Surgical aortic valve replacement in the era of transcatheter aortic valve implantation: a review of the UK national database.

OBJECTIVES: To date the reported outcomes of surgical aortic valve replacement (SAVR) are mainly in the settings of trials comparing it with evolving transcatheter aortic valve implantation. We set out to examine characteristics and outcomes in people who underwent SAVR reflecting a national cohort and therefore 'real-world' practice. DESIGN: Retrospective analysis of prospectively collected data of consecutive people who underwent SAVR with or without coronary artery bypass graft (CABG) surgery between April 2013 and March 2018 in the UK. This included elective, urgent and emergency operations. Participants' demographics, preoperative risk factors, operative data, in-hospital mortality, postoperative complications and effect of the addition of CABG to SAVR were analysed. SETTING: 27 (90%) tertiary cardiac surgical centres in the UK submitted their data for analysis. PARTICIPANTS: 31 277 people with AVR were identified. 19 670 (62.9%) had only SAVR and 11 607 (37.1%) had AVR+CABG. RESULTS: In-hospital mortality for isolated SAVR was 1.9% (95% CI 1.6% to 2.1%) and was 2.4% for AVR+CABG. Mortality by age category for SAVR only were: <60 years=2.0%, 60-75 years=1.5%, >75 years=2.2%. For SAVR+CABG these were; 2.2%, 1.8% and 3.1%. For different categories of EuroSCORE, mortality for SAVR in low risk people was 1.3%, in intermediate risk 1% and for high risk 3.9%. 74.3% of the operations were elective, 24% urgent and 1.7% emergency/salvage. The incidences of resternotomy for bleeding and stroke were 3.9% and 1.1%, respectively. Multivariable analyses provided no evidence that concomitant CABG influenced outcome. However, urgency of the operation, poor ventricular function, higher EuroSCORE and longer cross clamp and cardiopulmonary bypass times adversely affected outcomes. CONCLUSIONS: Surgical SAVR±CABG has low mortality risk and a low level of complications in the UK in people of all ages and risk factors. These results should inform consideration of treatment options in people with aortic valve disease.

Dissecting the Management and Outcomes of Thoracic Aortovascular Disease During the COVID-19 Pandemic.

OBJECTIVE: The COVID-19 pandemic has forced the cancellation of planned surgery and led to significant surgical service reductions. Early intervention in aortovascular disease is often critical and cannot be deferred despite these reductions. There is urgent need to evaluate the provision and outcomes of thoracic aortovascular intervention during the peak of the pandemic. METHODS: Prospective data was collected for patients receiving open and endovascular thoracic aortovascular intervention over two-time points; January-May 2020 and January-May 2019 at three tertiary cardiovascular centres. Baseline demographics, cardiovascular risk and COVID-19 screening results were noted. Primary outcomes were median length of intensive care unit and hospital stay, intra-operative mortality, 30-day mortality, post-operative stroke, and spinal cord injury. RESULTS: Patients operated in 2020 (41) had significantly higher median EuroSCORE II than 2019 (53) (7.44 vs. 5.86, P = 0.032) and rates of previous cardiac (19.5% vs. 3.8%, P = 0.019), aortic (14.6% vs. 1.9%, P = 0.041), and endovascular (22.0% vs. 3.8%, P = 0.009) intervention. There was an increase in proportion of urgent cases in 2020 (31.7% vs. 18.9%). There were no intra-operative deaths in 2020 and 1 in 2019 (P = 1.00). There were no significant differences (P ≥ 0.05) in 30-day mortality (4.9% vs. 13.2%), median intensive care unit length of stay (72 vs. 70 hr), median hospital length of stay (8 vs. 9 days), post-operative stroke (3 vs. 6), or spinal cord injury (2 vs. 1) between 2020 and 2019 respectively. CONCLUSIONS: Despite the increased mortality risk of patients and urgency of cases during COVID-19, complicated by the introduction of cohorting and screening regimens, thoracic aortovascular intervention remained safe with comparable in outcomes to pre-COVID-19.

