Resternotomy aortic root and arch replacement following previous complex type A aortic dissection requiring endovascular repair for malperfusion.

A redo sternotomy, aortic root, and arch replacement in a patient following previous complex surgical and endovascular type A aortic dissection repair is presented in this video case report. Shortly after having the initial type A aortic dissection repair with replacement of the ascending aorta, the patient developed severe visceral malperfusion due to a compressed distal true lumen and underwent emergency endovascular repair with ascending arch and descending thoracic aorta stents and chimney grafts for the aortic arch vessels as well as fenestration of the intimal flap of the abdominal aorta. Unfortunately, the patient developed permanent paraplegia and progressive symptomatic severe aortic regurgitation. The patient underwent a redo sternotomy, aortic root, and arch replacement with explantation of the ascending stent graft and chimney stent grafts. Antegrade cerebral perfusion was maintained throughout the procedure. The aortic arch was replaced using a Terumo Aortic Plexus multibranched graft distally anastomosed to the endovascular stent graft, and the innominate and left common carotid arteries were reimplanted onto the graft. The aortic root was replaced with a Bioconduit graft, using a modified Cabrol technique to reimplant the left coronary artery. A satisfactory postoperative course and computed tomography imaging highlight the feasibility of this highly complex aortic arch repair with careful preoperative planning.

A case report of an unusual mycotic pseudoaneurysm of the ascending aorta.

BACKGROUND: Mycotic pseudoaneurysms of the ascending aorta are a rare and devastating complication of previous cardiac surgery. CASE PRESENTATION: We present an unusual case of a fungal mycotic pseudoaneurysm secondary to an aortic suture line successfully repaired under deep hypothermic circulatory arrest. CONCLUSIONS: Patients with mycotic pseudoaneurysms of the aorta require a multidisciplinary team approach to prevent devastating complications that may occur in these complex surgical cases.

Evaluating the efficacy and safety of a novel prophylactic nasal spray in the prevention of SARS-CoV-2 infection: A multi-centre, double blind, placebo-controlled, randomised trial.

Background The COVID-19 pandemic continues to devastate communities all over the world. The aim of this study was to evaluate the efficacy and safety of the test agent as a prophylaxis against SARS-CoV-2 infection in a population of high-risk healthcare workers. Methods The study was a multi-centre, prospective, double blind, randomized, placebo-controlled trial. Key eligibility criteria included absence of significant co-morbidity and no previous SARS-CoV-2 infection or vaccination. Participants were randomised to either the active agent nasal spray or placebo using computer generated random number tables. The nasal spray was administered 3 times daily over a 45 day course. The primary end point was the percentage of subjects who tested positive for IgGS (anti-spike, immunoglobulin G specific to the spike protein of SARS-CoV-2) at day 45. Results Between 16th April 2021 and 26th July 2021, 556 participants were analysed for the primary endpoint (275 Test; 281 Placebo). The test agent significantly reduced SARS-CoV-2 infection compared to placebo [36 cases (13.1%) Vs 97 cases (34.5%); OR 0.29 (95% CI; 0.18-0.45), p < 0.0001]. Fewer clinical symptoms were also seen in the test group [57 cases (17.6%) vs 112 cases (34.6%); OR 0.40, (95% CI; 0.27-0.59), p < 0.0001]. No harmful effects were associated with taking the test agent. Conclusion The test agent significantly reduced SARS-CoV-2 infection in healthcare workers, with 62% fewer infections when compared to placebo. It was found to be safe and well tolerated and offers a novel treatment option for prophylaxis against SARS-CoV-2 infection.

A multi-centre prospective cohort study of patients on the elective waiting list for cardiac surgery during the COVID-19 pandemic.

