Risk profile and outcomes of aortic valve replacement in octogenarians.

AIM: To investigate the patient characteristics, relationship between the Logistic EuroSCORE (LES) and the observed outcomes in octogenarians who underwent surgical aortic valve replacement (AVR). METHODS: Two hundred and seventy three octogenarians underwent AVR between 1996 and 2008 at Bristol Royal Infirmary. Demographics, acute outcomes, length of hospital stay and mortality were obtained. The LES was calculated to characterize the predicted operative risk. Two groups were defined: LES ≥ 15 (n = 80) and LES < 15 (n = 193). RESULTS: In patients with LES ≥ 15, 30 d mortality was 14% (95% CI: 7%-23%) compared with 4% (95% CI: 2%-8%) in the LES < 15 group (P < 0.007). Despite the increase in number of operations from 1996 to 2008, the average LES did not change. Only 5% of patients had prior bypass surgery. The LES identified a low risk quartile of patients with a very low mortality (4%, n = 8, P < 0.007) at 30 d. The overall surgical results for octogenarians were excellent. The low risk group had an excellent outcome and the high risk group had a poor outcome after surgical AVR. CONCLUSION: It may be better treated with transcatheter aortic valve implantation.

Patient preference for coronary artery bypass graft surgery performed on the arrested or beating heart: a questionnaire study.

OBJECTIVE: Patient choice is now a major facet of health-care policy within the National Health Service. Our objective was to determine whether the patient would like to choose if the 'beating heart' technique or the 'arrested heart' technique is employed for their coronary artery bypass graft (CABG) surgery. METHODS: We undertook a cross-sectional, self-reported questionnaire survey of patients referred to a regional cardiac surgical unit for elective coronary artery surgery between October 2008 and July 2009. The questionnaire was split into five sections as follows: (1) the patients' awareness of 'beating heart' and 'arrested heart' techniques for CABG surgery, (2) an information sheet detailing both techniques, (3) patients' preference of technique to be used for CABG surgery, (4) whether the patient would like to choose their surgeon according to the surgeons' preferred technique and (5) demographics, including age, sex, and educational qualifications. Data are expressed as counts (percentages). RESULTS: The questionnaire was sent to 120 people; 88 returned a completed questionnaire, representing a response rate of 73%. Awareness of 'beating heart' and 'arrested heart' techniques for CABG surgery was reported by 35 respondents (40%). Of these, 74% respondents had no preference of technique used for CABG surgery. After reading the information sheet, 78 (89%) respondents reported no preference of technique used for CABG surgery. As many as 71 (81%) respondents reported that they did not want to be given an opportunity to choose the technique used for CABG surgery, and all respondents preferred to let the surgeon decide the appropriate technique. A binary logistic regression analysis showed that gender, age and level of education were not significant predictors of whether patients wanted to choose the technique to be used for their CABG surgery. CONCLUSION: Cardiac surgical patients prefer to allow the surgeon to determine the technique to be used for their coronary artery operation and do not want to be offered the chance to choose their surgeon according to the surgeons' preferred technique. Involvement of the patient in determining the operative technique is not always desired.

Contribution of bone marrow-derived cells to skin: collagen deposition and wound repair.

The bone marrow provides inflammatory cells and endothelial progenitor cells to healing cutaneous wounds. To further explore the bone marrow contribution to skin and healing wounds, we used a chimeric mouse model in which the bone marrow from enhanced green fluorescent protein (EGFP) transgenic mice is transplanted into normal C57BL mice. We found that normal skin is a target organ for bone marrow-derived cells from both the hematopoietic and the mesenchymal stem cell pool. We present evidence that the bone marrow contribution to normal skin and the healing cutaneous wound is substantially greater than the previously recognized CD45+ subpopulation, where 15%-20% of the spindle-shaped dermal fibroblasts were bone marrow-derived (EGFP+). Furthermore, the bone marrow-derived cells were able to contract a collagen matrix and transcribe both collagen types I and III, whereas the skin-resident cells transcribed only collagen type I. Whereas endothelial progenitor cells were found early during the wound repair process, bone marrow-derived endothelial cells were not seen after epithelialization was complete. Our data show that wound healing involves local cutaneous cells for reconstituting the epidermis but distant bone marrow-derived cells and the adjacent uninjured dermal mesenchymal cells for reconstituting the dermal fibroblast population.

The evolution of training in off-pump coronary surgery in a single institution.

BACKGROUND: This study analyses the development of off-pump coronary artery bypass (OPCAB) surgery training at a single institution, and compares the early and midterm clinical outcomes of OPCAB and conventional coronary artery bypass grafting (CABG) procedures performed by trainees with or without direct consultant cardiothoracic surgeon supervision. METHODS: Analysis was undertaken on data prospectively recorded on a computer database (Patient Analysis and Tracking System). Of the 2,422 CABG operations performed between January 1999 and December 2001, 969 (40%) were carried out by trainees either off pump (422) or on pump (547). RESULTS: Although the total number of CABG operations performed by trainees remained constant, there was a significant increase in the number of OPCAB operations during the study period compared with conventional CABG, as well as an increase in the average number of grafts per patient in the OPCAB group (both p < 0.05). Furthermore, a significant trend towards using two or more arterial conduits in the OPCAB group was observed in the study period. The number of OPCAB operations performed by trainees as independent operators without direct consultant supervision also increased significantly (p < 0.05). Early and midterm clinical outcomes were similar between patients operated by trainees on pump or off pump as independent operators versus under direct consultant supervision. CONCLUSIONS: The significant increase in OPCAB operations performed by trainees as independent operators or under direct consultant supervision, as well as the increase in the number of grafts per patient and arterial conduits used for myocardial revascularization, demonstrate a progression of training in beating heart surgery for cardiothoracic trainees. Improvements in the techniques have made it safe to teach trainees off-pump multivessel coronary artery revascularization.