A Single-Centre Experience of the Management of Infective Endocarditis.

BACKGROUND: Treatment for infective endocarditis (IE) is usually medical, with surgery reserved for those failing medical management or developing complications. Currently, 25%-50% of patients undergo surgery for IE with a 70%-80% immediate survival rate. However, there is controversy over the timing of surgery following cerebrovascular events, which occur in 15%-30% of IE patients. This study aimed to investigate whether surgical management is superior to medical management in patients with IE and to determine the optimal timing for surgery following the development of neurological symptoms. METHODS: Data were collected retrospectively between 2012 and 2018 from 436 patients diagnosed with IE and treated at our tertiary teaching hospital. The authors analysed the type of treatment, the timing of surgery, and the outcomes of these including mortality, IE recurrence, and length of hospital stay. RESULTS: A total of 421 patients were included in the analysis. More than two-thirds (69.1%) of patients underwent surgical intervention. The survival rate of patients having surgery for IE was 77.2%, compared to 50.7% in patients who did not undergo surgical intervention. 6.8% of patients presented with neurological symptoms; 73.3% of these patients had surgery within 14 days with a 90.9% survival. CONCLUSION: This study finds surgery to be safe with a seemingly higher survival rate compared to medical management alone, although this may be confounded by patients in the medical group being less likely to have surgery. Surgery in patients presenting with neurological symptoms is safe within 2 weeks from presentation with excellent outcomes.

The Best Second Arterial Conduit for Coronary Artery Bypass Grafting: A Meta-Analysis of Reconstructed Individual Patient Data.

Multiple arterial conduit revascularization in coronary bypass surgery is being advocated over the use of venous conduits. However, there is a critical gap regarding the optimal sequence of arterial conduit selection following the left internal thoracic artery. This study is the first individual patient data meta-analysis, which aimed to compare the right internal thoracic artery (RITA) versus the radial artery (RA) as a second-best arterial conduit. A comprehensive literature search was conducted in MEDLINE, Embase, Scopus, and CENTRAL. A forward-backward citation check was performed to identify other relevant studies. The study protocol was registered in the PROSPERO (CRD42023455543). Eligible studies included randomized controlled trials and propensity-score-matched cohort studies reporting long-term outcomes (>3 years) after coronary bypass surgery using the RITA versus RA as the second arterial conduit after left internal thoracic artery. Overall, long-term survival between the RITA and RA groups showed no significant difference. Landmark analyses demonstrated the superiority of RITA as a second arterial conduit at 1 [hazard ratio (HR): 0.86 (95% CI, 0.75-0.99), P = 0.036], 2 [0.83 (95% CI, 0.72-0.96), P = 0.011], and 5 years [HR: 0.80 (95% CI, 0.68-0.95), P = 0.036] post-surgery. Freedom from major cardiovascular events was significantly higher using the RITA conduit [HR: 0.72 (95% CI, 0.59-0.89), P = 0.002]. This study supports the use of RITA, especially when used in a skeletonized in situ fashion, as a second choice following the left internal thoracic artery as it has the potential to enhance long-term survival and outcomes. Further research with standardized surgical techniques is warranted.

Local versus General Anaesthesia for Transcatheter Aortic Valve Implantation (TAVI): A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomised and Propensity-Score Matched Studies.

Transcatheter aortic valve implantation (TAVI) is a common practice for severe aortic stenosis, but the choice between general (GA) and local anesthesia (LA) remains uncertain. We conducted a comprehensive literature review until April 2023, comparing the safety and efficacy of LA versus GA in TAVI procedures. Our findings indicate significant advantages of LA, including lower 30-day mortality rates (RR: 0.69; 95% CI [0.58, 0.82]; p < 0.001), shorter in-hospital stays (mean difference: -0.91 days; 95% CI [-1.63, -0.20]; p = 0.01), reduced bleeding/transfusion incidents (RR: 0.64; 95% CI [0.48, 0.85]; p < 0.01), and fewer respiratory complications (RR: 0.56; 95% CI [0.42, 0.76], p<0.01). Other operative outcomes were comparable. Our findings reinforce prior evidence, presenting a compelling case for LA's safety and efficacy. While patient preferences and clinical nuances must be considered, our study propels the discourse towards a more informed anaesthesia approach for TAVI procedures.

