedures. We also tried to answer whether PP is effective in patients undergoing aortic valve procedures. However, we received a completely different result that may add some information on the pathophysiology of POAF. Our randomized controlled trial included patients aged 18-69 years undergoing primary isolated aortic valve replacement.6Kaleda V.I. Boldyrev S.Y. Belash S.A. Yakuba I.I. Babeshko S.S. Barbuhatti K.O. Efficacy of posterior pericardiotomy in prevention of atrial fibrillation and pericardial effusion after aortic valve replacement: a randomized controlled trial.Circ Pathol Cardiac Surg. 2017; 21: 60-67Crossref Google Scholar Besides preoperative atrial fibrillation, there was a long list of exclusion criteria, including the majority of known risk factors of atrial fibrillation and conditions that hinder PP performance: a history of thyroid dysfunction, amiodarone intake, pericardial effusion, severe chronic obstructive pulmonary disease, left ventricular ejection fraction <30%, left atrial systolic diameter >50 mm, active infective endocarditis, pericardial and/or pleural adhesions, and minimally invasive approach. Assuming a rate of POAF of 35% (a close number was used in an initial PALACS protocol7Abouarab A.A. Leonard J.R. Ohmes L.B. Lau C. Rong L.Q. Ivascu N.S. et al.Posterior Left pericardiotomy for the prevention of postoperative Atrial fibrillation after Cardiac Surgery (PALACS): study protocol for a randomized controlled trial.Trials. 2017; 18: 593Crossref PubMed Scopus (9) Google Scholar), we estimated that a sample size of 90 participants would have provided 80% power and 5% confidence level to detect a reduction of the primary outcome down to 11% (based on our systematic review8Kaleda V.I. McCormack D.J. Shipolini A.R. Does posterior pericardiotomy reduce the incidence of atrial fibrillation after coronary artery bypass grafting surgery?.Interact Cardiovasc Thorac Surg. 2012; 14: 384-389Crossref PubMed Scopus (23) Google Scholar) in the PP group compared with the control group. In 2013—2015 we recruited 100 patients. The results of the study were surprising: the overall incidence of POAF was much lower than expected, and there was no difference between the groups in terms of both atrial fibrillation and pericardial effusion (Table 1).Table 1Patients and outcomes (full data available in Kaleda and colleagues6Kaleda V.I. Boldyrev S.Y. Belash S.A. Yakuba I.I. Babeshko S.S. Barbuhatti K.O. Efficacy of posterior pericardiotomy in prevention of atrial fibrillation and pericardial effusion after aortic valve replacement: a randomized controlled trial.Circ Pathol Cardiac Surg. 2017; 21: 60-67Crossref Google Scholar)Posterior pericardiotomy (n = 49)Control (n = 51)Р valueAge, y56.6 ± 9.955.4 ± 10.5.564Sex (male)28 (57%)33 (65%).438Cardiopulmonary bypass time, min64 ± 1664 ± 20.664Crossclamp time, min45 ± 1346 ± 12.844Mechanical prosthesis35 (70%)40 (80%).419Chest tubes removal, POD4.4 ± 1.43.3 ± 0.6<.0001Postoperative AF8 (16%)7 (14%).716Onset of AF, POD3.6 ± 2.53.0 ± 2.6.551AF at discharge1 (2%)1 (2%).977Pericardial separation ≥5 mm5 (10%)6 (12%).803Data presented as mean ± standard deviation and n (%). POD, Postoperative day; AF, atrial fibrillation. Open table in a new tab Data presented as mean ± standard deviation and n (%). POD, Postoperative day; AF, atrial fibrillation. We have 2 explanations for our results. First, we excluded patients with any known risk of atrial fibrillation, so we obtained a low incidence of this event in both groups, whereas, probably, PP works only in high-risk patients. Second, the results could be affected by our chest drainage strategy. While there is a clear trend to remove chest tubes as soon as possible (usually on the next day after surgery), we used a very conservative volume threshold for tube removal of 100 mL/day. This strategy led to really long chest tube duration—on the average of 4.4 days in PP group and 3.3 days in the control group (P < .0001). Consequently, in most patients the tubes (including the pericardial tube in the control group) were still in place at the time of greatest POAF risk. Early chest tube removal has been associated with an increased risk of pericardial effusion.9Andreasen J.J. Sørensen G.V.B. Abrahamsen E.R. Hansen-Nord