Incidence and outcomes of surgical pulmonary embolectomy in the UK.

BACKGROUND: Surgical pulmonary embolectomy is rarely used for the treatment of massive acute pulmonary embolism. The aim of this study was to assess the incidence and outcomes of this operation by undertaking a retrospective analysis of a large national registry in the UK. METHODS: All acute pulmonary embolectomies performed between 1996 and 2018 were captured in the National Institute of Cardiovascular Outcomes Research central database. Trends in the number of operations performed during this interval and reported in-hospital outcomes were analysed retrospectively. Multivariable logistic regression was used to identify independent risk factors for in-hospital death. RESULTS: All 256 patients treated surgically for acute pulmonary embolism during the study interval were included in the analysis. Median age at presentation was 54 years, 55.9% of the patients were men, 48.0% had class IV heart failure symptoms, and 37.5% had preoperative cardiogenic shock. The median duration of bypass was 73 min, and median cross-clamp time was 19 min. Cardioplegic arrest was used in 53.1% of patients. The median duration of hospital stay was 11 days. The in-hospital mortality rate was 25%, postoperative stroke occurred in 5.4%, postoperative dialysis was required in 16%, and the reoperation rate for bleeding was 7.5%. Risk-adjusted multivariable analysis revealed cardiogenic shock (OR 2.54, 95% c.i. 1.05 to 6.21; P = 0.038), preoperative ventilation (OR 5.85, 2.22 to 16.35; P < 0.001), and duration of cardiopulmonary bypass exceeding 89 min (OR 7.82, 3.25 to 20.42; P < 0.001) as significant independent risk factors for in-hospital death. CONCLUSION: Surgical pulmonary embolectomy is rarely performed in the UK, and is associated with significant mortality and morbidity. Preoperative ventilation, cardiogenic shock, and increased duration of bypass were significant predictors of in-hospital death.

A blood clot in the lung can prevent the lungs from working properly and put pressure on the heart to work harder. Small clots can be treated with medications taken at home and are not a danger to life. Larger blood clots can put a lot of pressure on the heart and need immediate hospital treatment. Large blood clots can be treated with 'clot busting' medications, the delivery of a small tube into the blood vessels of the lung to suck up the clot or deliver medications directly on to its surface, and finally a form of open-heart surgery. With this surgery, a surgeon opens the chest, make a cut into the large vessels containing the clot, and physically removes the large piece of obstructing clot. The aim of this study was to describe and analyse the outcomes of this operation done in the UK over a long period. A database was used to find out how often and where this operation took place and its results. The available data were studied to try to understand how helpful this operation is to patients with lung blood clots. Between 1996 and 2018, 256 people had this operation. One in four patients did not survive the operation, 5.4% developed a clot or bleed in the brain, 16% needed to go on to a dialysis machine, and 7.5% had to be rushed back into theatre because of bleeding. Needing a ventilator machine for help with breathing, being in a sudden state of heart failure, and a long time on the heart bypass machine were all linked with patients who did not survive. This operation is rarely performed in the UK, and is often linked to a high chance of death or serious complication. In this study, the points described above were linked to a bad outcome.

Correction to: The Peacock study: feasibility of the dynamic characterisation of the paediatric hypothalamic-pituitary-adrenal function during and after cardiac surgery.

An amendment to this paper has been published and can be accessed via the original article.

The Peacock study: feasibility of the dynamic characterisation of the paediatric hypothalamic-pituitary-adrenal function during and after cardiac surgery.