OBJECTIVES: During the worldwide COVID-19 pandemic, elective cardiac surgery was suspended to provide ICU beds for COVID-19 patients and those requiring urgent cardiac surgery. The aim of this study is to assess the effect of the pandemic on outcomes of patients awaiting elective cardiac surgery. DESIGN: A multi-centre prospective cohort study. SETTING: The elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres. PARTICIPANTS: Patients on the elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres. MAIN OUTCOME MEASURES: Primary outcome was surgery, percutaneous therapy or death at one year. METHODS: Data were collected prospectively on patients on the elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres. Primary outcome was surgery, percutaneous therapy or death at one year. Demographic data and outcomes were obtained from local electronic records, anonymised and submitted securely to the lead centre for analysis. RESULTS: On 1 March 2020, there were 1099 patients on the elective waiting list for cardiac surgery. On 1 March 2021, 83% (n = 916) had met a primary outcome. Of these, 840 (92%) had surgery after a median of 195 (118-262) days on waiting list, 34 (3%) declined an offer of surgery, 23 (3%) had percutaneous intervention, 12 (1%) died, 7 (0.6%) were removed from the waiting list. The remainder of patients, 183 (17%) remained on the elective waiting list. CONCLUSIONS: This study has shown, for the first time, significant delays to treatment of patients awaiting elective cardiac surgery. Although there was a low risk of mortality or urgent intervention, important unmeasured adverse outcomes such as quality of life or increased perioperative risk may be associated with prolonged waiting times.

Open Repair of Superior Vena Cava Syndrome With High Intracranial Pressures Using a 'Y' Graft.

We present the case of a young patient with benign superior vena cava (SVC) syndrome resulting from a complex autoimmune disease. Initial attempts of endovascular repair were unsuccessful. Subsequently, an open bypass of both innominate veins was performed with a cryopreserved femoral arterial 'Y' graft. This was a challenging case due to the combination of complex comorbidities and severe tissue fragility that made the intervention technically difficult. The postoperative recovery was uncomplicated and at 6-week follow-up, the patient reported a complete remission of her preoperative symptoms.

Obesity and diabetes are major risk factors for epicardial adipose tissue inflammation.

BACKGROUNDEpicardial adipose tissue (EAT) directly overlies the myocardium, with changes in its morphology and volume associated with myriad cardiovascular and metabolic diseases. However, EAT's immune structure and cellular characterization remain incompletely described. We aimed to define the immune phenotype of EAT in humans and compare such profiles across lean, obese, and diabetic patients.METHODSWe recruited 152 patients undergoing open-chest coronary artery bypass grafting (CABG), valve repair/replacement (VR) surgery, or combined CABG/VR. Patients' clinical and biochemical data and EAT, subcutaneous adipose tissue (SAT), and preoperative blood samples were collected. Immune cell profiling was evaluated by flow cytometry and complemented by gene expression studies of immune mediators. Bulk RNA-Seq was performed in EAT across metabolic profiles to assess whole-transcriptome changes observed in lean, obese, and diabetic groups.RESULTSFlow cytometry analysis demonstrated EAT was highly enriched in adaptive immune (T and B) cells. Although overweight/obese and diabetic patients had similar EAT cellular profiles to lean control patients, the EAT exhibited significantly (P ≤ 0.01) raised expression of immune mediators, including IL-1, IL-6, TNF-α, and IFN-γ. These changes were not observed in SAT or blood. Neither underlying coronary artery disease nor the presence of hypertension significantly altered the immune profiles observed. Bulk RNA-Seq demonstrated significant alterations in metabolic and inflammatory pathways in the EAT of overweight/obese patients compared with lean controls.CONCLUSIONAdaptive immune cells are the predominant immune cell constituent in human EAT and SAT. The presence of underlying cardiometabolic conditions, specifically obesity and diabetes, rather than cardiac disease phenotype appears to alter the inflammatory profile of EAT. Obese states markedly alter EAT metabolic and inflammatory signaling genes, underlining the impact of obesity on the EAT transcriptome profile.FUNDINGBarts Charity MGU0413, Abbott, Medical Research Council MR/T008059/1, and British Heart Foundation FS/13/49/30421 and PG/16/79/32419.

Fifty years of the pericardial valve: Long-term results in the aortic position.

It is now 50 years since the development of the first pericardial valve in 1971. In this time significant progress has been made in refining valve design aimed at improving the longevity of the prostheses. This article reviews the current literature regarding the longevity of pericardial heart valves in the aortic position. Side by side comparisons of freedom from structural valve degeneration are made for the valves most commonly used in clinical practice today, including stented, stentless, and sutureless valves. Strategies to reduce structural valve degeneration are also discussed including methods of tissue fixation and anti-calcification, ways to minimise mechanical stress on the valve, and the role of patient prosthesis mismatch.

Spontaneous splenic rupture following mitral valve replacement for infective endocarditis successfully managed with splenic artery embolisation.