E. Bundgaard K. Bendtsen M.D. et al.Early chest tube removal following cardiac surgery is associated with pleural and/or pericardial effusions requiring invasive treatment.Eur J Cardiothorac Surg. 2016; 49: 288-292Crossref PubMed Scopus (17) Google Scholar Several years ago, an assumption was made that additional posterior pericardial tube may be as good as PP,10Conti V.R. Draining the posterior pericardial space: pericardiotomy versus just another tube.J Thorac Cardiovasc Surg. 2017; 153: 876-877Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar and our results support this assumption. In fact, the effect of pericardial drainage using an additional tube placed posteriorly in the pericardium has been investigated. In a prospective randomized controlled trial by Eryilmaz and colleagues,11Eryilmaz S. Emiroglu O. Eyileten Z. Akar R. Yazicioglu L. Tasoz R. et al.Effect of posterior pericardial drainage on the incidence of pericardial effusion after ascending aortic surgery.J Thorac Cardiovasc Surg. 2006; 132: 27-31Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar a conventional 1-tube strategy was compared with a 2-tube strategy in patients undergoing ascending aortic surgery. The study showed that a thin drain placed retrocardially is effective in the prevention of posterior pericardial effusion. However, a dedicated prospective randomized controlled study by Sen and colleagues12Sen O. Aydin U. Iyigun T. Reyhancan A. Timur B. Kadirogullari E. et al.Right pericardial window opening: a method of preventing pericardial effusion.Gen Thorac Cardiovasc Surg. 2020; 68: 485-491Crossref PubMed Scopus (2) Google Scholar demonstrated the superiority of the right pericardial window (a technique that seems to be an analog of PP) over posterior pericardial tube in terms of reducing pericardial effusion. The superiority of PP over the posterior pericardial tube is easily explained by its longer functioning. So, these 2 explanations of why PP did not work in our study may extend our understanding of the pathophysiology of POAF, but have no practical implications, because (1) nowadays most patients, such as those included in our study, are usually operated on via a minimally invasive approach, which hinders PP performance; so, recommendation not to perform PP in these patients would be meaningless, and (2) we cannot recommend prolonged chest drainage strategy because it hinders early postoperative physical activity and fast track recovery. Interestingly, PP has been included in 2 clinical guidelines on prevention and management of POAF: by the American College of Chest Physicians (2005; strength of recommendation, B; evidence grade, fair; net benefit, intermediate)13Creswell L.L. Alexander Jr., J.C. Ferguson Jr., T.B. Lisbon A. Fleisher L.A. Intraoperative interventions: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery.Chest. 2005; 128: 28S-35SAbstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar and the European Association for Cardio-Thoracic Surgery (2006; grade B recommendation based on an individual level 1b study).14Dunning J. Treasure T. Versteegh M. Nashef S.A.M. Guidelines on the prevention and management of de novo atrial fibrillation after cardiac and thoracic surgery.Eur J Cardiothorac Surg. 2006; 30: 852-872Crossref PubMed Scopus (147) Google Scholar However, during the past 15 years, none of these documents has been updated. To conclude, despite the findings of our trial, we believe that we should perform PP in every patient done through a full sternotomy and that the PALACS trial is an essential cornerstone on the way to a wider adoption of this technique in cardiac surgery. However, further research is needed to investigate the long-term effect of PP, as well as its effect in patients undergoing mitral and tricuspid valve procedures. The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. Commentary: A small incision to cut in half postoperative atrial fibrillationJTCVS TechniquesVol. 14PreviewPostoperative atrial fibrillation (POAF) is the most frequent complication of cardiac surgery and carries an increased risk of mortality and morbidity.1 Due to its frequency and increased risk of adverse events, prevention of this condition is paramount. Full-Text PDF Open Access