Initial conservative management strategy of HeartWare left ventricular assist device thrombosis with intravenous heparin or bivalirudin.

INTRODUCTION AND OBJECTIVES: Pump thrombosis is a serious left ventricular assist device complication, though there are no guidelines regarding its treatment. The main aim of this study was to describe a strategy of intravenous anticoagulation as the initial treatment in these patients and then to compare intravenous heparin with bivalirudin. METHODS: All consecutive patients who received a HeartWare left ventricular assist device from July 2009 to March 2019 were retrospectively analysed. Patients developing a pump thrombosis were selected, and treatment, outcomes and complications were recorded. RESULTS: During this period of time (116 months), 220 patients underwent HeartWare left ventricular assist device implantation and 57 developed pump thrombosis, with an incidence rate of first pump thrombosis of 0.17 events per patient-year of support (incidence rate of all episodes of pump thrombosis: 0.30 events per patient-year of support). All the patients were initially treated medically, predominantly with either intravenous heparin (n = 26) or bivalirudin (n = 16). Patients treated with bivalirudin during the first pump thrombosis episode had less subsequent re-thrombosis episodes (18.7% vs 57.7%, p < 0.05). In addition, percentage time in therapeutic range was greater for bivalirudin compared with heparin (68.5% ± 16.9% vs 37.4% ± 31.0%, p < 0.01). During the first pump thrombosis episode, 26.3% of the patients needed surgery (left ventricular assist device exchange (n = 8), transplant (n = 6) or decommissioning (n = 1)). The overall survival at 1 year was 61.4%, and there was no significant difference in survival. CONCLUSION: Left ventricular assist device thrombosis is a serious life-threatening complication; hence, we propose an initial conservative management of pump thrombosis with enhanced intravenous anticoagulation with either intravenous heparin or bivalirudin, with surgery reserved for refractory cases.

Impact of donor variables on heart transplantation outcomes in mechanically bridged versus standard recipients†.

OBJECTIVES: This study aimed to quantify the impact of donor variables on post-heart transplantation mortality and morbidity in recipients with and without a pretransplant left ventricular assist device (LVAD). METHODS: This is a prospective cohort study of the ISHLT Transplant Registry that includes all primary heart transplants in adult recipients (January 2005-June 2013, n = 15 532). All recipients were divided into patients with a durable continuous-flow LVAD (LVAD recipient, n = 3315) and without mechanical support (standard recipient, n = 12 217). Donors were classified as high risk (n = 3751) and low risk (n = 11 781). Transplants were categorized into low-risk donor/standard recipient (n = 9214), high-risk donor/standard recipient (n = 3003), low-risk donor/LVAD recipient (n = 2567) and high-risk donor/LVAD recipient (n = 748). Outcomes prior to discharge, survival at 5 years and freedom from complications were computed for each group. RESULTS: LVAD recipients experienced more episodes of infection, stroke and acute rejection with both low- (P < 0.001, P < 0.001, P < 0.001) and high-risk donors (P < 0.001, P = 0.008, P = 0.028) prior to transplant discharge. Within standard recipients, a higher rate of primary graft failure (P = 0.035), infection (P = 0.001), dialysis (P = 0.012), acute rejection (P = 0.037) and less freedom from cardiac allograft vasculopathy (P < 0.001) and malignancy (P = 0.004) was observed with high-risk donors. Within LVAD recipients, no differences in complications prior to discharge or long-term morbidity were detected between low- and high-risk donors. When compared to standard recipient/low-risk donors, all the 3 remaining categories had an increased probability of death or graft failure within 90 days: LVAD recipient/low-risk donor [hazard ratio (HR) 1.26, confidence interval (CI) 1.05-1.51; P = 0.012], standard recipient/high-risk donor (HR 1.47, CI 1.27-1.71; P < 0.001) and LVAD recipient/high-risk donor (HR 1.72, CI 1.32-2.24; P < 0.001). Between 90 days and 5 years, only standard recipient/high-risk donor had an increased probability of death or graft failure (HR 1.140, CI 1.020-1.274; P = 0.021) when compared to standard recipient/low-risk donor. CONCLUSIONS: LVAD recipients, whether with high- or low-risk donors, have worse early (but not late) survival and more early complications than those of standard recipients. We found that adverse donor characteristics are less predictive for determining the outcome of LVAD-bridged recipients than standard recipients.

