Mitral valvular surgery outcomes in a centre with a dedicated mitral multi-disciplinary team.

International guidelines recommend 'heart teams' as the preferred method for decision-making. Heart team processes, mandatory attendees and investigations vary significantly between hospitals. We assessed outcomes following mitral valvular surgery in a tertiary referral centre with a dedicated mitral multi-disciplinary team (MDT). This was a single-centre retrospective review of prospectively collected data within the 'mitral database' of mitral valvular disease patients. The 'mitral MDT' meeting involved pre-operative imaging and clinical data review, including mandatory transoesophageal echocardiography; recommendation for planned procedure, as well as an appropriate surgeon; and review of echocardiography images and clinical outcomes after surgery had been performed. Between 2016 and 2020, 395 patients with mitral valvular disease were discussed at MDT. Of these, 310 patients underwent surgery. During the same time interval, 75 patients had surgery without MDT discussion: 84% of patients not discussed were urgent or emergent procedures and, in these, the most common pathology was degenerative mitral regurgitation (DMR, 46%) followed by infective endocarditis (30%). Of those discussed at MDT the pathology was: DMR 65%; mitral stenosis 14%; functional mitral regurgitation (MR) 5%; rheumatic MR 4%; endocarditis 4%; ischaemic MR 4%; and other pathologies 4%. For patients with DMR having elective surgery, the repair rate was 93% with mortality 2% and median (IQR) length of stay 5 (4-6) days. Postoperative transthoracic echocardiography demonstrated 99% of elective DMR patients had ≤2+ MR and <1% severe (3+) MR. In conclusion, a dedicated 'mitral MDT' can enhance the safe delivery of care with consistently high repair rates for DMR patients with excellent outcomes.

Role of vitamin D supplementation in modifying outcomes after surgery: a systematic review of randomised controlled trials.

BACKGROUND: There is increasing evidence to suggest vitamin D plays a role in immune and vascular function; hence, it may be of biological and clinical relevance for patients undergoing major surgery. With a greater number of randomised studies being conducted evaluating the impact of vitamin D supplementation on surgical patients, it is an opportune time to conduct further analysis of the impact of vitamin D on surgical outcomes. METHODS: MEDLINE, EMBASE and the Cochrane Trials Register were interrogated up to December 2023 to identify randomised controlled trials of vitamin D supplementation in surgery. The risk of bias in the included studies was assessed using the Cochrane Risk of Bias tool. A narrative synthesis was conducted for all studies. The primary outcome assessed was overall postoperative survival. RESULTS: We screened 4883 unique studies, assessed 236 full-text articles and included 14 articles in the qualitative synthesis, comprising 1982 patients. The included studies were highly heterogeneous with respect to patient conditions, ranging from open heart surgery to cancer operations to orthopaedic conditions, and also with respect to the timing and equivalent daily dose of vitamin D supplementation (range: 0.5-7500 mcg; 20-300 000 IU). No studies reported significant differences in overall survival or postoperative mortality with vitamin D supplementation. There was also no clear evidence of benefit with respect to overall or intensive care unit length of stay. DISCUSSION: Numerous studies have reported the benefits of vitamin D supplementation in different surgical settings without any consistency. However, this systematic review found no clear evidence of benefit, which warrants the supposition that a single biological effect of vitamin D supplementation does not exist. The observed improvement in outcomes in low vitamin D groups has not been convincingly proven beyond chance findings. TRIAL REGISTRATION NUMBER: CRD42021232067.

Prehabilitation in elective patients undergoing cardiac surgery: a randomised control trial (THE PrEPS TRIAL) - a study protocol.

