Redo aortic valve replacement versus valve-in-valve trans-catheter aortic valve implantation: a UK propensity-matched analysis.

This study sought to compare the morbidity and mortality of redo aortic valve replacement (redo-AVR) versus valve-in-valve trans-catheter aortic valve implantation (valve-in-valve TAVI) for patients with a failing bioprosthetic valve. A multicenter UK retrospective study of redo-AVR or valve-in-valve TAVI for patients referred for redo aortic valve intervention due to a degenerated aortic bioprosthesis. Propensity score matching was performed for confounding factors. From July 2005 to April 2021, 911 patients underwent redo-AVR and 411 patients underwent valve-in-valve TAVI. There were 125 pairs for analysis after propensity score matching. The mean age was 75.2±8.5 years. In-hospital mortality was 7.2% (n=9) for redo-AVR versus 0 for valve-in-valve TAVI, p=0.002. Surgical patients suffered more post-operative complications, including intra-aortic balloon pump support (p=0.02), early re-operation (p<0.001), arrhythmias (p<0.001), respiratory and neurological complications (p=0.02 and p=0.03) and multi-organ failure (p=0.01). The valve-in-valve TAVI group had a shorter intensive care unit and hospital stay (p<0.001 for both). However, moderate aortic regurgitation at discharge and higher post-procedural gradients were more common after valve-in-valve TAVI (p<0.001 for both). Survival probabilities in patients who were successfully discharged from the hospital were similar after valve-in-valve TAVI and redo-AVR over the 6-year follow-up (log-rank p=0.26). In elderly patients with a degenerated aortic bioprosthesis, valve-in-valve TAVI provides better early outcomes as opposed to redo-AVR, although there was no difference in mid-term survival in patients successfully discharged from the hospital.

Case of retained guide wires traversing anatomical boundaries with neurological and cardiac morbidity.

A 69-year-old woman with a history of multiple hospital attendances for cardiac and neurological symptoms, presented with multifocal cerebral infarcts due to embolisation from retained guide wires and was referred for retrieval of two wires. One was intracardiac and the other had migrated through major vascular structures, breeching anatomical boundaries. Just before surgery, she half-expectorated a 35 cm wire that was removed with a video laryngoscope. Three days later, the second wire had traversed the right ventricular myocardium in an attempt to exteriorise, and a 7 cm wire was removed by emergency left anterior mini-thoracotomy. Her recovery was uneventful.

Outcomes following coronary artery bypass surgery in diabetic treatment sub-groups. A propensity matched analysis of >7000 patients over 18 years.

BACKGROUND: European System for Cardiac Operative Risk Evaluation II incorporates insulin-controlled diabetes whilst omitting tablet-controlled diabetes. Differences in adverse clinical outcomes following coronary artery bypass graft between these groups are poorly established. Therefore, a propensity matched comparison of short and longer term mortality and morbidity in insulin-controlled diabetes, tablet-controlled diabetes and non-diabetic patients was undertaken. METHODS: Isolated first-time coronary artery bypass graft surgeries between April 1999 and April 2017 were propensity score matched by pre- and intra-operative variables. RESULTS: 8241 patients; 23.5% diabetics and 76.5% non-diabetics. The groups' demographical and clinical characteristics were comparable after matching. Insulin-controlled diabetes patients had significantly higher in-hospital mortality (3.8% vs. 1.7%, p < 0.05), multisystem failure (2.6% vs. 1.8%, p < 0.05), sternal wound infections requiring debridement (3.6% vs. 1.3%, p < 0.05), respiratory complications (25.6% vs. 21.9%, p < 0.05), new dialysis (4.7% vs. 0.9%, p < 0.05) and longer hospital stays (13.5 ± 13.3 vs. 10.6 ± 8.0, p < 0.05) compared to non-diabetic patients.Tablet-controlled diabetes patients had significantly higher strokes (2.9% vs. 1.2, p < 0.05), superficial sternal wound infections (6.7% vs. 5.4%, p < 0.05), respiratory complications (25.7% vs. 22.7%, p < 0.05), new dialysis (1.7% vs. 0.6%, p < 0.05), post-operative atrial fibrillation (37.1% vs. 33.9%, p < 0.05) and readmission with myocardial infarction (22.4% vs. 19.6%, p < 0.05) compared to non-diabetic patients. CONCLUSION: Diabetic treatment sub-groups are an independent risk factor for sternal wound infection, new dialysis requirement, multisystem failure and readmission with myocardial infarction after isolated first coronary artery bypass graft surgery. The findings suggest the need for better risk stratification of diabetic groups prior to cardiac surgery and for improved cardiovascular risk management post-surgery in tablet-controlled diabetes patients.