Donor and recipient risk factor analysis of inferior postheart transplantation outcome in the era of durable mechanical assist devices.

The study objective is to quantify the impact of donor and recipient variables on heart transplant survival in recipients with a significant proportion of implanted continuous-flow left ventricular assist devices (LVADs). This is a prospective cohort study of International Society for Heart and Lung Transplantation (ISHLT) Registry that includes all primary heart-alone transplants in adult recipients (January 2005 and June 2013, N = 15 532, 27% LVADs). Donor and recipient characteristics were assessed for association with death or graft failure within 90 days and between 90 days and 5 years after transplantation. On Cox proportional hazard model donor cause of death other than head trauma (hazard ratio [HR] 1.985, P < 0.0001), recipient congenital (HR 2.7555, P < 0.0001) and ischemic (HR 1.165, P = 0.0383) vs dilated etiology and female donor heart transplanted into male recipient (HR 1.207, P = 0.0354) were predictors of death or graft failure within 90 days. Between 90 days and 5 years, donor cigarette use (HR 1.232, P = 0.0001), recipient cigarette use (HR 1.193, P = 0.0003), diabetes (HR 1.159, P = 0.0050), arterial hypertension (HR 1.129, P = 0.0115), and ischemic vs dilative cardiomyopathy had an increased probability of death or graft failure.

Training cardiothoracic surgeons of the future: The UK experience.

OBJECTIVE: The study aimed to assess targeted simulation courses, including live animal operating, as complementary training tools with regard to 2 key surgical skills in early cardiothoracic surgeon training. METHODS: Twenty UK surgical trainees (equivalent to cardiothoracic surgery resident physicians in the United States) in their first year of residency training were evaluated. Assessment of skills in pulmonary wedge resection and cardiopulmonary bypass were undertaken before and after 2 boot camp-style courses, including live animal operating (boot camp 1 and boot camp 2). Resident performance was evaluated by surgical trainers using objective structured assessment of technical skills matrices. Trainers completed a survey on skill development and trainer confidence in the trainee precourse and postcourse. RESULTS: Trainee assessment scores pre- and postcourses were analyzed using a 2-tailed Wilcoxon signed-rank test demonstrating a significant improvement in trainee performance in boot camp 1 in performing cardiopulmonary bypass (median score, 21 precourse and 28 postcourse; P = .001) and pulmonary wedge resection (median score, 25 precourse and 32 postcourse; P = .012), and in boot camp 2, in performing cardiopulmonary bypass (median score, 28 precourse and 30.5 postcourse; P = .018) and pulmonary wedge resection (median score, 31.5 precourse and 37 postcourse; P = .018). Trainers reported increased confidence and decision-making competency of residents and increased confidence of trainers to allow more participation in management. It was found that 83.3% of trainers would support trainee attendance in subsequent years. CONCLUSIONS: Live animal operating as a component of targeted cardiothoracic surgery skill training courses significantly improves technical skills, builds confidence of surgical trainers in resident physicians' practice, and should be supported by the surgery community.

Novel Management of Atrial Septal Defect at Time of Lung Transplantation.

We present a case of a young female patient with end-stage lung failure because of pulmonary arterial hypertension who was failing maximal medical therapy and was listed for a single sequential lung transplantation. The challenge of the case was a concomitant presence of a large atrial septal defect. The novelty of our approach was a device closure of atrial septal defect before performing transplantation with the use of intraoperative venoarterial extracorporeal membrane oxygenation.

Managing a Mycotic Thoracoabdominal Aneurysm: The Importance of Molecular Diagnostics.

