Long-term clinical outcomes and cost-effectiveness of catheter vs thoracoscopic surgical ablation in long-standing persistent atrial fibrillation using continuous cardiac monitoring: CASA-AF randomized controlled trial.

BACKGROUND: Long-term clinical outcomes of catheter ablation (CA) compared to thoracoscopic surgical ablation (SA) to treat patients with long-standing persistent atrial fibrillation (LSPAF) are not known. OBJECTIVE: The purpose of this study was to compare the long-term (36-month) clinical efficacy, quality of life, and cost-effectiveness of SA and CA in LSPAF. METHODS: Participants were followed up for 3 years using implantable loop recorders and questionnaires to assess the change in quality of life. Intention-to-treat analyses were used to report the findings. RESULTS: Of the 115 patients with LSPAF treated, 104 (90.4%) completed 36-month follow-up [CA: n = 57 (95%); SA: n = 47 (85%)]. After a single procedure without antiarrhythmic drugs, 7 patients (12%) in the CA arm and 5 (11%) in the SA arm [hazard ratio 1.22; 95% confidence interval (CI) 0.81-1.83; P = .41] were free from atrial fibrillation/tachycardia (AF/AT) ≥30 seconds at 36 months. Thirty-three patients (58%) in the CA arm and 26 (55%) in the SA arm (hazard ratio 1.04; 95% CI 0.57-1.88; P = .91) had their AF/AT burden reduced by ≥75%. The overall impact on health-related quality of life was similar, with mean quality-adjusted life year estimates of 2.45 (95% CI 2.31-2.59) for CA and 2.32 (95% CI 2.13-2.52) for SA. Estimated costs were higher for SA (mean £24,682; 95% CI £21,746-£27,618) than for CA (mean £18,002; 95% CI £15,422-£20,581). CONCLUSION: In symptomatic LSPAF, CA and SA were equally effective at achieving arrhythmia outcomes (freedom from AF/AT ≥30 seconds and ≥75% burden reduction) after a single procedure without antiarrhythmic drugs. However, SA is significantly more costly than CA.

Foreign Body Misdiagnosed as Mucus Plugging After Percutaneous Tracheostomy.

We report a case of a 59-year-old male who presented with a persistent cough for a year after being discharged from critical care following a subarachnoid haemorrhage. As part of his initial critical care management and in order to allow full neurological assessment, the patient required a period of prolonged mechanical ventilation, which necessitated a percutaneous tracheostomy. Following recovery and subsequent discharge, the patient presented on multiple occasions with cough, undergoing serial computed tomography (CT) scans which reported mucus plugging as a possible cause of the cough. As his symptoms continued to worsen, a flexible bronchoscopy was carried out, which identified a foreign body in the trachea. This object was later recognised as a retained part of the guiding catheter, part of the percutaneous tracheostomy tube dilator. After the object was retrieved, the patient reported a complete resolution of symptoms. Percutaneous tracheostomy is a common procedure within critical care units, and early complications such as bleeding or airway obstruction are typically recognised immediately after insertion. This report documents a late complication caused by the retention of a foreign object from insertion, which was misdiagnosed on serial CT scans, leading to persistent cough over a period of months.

Myocardial rupture and left ventricular pseudoaneurysm due to late STEMI presentation during the COVID-19 pandemic lockdown: a classical case report.

BACKGROUND: Left ventricular (LV) pseudoaneurysm is a serious and rare complication of myocardial infarction (MI). It occurs when an injured myocardial wall ruptures and is contained by overlying adherent pericardium or scar tissue, most commonly it develops in patients with late presentation of MI and delayed revascularization. CASE SUMMARY: A 64-year-old man presented to the emergency department with intermittent central chest pain radiating to back and neck and increasing on deep inspiration, which was considered to be of musculoskeletal origin for a week, but worsened despite medications. Electrocardiography showed features of ST-elevation MI; a circumflex artery occlusion was found on coronary angiogram and angioplasty was performed. Cardiovascular magnetic resonance (CMR) revealed features of healed lateral wall rupture with adherent parietal pericardium and the patient was managed conservatively. Two months later the patient returned with severe chest pain; echocardiogram and cardiac computed tomography showed significant interval progression of the pseudoaneurysm. Aneurysmectomy was performed, after which the patient recovered and had none of the previous symptoms since. Follow-up CMR study revealed improvement of LV systolic function. DISCUSSION: A rare case of post-infarction LV pseudoaneurysm was reported. Multimodality imaging helped to detect and to differentiate this complication from the true aneurysm and to follow it up and plan the treatment. Conservative treatment was not effective in this case as the pseudoaneurysm progressed; aneurysmectomy helped to improve LV systolic function.

