Outcomes of Patients Presenting with Non-ST Elevation Myocardial Infarction Undergoing Surgical Revascularization

Non-ST-segment elevation myocardial infarction (NSTEMI) is a leading cause of emergency hospitalisation across Europe. This study evaluates the in-hospital and mid-term outcomes of patients undergoing coronary artery bypass grafting (CABG) following NSTEMI. A retrospective analysis of all cases undergoing isolated CABG following NSTEMI from September/2017 to September/2022 at our Centre. Patients were stratified according to in-hospital survival. Patient characteristics, operative details, and procedural complications were compared between those who survived and those who did not. Predictors of in-hospital and mid-term mortality were evaluated using logistic and Cox regression modelling. Kaplan Meier analysis was used to generate a survival curve for all alive patients at the time of discharge. Among 1011 patients (median age 64 [56 - 72] years, 852 [84.3%] male), 735 (72.7%) underwent urgent, 239 (23.6%) elective, and 37 (3.7%) emergency CABG. The in-hospital mortality was 1.5% (15/1011 patients). Those who died were more likely to be NYHA class III/IV, have LVEF <21%, severe renal impairment, peripheral vascular disease (PVD), or poor mobility. Emergency procedures, pre-operative ventilation, inotropic support, and intra-aortic balloon pump (IABP) use were also more prevalent among those who died. Logistic regression modelling revealed new postoperative stroke (OR:22.0; 95% CI:3.6-135.5; p=0.001), pre-operative IABP use (11.4; 2.4-53.7; p=0.002), new haemodialysis (9.6; 2.7-34.7; p<0.001), PVD (5.6; 1.6-20.0; p=0.008), and poor mobility (OR: 4.8; 95% CI: 1.3-18.2; p=0.022) as independent predictors of in-hospital mortality. In conclusion, new postoperative stroke, pre-operative IABP use, new haemodialysis, PVD and poor mobility are independent predictors of mortality in NSTEMI patients undergoing isolated CABG.

Aortic Arch Debranching and Thoracic Endovascular Aortic Repair (TEVAR) for Type B Aortic Dissection

BACKGROUND

Since its introduction, thoracic endovascular aortic repair (TEVAR) has revolutionized the treatment of type B aortic dissections (TBADs). However, the proximal aspect of the aortic pathology treated may infringe on the origin of the left subclavian artery or even more proximally. Hence, to ensure durable outcomes, the origin of these vessels needs to be covered, but an extra-anatomical bypass is required to perfuse vital branches, known as aortic arch debranching. This series aims to describe and delineate the disparities of aortic arch debranching during TEVAR for TBAD.

METHODS

A retrospective review and analysis of a multicenter international database was conducted to identify patients with TBAD treated with TEVAR between 2005 and 2021. Data analyzed included patient demographics, disease characteristics, operative characteristics, and postoperative outcomes with follow-up on mortality and reintervention. All statistical analyses were carried out using IBM SPSS 26. Patient survival was calculated using a Kaplan-Meier survival analysis, and a P value of less than 0.05 was considered statistically significant.

RESULTS

A total of 58 patients were included in the analysis, of which 27 (46.6%) presented with complicated disease and 31 were uncomplicated, of which 10 (17.2%) were classed as high risk and 21 (36.2%) low risk. Zone 2 was the most common proximal landing zone for the stent graft. Left subclavian artery bypass was performed selectively (26%), with 1 stroke occurring, likely due to embolic reasons. A further 6 underwent more proximal aortic debranching before TEVAR (10%) and was a significant risk factor for mortality and the number of stents deployed. The overall rates of reintervention and mortality were 17.2% (n = 10) and 29.3% (n = 17).

CONCLUSIONS

Aortic arch debranching and TEVAR for TBAD is associated with significant mortality. Future developments to treat aortic arch pathology could incorporate branched graft devices, eliminating the need for debranching, improving stroke rates, and reducing future reinterventions.

Surgical management of atrial fibrillation in patients undergoing cardiac surgery: a systematic review of clinical practice guidelines and recommendations

AIMS

Surgical ablation of atrial fibrillation (AF) has been demonstrated to be a safe procedure conducted concomitantly alongside cardiac surgery. However, there are conflicting guideline recommendations surrounding indications for surgical ablation. We conducted a systematic review of current recommendations on concomitant surgical AF ablation.

