Minimal-Access Atrial Septal Defect (ASD) Closure.

Progress towards the development and adoption of minimally invasive techniques in cardiac surgery has been slower than that seen in other surgical specialties. Congenital heart disease (CHD) patients represent an important population within cardiac disease, of which atrial septal defect (ASD) is one of the most common diagnoses. Management of ASD encompasses a range of minimal-access and minimally invasive approaches, including transcatheter device closure, mini-sternotomy, thoracotomy, video-assisted, endoscopic, and robotic approaches. In this article, we will discuss the pathophysiology of ASD, along with diagnosis, management, and indications for intervention. We will review the current evidence supporting minimally invasive and minimal-access surgical ASD closure in the adult and paediatric patient, highlighting peri-operative considerations and areas for further research.

Organ Transplants From Deceased Donors With Primary Brain Tumors and Risk of Cancer Transmission.

Importance: Cancer transmission is a known risk for recipients of organ transplants. Many people wait a long time for a suitable transplant; some never receive one. Although patients with brain tumors may donate their organs, opinions vary on the risks involved. Objective: To determine the risk of cancer transmission associated with organ transplants from deceased donors with primary brain tumors. Key secondary objectives were to investigate the association that donor brain tumors have with organ usage and posttransplant survival. Design, Setting, and Participants: This was a cohort study in England and Scotland, conducted from January 1, 2000, to December 31, 2016, with follow-up to December 31, 2020. This study used linked data on deceased donors and solid organ transplant recipients with valid national patient identifier numbers from the UK Transplant Registry, the National Cancer Registration and Analysis Service (England), and the Scottish Cancer Registry. For secondary analyses, comparators were matched on factors that may influence the likelihood of organ usage or transplant failure. Statistical analysis of study data took place from October 1, 2021, to May 31, 2022. Exposures: A history of primary brain tumor in the organ donor, identified from all 3 data sources using disease codes. Main Outcomes and Measures: Transmission of brain tumor from the organ donor into the transplant recipient. Secondary outcomes were organ utilization (ie, transplant of an offered organ) and survival of kidney, liver, heart, and lung transplants and their recipients. Key covariates in donors with brain tumors were tumor grade and treatment history. Results: This study included a total of 282 donors (median [IQR] age, 42 [33-54] years; 154 females [55%]) with primary brain tumors and 887 transplants from them, 778 (88%) of which were analyzed for the primary outcome. There were 262 transplants from donors with high-grade tumors and 494 from donors with prior neurosurgical intervention or radiotherapy. Median (IQR) recipient age was 48 (35-58) years, and 476 (61%) were male. Among 83 posttransplant malignancies (excluding NMSC) that occurred over a median (IQR) of 6 (3-9) years in 79 recipients of transplants from donors with brain tumors, none were of a histological type matching the donor brain tumor. Transplant survival was equivalent to that of matched controls. Kidney, liver, and lung utilization were lower in donors with high-grade brain tumors compared with matched controls. Conclusions and Relevance: Results of this cohort study suggest that the risk of cancer transmission in transplants from deceased donors with primary brain tumors was lower than previously thought, even in the context of donors that are considered as higher risk. Long-term transplant outcomes are favorable. These results suggest that it may be possible to safely expand organ usage from this donor group.

The Impact of Same Gender Speed-Mentoring on Women's Perceptions of a Career in Surgery - A Prospective Cohort Study.

BACKGROUND: Mentoring is critically important for the personal and professional development of a surgeon. Early career stage mentoring by same-gender role models may help ameliorate the gender imbalance in surgery based on our understanding of barriers for women pursuing surgical careers. A novel method of establishing these relationships is speed mentoring. This study aims to examine the impact of a one-day speed-mentoring session with same gender mentors on a cohort's perceptions of a career in surgery. DESIGN: This prospective pre-post study compared attitudes and perceptions of a career in surgery before and after a speed-mentoring session with female surgeons. Mentees were assigned into groups of 1 or 2 and were paired with a female surgeon for 8 minutes. Each mentee group then rotated to another mentor for the same amount of time and this process continued for a total of twelve sessions. Mentees completed a 19-point questionnaire before and after the speed mentoring intervention. SETTING: This multicenter study included participants from across the United Kingdom. PARTICIPANTS: Inclusion criteria were female gender and medical student or foundation year doctor (internship year 1 or 2) status. Three hundred and forty participants participated in the intervention, 191 were included in the analysis. RESULTS: Following intervention, the percentage of participants who agreed that having a family would negatively impact a woman's surgical career progression significantly decreased from 46.6% to 23.0%. The percentage of participants who agreed that an "old boys' club" attitude exists in surgery also significantly decreased (73.8%-58.1%). The percentage of participants who agreed it was more difficult for a woman to succeed in her surgical career than a man significantly decreased (73.8%-64.9%). One hundred and eighty-three (96%) participants agreed that mentorship is important for career progression and 153 (71.2%) participants stated that they did not have someone who they considered a mentor. CONCLUSIONS: Conducting a speed mentoring program with same-gender role models significantly changed female medical students' and junior doctors' perceptions of women in surgery. The results suggest that such programs may be effective tools for facilitating mentor-mentee relationships and could be employed by surgical organizations to encourage a diverse uptake into surgery.