Catheter ablation vs. thoracoscopic surgical ablation in long-standing persistent atrial fibrillation: CASA-AF randomized controlled trial.

AIMS: Long-standing persistent atrial fibrillation (LSPAF) is challenging to treat with suboptimal catheter ablation (CA) outcomes. Thoracoscopic surgical ablation (SA) has shown promising efficacy in atrial fibrillation (AF). This multicentre randomized controlled trial tested whether SA was superior to CA as the first interventional strategy in de novo LSPAF. METHODS AND RESULTS: We randomized 120 LSPAF patients to SA or CA. All patients underwent predetermined lesion sets and implantable loop recorder insertion. Primary outcome was single procedure freedom from AF/atrial tachycardia (AT) ≥30 s without anti-arrhythmic drugs at 12 months. Secondary outcomes included clinical success (≥75% reduction in AF/AT burden); procedure-related serious adverse events; changes in patients' symptoms and quality-of-life scores; and cost-effectiveness. At 12 months, freedom from AF/AT was recorded in 26% (14/54) of patients in SA vs. 28% (17/60) in the CA group [OR 1.128, 95% CI (0.46-2.83), P = 0.83]. Reduction in AF/AT burden ≥75% was recorded in 67% (36/54) vs. 77% (46/60) [OR 1.13, 95% CI (0.67-4.08), P = 0.3] in SA and CA groups, respectively. Procedure-related serious adverse events within 30 days of intervention were reported in 15% (8/55) of patients in SA vs. 10% (6/60) in CA, P = 0.46. One death was reported after SA. Improvements in AF symptoms were greater following CA. Over 12 months, SA was more expensive and provided fewer quality-adjusted life-years (QALYs) compared with CA (0.78 vs. 0.85, P = 0.02). CONCLUSION: Single procedure thoracoscopic SA is not superior to CA in treating LSPAF. Catheter ablation provided greater improvements in symptoms and accrued significantly more QALYs during follow-up than SA. CLINICAL TRIAL REGISTRATION: ISRCTN18250790 and ClinicalTrials.gov: NCT02755688.

Early experience of thoracoscopic vs. catheter ablation for atrial fibrillation.

AIMS: Video-assisted thoracoscopic surgery (VATS) ablation has been advocated as a treatment option for non-paroxysmal atrial fibrillation (AF) in recent guidelines. Real-life data on its safety and efficacy during a centre's early experience are sparse. METHODS AND RESULTS: Thirty patients (28 persistent/longstanding persistent AF) underwent standalone VATS ablation for AF by an experienced thoracoscopic surgeon, with the first 20 cases proctored by external surgeons. Procedural and follow-up outcomes were collected prospectively, and compared with 90 propensity-matched patients undergoing contemporaneous catheter ablation (CA). Six (20.0%) patients undergoing VATS ablation experienced ≥1 major complication (death n = 1, stroke n = 2, conversion to sternotomy n = 3, and phrenic nerve injury n = 2). This was significantly higher than the 1.1% major complication rate (tamponade requiring drainage n = 1) seen with CA (P < 0.001). Twelve-month single procedure arrhythmia-free survival rates without antiarrhythmic drugs were 56% in the VATS and 57% in the CA cohorts (P = 0.22), and 78% and 80%, respectively given an additional CA and antiarrhythmic drugs (P = 0.32). CONCLUSION: During a centre's early experience, VATS ablation may have similar success rates to those from an established CA service, but carry a greater risk of major complications. Those embarking on a programme of VATS AF ablation should be aware that complication and success rates may differ from those reported by selected high-volume centres.

Catheter Ablation versus Thoracoscopic Surgical Ablation in Long Standing Persistent Atrial Fibrillation (CASA-AF): study protocol for a randomised controlled trial.