METHODS AND RESULTS

We identified publications from MEDLINE and EMBASE between January 2011 and December 2022 and additionally searched Guideline libraries and websites of relevant organizations in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Of 895 studies screened, 4 were rigorously developed (AGREE-II > 50%) and included. All guidelines agreed on the definitions of paroxysmal, persistent, and longstanding AF based on duration and refraction to current treatment modalities. In the Australia-New Zealand (CSANZ) and European (EACTS) guidelines, opportunistic screening for patients >65 years is recommended. The EACTS recommends systematic screening for those aged >75 or at high stroke risk (Class IIa, Level B). However, this was not recommended by American Heart Association or Society of Thoracic Surgeons guidelines. All guidelines identified surgical AF ablation during concomitant cardiac surgery as safe and recommended for consideration by a Heart Team with notable variation in recommendation strength and the specific indication (three guidelines fail to specify any indication for surgery). Only the STS recommended left atrial appendage occlusion (LAAO) alongside surgical ablation (Class IIa, Level C).

CONCLUSION

Disagreements exist in recommendations for specific indications for concomitant AF ablation and LAAO, with the decision subject to Heart Team assessment. Further evidence is needed to develop recommendations for specific indications for concomitant AF procedures and guidelines need to be made congruent.

Uncomplicated Type B Aortic Dissection: Challenges in Diagnosis and Categorisation

BACKGROUND

Acute type B aortic dissection (TBAD) is a rare disease that is likely under-diagnosed in the UK. As a progressive, dynamic clinical entity, many patients initially diagnosed with uncomplicated TBAD deteriorate, developing end-organ malperfusion and aortic rupture (complicated TBAD). An evaluation of the binary approach to the diagnosis and categorisation of TBAD is needed.

METHODS

A narrative review of the risk factors predisposing patients to progression from unTBAD to coTBAD was undertaken.

RESULTS

Key high-risk features predispose the development of complicated TBAD, such as maximal aortic diameter > 40 mm and partial false lumen thrombosis.

CONCLUSION

An appreciation of the factors that predispose to complicated TBAD would aid clinical decision-making surrounding TBAD.

Comparing Outcomes Between Surgical and Transcatheter Aortic Valve Replacement in Classical Low-Flow Low-Gradient Aortic Stenosis

Patients with classic low-flow low-gradient (cLFLG) aortic stenosis (AS) have a poor prognosis but still benefit from aortic valve replacement. There is a paucity of evidence to guide the choice between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). This study compared procedural and midterm outcomes in patients with cLFLG AS between TAVR and SAVR. Patients with cLFLG AS, defined as an aortic valve area ≤1 cm², mean gradient <40 mm Hg, and left ventricular ejection fraction <50%, were selected from a single center between 2015 and 2020. Inverse probability weighting and regression were used to adjust for differences in baseline characteristics, the nonrandom assignment of treatment modalities, and procedural differences. The primary end point was all-cause mortality. A total of 322 patients (220 TAVR and 102 SAVR) were included. At a follow-up of 4.4 ± 1.5 years, the adjusted hazard ratio (HR) for mortality after inverse probability weighting with SAVR was 0.66, 95% confidence interval (CI) 0.31 to 1.35; p = 0.24. Worse renal function at baseline (per 10 ml/min/m² increase HR 0.92, 95% CI 0.84 to 1.00, p = 0.04) and multiple valve interventions (HR 5.39, 95% CI 2.62 to 11.12, p <0.001) independently predicted mortality. There was no difference in stroke and permanent pacemaker implantation, but the rates of renal replacement therapy were higher among the SAVR cohort: 13.7% versus 0%; p <0.001. In conclusion, among patients with cLFLG AS, there was no difference in midterm mortality between TAVR and SAVR, supporting the use of either treatment. However, in patients with poor renal function or at risk of renal failure, TAVR may be the preferred option.

Risk Prediction Models for Management of Patients following Acute Aortic Dissection

Risk prediction of adverse outcomes post aortic dissection is dependet not only on the postdissection-associated clinical factors but on the very foundation of the risk factors that lead up to the dissection itself. There are various such risk factors existing prior to the dissection which impact the postdissection outcomes. In this paper, we review the literature to critically analyze various risk models, burdened by their significant limitations, that attempt to stratify risk prediction based on postdissection patient characteristics. We further review several studies across the literature that investigate the diverse set of predissection risk factors impacting postdissection outcomes. We have discussed and appraised numerous studies which attempt to develop a tool to stratify risk prediction by incorporating the impacts of different factors: malperfusion, blood biochemistry, and perioperative outcomes. The well-validated Penn classification has clearly demonstrated in the literature the significant impact that malperfusion has on adverse outcomes postdissection. Other risk models, already severely hindered by their limitations, lack such validation. We further discuss additional alluded risk factors, including the impact of predissection aortic size, the syndromic and nonsyndromic natures of dissection, and the effects of family history and genetics, which collectively contribute to the risk of adverse outcomes postdissection and prognosis. To achieve the goal of a true risk model, there remains the vital need for appreciation and appropriate consideration for all such aforementioned factors, from before and after the dissection, as discussed in this paper. By being able to incorporate the value of true risk prediction for a patient into the decision-making framework, it will allow a new page of precision medical decision-making to be written.

