The Impact of a Dedicated Chronic Total Occlusion PCI Program on Heart Team Decision Making.

BACKGROUND: Guidelines endorse a heart team (HT) approach to standardize the decision-making process for patients with complex coronary artery disease (CAD). With percutaneous treatment options for complex CAD increasing, we hypothesized that practice had changed over the past decade-and that more individuals, previously deemed too high risk for intervention, would now be referred for either surgical or percutaneous revascularization. METHODS: This observational study was conducted at St Thomas' Hospital (London, United Kingdom). All patients discussed at HT meetings were recorded and treatment recommendations audited. A subset of historic cases was selected for blinded, repeat discussion. RESULTS: From April 2018 to 2019, a total of 52 HT meetings discussing 375 cases were held. Patients tended to be male, with a majority demonstrating multivessel CAD in the context of preserved left ventricular function. SYNTAX scores were balanced across the tertiles. Thirty-five percent of patients had at least 1 chronic total occlusion (mean J-CTO, 3 [interquartile range, 2-3]), affecting the right coronary artery in 60%. Fifteen historic patients with isolated CTOs were re-presented an average of 8 years later; only 3 patients received the same outcome, with 80% now receiving a recommendation for revascularization over medical therapy. CONCLUSIONS: A dedicated program supporting complex coronary intervention is associated with a change in treatment recommendations issued by the local HT. In line with international guidelines, this might indicate that any complex or multivessel CAD should be discussed at HT meetings with, ideally, the presence of CTO operators.

Transcatheter Valve Implantation in Mitral Annular Calcification During Open Surgery: Extended Collar Technique.

We describe an improvised technique during open surgery of inserting a transcatheter heart valve in the mitral position under very challenging circumstances. This is the first described use of the "extended collar" technique, which allowed implantation of a transcatheter heart valve in severe mitral valve annular calcification, into which a surgical valve could not safely be implanted. We believe that this technique is reproducible and may be helpful to other surgeons when faced with similar difficult circumstances.

Mitral valve-in-valve and valve-in-ring for failing surgical bioprosthetic valves and rings.

The transcatheter valve-in-valve (VIV) procedure for failed aortic bioprostheses is recognized as an alternative treatment to conventional surgery in high-risk patients. This less invasive option has now been applied to failed mitral bioprostheses (VIV) or failed repairs i.e. valve-in-ring (VIR). In this emerging field, to get an optimal result, a good understanding of the design features of the failed surgical heart valve/ring, the transcatheter heart valve being used and their compatibility, is of paramount importance. Although similar in many ways to the aortic counterpart, a mitral VIV/VIR procedure can pose certain different challenges such as delayed migration and left ventricular outflow tract obstruction. This review describes the features of bioprostheses, rings and THVs relevant to a VIV/VIR procedure, and also provides guidance regarding sizing, positioning and how to avoid some of the major complications therefore improving the chances of a successful outcome.

Day surgery unit thoracic surgery: the first UK experience.

OBJECTIVE: Operating in a day surgery unit has potential benefits, including lower risk of cancellation, reduced infection rates, cost effectiveness and increased patient satisfaction. We believe that we are the first unit in the UK to regularly perform thoracic surgery in a dedicated day surgery unit, and describe our experience to date. METHODS: Data were collected prospectively from 1 September 2007 to 31 December 2009. Following surgery, patients were observed in a recovery area for 1h before transfer back to a short-stay ward. When chest drains were used, they were attached to an ambulatory drainage device for the patient to be discharged with. All patients were reviewed postoperatively, and were discharged home within 4-6h if appropriate. RESULTS: Ninety-eight patients underwent thoracic surgery in our day surgery unit. Sixty (61.2%) patients were male. The mean age was 53.0 (17-83) years. There were no deaths. Twenty-nine (29.6%) were mediastinal procedures (MED group) such as mediastinoscopy/otomy, 31 (31.6%) were video-assisted thoracoscopic surgery (VATS group) procedures such as lung biopsies and pleurodeses and 38 (38.8%) were a variety of other (OTHER group) procedures such as chest wall interventions and sternal wire removal. Out of the cohort, three (3.1%) patients required admission directly from the day surgery unit, and three (3.1%) were admitted late after discharge with problems relating to their surgery. Our Day Surgery Programme accounted for 12.0% of the total thoracic workload during the time period. CONCLUSIONS: Surgeons are continually trying to fast track increasingly complex procedures and, with good patient selection, thoracic surgery can be performed safely and effectively in day surgery units.