BACKGROUND: Cortisol is the main stress hormone mobilised during surgery to establish homeostasis. Our current understanding of the hypothalamic-pituitary-adrenal axis physiology in children undergoing cardiopulmonary bypass is very limited due to: (1) very few cortisol time point measurements over long periods (2) difficulties of sampling in low weight babies and (3) the concomitant use of glucocorticoids at anaesthesia induction. This lack of understanding is reflected in a lack of consensus on the utility of glucocorticoids perioperatively in cardiac surgery with the use of cardiopulmonary bypass. METHODS: The Peacock Study is a prospective, two-centre, observational cohort study of 78 children (undergoing cardiopulmonary bypass procedures and non-surgical procedures - split by age/cyanosis) that aims to characterise in detail the hypothalamic-pituitary-adrenal axis physiology of children using the stress model of paediatric cardiac surgery. Also, we aim to correlate cortisol profiles with clinical outcome data. We herein describe the main study design and report the full cortisol profile of one child undergoing heart surgery, thus proving the feasibility of the method. RESULTS: We used an automated, 24-h tissue microdialysis system to measure cortisol and cortisone, every 20 min. We herein report one cortisol profile of a child undergoing heart surgery. Besides, we measured serum cortisol and adrenocorticotrophic hormone at seven-time points for correlation. Tissue concentrations of cortisol increased markedly several hours after the end of surgery. We also noted an increase in the tissue cortisol/cortisone ratio during this response. CONCLUSION: We report for the first time, the use of an automated microdialysis sampling system to evaluate the paediatric adrenal response in children. Changes in cortisol and cortisone could be measured, and the concentration of cortisol in the tissues increased after the end of cardiac surgery. The method has wide application to measure other hormones dynamically and frequently without the limitation of the circulating blood volume. The data from the main study will clarify how these cortisol profiles vary with age, pathology, type of procedure and correlation to clinical outcomes. TRIAL REGISTRATION: ISCRTN registry, number: 982586.

The Pan London Emergency Cardiac Surgery service blueprint.

The authors share their experience of managing the cardiac surgery services across London during the challenging Covid-19 pandemic. The Pan London Emergency Cardiac Surgery Service model could serve as a blueprint to design policies applicable to other surgical specialities and parts of the UK and worldwide.

Impact of Preoperative Atrial Fibrillation on In-Hospital Outcomes of Coronary Artery Bypass Grafting.

Perioperative atrial fibrillation (AF) is associated with increased mortality, morbidity, and excess healthcare costs. The objective of our study was to assess if preoperative AF in patients undergoing coronary artery bypass grafting is a predictor of operative mortality, postoperative stroke, and need for postoperative dialysis by interrogating a large registry database. We included all isolated procedures performed between February 1996 and March 2019. We used a generalized linear mixed model to assess the effect of preoperative AF on mortality stroke and the need for postoperative dialysis after adjusting for the relevant confounders derived from EuroSCORE 2. Confounders considered included age, gender, neurological dysfunction, renal dysfunction, recent myocardial infarction, pulmonary disease, unstable angina, NYHA class, pulmonary hypertension, diabetes on insulin and peripheral vascular disease, and urgency of the operation. We treated the hospital and operating consultant as random effect variables. We also performed LV function subgroup analyses to assess the effect of preoperative AF on the outcomes of interest. The incidence of pre-existent AF in the cohort of patients we analyzed (N = 356,040 patients) was 3.5% (N = 12,664). In the unadjusted baseline characteristics, preoperative AF patients had more associated comorbidities. After adjustment, preoperative AF remained a significant predictor of increased mortality (odds ratio [OR]: 1.63, confidence interval [CI] 1.48-1.79, p < 0.001), stroke (OR: 1.33, CI 1.16-1.54, p = 0.001), and need for renal dialysis (OR:1.61, CI 1.46-1.78, p < 0.001). Preoperative AF was a significant predictor of adverse outcomes in patients with moderate and good LV function but not in patients with poor LV function (EF <30%). Our study suggests that preoperative AF is associated with an increased risk for perioperative mortality and stroke in patients undergoing coronary artery bypass grafting.

Weekday and outcomes of elective cardiac surgery in the UK: a large retrospective database analysis.