Pneumococcal mycotic aneurysms are rare and associated with significant mortality and morbidity. Early intravenous antibiotic therapy and surgical intervention is the mainstay of treatment. Pneumococci frequently autolyze in blood cultures, making microbiological diagnosis challenging. We present the case of a man in his mid 70s with multiple thoracoabdominal mycotic aneurysms. Surgery was performed to a threatening saccular aortic arch aneurysm. Samples were sent for microbiological analysis and all were culture negative. The samples were then referred for bacterial 16S ribosomal RNA sequencing, which revealed evidence of infection with Streptococcus pneumoniae.

Sarcoidosis or acute coronary syndrome: Easily distinguishable?

Sinus of Valsalva aneurysm is a rare presenting feature of ST-elevation myocardial infarction. We describe such a case which resolved with thrombolysis, and on further investigation, the patient was found to have a large sinus of Valsalva aneurysm. Abnormal gross pathology at the time of surgery was suspected to be aortitis which was only confirmed on postmortem examination 6 months later. We highlight the importance of working closely with a pathologist when aortitis is suspected, because failure to treat it medically results in a poor outcome.

A novel approach: how an intracoronary shunt proved to be lifesaving.

Outcomes and complications following internal massage in cardiac surgery are unknown due to the lack of cumulative effort to capture those events and subsequently developing a registry. Therefore, under the circumstances there are no algorithms defined in the literature. This case report outlines the importance of sound decision-making under pressure in order to achieve a favourable outcome. A potential solution is outlined to a very complex and rare problem: anastomotic disruption during internal cardiac massage in an intensive care unit setting, demonstrating the use of an intracoronary shunt for initial stabilization prior to a definitive procedure.

A case of focal lung infarction following right upper lobectomy in case of undeveloped lung fissure.

We present a case of infarction of residual upper lobe tissue during right upper lobectomy. We believe that although the blood supply to the upper lobe had been isolated and divided in order to perform the right upper lobectomy, residual right upper lobe had been left behind secondary to "poorly estimated" staple separation of the upper from the middle lobe in a patient with non-developed oblique fissure. We suggest that in this situation the upper lobe bronchus should be identified and clamped and the lung re-inflated in order to accurately demarcate the borders of the upper and middle lobe prior to the application of the stapler to prevent infarction of residual upper lobe tissue. Therefore, this case emphasises that routine lung inflation during fissure development in right upper lobectomy may prevent unpredictable complications.

Addressing discrepancies: personal experience of a cardiac mission programme in Africa.

The worldwide incidence of cardiovascular disease (CVD) is increasing, reflecting a combination of ongoing infective diseases and a rapid rise in traditional 'western' risk factors. It is estimated that in the next 20 years that CVD be the leading cause of death in developing nations. There are high incidences of rheumatic heart disease, coronary artery disease, cardiomyopathies, uncorrected congenital heart disease and human immunodeficiency virus (HIV) associated disease in many low-income countries. Such high levels combined with a lack of diagnostic tests and therapeutic options means mortality and morbidity rates are high. A number of charities and organizations have tried to address the discrepancy of cardiac care within developing areas although the needs remain great. However there is no one global cardiac organization that coordinates such humanitarian work. The challenges of missionary work include the need for appropriate facilities, financial constraints of clinical consumables, and lack of education of local healthcare staff, making the move away from the mission model difficult. The strategy for delivery of care in developing countries should be long term educational and technical support, so that local case volumes increase. However it must be realized that there are many different levels of local services within developing nations with different health and educational needs, including some countries with very high facilities and skills levels, yet high case loads. This paper highlights the personal experience of our organization and the types of diseases encountered in developing countries.

The mediastinal staging accuracy of 18F-Fluorodeoxyglycose positron emission tomography/computed tomography in non-small cell lung cancer with variable time intervals to surgery.