Short-term and long-term impact of diagnosed and undiagnosed chronic obstructive pulmonary disease on coronary artery bypass grafting surgery.

OBJECTIVES: This study sought to compare clinical outcomes between three categories of patients: non-chronic obstructive pulmonary disease (COPD), diagnosed COPD and undiagnosed COPD in coronary artery bypass grafting surgery. METHODS: A single-centred retrospective study from January 2010 to December 2019. Primary outcomes were postoperative complications, length of ITU admission and in-hospital staying. Secondary outcomes were reintervention rate, in-hospital and long-term mortality. RESULTS: A total of 4020 patients were analysed and divided into three cohorts: non-COPD (group A) (74.55%, n=2997), diagnosed COPD (group B) (14.78%, n=594) and undiagnosed COPD (group C) (10.67%, n=429). The rate of respiratory complications was noted in this order: group B>group C>group A (p 0.00000002). Periooperative acute kidney injury and wound complications were higher in group B (p 0.0004 and p 0.03, respectively). Prolonged in-hospital staying (days) resulted in group B (p 0.0009). Finally, long-term mortality was statistically higher in group B and C compared with group A (p 0.0004). No difference in long-term mortality was noted in relation to the expected FEV1% in group B (p 0.29) and group C (p 0.82). CONCLUSIONS: In CABG surgery, COPD is a well-known independent risk factor for morbidity. Patients with preoperative spirometry results indicative of COPD result in the same outcomes of known patients with COPD. As a result of that, greater value should be given to the preoperative spirometry in the EuroSCORE. Finally, the expected FEV1% appears not be a predictor for long-term survival.

Permanent pacemaker post-valve surgery: Do valve type and position matter? A propensity score matching study.

BACKGROUND AND AIM: This study evaluates whether aortic valve replacement (AVR) or mitral valve replacement (MVR) with biological versus mechanical prostheses is independent risk factors for permanent pacemaker (PPM) post-cardiac surgery, alongside traditionally accepted determinants. METHODS: This study focused on single-centre retrospective analysis of 10 years of activity. Case-control 1-to-9 matching was performed for 7 pre-operative and 2 intraoperative confounding factors. RESULTS: After matching, 617 patients were included for analysis: AVR (79.4% n=490) and MVR (20.6% n=127). PPM was implanted in 3.7% (n=18) and 3.1% (n=4), P=0.8, respectively. A further analysis for PPM rate in biological versus mechanical prostheses did not provide any significant result (P=0.6 AVR and P=0.8 MVR). Post-operative complications in AVR and MVR groups were as follows: Reopening (4.5% vs. 6.3%, P=0.4), myocardial infarction (0.8% vs. 3.2%, P=0.04), pulmonary (32.9% vs. 38.6%, P=0.3), neurological (9.2% vs. 11.8%, P=0.4), renal (9.8% vs. 7.9%, P=0.5), wound (1.4% vs. 2.4%, P=0.5), infective (5.5% vs. 8.7%, P=0.2), and multiple organ failure (4.9% vs. 5.5%, P=0.6). The length of intensive care unit (hours) and hospital stay (days) was 71±163.8 versus 106.5±243.7 (P=0.5) and 14.7±14.7 versus 18.9±20.8 (P=0.01). In-hospital mortality resulted in 4.1% for AVR and 3.9% for MVR, P=0.9. CONCLUSION: Valve position and valve type do not affect the likelihood of requiring permanent pacing in patients undergoing isolated aortic and MVR. RELEVANCE FOR PATIENTS: A significant proportion of patients undergoing cardiac surgery develop arrhythmias and conduction disturbances postoperatively, often requiring the implantation of a PPM. Determining factors associated with an increase likelihood of permanent pacing would allow the optimization of per- and intra-operative care, with the aim of reducing the incidence of patients requiring post-operative PPM insertion.

