Optimising bloodless cardiovascular surgery for Jehovah's Witnesses and beyond.

Emerging evidence suggests surgical outcomes of patients undergoing cardiovascular surgery that refuse autologous transfusion is comparable to those who accept whole blood product transfusions. There are several methods that can be used to minimize blood loss during cardiovascular surgery. These methods can be categorised into pharmacological measures, including the use of erythropoietin, iron and tranexamic acid, surgical techniques, like the use of polysaccharide haemostat, and devices such as those used in acute normovolaemic haemodilution. More prospective studies with stricter protocols are required to assess surgical outcomes in bloodless cardiac surgery as well as further research into the long-term outcomes of bloodless cardiovascular surgery patients. This review summarizes current evidence on the use of pre-, intra-, and post-operative strategies aimed at the subset of patients who refuse blood transfusion, for example Jehovah's Witnesses.

Transcatheter versus surgical closure of atrial septal defects: a systematic review and meta-analysis of clinical outcomes.

BACKGROUND: Atrial septal defects are a common form of CHD and dependent on the size and nature of atrial septal defects, closure may be warranted. The paper aims to compare outcomes of transcatheter versus surgical repair of atrial septal defects. METHODS: A comprehensive electronic literature search was conducted. Primary studies were included if they compared both closure techniques. Primary outcomes included procedural success, mortality, and reintervention rate. Secondary outcomes included residual defect and mean hospital stay. RESULTS: A total of 33 studies were included in meta-analysis. Mean total hospital stay was significantly shorter in the transcatheter cohort across both the adult (95% confidence interval, mean difference -4.05 (-4.78, -3.32) p < 0.00001) and paediatric populations (95% confidence interval, mean difference -4.78 (-5.97, -3.60) p < 0.00001). There were significantly fewer complications in the transcatheter group across both the adult (odds ratio 0.45, 95% confidence interval, [0.28, 0.72], p < 0.00001) and paediatric cohorts (odds ratio 0.26, 95% confidence interval, [0.14, 0.49], p < 0.00001). No significant difference in overall mortality was found between transcatheter versus surgical closure across the two groups, adult (odds ratio 0.76, 95% confidence interval, [0.40, 1.45], p = 0.41), paediatrics (odds ratio 0.62, 95% confidence interval, [0.21, 1.83], p = 0.39). CONCLUSION: Both transcatheter and surgical approaches are safe and effective techniques for atrial septal defect closure. Our study has demonstrated the benefits of transcatheter closure in terms of lower complication rates and mean hospital stay. However, surgery still has a place for more complex closure and, as we have demonstrated, shows no difference in mortality.

Pedicled or skeletonized bilateral internal mammary artery harvesting - a meta- analysis and trial sequential analysis.

OBJECTIVE: There is varying evidence on the role of skeletonization of internal mammary artery in reducing the risk of sternal wound infections and ischemia following bilateral internal mammary artery grafting. Post-operative clinical outcomes of skeletonized bilateral internal mammary artery versus pedicled bilateral internal mammary artery harvesting in patients undergoing coronary artery bypass surgery were compared. METHODS: A comprehensive electronic search was conducted using MEDLINE, Scopus, EMBASE, Cochrane database and Google Scholar from inception until 15 June 2020. All studies directly comparing skeletonized and pedicled bilateral internal mammary artery harvesting were included. Meta-analysis and trial sequential analysis were conducted. RESULTS: Nine studies (one randomized controlled trial and eight observational studies) consisting of 3649 patients (2050 patients with skeletonized bilateral internal mammary artery grafting and 1599 patients with pedicled bilateral internal mammary artery grafting) were included. Pooled effects analysis and trial sequential analysis reported significantly lower risk of sternal wound infection with skeletonized bilateral internal mammary artery harvesting (OR 0.27, 95% CI 0.20-0.51, p < 0.00001). CONCLUSIONS: Skeletonization reduces the risk of sternal wound infections by preserving vasculature as much as possible. This facilitates its use in patients at high risk of sternal wound infection.

Outcomes in minimally invasive double valve surgery.

OBJECTIVE: To review current literature evidence on outcomes of minimally invasive double valve surgeries (MIS). METHODS: A comprehensive electronic literature search was done from inception to 20th June 2020 identifying articles that discussed outcomes of minimally invasive approach in double valve surgeries either as a solo cohort or as comparative to conventional sternotomies. No limit was placed on time and place of publication and the evidence has been summarized in narrative manner within the manuscript. RESULTS: Majority of current literature reported similar perioperative and clinical outcomes between MIS and conventional median sternotomy; except that MIS has better cosmetic effects and pain control. Nevertheless, minimal invasive techniques are associated with longer cardiopulmonary bypass and aortic cross-clamp times which may have impact on the reported outcomes and overall morbidity and mortality rates. CONCLUSION: Minimally invasive double valve surgery continues to develop, but scarcity in the literature suggests uptake is slow, possibly due to the learning curve associated with MIS. Many outcomes appear to be comparable to conventional sternotomy. There is need for larger, multi-center, and randomized trial to fully evaluate and establish the early, mid- and long-term morbidity and mortality rates associated with both techniques.