BACKGROUND: Atrial fibrillation is the commonest arrhythmia which raises the risk of heart failure, thromboembolic stroke, morbidity and death. Pharmacological treatments of this condition are focused on heart rate control, rhythm control and reduction in risk of stroke. Selective ablation of cardiac tissues resulting in isolation of areas causing atrial fibrillation is another treatment strategy which can be delivered by two minimally invasive interventions: percutaneous catheter ablation and thoracoscopic surgical ablation. The main purpose of this trial is to compare the effectiveness and safety of these two interventions. METHODS/DESIGN: Catheter Ablation versus Thoracoscopic Surgical Ablation in Long Standing Persistent Atrial Fibrillation (CASA-AF) is a prospective, multi-centre, randomised controlled trial within three NHS tertiary cardiovascular centres specialising in treatment of atrial fibrillation. Eligible adults (n = 120) with symptomatic, long-standing, persistent atrial fibrillation will be randomly allocated to either catheter ablation or thoracoscopic ablation in a 1:1 ratio. Pre-determined lesion sets will be delivered in each treatment arm with confirmation of appropriate conduction block. All patients will have an implantable loop recorder (ILR) inserted subcutaneously immediately following ablation to enable continuous heart rhythm monitoring for at least 12 months. The devices will be programmed to detect episodes of atrial fibrillation and atrial tachycardia ≥ 30 s in duration. The patients will be followed for 12 months, completing appropriate clinical assessments and questionnaires every 3 months. The ILR data will be wirelessly transmitted daily and evaluated every month for the duration of the follow-up. The primary endpoint in the study is freedom from atrial fibrillation and atrial tachycardia at the end of the follow-up period. DISCUSSION: The CASA-AF Trial is a National Institute for Health Research-funded study that will provide first-class evidence on the comparative efficacy, safety and cost-effectiveness of thoracoscopic surgical ablation and conventional percutaneous catheter ablation for long-standing persistent atrial fibrillation. In addition, the results of the trial will provide information on the effects on patients' quality of life. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN18250790 . Registered on 24 April 2015.

Minimally Invasive Epicardial Surgical Ablation Alone Versus Hybrid Ablation for Atrial Fibrillation: A Systematic Review and Meta-Analysis.

Maintaining sinus rhythm in patients with non-paroxysmal AF is an elusive goal. Some suggest that hybrid ablation, combining minimally invasive epicardial surgical ablation with endocardial catheter ablation, may be more effective than either modality alone. However, randomised trials are lacking. We investigated whether hybrid ablation is more effective than epicardial ablation alone at preventing recurrent AF by performing a systematic review and meta-analysis. The review was prospectively registered with PROSPERO (CRD42016043389). MEDLINE and EMBASE were searched for studies of standalone minimally invasive epicardial ablation of AF and/or hybrid ablation, identifying 41 non-overlapping studies comprising 2737 patients. A random-effects meta-analysis, meta-regression and sensitivity analysis were performed. Single-procedure survival free from atrial arrhythmias without antiarrhythmic drugs was similar between epicardial-alone and hybrid approaches at 12 months (epicardial alone 71.5 %; [95 % CI 66.1-76.9], hybrid 63.2 %; [95 % CI 51.5-75.0]) and 24 months (epicardial alone 68.5 %; [95 % CI 57.7-79.3], hybrid 57.0 %; [95 % CI 33.6-80.4]). Freedom from atrial arrhythmias with AADs and rates of unplanned additional catheter ablations were also similar between groups. Major complications occurred more often with hybrid ablation (epicardial alone 2.9 %; [95 % CI 1.9-3.9], hybrid 7.3 %; [95 % CI 4.2-10.5]). Meta-regression suggested that bipolar radiofrequency energy and thoracoscopic access were associated with greater efficacy, but adjusting for these factors did not unmask any difference between epicardial-alone and hybrid ablation. Hybrid and epicardial ablation alone appear to be equally effective treatments for AF, although hybrid ablation may be associated with higher complication rates. These data derived from observational studies should be verified with randomised data.

Smoking status and 30-day mortality in patients undergoing pulmonary resections.

BACKGROUND: Smoking status has not been shown to have a significant effect on 30-day mortality after potentially curative resectional surgery for non-small-cell lung cancer, and this is reflected in the guidelines of the National Institute for Health and Care Excellence in the United Kingdom. METHODS: A validated prospective thoracic surgery database of consecutive patients undergoing potentially curative resection at a single institution was analyzed. Univariate and propensity analyses of 30-day mortality were performed. RESULTS: Univariate analysis identified 30-day mortality as significantly lower in current smokers (n = 852, 2.6%) than ex-smokers (n = 1587, 4.9%; p < 0.001). Propensity 1:1 matching of male patients resulted in 727 current smokers being matched to 727 ex-smokers. The overall balance test (χ(2 )= 6.1, degrees of freedom = 8, p = 0.6), indicated a good match. After propensity matching, the mortality rate was significantly higher in current smokers (p = 0.01). CONCLUSIONS: Current smokers and ex-smokers are statistically different with regard to risk factors for death. This results in a skewed population of current and ex-smokers undergoing resection for non-small-cell lung cancer. Development of a risk model for 30-day mortality revealed that current smokers have a lower predicted 30-day mortality than ex-smokers, a finding that is counterintuitive. Propensity matching balanced the current and ex-smoker groups to correct for group differences. Analysis after propensity matching identified current smoking as a significant factor determining 30-day mortality.