We report a rare case of infective endocarditis complicated by postoperative splenic rupture. A patient underwent urgent mitral valve replacement for infective endocarditis believed to be associated with a recent spinal surgical intervention. The patient developed haemodynamic compromise on the third day postoperatively. Computed tomography showed a splenic rupture as the cause. The patient underwent emergency radiological intervention with coil embolization avoiding the need for a splenectomy and was discharged home.

Outcomes of patients diagnosed with COVID-19 in the early postoperative period following cardiac surgery.

The coronavirus 2019 (COVID-19) pandemic has disrupted patient care across the NHS. Following the suspension of elective surgery, priority was placed in providing urgent and emergency surgery for patients with no alternative treatment. We aim to assess the outcomes of patients undergoing cardiac surgery who have COVID-19 infection diagnosed in the early postoperative period. We identified 9 patients who developed COVID-19 infection following cardiac surgery. These patients had a significant length of hospital stay and extremely poor outcomes with mortality of 44%. In conclusion, the outcome of cardiac surgical patients who contracted COVID-19 infection perioperatively is extremely poor. In order to offer cardiac surgery, units must implement rigorous protocols aimed at maintaining a COVID-19 protective environment to minimize additional life-threatening complications related to this virus infection.

Doing Simple Things Well: Practice Advisory Implementation Reduces Atrial Fibrillation After Cardiac Surgery.

OBJECTIVES: The authors aimed to adapt a practice advisory for the prevention of atrial fibrillation after cardiac surgery (AFACS) recently published in this journal into the authors' local perioperative protocols, implementing the recommendations, with a focus on early postoperative (re)introduction of ß-blockers and overcoming frequent guideline implementation barriers. DESIGN: Development of a prevention care bundle and repeated audit after a model of improvement approach with retrospective analysis. SETTING: Single center (tertiary academic hospital). PARTICIPANTS: A total of 384 patients in 2 cohorts of consecutive patients undergoing open cardiac surgery before and after hospital-wide implementation of a care bundle. INTERVENTIONS: After auditing the standard of care in the authors' center, an AFACS prevention care bundle was designed and implemented, consisting of a graphic tool with 5 pillars based on current evidence for the early postoperative phase. Multidisciplinary teaching and training of staff were delivered, and a second audit was conducted after the implementation period. MEASUREMENTS AND MAIN RESULTS: Significantly more patients received postoperative ß-blockers after care bundle implementation (82.7% pre- v 91.3% post-bundle, p = 0.019), with a higher proportion on day 1 (36.7% pre- v 67% post-bundle, p < 0.001), indicating a successful uptake. The incidence of AFACS was significantly reduced from 35.4% to 23.3% (p = 0.009), with a particularly marked reduction in the age group 65- to 75- years and for isolated aortic valve and coronary artery bypass graft surgery. CONCLUSION: An AFACS prevention care bundle improved adherence to current guidelines with regard to early ß-blocker administration and significantly reduced the incidence of atrial fibrillation after cardiac surgery.

The Pan London Emergency Cardiac Surgery service: Coordinating a response to the COVID-19 pandemic.

Over the last 4 months, the novel coronavirus, SARS-CoV-2, has caused a significant economic, political, and public health impact on a global scale. The natural history of the disease and surge in the need for invasive ventilation has required the provision of intensive care beds in London to be reallocated. NHS England have proposed the formation of a Pan-London Emergency Cardiac surgery (PLECS) service to provide urgent and emergency cardiac surgery for the whole of London. In this initial report, we outline our experience of setting up and delivering a pan-regional service for the delivery of urgent and emergency cardiac surgery with a focus on maintaining a COVID-free in-hospital environment. In doing so, we hope that other regions can use this as a starting point in developing their own region-specific pathways if the spread of coronavirus necessitates similar measures be put in place across the United Kingdom.

Cardiothoracic surgery in the midst of a pandemic: Operative outcomes and maintaining a coronavirus disease 2019 (COVID-19)-free environment.