We appreciate Aydın et al. for their interest in our work.1 We agree that externalization of a venous cannula through an intercostal space is not a new technique and that it may be performed using various approaches, including the one described by the authors of the letter (however, without details). Indeed, from communication with different colleagues around the world, we know that this approach has been used for years. We also utilized a similar technique at the beginning of our experience, using a finger of a surgical glove to protect the tip of the cannula from fat contamination. First, we passed the cannula through an intercostal space from the outside in and only then inserted it into the right atrial appendage. However, an acute angle between the position of the cannula before cannulation (cranial, fixed in an intercostal space) and the direction it should be guided to (caudal, towards an inferior vena cava) made venous cannulation not only cumbersome, but painful to a surgeon in many cases. Moreover, this clumsy insertion of a venous cannula into the right atrial appendage could cause hemodynamic compromise at the time the cannula was still not in place to start cardiopulmonary bypass. These are the reasons why we introduced an adjunct to ease externalization of the venous cannula from inside to outside after the cannulation. Though our device is still not on the market, it has a reusable design and its economy load is expected to be low.

OBJECTIVE:Various methods for cardiothoracic, cardiovascular, and cardiac surgical training exist across the globe, with the common goal of producing safe, independent surgeons. A comparative analysis of international training paradigms has not been undertaken, and our goal in doing so was to offer insights into how to best prepare future trainees and ensure the health of our specialty.METHODS:We performed a comparative analysis of available publications offering detailed descriptions of various cardiothoracic, cardiovascular, and cardiac surgical training paradigms. Corresponding authors from previous publications and other international collaborators were also reached directly for further data acquisition.RESULTS:We report various approaches to common challenges surrounding (1) selection of trainees and plans for the future surgical workforce; (2) trainee assessments and certification of competency before independent practice; and (3) challenges related to a changing practice landscape.CONCLUSIONS:Cardiothoracic surgery remains a dynamic and rewarding specialty. Current and future trainees face several challenges that transcend national borders. To foster collaboration and adoption of best practices, we highlight international strengths and weaknesses of various nations in terms of workforce selection, trainee operative experience and assessment, board certification, and preparation for future changes anticipated in cardiothoracic surgery.

There are several approaches to venous cannulation in minimally invasive aortic valve surgery. Frequently used options include central dual-stage right atrial cannulation, or peripheral femoral venous cannulation. During minimally invasive aortic surgery via an upper hemisternotomy, central venous cannulas may obstruct the surgeon's visualization of the aortic valve and root, or require extension of the skin incision, while femoral venous cannulation requires an additional incision, time and resources. Here we describe a technique for central venous cannulation during minimally invasive aortic surgery, utilizing a novel device, to facilitate simple, convenient, and expedient central cannulation with a cannula-free surgical working space.

OBJECTIVES:Patients with patent internal thoracic artery (ITA) grafts after prior coronary artery bypass grafting surgery who require aortic valve replacement (AVR) pose unique technical challenges for safe and optimal myocardial protection. The purpose of this study is to review our short- and long-term outcomes with redo minimally invasive AVR in patients with patent in situ ITA grafts.METHODS:From 2008 to 2016, 48 patients with at least 1 patent in situ mammary artery graft underwent minimally invasive AVR. Preoperative computed tomography was performed in all patients to evaluate the relationship of patent grafts to the sternum. Retrograde coronary sinus and pulmonary vent catheters were placed via the right internal jugular vein. The in situ ITA grafts were not clamped during AVR. Transverse aortotomy, taking care to avoid the grafts arising from the aorta, was performed to expose the aortic valve.RESULTS:The median age of the patients was 78 years [Quartile 1 (Q1)-Quartile 3 (Q3): 71-81]. Thirty-nine (81%) patients were men, and 46 (96%) patients had aortic stenosis. The median cardiopulmonary bypass and cross-clamp times were 124 (Q1-Q3: 108-164) and 92 (Q1-Q3: 83-116) min, respectively. Moderate hypothermia at 28-30°C was used in all patients. Most patients received cold blood cardioplegia with antegrade induction and continuous retrograde delivery. Four patients received only retrograde delivery due to some degree of aortic insufficiency. Thirty-day mortality was 4% (2 of 48 patients). There was no conversion to full sternotomy, and no reoperations were performed for postoperative bleeding or sternal wound infection. Excluding the 2 patients who died in the hospital, the median postoperative length of stay was 7 days (Q1-Q3: 5-8). Overall survival at 1, 5 and 10 years was 94%, 87% and 44%, respectively.CONCLUSIONS:Percutaneous retrograde cardioplegia combined with antegrade cardioplegia and moderate hypothermia, without interruption of ITA flow, is a safe and reliable strategy in patients with patent ITA grafts undergoing aortic valve replacement. This strategy combined with a minimally invasive approach may reduce surgical trauma, and is a safe and effective technique in these challenging patients.