Cardiothoracic surgery leadership and learning are indispensable to each other

Cardiothoracic surgery is facing a multitude of challenges in leadership and training on the global scale, these being a complex and aging patient population, shortage of cardiac surgeons, diminishing student interest and trainee enthusiasm, increasingly challenging training obstacles and work-life imbalances, suboptimal job prospects, reports of discrimination and bullying and lack of diversity as well as gap between innovation and technology, clinical application, and training of future surgeons. The survival of cardiac surgery hinges on the leadership attracting and retaining young surgeons into the specialty. Mentoring, leading through example, recognizing the work-life imbalances, adapting to diverse and modern training models and embracing diversity with respect to gender and race, will ultimately be required to create and cultivate a nurturing environment of training and preparing future leaders. The vision for training future generations of cardiothoracic surgeons must rely heavily on strengthening the unity of the heart team. In doing so we can provide the best possible care for our patients and a most fulfilling career for the future generation of cardiac surgeons.

Effect of Transcatheter Aortic Valve Implantation vs Surgical Aortic Valve Replacement on All-Cause Mortality in Patients With Aortic Stenosis: A Randomized Clinical Trial

IMPORTANCE

Transcatheter aortic valve implantation (TAVI) is a less invasive alternative to surgical aortic valve replacement and is the treatment of choice for patients at high operative risk. The role of TAVI in patients at lower risk is unclear.

OBJECTIVE

To determine whether TAVI is noninferior to surgery in patients at moderately increased operative risk.

DESIGN, SETTING, AND PARTICIPANTS

In this randomized clinical trial conducted at 34 UK centers, 913 patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk due to age or comorbidity were enrolled between April 2014 and April 2018 and followed up through April 2019.

INTERVENTIONS

TAVI using any valve with a CE mark (indicating conformity of the valve with all legal and safety requirements for sale throughout the European Economic Area) and any access route (n = 458) or surgical aortic valve replacement (surgery; n = 455).

MAIN OUTCOMES AND MEASURES

The primary outcome was all-cause mortality at 1 year. The primary hypothesis was that TAVI was noninferior to surgery, with a noninferiority margin of 5% for the upper limit of the 1-sided 97.5% CI for the absolute between-group difference in mortality. There were 36 secondary outcomes (30 reported herein), including duration of hospital stay, major bleeding events, vascular complications, conduction disturbance requiring pacemaker implantation, and aortic regurgitation.

RESULTS

Among 913 patients randomized (median age, 81 years [IQR, 78 to 84 years]; 424 [46%] were female; median Society of Thoracic Surgeons mortality risk score, 2.6% [IQR, 2.0% to 3.4%]), 912 (99.9%) completed follow-up and were included in the noninferiority analysis. At 1 year, there were 21 deaths (4.6%) in the TAVI group and 30 deaths (6.6%) in the surgery group, with an adjusted absolute risk difference of -2.0% (1-sided 97.5% CI, -∞ to 1.2%; P < .001 for noninferiority). Of 30 prespecified secondary outcomes reported herein, 24 showed no significant difference at 1 year. TAVI was associated with significantly shorter postprocedural hospitalization (median of 3 days [IQR, 2 to 5 days] vs 8 days [IQR, 6 to 13 days] in the surgery group). At 1 year, there were significantly fewer major bleeding events after TAVI compared with surgery (7.2% vs 20.2%, respectively; adjusted hazard ratio [HR], 0.33 [95% CI, 0.24 to 0.45]) but significantly more vascular complications (10.3% vs 2.4%; adjusted HR, 4.42 [95% CI, 2.54 to 7.71]), conduction disturbances requiring pacemaker implantation (14.2% vs 7.3%; adjusted HR, 2.05 [95% CI, 1.43 to 2.94]), and mild (38.3% vs 11.7%) or moderate (2.3% vs 0.6%) aortic regurgitation (adjusted odds ratio for mild, moderate, or severe [no instance of severe reported] aortic regurgitation combined vs none, 4.89 [95% CI, 3.08 to 7.75]).

CONCLUSIONS AND RELEVANCE

Among patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk, TAVI was noninferior to surgery with respect to all-cause mortality at 1 year.

TRIAL REGISTRATION

isrctn.com Identifier: ISRCTN57819173.