OBJECTIVES: Several studies have shown worse outcomes in patients operated on later in the week. We tested this hypothesis in a large UK national audit database in elective patients undergoing adult cardiac surgery. METHODS: We used a generalized additive model to evaluate the effect of the day of the week on the following postoperative outcomes: 30-day mortality, stroke, need for dialysis and return to theatre for bleeding. We have adjusted for the relevant European System for Cardiac Operative Risk Evaluation (EuroSCORE) II covariates, plus responsible consultant, hospital and year of operation and performed subgroup analysis for isolated coronary artery bypass grafting (CABG) procedures. RESULTS: Out of 371 500 patients, 60 555 (16.3%) underwent AVR, 36 553 (9.8%) AVR plus CABG, 238 812 (64.3%) isolated CABG, 26 517 (7.1%) isolated mitral valve repair or replacement and 9063 (2.4%) mitral valve plus CABG. A total of 13 997 (3%) had surgery over the weekend. After covariate adjustment, we found no effect of day of surgery on mortality (P = 0.081), stroke (P = 0.137) and need for postop dialysis (P = 0.732). However, across all operations, there was evidence of a lower rate of return to theatre for bleeding/tamponade at the weekend (P = 0.039). In subgroup analysis of isolated CABG, the day of the week did not affect any outcomes. CONCLUSIONS: We found no effect of the day of the week on risk-adjusted short-term mortality, stroke, and the requirement for postoperative dialysis after elective cardiac surgery. Overall, the patients operated on during the weekdays were less likely to return to theatre for bleeding. In isolated CABG, the day of the week did not affect any outcomes.

Type A acute aortic dissection repair during night time: is it safe?

BACKGROUND: Out-of-hours work is believed to lead to a higher complication rate and mortality after surgery. However, there is no data supporting this perception in type A acute aortic dissections (TAAD) repair. We present an observational study of prospectively collected data comparing operative outcomes and late survival of TAAD repair performed after hours versus regular daytime working hours. METHODS: A total of 196 patients undergoing emergency TAAD repair (mean age 59 ± 13 years, range 18-81, F/M 57/139) were included in the final analysis. Patients were stratified as daytime between 7 AM and 7 PM (n = 124), and night time between 7 PM and 7 AM (n = 72). Inverse propensity score (PS) weighting for modelling causal effects was used to assess the effect of time procedure on outcomes of interest. RESULTS: Overall 30-day mortality was 14.3% (28 patients). No significant differences were found between the night-time and day-time groups with regard to operative mortality (8.3% versus 17.3%; adjusted OR 0.35; 95%CI 0.12-1.04; P = 0.06), re-exploration (12.5% versus 9.7%; adjusted OR 2.09; 95%CI 0.72-6.07; P = 0.18) and neurological deficit (18.1% versus 16.9%; adjusted OR 0.91; 95%CI 0.33-2.54; P = 0.87). Long-term survival at mean 9 years follow-up was comparable between the two groups (adjusted log-rank P = 0.28). CONCLUSIONS: Night-time surgical repair of TAAD when compared with day-time repair does not seem to be associated with a greater risk of surgical complications, operative mortality and long-term mortality.

Left thoracotomy approach for off-pump coronary artery bypass grafting surgery: 15 years of experience in 2500 consecutive patients.

OBJECTIVES: Our goal was to describe the experience at 2 centres with off-pump coronary artery bypass grafting using a left thoracotomy. METHODS: From January 2002 to December 2017, a total of 2528 consecutive patients (578 women, mean age 62.3 ± 9.1 years) were operated on using this technique. Data were collected prospectively and analysed retrospectively. RESULTS: There were no conversions to median sternotomy and 6 patients (0.2%) were converted to on-pump CABG. The mean number of grafts per patient was 2.8 ± 0. 9. The 30-day mortality rate was 1.0% (25 patients). Most patients were extubated in the operating theatre (97.3%), and 47 patients (1.9%) needed re-exploration for bleeding. Seven patients (0.3%) experienced a cerebrovascular event; 4 (0.3%) had a postoperative myocardial infarction; and 84 (3.4%) had new-onset atrial fibrillation. A total of 1510 patients (61.1%) were discharged from the hospital in the first 48 h after surgery. Long-term survival rates were 98.8%, 93.6% and 69.1% at 1, 5 and 10 years, respectively (central image). During the follow-up period, 60 patients (2.9%) were re-examined for recurrence of angina with a new coronary angiogram; of those, 24 (1.2%) required percutaneous coronary intervention and 11 (0.5%) had redo surgery. CONCLUSIONS: A left thoracotomy is a safe alternative to a median sternotomy for coronary artery bypass grafting on the beating heart, with low early complications and good mid- and long-term results.

Surgical versus balloon valvotomy in neonates and infants: results from the UK National Audit.