OBJECTIVE: In the United Kingdom, the coronavirus disease 2019 (COVID-19) pandemic has led to the cessation of elective surgery. However, there remains a need to provide urgent and emergency cardiac and thoracic surgery as well as to continue time-critical thoracic cancer surgery. This study describes our early experience of implementing a protocol to safely deliver major cardiac and thoracic surgery in the midst of the pandemic. METHODS: Data on all patients undergoing cardiothoracic surgery at a single tertiary referral center in London were prospectively collated during the first 7 weeks of lockdown in the United Kingdom. A comprehensive protocol was implemented to maintain a COVID-19-free environment including the preoperative screening of all patients, the use of full personal protective equipment in areas with aerosol-generating procedures, and separate treatment pathways for patients with and without the virus. RESULTS: A total of 156 patients underwent major cardiac and thoracic surgery over the study period. Operative mortality was 9% in the cardiac patients and 1.4% in thoracic patients. The preoperative COVID-19 protocol implemented resulted in 18 patients testing positive for COVID-19 infection and 13 patients having their surgery delayed. No patients who were negative for COVID-19 infection on preoperative screening tested positive postoperatively. However, 1 thoracic patient tested positive on intraoperative bronchoalveolar lavage. CONCLUSIONS: Our early experience demonstrates that it is possible to perform major cardiac and thoracic surgery with low operative mortality and zero development of postoperative COVID-19 infection.

Migration of a Varicocele Coil to the Right Heart.

We describe a case of an adult patient with embolization of a varicocele coil (7 × 70 mm) to the right ventricle. We review the multimodality imaging techniques used to identify location and the importance of a multidisciplinary approach in determining management. (Level of Difficulty: Advanced.).

Is there a role for biomarkers in thoracic aortic aneurysm disease?

Thoracic aortic aneurysm (TAA) represents a major cause of mortality and morbidity in Western countries. The natural history of TAA is indolent, with patients usually being asymptomatic until a catastrophic event such as rupture or dissection ensues. As such, early diagnosis is crucial and the search is ongoing for a biomarker that can indicate the presence of TAA with sufficient accuracy to act as a screening tool. To date, no such marker has been developed for the diagnosis of non-familial or 'sporadic' TAA. However, our increased understanding of the pathogenesis of both familial and sporadic TAA has suggested potential candidates for diagnostic biomarkers. Many markers/pathways have been shown to have differential activity levels or expression in the aortic tissue of TAA. However, priority is given to markers that have shown differential levels in blood plasma, as blood tests represent the easiest route for mass screening for TAA. This review aims to evaluate the efficacy of clinical tests already in use in diagnosing TAA, explore novel proposed biomarkers and identify key areas of future interest.

Pathogenesis of large vessel vasculitis: Implications for disease classification and future therapies.

Despite being recognised over a century ago, the aetiology and pathogenesis of large vessel vasculitis (LVV) still remains elusive. Takayasu's arteritis (TA) and giant cell arteritis (GCA) represent the two major categories of LVV, each with distinctive clinical features. Over the last 10 years an increased understanding of the immunopathogenesis of the inflammatory cascade within the aortic wall has revived the view that LVVs may represent subtypes of the same pathological process, with implications in the treatment of this disease. In this review, the histological, genetic and immunopathological features of TA and GCA will be discussed and the evidence for a common underlying disease mechanism examined. Novel markers of disease activity and therapies based on advances in our understanding of the immunopathogenesis of these conditions will also be discussed.

Can Transesophageal Echocardiography Be Performed Safely Using a Laryngeal Mask Airway During Atrial Fibrillation Ablation?

OBJECTIVE: To investigate the feasibility and safety of using a laryngeal mask airway (LMA) compared with a cuffed oral endotracheal tube (COETT) for atrial fibrillation (AF) ablation with transesophageal echocardiography (TEE). DESIGN: Prospective, cohort study. SETTING: A single-center inner-city hospital. PARTICIPANTS: The study comprised adult patients undergoing elective AF ablation with periprocedural TEE over a 3-year period. INTERVENTIONS: Patients were treated with either an LMA or a COETT before undergoing a standardized protocol for TEE and AF ablation. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the need for conversion from an LMA to a COETT. Between January 2014 and January 2017, 346 patients underwent AF ablation. Of those, 126 procedures were performed with a COETT (36.4%) and 220 (63.6%) with an LMA. There were no differences between groups in terms of baseline characteristics, including age, sex, body mass index, and American Society of Anesthesiologists grade. An adequate airway seal was unable to be maintained in 3 patients in the LMA group (1.4%), and those patients were converted to a COETT. No episodes of airway complications occurred in either group. No difference was found in mean propofol (2%) dose between COETT and LMA (385 mg/h v 374 mg/h; p = 0.127). However, the mean remifentanil dose (100 µg/mL) was reduced significantly in the LMA group compared with the COETT group at 355 µg/h and 939 µg/h, respectively (p < 0.001). CONCLUSIONS: LMA use is safe and feasible in the vast majority of patients undergoing AF ablation with TEE and is an acceptable alternative to COETT. A significantly reduced rate of remifentanil was required to maintain anesthesia in the LMA group.