Penetration of the Heart by an Airgun Pellet: A Case Without Significant Effusion or Valvular Injury.

Cardiac gunshot injuries are rare in the United Kingdom, but they are associated with significant morbidity and mortality. We present the case of a young male who was shot at close range with a low-caliber air rifle. The projectile entered the thorax through the right axilla, but it was identified at the cardiac apex on initial imaging. Subsequent investigations demonstrated the pellet at the apex of the left ventricle. The potential for embolization was considered, and the pellet was retrieved after surgical exploration. No significant valvular injury was sustained despite the pellet's trajectory, and the patient made an uncomplicated recovery.

A diagnostic cohort study on the accuracy of 18-fluorodeoxyglucose (18FDG) positron emission tomography (PET)-CT for evaluation of malignancy in anterior mediastinal lesions: the DECiMaL study.

OBJECTIVES: The aim of this study is to collate multi-institutional data to determine the value by defining the diagnostic performance of fluorodeoxyglucose positron emission tomography (FDG PET)/CT for malignancy in patients undergoing surgery with an anterior mediastinal mass in order to ascertain the clinical utility of PET/CT to differentiate malignant from benign aetiologies in patients presenting with an anterior mediastinal mass SETTING: DECiMaL Study is a multicentre, retrospective, collaborative cohort study in seven UK surgical sites. PARTICIPANTS: Between January 2002 and June 2015, a total of 134 patients were submitted with a mean age (SD) of 55 years (16) of which 69 (51%) were men. We included all patients undergoing surgery who presented with an anterior mediastinal mass and underwent PET/CT. PET/CT was considered positive for any reported avidity as stated in the official report and the reference was the resected specimen reported by histopathology using WHO criteria. PRIMARY AND SECONDARY OUTCOME MEASURES: Sensitivity, specificity, positive and negative predicted values of [18F]-FDG PET in determining malignant aetiology for an anterior mediastinal mass. RESULTS: The sensitivity and specificity of PET/CT to correctly classify malignant disease were 83% (95% CI 74 to 89) and 58% (95% CI 37 to 78). The positive and negative predictive values were 90% (95% CI 83% to 95%) and 42% (95% CI 26% to 61%). CONCLUSIONS: The results of our study suggest reasonable sensitivity but no specificity implying that a negative PET/CT is useful to rule out the diagnosis of malignant disease whereas a positive result has no value in the discrimination between malignant and benign diseases of the anterior mediastinum.

Harlequin syndrome following upper lobectomy.

A 58-year-old women developed unilateral facial flushing and sweating on the left side of her face immediately after a right thoracotomy upper lobectomy and paravertebral block. She was diagnosed with Harlequin syndrome in the absence of any other neurological signs or symptoms. She had recovered completely from this episode on follow-up.

Mini-extracorporeal circulation technology, conventional bypass and prime displacement in isolated coronary and aortic valve surgery: a propensity-matched in-hospital and survival analysis.