Tricuspid regurgitation management: a systematic review of clinical practice guidelines and recommendations

Tricuspid regurgitation (TR) is a highly prevalent condition and an independent risk factor for adverse outcomes. Multiple clinical guidelines exist for the diagnosis and management of TR, but the recommendations may sometimes vary. We systematically reviewed high-quality guidelines with a specific focus on areas of agreement, disagreement, and gaps in evidence. We searched MEDLINE and EMBASE (1 January 2011 to 30 August 2021), the Guidelines International Network International, Guideline Library, National Guideline Clearinghouse, National Library for Health Guidelines Finder, Canadian Medical Association Clinical Practice Guidelines Infobase, Google Scholar, and websites of relevant organizations for contemporary guidelines that were rigorously developed (as assessed by the Appraisal of Guidelines for Research and Evaluation II tool). Three guidelines were finally retained. There was consensus on a TR grading system, recognition of isolated functional TR associated with atrial fibrillation, and indications for valve surgery in symptomatic vs. asymptomatic patients, primary vs. secondary TR, and isolated TR forms. Discrepancies exist in the role of biomarkers, complementary multimodality imaging, exercise echocardiography, and cardiopulmonary exercise testing for risk stratification and clinical decision-making of progressive TR and asymptomatic severe TR, management of atrial functional TR, and choice of transcatheter tricuspid valve intervention (TTVI). Risk-based thresholds for quantitative TR grading, robust risk score models for TR surgery, surveillance intervals, population-based screening programmes, TTVI indications, and consensus on endpoint definitions are lacking.

Concomitant Atrial Fibrillation Procedures During Cardiac Surgery in a UK Center: Reflection of Worldwide Practice?

Background

Guidelines recommend concomitant atrial fibrillation (AF) ablation during cardiac surgery to restore normal sinus rhythm (NSR). The study determines, to what extent patients with AF undergoing cardiac surgery at our institution received a concomitant AF procedure, what these procedures entailed, and short-term outcomes.

Methods

A retrospective study of 2,984 patients undergoing cardiac surgery over 18 months. Patients who were in preoperative AF were identified and those who underwent a concomitant AF procedure (Group 1) were compared with those who did not (Group 2).

Results

Three hundred and thirteen (10.5%) patients had pre-operative AF; paroxysmal (19.5%), persistent (11.8%), longstanding (63%), unknown (5.8%). 116/313 (37.1%) patients had a concomitant AF procedure: 7.7% patients had a concomitant AF ablation and 29.4% had only a Left Atrial Appendage Occlusion (LAAO). Fewer patients with paroxysmal and persistent AF underwent concomitant AF procedures compared with the ones who had no AF procedures (6.7 vs. 12.8% and 17.6 vs. 31%, respectively). Greater in-hospital survival (99.1 vs. 93.9%, p = 0.025) and survival at a mean follow up of 6 weeks (97.4 vs. 89.3%, p = 0.09) was probably determined by patient's preoperative comorbidities. There were no differences in readmission rates, permanent pacemaker insertion, cerebral events or NSR at discharge or follow-up, between groups.

Conclusions

In our center, concomitant AF ablation is performed only in 7.7% of cases, 29.4% had only an LAAO performed at the time of surgery. There was no difference in restoring NSR, cerebral events, or readmission rates compared with patients who had nothing done for their preoperative AF.

Severe hyponatraemia in a patient with a large left atrial myxoma: a case report

Background

Atrial myxomas (AMs) are the most commonly encountered cardiac tumours. They can be genetically inherited and are commonly found in the left atrium. They usually present with dyspnoea, syncopal episodes, heart failure from mitral valve obstruction, and constitutional symptoms including weight loss, fatigue, and fever. We present a rare case of severe symptomatic hyponatraemia secondary to a large AM and discuss possible aetiology.

Case summary

A 75-year-old Caucasian female presented with acute nausea, vomiting, confusion, and drowsiness. She had a background of palpitations for about 20 years. Her blood test results revealed severe hyponatraemia (serum sodium—103 mmol/L). Further investigations for hyponatraemia including serum cortisol and urine biochemistry suggested Syndrome of Inappropriate Anti-Diuretic Hormone (SIADH) secretion. Computer tomography scan revealed an incidental large left AM. Echocardiography confirmed the AM attached to the left side of the inter-atrial septum and occupying the majority of the left atrium. She was treated medically for hyponatraemia and referred for excision of myxoma. She underwent urgent resection of the myxoma once sodium levels were optimized. Postoperatively, her serum sodium remained low but gradually returned to normal on postoperative Day 11.

Conclusion

This is only the third reported case of significant hyponatraemia associated with a large AM. It has been previously hypothesized that large left AM stretch the atrium causing release of atrial natriuretic peptide and subsequent hyponatraemia. The excision of myxoma and reduction in left atrial size postoperatively with an improvement in sodium levels suggests an association between the two pathologies.

