OBJECTIVES With development of antegrade cerebral perfusion, the necessity of deep hypothermic circulatory arrest (CA) in aortic arch surgery has been called into question. To minimize the adverse effects of hypothermia, surgeons now perform these procedures closer to normothermia. This study examined postoperative outcomes of hemiarch replacement patients using unilateral selective antegrade cerebral perfusion and mild hypothermic CA. METHODS Single-centre retrospective review of 66 patients undergoing hemiarch replacement with mild hypothermic CA (32°C) and unilateral selective antegrade cerebral perfusion between 2011 and 2018. Antegrade cerebral perfusion was delivered using right axillary artery cannulation. Postoperative data included death, neurological dysfunction, acute kidney injury and renal failure requiring new dialysis. Additional intraoperative metabolic data and blood transfusions were obtained. RESULTS Eighty-six percent of patients underwent elective surgery. Mean age was 67 ± 3 years. Lowest mean core body temperature was 32 ± 2°C. Average CA was 17 ± 5 min. No intraoperative or 30-day mortality occurred. Survival was 97% at 1 year, 91% at 3 years and 88% at 5 years. Permanent and temporary neurological dysfunction occurred in 1 (2%) and 2 (3%) patients, respectively. Only 3 (5%) patients suffered postoperative stage 3 acute kidney injury requiring new dialysis. Intraoperative transfusions occurred in 44% of patients and no major metabolic derangements were observed. CONCLUSIONS In patients undergoing hemiarch surgery, mild hypothermia (32°C) with unilateral selective antegrade cerebral perfusion via right axillary cannulation is associated with low mortality and morbidity, offering adequate neurological and renal protection. These findings require validation in larger, prospective clinical trials.

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Objective: We sought to develop a simulation model to train resident physicians in the performance of a median sternotomy.Methods: A modified Delphi consensus process was used with cardiac surgery staff to develop a 20-point checklist for the safe performance of a median sternotomy. Thirteen junior cardiac surgery trainees from across Canada participated in this study to assess the simulation model. Trainees performed the sternotomy before and after reviewing an instructional video. Two senior cardiac surgery resident physicians assessed the participants with the checklist during each session. An entry and exit questionnaire was given to the participants to evaluate the simulation model. Results: Participants scored higher after the training (14.3 AE 2.0) compared with before training (8.0 AE 3.1) (P < .001). The mean duration of time for participants to complete the sternotomy was shorter before training (188 AE 52 seconds vs 228 AE 58 seconds; P ¼ .003). The checklist interrater reliability was k ¼ 0.47 (moderate) for before training and k ¼ 0.37 (fair) for after training. All study participants rated the simulation sessions as very useful or extremely useful. Conclusions: Using the simulation model, training video, and checklist, trainees were able to improve their skill in performing a median sternotomy. This improvement was associated with longer times to complete all procedure steps. Rater training may further improve interrater reliability. Our median sternotomy checklist and simulation model can be adopted for the technical skills training of future cardiac surgery trainees. (JTCVS Techniques 2020;2:109-16

BACKGROUND: Contemporaneous Methods of cerebral protection during aortic arch surgery rely largely on systemic, moderate hypothermia (22 -28 C) and continuous antegrade cerebral perfusion (ACP). Recently, innominate artery cannulation has been introduced as a simplified, alternative route for ACP; however, clinical outcomes have yet to be evaluated against the gold standard of axillary cannulation. METHODS: We compared the outcomes of 97 consecutive patients who underwent hemiarch reconstruction (+/-root, valve, and other concomitant procedures) with moderate hypothermia and continuous ACP at two institutions between September 2008 and March 2014. Axillary cannulation (8-mm side graft) for ACP was utilized in 41 patients (26.8% female, 63.1 AE 13.0 years) while the remaining 56 patients (23.2% female, 60.4 AE 10.2) had ACP delivered via an innominate artery cannula. Patient characteristics were similar between the two groups; however, more patients in the in the axillary group underwent valve-sparing root replacements (22%) compared to the innominate group (1.8%; p¼0.002) and there were more aortic valve replacements (AVR) in the innominate group (Axillary 12.2%, Innominate 30.4%; p ¼0.035). A total operative time subgroup analysis was also performed investigating patients who underwent only aortic root and hemiarch reconstruction (Axillary n¼19; Innominate n¼20). RESULTS: Neurological outcomes were similarly excellent between the two groups with no patients in the Axillary group, and one patient (1.8%) in the Innominate group suffering from a perioperative stroke (p >0.999). There were no differences in transient neurological deficits or delirium (p¼0.11) between

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