Clinical Practice Guideline for Solid Organ Donation and Transplantation During the COVID-19 Pandemic.

The coronavirus 2019 (COVID-19) pandemic has disrupted health systems worldwide, including solid organ donation and transplantation programs. Guidance on how best to screen patients who are potential organ donors to minimize the risks of COVID-19 as well as how best to manage immunosuppression and reduce the risk of COVID-19 and manage infection in solid organ transplant recipients (SOTr) is needed. METHODS: Iterative literature searches were conducted, the last being January 2021, by a team of 3 information specialists. Stakeholders representing key groups undertook the systematic reviews and generation of recommendations using a rapid response approach that respected the Appraisal of Guidelines for Research and Evaluation II and Grading of Recommendations, Assessment, Development and Evaluations frameworks. RESULTS: The systematic reviews addressed multiple questions of interest. In this guidance document, we make 4 strong recommendations, 7 weak recommendations, 3 good practice statements, and 3 statements of "no recommendation." CONCLUSIONS: SOTr and patients on the waitlist are populations of interest in the COVID-19 pandemic. Currently, there is a paucity of high-quality evidence to guide decisions around deceased donation assessments and the management of SOTr and waitlist patients. Inclusion of these populations in clinical trials of therapeutic interventions, including vaccine candidates, is essential to guide best practices.

Heart transplantation in the UK during the first wave of the SARS-CoV-2 pandemic.

BACKGROUND: We aim to evaluate practice and understand the impact of the first wave of the SARS-CoV-2 pandemic on heart transplantation in the UK. METHODS: A retrospective review of the UK Transplant Registry (UKTR) and a national survey of UK heart transplant centers have been performed. The early pandemic period is defined here as 1 March to 31 May 2020. RESULTS: There was geographic variation in the prevalence of COVID-19 across the UK. All centers reported adaptations to maintain the safety of their staff, candidate, and recipient populations. The number of donors fell by 31% during the early pandemic period. Heart utilization increased to 35%, compared to 26% during the same period of 2019. The number of heart transplants was well maintained, across all centers, with 38 performed, compared to 41 during the same period of 2019, with no change in 30-day survival. Twenty-seven heart transplant recipients with confirmed COVID-19 infection were reported during the study period. CONCLUSION: All UK heart transplant centers have successfully adapted their programs to overcome the challenges of staff redeployment and ICU and hospital resource limitation, associated with the pandemic, whilst continuing heart transplant activity. On-going evaluation of practice changes, with sharing of lessons learned, is required as the pandemic continues.

The impact of the SARS-CoV-2 pandemic and COVID-19 on lung transplantation in the UK: Lessons learned from the first wave.

BACKGROUND: Lung transplantation is particularly susceptible to the impact of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic, and evaluation of changes to practice is required to inform future decision-making. METHODS: A retrospective review of the UK Transplant Registry (UKTR) and national survey of UK lung transplant centers has been performed. RESULTS: There was geographic variation in the prevalence of COVID-19 infection across the UK. The number of donors fell by 48% during the early pandemic period. Lung utilization fell to 10% (compared with 24% for the same period of 2019). The number of lung transplants performed fell by 77% from 53, March to May 2019, to 12. Seven (58%) of these were performed in a single-center, designated "COVID-light." The number of patients who died on the lung transplant waiting list increased, compared to the same period of 2019 (p = .0118). Twenty-six lung transplant recipients with confirmed COVID-19 infection were reported during the study period. CONCLUSION: As the pandemic continues, reviewing practice and implementing the lessons learned during this period, including the use of robust donor testing strategies and the provision of "COVID-light" hospitals, are vital in ensuring the safe continuation of our lung transplant program.