Management of aortic stenosis: a systematic review of clinical practice guidelines and recommendations

Multiple guidelines exist for the management of aortic stenosis (AS). We systematically reviewed current guidelines and recommendations, developed by national or international medical organizations, on management of AS to aid clinical decision-making. Publications in MEDLINE and EMBASE between 1 June 2010 and 15 January 2021 were identified. Additionally, the International Guideline Library, National Guideline Clearinghouse, National Library for Health Guidelines Finder, Canadian Medical Association Clinical Practice Guidelines Infobase, and websites of relevant organizations were searched. Two reviewers independently screened titles and abstracts. Two reviewers assessed rigour of guideline development and extracted the recommendations. Of the seven guidelines and recommendations retrieved, five showed considerable rigour of development. Those rigourously developed, agreed on the definition of severe AS and diverse haemodynamic phenotypes, indications and contraindications for intervention in symptomatic severe AS, surveillance intervals in asymptomatic severe AS, and the importance of multidisciplinary teams (MDTs) and shared decision-making. Discrepancies exist in age and surgical risk cut-offs for recommending surgical aortic valve replacement (SAVR) vs. transcatheter aortic valve implantation (TAVI), the use of biomarkers and complementary multimodality imaging for decision-making in asymptomatic patients and surveillance intervals for non-severe AS. Contemporary guidelines for AS management agree on the importance of MDT involvement and shared decision-making for individualized treatment and unanimously indicate valve replacement in severe, symptomatic AS. Discrepancies exist in thresholds for age and procedural risk used in choosing between SAVR and TAVI, role of biomarkers and complementary imaging modalities to define AS severity and risk of progression in asymptomatic patients.

841 The psychological impact of Foundation Interim Year 1 Placements on Final Year UK Medical Students Transitioning to Foundation Year One During the COVID Era

Introduction

During the COVID pandemic, the 2019-2020 cohort of final year students were invited to participate in Foundation interim Year 1 placements (FiY1). FiY1 aimed to ease transition to Foundation Year 1 doctor (FY1). We assessed the psychological impact of FiY1 on final year medical students.

Method

A cross-sectional survey was distributed to final year medical students in the UK between June 4th and July 4th, 2020. The survey contained the following domains: participant demographics, rationale for FiY1 participation, a checklist of the key safety principles for FiY1s, the Hospital Anxiety and Depression Scale and the Perceived Stress scale-4.

Results

107 final years responded to the survey. 72.0% (n = 77) of final year students surveyed were working as FiY1s. Final year students participating in FiY1 postings had reduced rates of anxiety (29.9% vs 43.4%, P = 0.186), depression (5.2% vs 20.0%, P = 0.018) and lower perceived stress levels (5.0 vs 7.2, P &lt; 0.001). 19.5% (15/77) FiY1s reported working beyond their competency, 27.3% (22/77) felt unsupervised, but 94.8% (73/77) of FiY1s felt the post prepared them for FY1.

Conclusions

Students participating in FiY1 postings felt less stressed and depressed than those not participating in the scheme and the majority felt it was preparing them for FY1.

NHS staff mental health status in the active phase of the COVID-19 era: a staff survey in a large London hospital

Background

Experiencing a pandemic can be very unsettling and may have a negative impact on the mental health of frontline healthcare workers (HCWs). This may have serious consequences for the overall well-being of HCWs, which in turn may adversely affect patient safety and the productivity of the institution.

Aims

We designed a study to assess the prevalence of generalised anxiety disorder (GAD), depression and work-related stress experienced by the National Health Service staff in a large tertiary London hospital treating patients with COVID-19 during the current active phase of the COVID-19 era.

Methods

An anonymous survey was designed with demographic data and three questionnaires. The Generalised Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 were used to assess anxiety and depression, respectively. The Health and Safety Executive Management Standards Indicator Tool was used to assess work-related stress. Staff from multiple specialties embracing cardiothoracic surgery, cardiology, respiratory medicine, endocrinology, oncology, imaging, anaesthesia and intensive care at our hospital were asked to complete the questionnaire between 25 May and 15 June 2020.

Results

A total of 302 staff members (106 males and 196 females) completed the survey. The overall prevalence of GAD and depression was 41.4% and 42.7%, respectively. The prevalence of GAD and depression was significantly higher in females than in males and was statistically significant. Nurses were four times more likely to report moderate to severe levels of anxiety and depression as compared with doctors. Work-related stress was also observed to be prevalent in our surveyed population with the following standards: relationships, role, control and change showing a need for improvement.

Conclusions

Our study presents early evidence suggestive of a high prevalence of GAD, depression and work-related stress in HCWs. It is imperative that coherent strategies are implemented to improve the healthcare work environment during this pandemic and mitigate further injury to the mental health status of the healthcare population.