A comparison of survival between on-pump and off-pump left internal mammary artery bypass graft surgery for isolated left anterior descending coronary artery disease: an analysis of the UK National Adult Cardiac Surgery Audit Registry.

OBJECTIVES: To determine if the use of cardiopulmonary bypass is associated with all-cause in-hospital and mid-term survival for patients undergoing left internal mammary artery (LIMA) to left anterior descending (LAD) coronary artery bypass grafting (CABG) for single coronary vessel disease. METHODS: Data from the National Adult Cardiac Surgery Audit registry for all elective and urgent isolated CABG procedures performed between April 2003 and March 2013 in first-time cardiac surgery patients were extracted. Experienced surgeons (those with ≥300 records) were classified by their technique preference (as 'off-pump preference', 'mixed practice', 'on-pump preference') based on their entire isolated CABG data. In-hospital mortality and time to death were analysed using logistic and Cox proportional hazards regression models, respectively. RESULTS: From a total of 3402 records, 65.5% were performed off-pump. There were 16 (0.47%) in-hospital deaths: 6 (0.51%) in the on-pump group and 10 (0.45%) in the off-pump group. The risk-adjusted odds ratio of in-hospital mortality in the direction of on-pump was 1.09 [95% confidence interval (CI): 0.39-3.04; P = 0.86]. The overall 5-year survival in the on- and off-pump groups was 93.1 and 93.4%, respectively. The adjusted hazard ratio (HR) for mortality in the direction of on-pump CABG was 1.15 (95% CI: 0.89-1.49; P = 0.28). Comparing off-pump cases performed by experienced CABG surgeons with a preference for the off-pump technique with on-pump cases performed by surgeons with a preference for the on-pump technique indicated a significant difference (HR for on-pump = 1.72; 95% CI: 1.19-2.47; P = 0.004). CONCLUSIONS: Elective and urgent first-time CABG for isolated LAD disease is associated with excellent mid-term survival in the England and Wales population, conferring a 5-year survival rate of 93.1 and 93.4% in the on-pump and off-pump groups, respectively. There was no difference in risk-adjusted survival between the on-pump and off-pump techniques when analysing all procedures; however, supportive analysis demonstrated that off-pump surgery performed by experienced surgeons with a preference for the off-pump technique in their CABG caseload is associated with improved mid-term survival when compared with on-pump surgery performed by surgeons with a preference for the on-pump technique.

A Single-Center Randomized Trial of Intraoperative Zero-Balanced Ultrafiltration During Cardiopulmonary Bypass for Patients With Impaired Kidney Function Undergoing Cardiac Surgery.

OBJECTIVES: The authors investigated whether zero-balance ultrafiltration (Z-BUF) during bypass significantly improves clinical and cost outcomes or biomarkers of kidney injury for patients with preoperative kidney impairment (estimated glomerular filtration rate [eGFR]<60 mL/minute) undergoing cardiac surgery. DESIGN: A single-center randomized controlled trial recruited, patients between 2010 and 2013, with a 12-months follow-up. SETTING: Hospital. PARTICIPANTS: One hundred ninety-nine patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). INTERVENTIONS: Patients were assigned randomly to receive zero-balance ultrafiltration (Z-BUF) or not, with stratification for degree of kidney dysfunction and diabetes. MEASUREMENTS AND MAIN RESULTS: The authors assessed clinical efficacy and kidney function biomarkers. Cumulative probability of discharge from the intensive care unit (ICU) was assessed by Kaplan-Meier plots and was found not to be significantly different between the two trial arms (p = 0.61). After adjusting for EuroSCORE, diabetes, eGFR, cardioplegia types and type of surgery in a Cox proportional hazard model, hazard ratios (HR) for ICU length of stay between the Z-BUF and no-Z-BUF groups was not significantly different: HR (95% CI): 0.89 (0.66, 1.20; p = 0.44). In contrast, significant reductions in postoperative chest infections and the composite of clinical endpoints (death, strokes, and myocardial infarctions) in the Z-BUF group were observed. In addition, Z-BUF significantly abrogated the rise in the kidney damage markers urinary NGAL/creatinine ratio, urea, creatinine and eGFR during CPB and adverse events risks. CONCLUSIONS: Z-BUF during bypass surgery is associated with significant reductions in morbidity and biomarkers of CPB-induced acute kidney injury soon after CPB, which are indicative of clearance of inflammatory/immune mediators from the circulation.