INTRODUCTION: Prehabilitation prior to surgery has been shown to reduce postoperative complications, reduce length of hospital stay and improve quality of life after cancer and limb reconstruction surgery. However, there are minimal data on the impact of prehabilitation in patients undergoing cardiac surgery, despite the fact these patients are generally older and have more comorbidities and frailty. This trial will assess the feasibility and impact of a prehabilitation intervention consisting of exercise and inspiratory muscle training on preoperative functional exercise capacity in adult patients awaiting elective cardiac surgery, and determine any impact on clinical outcomes after surgery. METHODS AND ANALYSIS: PrEPS is a randomised controlled single-centre trial recruiting 180 participants undergoing elective cardiac surgery. Participants will be randomised in a 1:1 ratio to standard presurgical care or standard care plus a prehabilitation intervention. The primary outcome will be change in functional exercise capacity measured as change in the 6 min walk test distance from baseline. Secondary outcomes will evaluate the impact of prehabilitation on preoperative and postoperative outcomes including; respiratory function, health-related quality of life, anxiety and depression, frailty, and postoperative complications and resource use. This trial will evaluate if a prehabilitation intervention can improve preoperative physical function, inspiratory muscle function, frailty and quality of life prior to surgery in elective patients awaiting cardiac surgery, and impact postoperative outcomes. ETHICS AND DISSEMINATION: A favourable opinion was given by the Sheffield Research Ethics Committee in 2019. Trial findings will be disseminated to patients, clinicians, commissioning groups and through peer-reviewed publication. TRIAL REGISTRATION NUMBER: ISRCTN13860094.

Which antithrombotic strategy provides the best outcomes after mitral valve repair in patients who remain in sinus rhythm?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'in the first 3-months after mitral valve repair (MVRep) which antiplatelet and/or anticoagulant strategy should be instigated in patients who remain in normal sinus rhythm'. Altogether 77 papers were found using the reported search, of which 8 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that there remains a lack of high-quality randomized studies, controlling for postoperative cardiac rhythm, comparing vitamin K antagonists (VKA) and antiplatelet therapy in the early postoperative period following isolated MVRep. Current guidelines are based on limited evidence or expert consensus alone. Based on the currently available evidence, the authors conclude that antiplatelet therapy (e.g. aspirin) is safe and appropriate to use in the 3-month postoperative period following isolated MVRep, in those without preoperative, or postoperative atrial fibrillation. Rates of thromboembolic events are comparable between these patient groups (i.e. VKA versus aspirin), whilst VKA therapy is associated with increased rates of major bleeding events and mortality.

The Importance of Culture Change Associated With Novel Surgical Approaches and Innovation: Does Perioperative Care Transcend Technical Considerations for Pulmonary Lobectomy?

Robotic thoracic surgery for pulmonary lobectomy was introduced at our unit in 2015, along with enhanced perioperative patient care pathways. We evaluated the effect of this practice change on short-term outcomes. Data on all adult patients who underwent a lobectomy in our unit between 2015 and 2019 were obtained retrospectively from our surgical database. Patients fell into three groups: conventional open surgery via thoracotomy, video-assisted thoracoscopic surgery (VATS), and robot-assisted thoracoscopic surgery (RATS). Survival was defined as survival to discharge. Our cohort included 722 patients. Three hundred and ninety-two patients (54.3%) underwent an open operation, 259 patients (35.9%) underwent VATS surgery, and 71 patients (9.8%) underwent a robotic procedure. Comparing these surgical approaches, there was no statistically significant difference in the overall incidence of post-operative complications (p = 0.15) as well as the incidence of wound infections, arrhythmias, prolonged air leaks, respiratory failure, or ICU readmissions. Additionally, there was no statistically significant difference in survival to discharge (p = 0.66). However, patients who had a VATS procedure were less likely to develop a post-operative chest infection (p = 0.01). Evaluating our practice over time, we found a decrease in the overall incidence of post-operative complications (p = 0.01) with an improvement in survival to discharge (p = 0.02). In our experience, VATS lobectomy was associated with a lower incidence of post-operative chest infections. However, the limitations of our study must be considered; factors such as patient selection that may have had a substantial impact. The culture change associated with adoption of a VATS and robotic surgical programme appears to have corresponded with an improved survival to discharge for all lobectomy patients, irrespective of surgical approach. Perioperative care may therefore have a more significant impact on outcomes than technical considerations.