Mechanical circulatory support-Challenges, strategies, and preparations

Background

Coronavirus disease 2019 (COVID‐19) is usually mild, but patients can present with pneumonia, acute respiratory distress syndrome (ARDS), and circulatory shock. Although the symptoms of the disease are predominantly respiratory, the involvement of the cardiovascular system is common. Patients with heart failure (HF) are particularly vulnerable when suffering from COVID‐19.

Aim of the Review

To examine the challenges faced by healthcare organizations, and mechanical circulatory support management strategies available to patients with heart failure, during the COVID‐19 pandemic.

Results

Extracorporeal membrane oxygenation (ECMO) can be lifesaving in patients with severe forms of ARDS, or refractory cardio‐circulatory compromise. The Impella RP can provide right ventricular circulatory support for patients who develop right side ventricular failure or decompensation caused by COVID‐19 complications, including pulmonary embolus. HT are reserved for only those patients with a high short‐term mortality. LVAD as a bridge to transplant may be a viable strategy to get at‐risk patients home quickly. Elective LVAD implantations have been reduced and only patients classified as INTERMACS profile 1 and 2 are being considered for LVAD implantation. Delayed recognition of LVAD‐related complications, misdiagnosis of COVID‐19, and impaired social and psychological well‐being for patients and families may ensue. Remote patient care with virtual or telephone contacts is becoming the norm.

Conclusions

HF incidence, prevalence, and undertreatment will grow as a result of new COVID‐19‐related heart disease. ECMO should be reserved for highly selected cases of COVID‐19 with a reasonable probability of recovery. Special considerations are needed for patients with advanced HF, including those supported by durable LVADs.

Transcatheter aortic valve implantation versus surgical aortic valve replacement during the COVID-19 pandemic-Current practice and concerns

COVID-19 has had a dramatic impact on the provision of healthcare. COVID-19 can manifest with cardiac and thrombotic presentations. Additionally, patients with cardiovascular comorbidities are at an increased risk of adverse outcomes related to COVID-19 infection. This in turn has led to a significant reduction in the provision of cardiac surgery with alternative management options utilized to address patients with significant disease. In terms of aortic valve disease, transcatheter aortic valve implantation (TAVI) provides advantages over surgical aortic valve replacement in with a lower burden on healthcare resources. COVID-19 also resulted in changes in management strategies and as such TAVI is now being considered in younger- and low-risk patients. However, long term data with regard to TAVI is still unknown, and the use in patient groups that have been excluded in the large pivotal studies that established TAVI as an alternative to surgery has raised specific concerns in the use of TAVI as the preferred treatment choice. With the long term ramification unknown, it is essential that decisions are made with caution.

Aortic valve replacement with sutureless Perceval S valve: A case report of aortic root homograft failure in the setting of Streptococcus constellatus endocarditis

BACKGROUND

Surgery for failed homograft aortic root replacement with extensive calcification in the setting of endocarditis alone is very challenging.

CASE SUMMARY

We report the case of redo aortic valve replacement and mitral valve replacement, in a 39 years old presenting with a rare Streptococcus constellatus endocarditis of a previously implanted homograft root and native mitral valve, where conventional valve replacement proved nonfeasible. S. constellatus had caused severe tissue destruction and the extensive calcification in the homograft prevented conventional valve replacement with sutures. In this case, a sutureless valve provided a useful alternative surgical strategy.

DISCUSSION

We consider heavily calcified failed homografts to be a good indication for sutureless (rapid deployment) valves.

Aortic stenosis of a bicuspid aortic valve in a patient with Klippel-Feil syndrome: a case report

Background

Klippel–Feil syndrome (KFS) is a rare congenital anomaly of the cervical spine, which is associated with a number of cardiovascular malformations, including coarctation of the aorta, bicuspid aortic valve (BAoV), and aortic aneurysm. Operative management of aortic stenosis of a BAoV in a patient with KFS has not been previously reported.

Case summary

A 54-year-old Caucasian woman with known KFS presented to her local hospital for elective cholecystectomy. An ejection systolic murmur was found incidentally on preoperative workup, which was confirmed to be due to a severely stenosed BAoV. The cholecystectomy was cancelled, and the patient was referred to our centre and accepted for surgical aortic valve replacement (AVR) based on symptomatic and prognostic grounds. Anaesthetic review of cervical spine imaging showed fusion of the C2–C6 vertebral bodies and a desiccated bulging disc at C4–C5 but no significant foraminal narrowing in the lower cervical spine. Valve replacement with a mechanical aortic prosthesis resulted in an uneventful recovery and the patient was discharged home to follow-up.