A 65-year-old man with hypertension presented with shortness of breath and III/IV diastolic murmur. Transesophageal echocardiogram (TEE) showed a bicuspid aortic valve with prolapse of the conjoint right (RC) and non-coronary (NC) cusp. Severe eccentric aortic regurgitation (AR) directed towards the anterior leaflet of the mitral valve was also noted. The measurements of the aortic annulus, sinuses of Valsalva and sinotubular junction (STJ) were 32, 40 and 34 mm respectively.

The very first clinical transplants used a technique, with anastomoses of atrium to atrium, which had been developed to allow successful canine experiments (1). A small modification by Barnard led the suture line away from the sino-atrial node. Many years later Sievers (2) described the intact right atrium, with separate caval anastomoses, now the standard procedure, with a proven decrease in need for permanent pacemakers. A further refinement, with intact left atrium and separate pulmonary venous cuff anastomoses (3), the “total orthotopic transplant" has not proven popular.

This video tutorial demonstrates the surgical technique for mitral valve replacement through the roof of the left atrium via an upper inverted T-shaped ministernotomy, with central cannulation for cardiopulmonary bypass.

We read with great interest the paper by Rahimi-Barfeh and colleagues [1Rahimi-Barfeh A. Grothusen C. Haneya A. et al.Transatrial cannulation of the left ventricle for acute type A aortic dissection: a 5-year experience.Ann Thorac Surg. 2016; 101: 1753-1758Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar] concerning excellent results achieved by their group in surgery for acute type A aortic dissection. The authors suggested the new technique of the arterial cannulation of left ventricle (LV) through the right upper pulmonary vein (RUPV) and left atrium. In our clinic we have tried to use various sites of the arterial cannulation for type A aortic dissection and the new transatrial technique described by Rahimi-Barfeh and colleagues seems to be the most attractive. Here we would like to share some details of our personal experience in order to advocate this technique. After the pericardiotomy the site of RUPV is invisible due to grossly distended and extremely fragile aneurysmatic aorta that is obviously untouchable. Nevertheless, slight gentle traction applied to the inserted venous cannula as described by the authors is extremely helpful in visualizing the RUPV. For arterial cannulation we used a simple one stage venous cannula (Medtronic DLP Venous Cannula 30F, Minneapolis, MN) with a rounded tip instead of a sharp pointed arterial cannula used by the authors. In our practice the point of the cannula was not well seen on transesophageal echocardiogram, but after introduction of cardiopulmonary bypass one can easily feel its tip through the LV wall without the risks of damaging it with the acute sharp point of the arterial cannula used by the authors. To avoid the over distension of LV in case of ventricular fibrillation that occurred in our case at core temperature of 34°C we lowered the CBP volume and applied gentle manual LV massage continuing to reduce the body temperature to 28°C, which was quickly achieved. We would like to ask the authors to describe more precisely the details of the positioning of the arterial cannula in the LV cavity because they have more experience and used to cooling to 18°C, which would take longer time with a fibrillating heart. On the whole, we think that the transatrial technique of arterial cannulation is a large step forward in making the surgery for type A aortic dissection safer and can be used in any type of aortic dissection. Transatrial Cannulation of the Left Ventricle for Acute Type A Aortic Dissection: A 5-Year ExperienceThe Annals of Thoracic SurgeryVol. 101Issue 5PreviewAcute type A aortic dissection (AAD) is a life-threatening disorder with a high rate of mortality and complications. All cannulation techniques currently used to establish arterial flow for cardiopulmonary bypass are associated with a considerable risk of organ malperfusion, stroke, or access site trauma. Here, we report the impact of transatrial cannulation of the left ventricle on patient outcome after surgical treatment of AAD. Full-Text PDF