Objective: There are conflicting data on choosing balloon aortic valvoplasty (BAV) or surgical aortic valvotomy (SAV) in neonates and infants requiring intervention for aortic valve stenosis. We aim to report the outcome of both techniques based on results from the UK national registry. Methods: This is a retrospective study, including all patients under 1 year undergoing BAV/SAV between 2000 and 2012. A modulated renewal approach was used to examine the effect of reinterventions on outcomes. Results: A total of 647 patients (488 BAV, 159 SAV, 292 neonates) undergoing 888 aortic valve procedures were included, with a median age of 40 days. Unadjusted survival at 10 years was 90.6% after initial BAV and 84.9% after initial SAV. Unadjusted aortic valve replacement (AVR) rate at 10 years was 78% after initial BAV and 80.3% after initial SAV. Initial BAV and SAV had comparable outcomes at 10 years when adjusted by covariates (p>0.4). AVR rates were higher after BAV and SAV reinterventions compared with initial valvoplasty without reinterventions (reference BAV, HR=3 and 3.8, respectively, p<0.001). Neonates accounted for 29/35 of early deaths after the initial procedure, without significant differences between BAV and SAV, with all late outcomes being worse compared with infants (p<0.005). Conclusions: In a group of consecutive neonates and infants, BAV and SAV had comparable survival and freedom from reintervention as initial procedures and when performed as reinterventions. These findings support a treatment choice based on patient characteristics and centre expertise, and further research into the best patient profile for each choice.

Transplantation of Allogeneic Pericytes Improves Myocardial Vascularization and Reduces Interstitial Fibrosis in a Swine Model of Reperfused Acute Myocardial Infarction.

BACKGROUND: Transplantation of adventitial pericytes (APCs) promotes cardiac repair in murine models of myocardial infarction. The aim of present study was to confirm the benefit of APC therapy in a large animal model. METHODS AND RESULTS: We performed a blind, randomized, placebo-controlled APC therapy trial in a swine model of reperfused myocardial infarction. A first study used human APCs (hAPCs) from patients undergoing coronary artery bypass graft surgery. A second study used allogeneic swine APCs (sAPCs). Primary end points were (1) ejection fraction as assessed by cardiac magnetic resonance imaging and (2) myocardial vascularization and fibrosis as determined by immunohistochemistry. Transplantation of hAPCs reduced fibrosis but failed to improve the other efficacy end points. Incompatibility of the xenogeneic model was suggested by the occurrence of a cytotoxic response following in vitro challenge of hAPCs with swine spleen lymphocytes and the failure to retrieve hAPCs in transplanted hearts. We next considered sAPCs as an alternative. Flow cytometry, immunocytochemistry, and functional/cytotoxic assays indicate that sAPCs are a surrogate of hAPCs. Transplantation of allogeneic sAPCs benefited capillary density and fibrosis but did not improve cardiac magnetic resonance imaging indices of contractility. Transplanted cells were detected in the border zone. CONCLUSIONS: Immunologic barriers limit the applicability of a xenogeneic swine model to assess hAPC efficacy. On the other hand, we newly show that transplantation of allogeneic sAPCs is feasible, safe, and immunologically acceptable. The approach induces proangiogenic and antifibrotic benefits, though these effects were not enough to result in functional improvements.

Current outcomes of off-pump versus on-pump coronary artery bypass grafting: evidence from randomized controlled trials.

Coronary artery bypass grafting remains the standard treatment for patients with extensive coronary artery disease. Coronary surgery without use of cardiopulmonary bypass avoids the deleterious systemic inflammatory effects of the extracorporeal circuit. However there is an ongoing debate surrounding the clinical outcomes after on-pump versus off-pump coronary artery bypass (ONCAB versus OPCAB) surgery. The current review is based on evidence from randomized controlled trials (RCTs) and meta-analyses of randomized studies. It focuses on operative mortality, mid- and long-term survival, graft patency, completeness of revascularisation, neurologic and neurophysiologic outcomes, perioperative complications and outcomes in the high risk groups. Early and late survival rates for both OPCAB and ONCAB grafting are similar. Some studies suggest early poorer vein graft patency with off-pump when compared with on-pump, comparable midterm arterial conduit patency with no difference in long term venous and arterial graft patency. A recent, pooled analysis of randomised trials shows a reduction in stroke rates with use off-pump techniques. Furthermore, OPCAB grafting seems to reduce postoperative renal dysfunction, bleeding, transfusion requirement and respiratory complications while perioperative myocardial infarction rates are similar to ONCAB grafting. The high risk patient groups seem to benefit from off-pump coronary surgery.