Discussion

We report the first case of severe aortic valve stenosis requiring AVR in a Klippel–Feil patient, in whom the aortic valve was confirmed to be bicuspid. This report provides further evidence of an association of KFS with BAoV and strengthens the case for screening and follow-up of KFS patients for BAoV and other cardiovascular pathologies, the consequences of which may be serious.

Impact of COVID-19 on cardiac surgical training: Our experience in the United Kingdom

The current evolving global pandemic caused by coronavirus disease‐2019 (COVID‐19) has dramatically impacted global health care systems, resulting in governments taking unprecedented measures to contain the spread of the infection, with adaptations by health care organizations. Research into understanding the pathophysiology behind this virus, to ascertain best medical management and treatment, has been accelerated to keep up with the rapidly evolving situation. There has been redeployment of medical and nursing staff to the frontlines and redistribution of health care resources. In addition, the cancellation of elective surgery and centralization of services to treat high‐risk surgical cases will all, undeniably, have an impact on current surgical training with possible future implications. We aim to explore the impact COVID‐19 is having on cardiac surgical training in the UK and what future implications this may have.

Coronary artery bypass vs percutaneous coronary intervention in under 50s

BACKGROUND

Young patients with coronary artery disease are undergoing percutaneous coronary intervention (PCI) primarily, with a view to deferring coronary artery bypass grafting (CABG). We investigated the validity of this approach, by comparing outcomes in patients ≤50 years undergoing CABG or PCI.

METHODS

One hundred consecutive patients undergoing PCI and 100 undergoing CABG in 2004 were retrospectively studied to allow for 5 and 12 years follow-up. The two groups were compared for the primary endpoints of major adverse cardiac or cerebrovascular event (MACCE).

RESULTS

Diabetes, peripheral vascular disease, and left ventricular ejection fraction <50% were higher in the CABG group. At 5 years, rates of myocardial infarction (MI) (9% vs 1%, P = .02), repeat revascularization (31% vs 7%, P < .01), and MACCE (34 vs 12, P < .01) were greater in the PCI vs the CABG group. Similarly, at 12 years, rates of MI (27.4% vs 19.4%, P = .19), repeat revascularization (41.1% vs 20.4%, P < .01), and MACCE (51 vs 40, P = .07) were greater in the PCI group. There were no differences in major outcomes in patients with 1 or 2VD, at 5 or 12 years. Rates of MI, revascularization, and MACCE were higher in patients with 3VD undergoing PCI (n = 21; MI, 47.6%; revascularization, 66.7%; and MACCE, 19 events) vs CABG (n = 78; MI, 19.2%; revascularization, 20.5%; and MACCE, 31 events); P < .01, for all end points.

CONCLUSIONS

MACCE was lower in young patients undergoing CABG vs PCI at both 5 and 12 years follow-up, primarily as a consequence of patients with 3VD undergoing PCI having more MI and repeat revascularization. CABG should remain the preferred method of revascularization in young patients with 3VD.

The EuroSCORE: a neglected measure of medium-term survival following cardiac surgery

OBJECTIVES

EuroSCORE is used to predict operative mortality following cardiac surgery. There are limited data to assess the ability of EuroSCORE to predict medium- to long-term survival. We aimed to test the ability of EuroSCORE to predict mid-term survival following cardiac surgery.

METHODS

We analysed prospectively collected data from all patients undergoing cardiac surgery in an urban tertiary cardiac centre over a 6-year period. All-cause mortality following cardiac surgery was determined via Office of National Statistics data. Patients were grouped into all comers, coronary artery bypass graft (CABG), isolated aortic valve replacement (AVR), isolated mitral valve repair and replacement (MVR) and combined AVR/MVR and CABG. Each group was separated into EuroSCORE quartiles. Kaplan-Meier curves were used to calculate 6-year actuarial survival. Log-rank test was used to calculate the P-value. C-statistic discriminated the ability of the EuroSCORE to predict medium-term survival.

RESULTS

A total of 9022 consecutive patients were identified. The mean age was 66.86 years, 73.7% were male. The cases were grouped according to their additive EuroSCORE into 0-5 (n = 5369), 6-10 (n = 3059), 11-15 (n = 506) and >15 (n = 93). Median follow-up was 2.92 years. The 6-year survival was 88.5, 71.8, 52.5 and 39.5%, respectively. The P-value for all operative categories was significant. The C-statistic was 0.68 (all comers), 0.72 for isolated MVR, 0.65 (isolated CABG), 0.62 (isolated AVR) and 0.69 (combined AVR/MVR and CABG).

CONCLUSIONS

Additive EuroSCORE may be used to predict medium-term survival in patients undergoing cardiac surgery; increasing additive EuroSCORE resulting in significant decreases in survival. It is a good predictive tool for patients undergoing isolated MVR and a fair tool for patients undergoing the remaining operative procedures studied.