OBJECTIVES: Conventional cardiopulmonary bypass is the most commonly used means of artificial circulation in cardiac surgery. However, it suffers from the effects of haemodilution and activation of inflammatory/coagulation cascades. Prime displacement (PD) can offset haemodilution and mini-extracorporeal technology (MIECT) can offset both. So far, no study has compared all of these modalities together; hence, we compared the outcomes of these 3 modalities at our institution. METHODS: This was a retrospective analysis of our cardiac surgical database. A total of 9626 patients underwent conventional bypass (CB), 3125 patients underwent a modification of CB, called PD, and 904 underwent MIECT. A 1:1 propensity-matching algorithm was employed using IBM SPSS 24 to match (i) 813 MIECT patients with 813 CB patients and (ii) 717 MIECT patients with 717 PD patients. The patients included coronary artery bypass grafting and valve surgery. RESULTS: MIECT had significantly (P < 0.05) longer bypass and cross-clamp times compared to CB and PD. MIECT had significantly higher rates of postoperative atrial fibrillation associated with it compared to CB. The mean red cell blood transfusion was significantly lower in the MIECT group compared to the CB group as was the mean platelet transfusion and fresh frozen plasma transfusion. The overall 5-year survival was higher in the MIECT group compared to the CB group (log-rank, P = 0.018). Between the MIECT and the PD groups, we found the incidence of renal failure and gastrointestinal complications to be significantly higher in the PD group compared to the MIECT group. CONCLUSIONS: MIECT has short-term advantages over CB and PD. However, due to the retrospective limitations of the study, including calendar time bias, a multicentre randomized controlled trial comparing all 3 modalities will be beneficial for the larger cardiac community.

The differential effects of systemic vasoconstrictors on human pulmonary artery tension.

OBJECTIVES: Acute pulmonary hypertension following cardiac surgery can have a significant effect on postoperative morbidity and mortality. However, limited data are available on the efficacy and potency of clinically used systemic vasopressors on the pulmonary vasculature. The aim of this study was to use human pulmonary artery to characterize the pharmacological effects of clinically used vasopressors on the human pulmonary vasculature. METHODS: Fifty-seven pulmonary artery rings of internal diameter 2-4 mm and 2 mm long, mounted in a multiwire myograph system, were used to measure changes in isometric tension. We constructed concentration response curves by cumulative addition to the myograph chambers of KCl, noradrenaline (NA), adrenaline (AD), vasopressin, endothelin-1 (ET-1) and prostaglandin F2a (PGF2a). RESULTS: AD, NA, ET-1, PGF2a and KCl caused dose-dependent vasoconstriction in the pulmonary artery samples (EC50 246 nM [95% confidence interval, CI, 153-394 nM], 150 nM [95% CI 51-447 nM], 1.46 nM [95% CI 0.69-3.1 nM], 6.35 µM [95% CI 3.58-11.2 µM] and 17.24 mM [95% CI 12.43-24.07 mM], respectively), whereas vasopressin had no significant effect. The order of efficacy was KCl = PGF2a > AD > NA > ET-1 and the order of potency was ET-1 T-AD = NA > PGF2a > KCl. CONCLUSIONS: This study demonstrated the efficacy and potency of clinically used vasopressors and endogenous vasopressors on human pulmonary vascular tone. PGF2a and KCl equally caused maximal amounts of constriction, whereas ET-1 had less effect and vasopressin had no effect. These effects may need to be taken into account in the clinical setting because they might result in the development of pulmonary hypertension.

Multicentre, propensity-matched study to evaluate long-term impact of implantation technique in isolated aortic valve replacement on mortality and incidence of redo surgery.

OBJECTIVES: Studies suggest that the use of semicontinuous suture (SC) technique increases the risk of redo valve surgery after aortic valve replacement (AVR). The objective of this study was to identify 30-day mortality, rate of redo operation and long-term outcomes after AVR using either a semicontinuous suture or interrupted suture (IS) technique. METHODS: A total of 1617 patients from 2 cardiothoracic centres, undergoing isolated AVR between April 2005 and August 2013 were included. AVR was performed using SC technique in 765 patients and IS technique in 852 patients. Data were collected prospectively and follow-up was obtained to date for all patients. We compared 30-day mortality, rate of redo operation and long-term mortality in SC and IS groups. One-to-one propensity-matching analysis was performed using IBM SPSS version 22 to evaluate outcomes. RESULTS: Four hundred and eleven patients in the SC group were matched to 411 patients in the IS group (total of 822 patients) using propensity-score matching. The baseline characteristics were similar between SC and IS groups after matching. There were no statistically significant differences in 30-day mortality (3.9 vs 2.7%; P = 0.328), long-term mortality at 9-year follow-up (14.4 vs 15.3%; log-rank = 0.524) or rate of redo surgery (2.9 vs 2.0%; P = 0.320) between SC and IS, respectively. However, shorter cross-clamp time (51.9 ± 15.2 vs 60.9 ± 17.6 min; P < 0.001), bypass time (71.3 ± 23.0 vs 81.3 ± 37.8 min; P < 0.001) and the use of larger valve sizes (23.4 ± 2.1 vs 21.9 ± 2.2 mm; P < 0.001) were observed in SC patients compared with IS patients. Multivariate analysis did not show the suture technique as a significant determinant of redo valve surgery. CONCLUSIONS: This multicentre study demonstrates that neither mortality nor the risk of redo surgery was influenced by the choice of implantation technique using semicontinuous vs interrupted suture techniques. The SC technique allowed shorter operations and larger size valves to be utilized.