Indications and results of systemic to pulmonary shunts: results from a national database.

OBJECTIVES: The systemic-to-pulmonary shunt (SPS) remains an important palliative therapy in many congenital heart defects. Unlike other surgical treatments, the mortality after shunt operations has risen. We used an audit dataset to investigate potential reasons for this change and to report national results. METHODS: A total of 1993 patients classified in 13 diagnoses underwent an SPS procedure between 2000 and 2013. Indication trends by era and also results before repair or next stage are reported. A dynamic hazard model with competing risks and modulated renewal was used to determine predictors of outcomes. RESULTS: The usage of SPS in Tetralogy of Fallot (ToF) has significantly decreased in the last decade, with cases of single ventricle (SV) and pulmonary atresia (PA) with septal communication increasing (P < 0.001 for trends). This is correlated with an increase of early mortality from 5.1% in the first half of the decade to 9.8% in the latter (P = 0.007 for trend). At 1.5 years, 13.9% of patients have died, 17.8% had a shunt reintervention and 68.3% of patients are alive and reintervention-free. Low weight, PA-intact septum, SV and central shunt type are among the factors associated with increased mortality, whereas PA-ventricular septal defect, corrected transposition, isomerism, central shunt and low weight are among those associated with increased reintervention, also having a dynamic effect on the relative risk when compared with ToF patients. Shunt reinterventions are not associated with worse outcomes when adjusted by other covariates, but they do have higher 30-day mortality if occurring earlier than 30 days from the index (P < 0.001). Patients operated in later years were found to have significantly lower survival at a distance from index. CONCLUSIONS: The observed historical rise in mortality for shunt operations relates to complex factors including changing practice for repair of ToF and for univentricular palliation. PA and SV patients are the groups of patients at the highest risk of death. Small size, shunt type and underlying anatomical defect are the main determinants of outcomes. Trends in indication and mortality seem to indicate that more severely ill patients benefit from shunting, but with an increase in mortality.

Outcomes following repair of anomalous coronary artery from the pulmonary artery in infants: results from a procedure-based national database.

BACKGROUND: Anomalous coronary artery from the pulmonary artery (ACAPA) is a very rare congenital anomaly that often occurs during infancy. Patients can present in a critical condition. METHODS: We analysed procedure-related data from a national audit database for the period 2000-2013. RESULTS: A total of 120 patients <1 year had repair of isolated ACAPA using a coronary transfer or the tunnel (Takeuchi) operation. Seven patients (6.8%) required a mitral valve procedure at index and eight patients (7.8%) had a mitral valve repair/replacement during follow-up, including mitral reoperations. Follow-up data (>30 days) were available in 102 patients and the mean follow-up time was 4.7 years. The 30-day overall mortality was 1.9%, higher for neonates (16.7% vs 1%, p=0.1) and after postoperative extracorporeal membrane oxygenation (ECMO) (20% vs 1%, p=0.09). At 10 years the survival estimate is 95.1%, freedom from coronary and mitral reintervention being 95.9% and 91.2%, respectively. Use of postoperative ECMO was a risk factor for long-term mortality (p<0.001). Risk factors for coronary reintervention were age under 30 days (p=0.06) and the need for postoperative ECMO (p=0.02). Age under 30 days (p=0.002) was a risk factor for mitral reintervention. CONCLUSIONS: To our knowledge this is the largest series to date. These preliminary national results show that early outcomes are good and medium-term attrition acceptable. Poor outcomes are correlated with early presentation, also with the need for postoperative circulatory support.

Transfusion related acute lung injury with massive pulmonary secretion during cardiac surgery. A case report.

A Indo-Caribbean patient undergoing cardiac surgery developed Transfusion Related Acute Lung Injury (TRALI) with massive endobronchial secretion of clear fluid mimicking severe pulmonary edema. Hypoxemia and lung stiffness were so severe that didn't allow closure of the sternum on completion of surgery. The patient was treated with invasive ventilation, high positive pressure and % FiO2 and aggressive endotracheal suction. After several hours, secretions reduced spontaneously and the patient made an uneventful recovery.