Metastatic index of non-small-cell lung cancer and long-term survival.

AIM: We aimed to determine whether metastatic index is a factor determining long-term survival in patients undergoing curative resection for non-small-cell lung cancer. METHODS: There were 2695 consecutive pulmonary resections performed between October 2001 and September 2011 in our institution; 1795 were potentially curative resections for non-small-cell lung cancer with bronchial margin length data available. Benchmarking against the International Association for the Study of Lung Cancer data set was performed. Cox multivariate analysis was undertaken. Metastatic index was defined as N stage× bronchial resection margin length. RESULTS: Benchmarking failed to reveal any significant differences between our data and the International Association for the Study of Lung Cancer data set. Univariate analysis identified metastatic index as a significant factor determining long-term survival (p = 0.04). Cox regression demonstrated that metastatic index (hazard ratio 1.29, p = 0.0002), age (hazard ratio 1.02, p < 0.0001), body mass index (hazard ratio 0.98, p = 0.006), female sex (hazard ratio 0.65, p < 0.0001), T1 stage (hazard ratio 0.67, p < 0.0001), T2 stage (hazard ratio 2.13, p < 0.0001), T3 stage (hazard ratio 1.59, p = 0.03), forced expiratory volume in 1 s (hazard ratio 0.70, p < 0.0001), pneumonectomy (hazard ratio 1.43, p = 0.001), histology subtype adenosquamous (hazard ratio 3.77, p = 0.01) and squamous (hazard ratio 0.83, p = 0.03) were all significant determinants of long-term survival. CONCLUSION: Metastatic index is a significant factor determining long-term survival in patents with adenocarcinoma undergoing potentially curative surgery with a lobectomy.

The validity of the original EuroSCORE and EuroSCORE II in patients over the age of seventy.

OBJECTIVES: EuroSCORE II, despite improving on the original EuroSCORE system, has not solved all the calibration and predictability issues. We investigated the sensitivity, specificity and predictability of original EuroSCORE and EuroSCORE II system in elderly patients. METHODS: The original logistic EuroSCORE and EuroSCORE II were assessed via receiver operator characteristic (ROC) and Hosmer-Lemeshow test probability analysis with regard to accuracy of predicting in-hospital mortality. Analysis was performed on isolated coronary artery bypass graft (CABG) (n = 2913), aortic valve replacement (AVR) (n = 814), mitral valve surgery (MVR) (n = 340), combined AVR and CABG cases (n = 517) and the above cases combined (n = 4584). Elderly was defined as ≥70 years old. Age <70 was used for comparative purposes. RESULTS: Institutional mortality was 2.9%, for all isolated CABG, AVR, MVR and combined AVR and CABG cases. In all patients aged ≥70 neither the original EuroSCORE nor EuroSCORE II had a ROC c-statistic above 0.7. For isolated CABG, the ROC c-statistic was not acceptable in patients ≥70 years of age, but was fine for patients under the age of 70 years. For isolated AVR the ROC c-statistic was good for patients aged less than 70 years of age for both risk models; however, the ROC was unacceptably low in patients aged ≥70 for both models. For isolated MVR, the ROC c-statistic and Hosmer-Lemeshow test probability was good for all patients regardless of age. For combined AVR and CABG, the ROC c-statistic was unacceptably low for all patients, regardless of age group using the original EuroSCORE, and in those aged ≥70 using the EuroSCORE II risk model. The original EuroSCORE had no issues with the Hosmer-Lemeshow test probability; however, EuroSCORE II had poor model predictability for all patients, P < 0.0001, and for isolated CABG, P = 0.05 and AVR, P = 0.06. CONCLUSIONS: The original EuroSCORE and the EuroSCORE II risk models should be used with caution in patients aged 70 or older undergoing cardiac surgery in the modern era. Below the age of 70, both models are sensitive, specific and have good predictive power. Our work needs validation by other large groups.

A need for speed? Bypass time and outcomes after isolated aortic valve replacement surgery.