Uniportal thoracoscopic management of middle lobe torsion after upper lobectomy.

Lobar torsion is a rare but potentially life-threatening complication following pulmonary resection. Surgical management usually entails an exploratory thoracotomy and resection of the involved lobe if nonviable. We present the case of a 67-year-old woman diagnosed with right middle lobe torsion 5 days after thoracotomy and right upper lobectomy for squamous carcinoma of the lung. A thoracoscopic right middle lobectomy was successfully performed utilizing a single 4-cm port placed along the midaxillary line in the 5th intercostal space.

Long-term prognosis and a prediction model for acute bowel ischaemia following cardiac surgery.

OBJECTIVES: Bowel ischaemia following cardiac surgery is associated with a high postoperative mortality. No scoring system exists as yet to predict this complication following surgery. In addition, the long-term survival is not known. We sought to evaluate in-hospital outcomes and long-term outcomes in bowel ischaemia following cardiac surgery. We also sought to devise a simple risk prediction model for this catastrophic entity. METHODS: This was a retrospective study of data entered prospectively into our cardiac surgical database between July 1999 and May 2014. We compared the short- and long-term outcomes of patients who developed bowel ischaemia following cardiac surgery with those who did not develop bowel ischaemia using propensity-matched analysis. We developed a prediction model for bowel ischaemia from logistic regression. RESULTS: In total, 13 853 patients underwent cardiac surgery. Of these, 85 had confirmed bowel ischaemia following surgery. The in-hospital mortality rate for those with bowel ischaemia was 60%, while in those without bowel ischaemia, the mortality rate was 3% (P < 0.0001). In those bowel ischaemia patients who had a laparotomy for corrective surgery, the in-hospital mortality was significantly less compared with those who did not have a laparotomy (39.2 vs 91.2%, P < 0.0001). The long-term survival for bowel ischaemia at 2, 6 and 10 years was 35% (±5), 31% (±5) and 26% (+/6), respectively. Multivariable analysis revealed that advanced age at surgery, peripheral vascular disease, intra-aortic balloon pump usage, NYHA IV and postoperative atrial fibrillation were the significant (P < 0.005) determinants of developing postoperative bowel ischaemia. We developed a model to predict bowel ischaemia and validated it within our population (c-index = 0.781). CONCLUSIONS: We have shown that whilst bowel ischaemia carries a higher short-term mortality, the long-term mortality is not significantly greater for those few who survive to discharge. We have developed a simple prediction model to identify those at high risk of developing bowel ischaemia following cardiac surgery in order to optimize perioperative strategies in future.

Ileocolic to right iliac arterial transposition for the treatment of chronic mesenteric ischemia.

The treatment of chronic mesenteric ischemia remains challenging and controversy exists over the best interventional option. Endovascular treatment has emerged as first-line management due to its associated lower morbidity and mortality than surgical reconstruction. However, open mesenteric reconstructions continue to play an important role in patients with lesions that are unsuitable for an endovascular option. Mesenteric operations utilize the aorta or iliac artery as the inflow source for a vein or prosthetic bypass to the celiac artery or superior mesenteric artery. We describe an exceptional case of chronic mesenteric ischemia due to atherosclerosis that was treated successfully with a novel ileocolic to right iliac arterial transposition.