European Society of Thoracic Surgeons electronic quality of life application after lung resection: field testing in a clinical setting.

OBJECTIVES: Technology has the potential to assist healthcare professionals in improving patient-doctor communication during the surgical journey. Our aims were to assess the acceptability of a quality of life (QoL) application (App) in a cohort of cancer patients undergoing lung resections and to depict the early perioperative trajectory of QoL. METHODS: This multicentre (Italy, UK, Spain, Canada and Switzerland) prospective longitudinal study with repeated measures used 12 lung surgery-related validated questions from the European Organisation for Research and Treatment of Cancer Item Bank. Patients filled out the questionnaire preoperatively and 1, 7, 14, 21 and 28 days after surgery using an App preinstalled in a tablet. A one-way repeated measures analysis of variance was run to determine if there were differences in QoL over time. RESULTS: A total of 103 patients consented to participate in the study (83 who had lobectomies, 17 who had segmentectomies and 3 who had pneumonectomies). Eighty-three operations were performed by video-assisted thoracoscopic surgery (VATS). Compliance rates were 88%, 90%, 88%, 82%, 71% and 56% at each time point, respectively. The results showed that the operation elicited statistically significant worsening in the following symptoms: shortness of breath (SOB) rest (P = 0.018), SOB walk (P < 0.001), SOB stairs (P = 0.015), worry (P = 0.003), wound sensitivity (P < 0.001), use of arm and shoulder (P < 0.001), pain in the chest (P < 0.001), decrease in physical capability (P < 0.001) and scar interference on daily activity (P < 0.001) during the first postoperative month. SOB worsened immediately after the operation and remained low at the different time points. Worry improved following surgery. Surgical access and forced expiratory volume in 1 s (FEV1) are the factors that most strongly affected the evolution of the symptoms in the perioperative period. CONCLUSIONS: We observed good early compliance of patients operated on for lung cancer with the European Society of Thoracic Surgeons QoL App. We determined the evolution of surgery-related QoL in the immediate postoperative period. Monitoring these symptoms remotely may reduce hospital appointments and help to establish early patient-support programmes.

Surgeon-Powered Robotics in Thoracic Surgery; An Era of Surgical Innovation and Its Benefits for the Patient and Beyond.

Following its introduction in 1992, the growth of minimally invasive thoracic surgery was initially hampered by the lack of specialized instruments, impeded visualization and stapling. However, in subsequent years these challenges were somewhat overcome and video-assisted thoracoscopic surgery (VATS) became the preferred modality of many centers. More recently, robotic surgery has come to the fore. Whilst it offers outstanding precision via robotic wristed instruments, robotic surgery is expensive and has safety implications as the surgeon is away from the patient's side. Wristed VATS instruments offer a new, exciting alternative. By placing the robotic-like wristed instruments in the hands of the surgeon, a concept we call surgeon-powered robotics, the benefits of robotic surgery can be achieved by the patient's side. We describe our experience of the ArtiSential® wristed instruments and discuss the benefits and challenges of this technology. By combining wristed instruments with the latest surgeon-controlled 3D camera technology, surgeon-powered robotics is an affordable reality.

The unexpected diagnosis of phaeochromocytoma in the anaesthetic room.

A 77-year-old man was admitted for aortic valve replacement and combined coronary bypass grafting. Grossly, labile arterial pressures were demonstrated on anesthetic induction prompting cancellation and Intensive Care Unit transfer. Urine analysis identified high normetadrenaline/creatinine ratio, plasma metanephrine, and plasma normetanephrine. A left adrenal lesion on computed tomography scan collectively indicated pheochromocytoma. Laparoscopic adrenalectomy was prioritized at multidisciplinary team before cardiac surgery. Vague symptoms of pheochromocytoma pose a diagnostic problem, being often attributed to common/co-existing pathology. The blood pressure instability on anesthetic required precise control, multidisciplinary input, and awareness of possible diagnosis as a routine intervention for hypotension may have been fatal in view of underlying cardiac pathology.