OBJECTIVES: To determine in the modern era if cardiopulmonary bypass (CPB) time has a significant effect on postoperative morbidity, mortality and long-term survival in patients undergoing isolated aortic valve replacement (AVR) surgery. METHODS: Analysis of a prospectively collected cardiac surgery database was performed. Uni- and multivariate analysis on the need of resternotomy for bleeding, mediastinal blood loss, intensive care unit (ICU) length of stay, hospital length of stay, in-hospital mortality and long- term survival was performed. Only patients with a cross-clamp time <90 min were analysed to exclude technical issues confounding the results. RESULTS: A total of 1863 isolated first-time AVR procedures were analysed, with an in-hospital mortality rate of 2.4%. The rate of long-term follow-up achieved was 100%. Univariate analysis revealed that CPB time (minutes) had no significant effect on resternotomy (P = 0.5), creatinine kinase muscle-brain isoenzyme (CKMB) release (P = 0.8) and long-term survival (P = 0.06), but was significantly associated with mediastinal blood loss (P = 0.01), ICU length of stay (P = 0.02), hospital length of stay (P = 0.03) and in-hospital mortality (P < 0.001). Multivariate analysis identified that bypass time (min) was a significant factor associated with mediastinal blood loss (P < 0.001), ICU length of stay (P = 0.01), postoperative length of stay (P < 0.001) and in-hospital mortality (odds ratio [OR] 1.02, 95% CI 1.01-1.04, P = 0.01), but not long-term survival. Multivariate analysis identified that era of surgery had no significant effect on CKMB release (P = 0.2), mediastinal blood loss (P = 0.4) and in-hospital mortality (P = 0.9), but the latter era of this study was significantly associated with a reduced postoperative length of stay (P < 0.001), reduced ICU length of stay (P < 0.001), reduced need for resternotomy for bleeding (OR 0.62, 95% CI 0.41-0.94, P = 0.02) and improved long-term survival (hazard ratio 0.76, 95% CI 0.59-0.96, P = 0.02). Adjusting for era made no difference with respect to the above study findings. CONCLUSIONS: Despite improvements over time with regard to morbidity, mortality and long-term survival, CPB time remains a significant factor determining mediastinal blood loss, ICU and hospital length of stay, and in-hospital mortality.

Pneumonectomy: risk factor or innocent bystander?

BACKGROUND: Pneumonectomy is associated with a higher operative mortality rate and worse 5-year survival after resection for non-small-cell lung cancer, compared to lobectomy. We investigated whether pneumonectomy is an independent risk factor for hospital mortality and poor long-term survival, after risk factor adjustment. METHODS: We analyzed a prospectively validated thoracic surgery database. Kaplan-Meier survival curves were constructed for patients who had undergone lobectomy (n = 1484) or pneumonectomy (n = 266). Logistic and Cox multivariate regression analysis and propensity matching were performed on hospital mortality and long-term survival data. RESULTS: Univariate analysis demonstrated that pneumonectomy was a significant risk factor for hospital death (p = 0.02) and long-term survival (p < 0.001). Logistic regression failed to demonstrate pneumonectomy as a risk factor for hospital mortality. Cox regression analysis failed to identify pneumonectomy as a statistically significant risk factor. Propensity analysis (n = 266 in each group with 1:1 matching) demonstrated that pneumonectomy was not associated with hospital mortality (p = 0.37) or poorer long-term survival (p = 0.19) compared to lobectomy. CONCLUSION: Pneumonectomy is not an independent risk factor for hospital mortality or long-term survival, after adjustment for confounding factors.

Virchow's triad and intestinal ischemia post cardiac surgery.

BACKGROUND: Intestinal ischemia is associated with a very high mortality rate. We combined the principles of Virchow's triad to produce preoperative and postoperative models for the development of intestinal ischemia. METHODS: A single institutional study was undertaken involving 18,325 consecutive patients from April 1997 to March 2012. Univariate and multivariate analysis was performed. RESULTS: Mortality was 87% in 91 patients who developed bowel ischemia. Multivariate logistic regression demonstrated that age, peripheral vascular disease, intraaortic balloon pump support, female sex, and preexisting renal failure were significant determinates of intestinal ischemia preoperatively. Logistic regression demonstrated that age, peripheral vascular disease, creatine kinase-MB level, reoperation for bleeding, and blood product usage were significant determinates of intestinal ischemia postoperatively. CONCLUSIONS: Potentially remedial causes of intestinal ischemia include blood product usage, reoperation for bleeding, and creatine kinase-MB release. Age, female sex, peripheral vascular disease, intraaortic balloon pump usage, and preexisting renal failure are fixed risk factors. Despite the continuing trend of reduced blood product usage in the field of cardiac surgery, the increase in patients' risk factors will mean that incidences of intestinal ischemia may increase in the future.

Should males ever undergo wedge resection for stage 1 non-small-cell lung cancer? A propensity analysis.