Mesenteric ischaemia following cardiac surgery: the influence of intraoperative perfusion parameters.

OBJECTIVES: Mesenteric ischaemia (MesI) remains a rare but lethal complication following cardiac surgery. Previously identified risk factors for MesI mortality (age, poor left ventricular (LV) function, cardiopulmonary bypass time and blood loss) are non-specific and cannot necessarily be modified. This study aims to identify potentially modifiable risk factors for MesI mortality through analysis of peri- and intraoperative perfusion data. METHODS: Patients who underwent cardiac surgery between 2006 and 2011 at Papworth Hospital were retrospectively divided into 3 outcome categories: death caused by MesI; death due to other causes and survival to discharge. A published MesI risk calculator was used to estimate risk of MesI for each patient and then to create 3 cohorts of matched patients from each outcome group. Pre-, intra- and postoperative variables were collected and conditional logistic regression methods were used to identify parameters associated specifically with MesI deaths after cardiac surgery. RESULTS: A total of 10 409 patients underwent cardiac surgery between 2006 and 2011. The incidence of MesI was 0.3% (30 patients). Two hundred and sixty-one patients died of non-MesI causes and 10 118 survived. It was possible to identify 25 patients in each group at equivalent risk of MesI. The following parameters were found to be associated with MesI mortality: recent myocardial infarction [odds ratio (OR) 4.98, 95% confidence interval (CI) 1.58-15.71, P = 0.01], standard EuroSCORE (OR 1.12, 95% CI 1.03-1.21, P = 0.01), vasopressor dose on bypass (OR 1.28, 95% CI 1.04-1.57, P = 0.02), metaraminol dose on bypass (OR 1.52, 95% CI 1.12-2.06, P = 0.01) and lowest documented mean arterial pressure (OR 0.90, 95% CI 0.83-0.97, P = 0.01). No other intraoperative perfusion-related parameters (e.g. flow, average activated clotting time or pressure) were associated with MesI mortality. CONCLUSIONS: Our study not only confirms previously known predictive factors, but also demonstrates a new association between intraoperative vasopressor use and MesI mortality.

Chronic thromboembolic pulmonary hypertension: an underdiagnosed entity?

Chronic thromboembolic pulmonary hypertension (CTEPH) is the only cause of pulmonary hypertension for which there is a potential cure, which is in the form of pulmonary endarterectomy. There is a strong link between pulmonary embolism (PE) and the development of CTEPH. Although CTEPH was initially believed to be a rare complication, this belief has been reconsidered following several studies suggesting that up to 8.8% of patients develop CTEPH within the 2 years after PE. However, considering the incidence of PE, there is a significant discrepancy in the number of patients who are diagnosed, referred, and treated for CTEPH. Potential reasons for this include its often vague clinical presentation, the variable association of CTEPH with PE, and discrepancies when interpreting imaging studies. Underdiagnosis of CTEPH is preventing patients from accessing potentially curative therapy. Increased awareness about this condition is an important initial step to improving diagnostic rates and treatment.

Pulmonary endarterectomy: outcomes in patients aged >70.

OBJECTIVES: Advanced age is not a barrier to cardiac surgery, with reports demonstrating excellent outcomes, but the effect of age on more complex surgery has not been studied. We assessed the outcomes of pulmonary endarterectomy (PEA) surgery in patients aged >70. METHODS: A retrospective review of consecutive patients who underwent PEA between January 2006 and March 2011 at a national referral centre. The total cohort was dichotomized according to age on the day of surgery, either below or above 70 years. Outcomes were in-hospital mortality, overall survival and the length of ICU and hospital stays. RESULTS: Four hundred and eleven patients underwent PEA during the 5-year period. The mean age was 56.9 years (range, 17-84 years). The in-hospital mortality was 14 of 308 (4.6%) for patients <70 years compared with 8 of 103 (7.8%) for patients ≥70 years (P = 0.21). The overall survival at 1, 2 and 3 years was 91.4, 89.9 and 87.7% in the <70-year old group and 85.9, 84.1 and 84.1% in the >70-year old group (log-rank test, P = 0.07), respectively. The length of ICU and in-hospital stays was longer in the >70-year old group, by 1 and 2 days, respectively (P = 0.005 and 0.001). CONCLUSIONS: PEA surgery in patients ≥70 years is safe and carries a comparable risk of early mortality in younger patients, but there is an increase in resource use due to longer ICU and hospital stays. Advanced age should be taken into consideration when assessing suitability for PEA, but age per se should not be a contraindication to surgery.