The Rationalisation of Intra-Operative Imaging During Cardiac Surgery: A Systematic Review.

INTRODUCTION: One critical complication of cardiac surgery is cerebrovascular accidents (CVAs). Ascending aorta atherosclerosis poses a significant risk of embolisation to distal vessels and to cerebral arteries. Epi-aortic ultrasonography (EUS) is thought to offer a safe, high-quality accurate visualisation of the diseased aorta to guide the surgeon on the best surgical approach to the planned procedure and potentially improve neurological outcomes post-cardiac surgery. METHOD: The authors conducted a comprehensive search of PubMed, Scopus and Embase. Studies that reported on epi-aortic ultrasound use in cardiac surgery were included. Major exclusion criteria were: (1) abstracts, conference presentations, editorials, literature reviews; (2) case series with <5 participants; (3) epi-aortic ultrasound in trauma or other surgeries. RESULTS: A total of 59 studies and 48,255 patients were included in this review. Out of the studies that reported patient co-morbidities prior to cardiac surgery, 31.6% had diabetes, 59.5% had hyperlipidaemia and 66.1% had a diagnosis of hypertension. Of those that reported significant ascending aorta atherosclerosis found on EUS, this ranged from 8.3% of patients to 95.2% with a mean percentage of 37.8%. Hospital mortality ranged from 7% to 13%; four studies reported zero deaths. Long-term mortality and stroke rate varied significantly with hospital duration. CONCLUSION: Current data have shown EUS to have superiority over manual palpation and transoesophageal echocardiography in the prevention of CVAs following cardiac surgery. Yet, EUS has not been implemented as a routine standard of care. Extensive adoption of EUS in clinical practice is warranted to aid large, randomised trials before making prospective conclusions on the efficacy of this screening method.

Clinical and technical outcomes of robotic versus manual percutaneous coronary intervention: A systematic review and meta-analysis.

BACKGROUND: Robotic percutaneous coronary intervention (R-PCI) is a promising medical procedure being used in clinical settings, which is thought to produce superior clinical and technical outcomes compared to the traditional manual approach. We performed a systematic review and meta-analysis to compare R-PCI to manual PCI (M-PCI). METHODS: A systematic literature search was performed using Pubmed, Medline (Ovid), Google Scholar, SCOPUS, and Embase from inception until the end of August 2021. Keywords used were ''Robotic PCI'' and ''Robotic angioplasty.'' Twenty studies were included for the qualitative analysis and seven for the pooled meta-analyses. RESULTS: There was no significant difference between R-PCI and M-PCI groups in terms of clinical success (risk ratio: 1.01, 95% CI: 0.99-1.02, p=0.45) and procedure time (mean difference: 4.55, 95% CI: 0.08-9.02, p=0.05). Both contrast volume (mean difference: -15.27, 95% CI: -22.37 - -8.18, p<0.0001) and fluoroscopy time (mean difference: -1.26, 95% CI: -2.37 - -0.16, p=0.03) were significantly lower in the R-PCI group. Technical success rates in all studies were equal to or greater than 70% (mean: 93.1, SD: 7.8), with four studies reporting 100% success rates. CONCLUSION: Given the comparable clinical short-term safety of R-PCI to that of M-PCI and the high technical success rates across several large, high-quality cohort studies, the clinician can be reassured about the ability of robotic devices. However, randomized long-term data are warranted before making prospective conclusions on the clinical and technical merits of R-PCI and adopting it as part of standard coronary interventions.

Malperfusion in Acute Type A Aortic Dissection: Management Strategies.

Over the decades, it has been well established that malperfusion complicates a number of acute type A aortic dissection (ATAAD) patients. Of the many complications that arise from ATAAD is malperfusion, which is the result of true lumen compression secondary to the dissection, and it is one of the most dangerous complications. Left untreated, malperfusion can eventually compromise circulation to the vascular beds of almost all vital organs. Clinicians must consider the diagnosis of malperfusion promptly following a diagnosis of acute aortic dissection. The outcomes post-surgery for patients with ATAAD with concomitant malperfusion remains poor, despite mortality for aortic surgery improving over time. Optimal management for ATAAD with associated malperfusion has yet to be implemented, further research is warranted to improve the detection and management of this potentially fatal pathology. In this review, we explore the literature surrounding the complications of malperfusion in ATAAD and the various symptom presentations, investigations, and management strategies available.