OBJECTIVES: Wedge resections are frequently performed for small peripheral lesions in patients unfit for a more extensive resection. We aimed to investigate whether patient sex and histology type are important factors determining survival in patients undergoing a wedge resection for stage I lung cancer. METHODS: We retrospectively analysed a prospective thoracic database of patients (n = 2859) who had undergone potentially curative wedge resection for stage I non-small-cell lung cancer. Only patients with adenocarcinoma or squamous carcinoma were included (n = 540). We benchmarked our 5-year survival against the sixth International Association for the Study of Lung Cancer results. Kaplan-Meier, Cox multivariate regression analysis and propensity analysis were utilized to assess the effect of sex and histology on survival post-wedge resection with regard to long-term survival. RESULTS: Cox regression of patients who had undergone wedge resection demonstrated that adenocarcinoma (odds ratio [OR]: 2.16, 95% confidence interval [CI]: 1.11-4.19), P = 0.02 was the only significant term determining long-term survival. Cox regression of male patients identified adenocarcinoma (OR: 3.29, 95% CI: 1.22-8.86), P = 0.02 as the only significant term determining long-term survival. Cox regression of female patients failed to identify any significant factors that determine long-term survival. Propensity matching based on gender identified that gender had no effect on survival, P = 0.46; however, histology was associated with a difference in survival, P = 0.02. This effect occurred in males, P = 0.02, but not females, P = 0.26. Propensity matching based on histology identified that gender had no effect on survival, P = 0.29; however, histology was associated with a difference in survival, P = 0.01. This effect occurred in males, P = 0.01, but not females, P = 0.26. Differing life expectancy between males and females was adjusted for by the use of the Framingham-predicted life expectancy. CONCLUSIONS: Long-term survival of patients with stage I non-small-cell lung cancer who undergo a wedge resection is affected by gender and histological type. Male patients undergoing wedge resections for adenocarcinoma have outcomes inferior to those of patients with squamous carcinoma. Histology type does not affect survival in female patients undergoing wedge resections.

Preoperative red cell distribution width in patients undergoing pulmonary resections for non-small-cell lung cancer.

OBJECTIVES: Red cell distribution width (RDW) has been identified as an independent risk factor with regard to prognosis in patients with cardiac disease. We sought to investigate the association of RDW in patients undergoing lung resections for non-small-cell lung cancer with respect to in-hospital morbidity, mortality and long-term survival. METHODS: Analysis of consecutive patients on a validated prospective thoracic surgery database was performed for those undergoing potentially curative resections at a single institution. Univariate and multivariate analyses were performed for postoperative invasive and non-invasive ventilation, superficial wound infections, length of hospital stay, in-hospital mortality and long-term survival. RESULTS: Overall mortality was 1.9% for all cases (n = 917). The median follow-up was 6.8 years. Univariate analysis demonstrated that RDW has a significant effect on hospital length of stay (P < 0.001), in-hospital mortality rates (P < 0.001), postoperative invasive and non-invasive ventilation (P < 0.001), superficial wound infections (P = 0.06) and long-term survival (P < 0.0001). Multivariate analysis revealed that RDW is a significant factor determining postoperative invasive and non-invasive ventilation, superficial wound infections, length of hospital stay, in-hospital mortality and long-term survival. Confounding factor analysis revealed that in the absence of anaemia, RDW was still a significant factor in the above analysis. CONCLUSIONS: RDW is a significant factor after risk adjustment, determining in-hospital morbidity, mortality and long-term survival in patients post-potentially curative resections for non-small-cell lung cancer. Further work is needed to elucidate the exact mechanism of RDW impact on in-hospital morbidity, mortality and long-term survival. We speculate that subtle bone marrow dysfunction may be an issue.

Statins and long-term survival after isolated valve surgery: the importance of valve type, position and procedure.

OBJECTIVES: To investigate whether valve position, type and procedure are important factors in determining the beneficial effects of statin therapy with regard to long-term survival in patients undergoing isolated single valve surgery. METHODS: A prospective single-institution cardiac surgery database was analysed. Univariate, multivariate stepwise linear, logistic and Cox regression analysis and propensity matching were performed to identify if statins were associated with increased survival post-valve surgery. RESULTS: Overall mortality was 3.4% (n = 172) for all cases, n = 5013. The median follow-up was 5.8 years. Kaplan-Meier survival analysis indicated that statin therapy was beneficial for all patients undergoing isolated valve surgery, n = 5013, P = 0.03 and isolated aortic valve surgery, n = 3220, P = 0.03, but not isolated mitral valve surgery n = 1793, P = 0.4. Cox regression analysis of the study cohort revealed that statin therapy was a significant factors determining long-term survival in the study cohort, postisolated aortic valve replacement and postisolated biological aortic valve replacement. Statins therapy was not associated with an increased long-term survival post-mitral valve replacement or repair. Propensity matching resulted in 1555 patients receiving statins being matched 1:1 with those not receiving statins. The results after propensity matching concurred with that of the Cox regression analyses, demonstrating that statin therapy was significantly associated with reduced in-hospital mortality, hospital length of stay and postoperative creatinine kinase, muscle-brain isoenzyme release. CONCLUSIONS: Previous publications have not distinguished valve type, position and repair as possible factors influencing statin-therapy outcomes. Statin therapy is associated with increased long-term survival postaortic valve replacement with a biological valve only. Statin therapy had no survival benefit in patients undergoing mitral valve repair or a mechanical valve replacement. A randomized trial is necessary to confirm or refute our findings.