A 58-year-old woman presented with decompensated rheumatic mitral valve stenosis and was evaluated for surgery. Preoperative chest radiography revealed a circumscribed mass shadow in the right upper lobe area (Figure 1A). Computed tomography angiography showed multiple pulmonary arteriovenous malformations between the right upper lobe artery and the left atrium (Figure 1B). Pulmonary arteriography revealed a massive right-to-left shunt through the malformations (Video 1). The patient underwent uneventful mitral valve replacement and a right upper lobectomy. Declaration of conflicting interests

We read with great interest a report by Gallo et al. [1] on a very rare coronary artery anatomy. In a classification of single coronary artery (SCA) by Lipton et al. [2] with modifications by Yamanaka and Hobbs [3], this case refers to the R-IIIC type of SCA. Indeed, there is little discrepancy between terminology and anatomy in this type of SCA, which is very apparent in the present case. According to the foregoing classification, the R-IIIC type of SCA is an anomaly where the left anterior descending artery (LAD) and left circumflex artery (LCx) arise separately from the proximal part of the normal right coronary artery (RCA). Then, LCx passes the great vessels posteriorly and LAD crosses anteriorly the infundibulum of the right ventricle to reach their usual locations [2, 3]. This LAD supplies only the middle and distal portions of the anterior interventricular sulcus (AIVS), and the proximal portion of the AIVS receives blood from the ‘LCx’ (it is clearly seen in Fig. 2A from [1]). Thus, AIVS has two sources of blood supply and this anatomy refers to Type IV dual LAD [4]. In more detail, we have discussed this anatomy in a recent similar case by Saxena et al. [5, 6]. Hence, the R-IIIC type of SCA is a combination of two anomalies: Type IV dual LAD and left main stem (LM) originating from the RCA, and the correct description of coronary arteries in this type should apply the terms long LAD, short LAD and LM. Correct diagnosis of dual LAD in SCA may be important in planning the strategy of revascularization in the case of atherosclerotic lesions in the LM or short LAD.

Avulsion of a graft after coronary artery bypass grafting surgery is a rare but very serious complication which leads to massive bleeding and possible life-threatening cardiac tamponade. In this paper we report a very rare case of a left internal mammary artery graft avulsion on the day of surgery in a patient with syphilis.

A 65-year-old woman presented with acute chest pain, orthopnea, and facial and arm swelling. She had undergone aortic valve replacement with a ball-valve prosthesis, for significant rheumatic aortic valve stenosis, in another country 25 years earlier. Transthoracic echocardiography showed a complex ascending aortic aneurysm to be the cause of her superior vena cava syndrome. The prosthesis functioned well with a maximum gradient of 42 mm Hg. Computed tomography showed an ascending aortic aneurysm with a dissection and a false lumen compressing the superior vena cava below the azygos vein. There was a single fenestration in the posterior wall of the ascending aorta. Another finding was a small anterior false aneurysm (Figure 1A–D). Further surgery confirmed the diagnosis. Histological examination of the aortic wall showed cystic medial necrosis.

We describe a case with left atrial volume reduction of a giant left atrium, treated successfully by partial cardiac autotransplantation, concomitant mitral and aortic valve replacement, and tricuspid valve plasty. We obtained good results at the 1-year follow-up.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether posterior pericardiotomy (PP) reduces the incidence of atrial fibrillation (AF) after coronary artery bypass grafting surgery. Twelve papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. One non-randomized prospective cohort controlled study generated early evidence that PP reduced the rate of postoperative AF and pericardial effusion. The operative details of PP were clearly explained in this paper. The efficacy of this procedure was subsequently examined in five prospective randomized controlled trials performed with some limitations, listed in the table. Meta-analysis of the randomized control trials examined a group of 763 patients (PP = 389, control = 374). It revealed a highly significant reduction in total arrhythmias and AF in the PP group (odds ratio 0.31 and 0.33, respectively). There was a 10.8% AF rate in the PP group (41/379) and a 28.1% AF rate in the control group (108/384). Furthermore, the PP group had a significant reduction in the rate of early and late pericardial effusion (P < 0.001). Moreover, the reduction in the incidence of arrhythmias was significantly associated with the reduction in the incidence of pericardial effusion. Referring to these studies, two guidelines recommend PP to reduce postoperative AF with grade B strength of recommendation. We conclude that PP significantly reduces the incidence of postoperative AF. The number needed to treat to prevent one case of AF is six.