BACKGROUND: PET/CT scanning can determine suitability for curative therapy and inform decision making when considering radical therapy in patients with non-small cell lung cancer (NSCLC). Metastases to central mediastinal lymph nodes (N2) may alter such management decisions. We report a 2 year retrospective series assessing N2 lymph node staging accuracy with PET/CT compared to pathological analysis at surgery. METHODS: Patients with NSCLC attending our centre (excluding those who had induction chemotherapy) who had staging PET/CT scans and pathological nodal sampling between June 2006 and June 2008 were analysed. For each lymph node assessed pathologically, the corresponding PET/CT status was determined. 64 patients with 200 N2 lymph nodes were analysed. RESULTS: Sensitivity of PET/CT scans for indentifying involved N2 lymph nodes was 39%, specificity 96% and overall accuracy 90%. For individual lymph node analysis, logistic regression demonstrated a significant linear association between PET/CT sensitivity and time from scanning to surgery (p=0.031) but not for specificity and accuracy. Those scanned <9 weeks before pathological sampling were significantly more sensitive (64% >9 weeks, 0% ≥ 9 weeks, p=0.013) and more accurate (94% <9 weeks, 81% ≥ 9 weeks, p=0.007). Differences in specificity were not seen (97% <9 weeks, 91% ≥ 9 weeks, p=0.228). No significant difference in specificity was found at any time point. CONCLUSIONS: We recommend that if a PET/CT scan is older than 9 weeks, and management would be altered by the presence of N2 nodes, re-staging of the mediastinum should be undertaken.

Endoscopic stent insertion versus primary operative management for spontaneous rupture of the esophagus (Boerhaave syndrome): an international study comparing the outcome.

Spontaneous rupture of the esophagus (Boerhaave syndrome) is an extremely rare, life-threatening condition. Traditionally surgery was the treatment of choice. Endoscopic stent insertion offers a promising alternative. The aim of this study was to compare the results of primary surgical therapy with endoscopic stenting. A British and a German high-volume center for esophageal surgery participated in this retrospective study. At the British center, operative therapy (primary repair or surgical drainage) was routinely carried out. Endoscopic stent insertion was the primary treatment option at the German center. Only patients with nonmalignant, spontaneous rupture of the esophagus (Boerhaave syndrome) were included. Demographic characteristics, comorbidity, clinical course, and outcome were analyzed. The study comprises 38 patients with a median age of 60 years. Time between rupture and treatment was less than 24 hours in 22 patients. Overall mortality was four of 38. Diagnosis greater than 24 hours was associated with higher risk for fatal outcome (odds ratio [OR], 4.64; 95% confidence interval [CI], 0.33 to 265.79). The surgery (S) and the endoscopic stent group (E) included 20 and 13 cases, respectively. Esophagectomy was unavoidable in three cases and two were managed conservatively. There were no significant differences in age, time to diagnosis less than 24 hours, intensive care unit days, hospital stay, sepsis, renal failure, slow respiratory weaning, or presence of comorbidity between the two groups. In 11 of 13 in the stent group, operative intervention (video-assisted thoracic surgery, thoracotomy, mediastinotomy) was eventually mandatory and three of 13 even required repeated surgery. The rate of reoperation in the surgery group was six of 20. Mortality was two of 13 (E) versus one of 20 (S). The odds for fatal outcome were 3.3 times higher in the stent group than in the surgery group (OR, 3.32; 95% CI, 0.15 to 213.98). Management of Boerhaave syndrome by means of endoscopic stent insertion offers no advantage regarding morbidity, intensive care unit or hospital stay, and is associated with frequent treatment failure eventually requiring surgical intervention. Furthermore, endoscopic stenting shows a higher risk for fatal outcome than primary surgical therapy.

Successful management of membrane oxygenator failure during cardiopulmonary bypass--the importance of safety algorithm and simulation drills.

With a high risk to time ratio, the advent of cardiopulmonary bypass has facilitated greater advances in technical procedures in cardiac surgery. This, however, has not come without its own complication risk and previous near misses have been reported with regard to various technical aspects of the cardiopulmonary bypass circuit. We present a case of a failed membrane oxygenator and discuss the real-life aspects to managing this complication without added risk to the patient.