Long-term survival of non-smokers undergoing coronary artery bypass surgery.

OBJECTIVES: We sought to investigate long-term survival of non-smokers undergoing coronary artery bypass surgery (CABG). METHODS: A prospective database of consecutive patients was retrospectively analysed and cross correlated with the UK strategic tracking service to evaluate survival after primary CABG. Univariate, multivariate and a propensity analyses were performed. RESULTS: We analysed 13 337 primary CABG procedures. Median follow-up was 7 years. Kaplan-Meier survival curves demonstrate that non-smokers have a significantly improved long-term survival compared with ex- and current smokers, P < 0.0001. Cox regression analysis identified smoking status, age, diabetes, ejection fraction (EF), body mass index, cerebrovascular disease, dialysis, left internal mammary artery (LIMA) non-usage, postoperative creatinine kinase muscle-brain isoenzyme (CKMB), radial artery usage, preoperative rhythm, forced vital capacity (FVC) and logistic EuroSCORE as significant risk factors determining long-term survival. Propensity matching resulted in 3575 non-smokers being matched 1:1, with ex-smokers. After matching, univariate analysis demonstrated the significantly worse long-term survival of ex-smokers compared with non-smokers, P < 0.0001. Cox regression analysis identified smoking status, age, postoperative CKMB, cerebrovascular disease, dialysis, diabetes, EF, FVC, LIMA non-usage, radial artery used, sinus rhythm and logistic EuroSCORE as significant risk factors determining long-term survival. Survival by smoking status plotted at the mean of the covariates, prepropensity matching, demonstrated that non-smokers had a significantly better long-term survival than ex-smokers, P < 0.0001; however, after propensity matching, non-smokers under 65 years of age had a significantly worse long-term survival compared with ex-smokers, P < 0.0001. CONCLUSIONS: Non-smokers under the age of 65 years of age have significantly worse long-term survival compared with ex-smokers after risk factor adjustment. We speculate that this is because ex-smokers have had the causative factor, smoking, removed, but non-smokers have not.

Is single-unit blood transfusion bad post-coronary artery bypass surgery?

OBJECTIVES: Publications in the surgical literature are very consistent in their conclusions that blood is dangerous with regard to in-hospital mortality, morbidity and long-term survival. Blood is frequently used as a volume expander while simultaneously increasing the haematocrit. We investigated the effects of a single-unit blood transfusion on long-term survival post-cardiac surgery in isolated coronary artery bypass grafting patients. METHODS: A prospective single-institution cardiac surgery database was analysed involving 4615 patients. Univariate, multivariate stepwise Cox regression analysis and propensity matching were performed to identify whether a single-unit blood transfusion was detrimental to long-term survival. RESULTS: Univariate analysis revealed that blood was significantly associated with a reduced long-term survival even with a single-unit transfused, P = 0.0001. Cox multivariate regression analysis identified age, ejection fraction, preoperative dialysis, logistic EuroSCORE, postoperative CKMB, blood transfusion, urgent operative status and atrial fibrillation as significant factors determining long-term survival. When the Cox regression was repeated with patients who received no blood or only one unit of blood, transfusion was not a risk factor for long-term survival. An interaction analysis revealed that blood transfusion was significantly interacting with preoperative haemoglobin levels, P = 0.02. Propensity analysis demonstrated that a single-unit transfusion is not associated with a detrimental long-term survival, P = 0.3. CONCLUSIONS: Cox regression and propensity matching both indicate that a single-unit transfusion is not a significant cause of reduced long-term survival. Preoperative anaemia is a significant confounding factor. Despite demonstrating the negligible risks of a single-unit blood transfusion, we are not advocating liberal transfusion and would recommend changing from a double-unit to a single-unit transfusion policy. We speculate that blood is not bad, but that the underlying reason that it is given might be.