Fluoroscopy-free cryoablation of atrial fibrillation guided solely by transoesophageal echocardiography: a case report.

BACKGROUND: Atrial fibrillation (AF) ablation has been shown to be possible using minimal or no fluoroscopic imaging for guidance. However, the techniques previously described focus on radiofrequency ablation or rely on the use of resource-heavy technology such as intra-cardiac echocardiography. We describe the first reported case in the literature of successful fluoroscopy-free AF cryoablation guided solely by transoesophageal echocardiography (TOE). CASE SUMMARY: A 65-year-old gentleman underwent cryoablation of paroxysmal AF using TOE guidance only with no use of fluoroscopy. Transoesophageal echocardiography was used in all stages of the procedure including guidance for transseptal puncture, ensuring balloon position in the pulmonary veins, and checking for post-procedure pericardial effusion. After 5 months of follow-up, the patient remains in sinus rhythm and has discontinued all antiarrhythmic and anticoagulant medication. DISCUSSION: This case demonstrates for the first time the feasibility of fluoroscopy-free cryoablation using only TOE for guidance.

Fluoroscopy-free AF ablation using transesophageal echocardiography and electroanatomical mapping technology.

PURPOSE: Guidelines recommend that radiation exposure during AF catheter ablation procedures should be 'as low as reasonably achievable' (ALARA), particularly since many patients may have multiple procedures. Consequently, avoiding radiation exposure altogether must, if safe to do so, be the ultimate goal. The primary objective was to determine the feasibility and efficacy of fluoroscopy-free AF ablation compared to the fluoroscopy-assisted procedure. METHODS: Patients underwent AF ablation using commercially available technology with no routine pre-procedural imaging. The use of non-fluoroscopic imaging/mapping technologies permitted us to initially reduce x-ray exposure before eliminating its use altogether. This evolution of our practice proceeded in two stages: a 9-month period of optimising our fluoroscopy-free ablation protocol followed by a 9-month period during which we set out to complete the whole procedure routinely without fluoroscopy. We describe the protocol developed and report salient endpoints, such as complications, procedure times, patient experience, and procedural success rates. RESULTS: During the study period, fluoroscopy-free AF ablation was attempted in 69 patients: 24 in the 9-month 'development phase' and 45 in the 'implementation phase'. During the development phase, 13 of 24 patients (54%) were treated without the use of fluoroscopy. In the implementation phase, 45 patients underwent AF ablation of which 42 (93.3%) were fluoroscopy-free. A detailed description is given of the three cases in which fluoroscopy had to be used despite an intention not to. CONCLUSIONS: Fluoroscopy-free complex ablation procedures for the treatment of atrial fibrillation are safe and feasible in most patients.

Is ministernotomy superior to right anterior minithoracotomy in minimally invasive aortic valve replacement?

A best evidence topic was constructed according to a structured protocol. The question addressed was whether, in patients undergoing minimally invasive aortic valve replacement (AVR), right anterior thoracotomy (RT) or mini-sternotomy (MS) was superior in terms of postoperative outcome? A total of 840 publications were found using the reported search. Of these, 6 represented the best available evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. In all, except 1 study, the primary outcome was early mortality, ranging from in-hospital mortality to 90 days postoperatively. The remaining study was a cost-benefit analysis. Four studies were non-randomized observational studies, one of which was multicentre. Two were meta-analyses of studies comparing minithoracotomy or MS with conventional sternotomy for AVR, rather than direct comparisons of the 2 minimal access techniques. We conclude that there is a lack of high-quality evidence comparing RT and MS for minimally invasive AVR, with no randomized controlled trials to date. The available evidence shows no difference in early mortality between RT and MS for surgical AVR. In studies that directly compared RT and MS, RT was found to be associated with reduced length of hospital stay, despite longer cardiopulmonary bypass times and cross-clamp times. One study reported groin complications (10.8%) with the RT group, where peripheral cannulation was used, while the other 5 studies did not comment on groin complications associated with peripheral cannulation. In the only cost-benefit analysis, RT was found to carry considerably more cost than MS over and above conventional AVR.