Microdetermination of nitrates and nitrites-III Gasometric and gravimetric methods based on reduction with formic acid

Simple microgasometric and gravimetric methods for the determination of the nitrate and nitrite groups are described. These are based on reduction with formic acid whereby one mole of nitrous oxide and four moles of carbon dioxide are simultaneously liberated per two moles of nitrate; two moles of nitrous oxide and six moles of carbon dioxide are liberated per seven moles of nitrite. Nitrous oxide is measured gasometrically and carbon dioxide gravimetrically. Results accurate to +/- 0.2% absolute are obtained for both nitrate and nitrite.

Microdetermination of nitrates and nitramines-I Titrimetric methods based on the reduction with iron(II), titanium(III), and a mixture of both

Organic and inorganic nitrates are satisfactorily determined on the microscale by reduction with Fe(II). Titanium(III) reduces the nitrates in strongly acidic, citrate-buffered, and acetate-buffered media with the comsumption of 3, 6 and 8 equivalents respectively of Ti(III) per nitrate group. Nitramines are determined by reduction with a mixture of Ti(III) and Fe(II). Determination of nitrates and nitramines by trans-nitration with salicylic acid is suitable on the microscale. A new electrolytic reduction automatic microburette was devised for the reduction, storage and use of the titanium(III) solution.

Single-stage repair of aneurysm of the ascending aorta associated with aortic coarctation

A 38-year-old man with a history of uncontrolled hypertension was investigated for atypical chest pains and found to have an aneurysm of the ascending aorta and a coexisting coarctation of the aorta. The timing and sequence of surgical repair of these 2 pathologies are controversial. We report an elective single-stage operation in which the ascending aorta was replaced and an extracardiac bypass from the ascending to the descending aorta was performed with excellent results.

Liposarcoma of the thyroid gland mimicking retrosternal goiter

Primary liposarcoma of the thyroid gland is extremely rare with only two previous reports in the literature. We report two further cases, both patients presenting with rapid airways compression. Patient 1 had clinical, radiographic, and biopsy appearances suggesting benign goiter. Patient 2 had a long-term history of benign goiter, a previous partial thyroidectomy, and more recent biopsies showing liposarcoma. The management of such rare conditions is always challenging.

Airway obstruction complicating mediastinal tuberculosis: a life-threatening presentation

We discuss the case of a young man with mediastinal tuberculosis who presented with pericarditis, thymic involvement, and respiratory failure because of upper airway obstruction. Although mediastinal tuberculosis is not uncommon, the simultaneous occurrence of these complications is exceedingly rare and in this patient resulted in an acute life-threatening illness. The diagnosis and treatment of this condition can be complex, and these aspects of the patient's care are discussed.

Concurrent cysts of the mediastinum, pleura and neck

A 14-year-old male was found to have a mediastinal mass on chest radiograph. Chest computed tomography scans showed a cystic lesion behind the left main bronchus. Magnetic resonance imaging revealed additional cystic lesions in the left chest and root of the neck. He underwent excision of mediastinal mass and a pleural cyst. The neck lesion was presumed to be a cystic hygroma. Histological examination of the two lesions resected showed them to be a foregut cyst and a benign mesothelial cyst. We know of no other report of concurrent multicystic lesions in the chest and neck and hypothesize that these cysts may have a common embryonic origin.

Ischemic preconditioning: a potential role for constitutive low molecular weight stress protein translocation and phosphorylation?

We have investigated whether translocation of constitutive low molecular weight stress proteins (alphaB-crystallin and HSP27) to the myofilament/cytoskeletal compartment occurs during ischemic preconditioning and assessed if this is causally associated with cardioprotection. Triton-insoluble preparations from fresh or aerobically perfused rat hearts (n=4/group) contained relatively little alphaB-crystallin (96 +/- 43 and 43 +/- 36 units respectively) or HSP27 (177 +/- 32 and 101 +/- 26 units respectively). Three preconditioning cycles of (5 min ischemia + 5 min reperfusion) increased the Triton-insoluble crystallin to 864 +/- 61 units (P<0.05) and HSP27 to 1353 +/- 53 units (P<0.05). Two hours of aerobic perfusion following the preconditioning protocol resulted the return of alphaB-crystallin and HSP27 to near control levels (189 +/- 14 units and 252 +/- 24 units, respectively). Stress protein translocation, comparable to that achieved by the IPC protocol was induced by aerobic perfusion with hypercarbic (pH 6.8) perfusion. Thus, three cycles of 5 min hypercarbia + 5 min normocarbia increased alphaB-crystallin to 628 +/- 30 units (P<0.05) and HSP27 to 1353 +/- 53 units. In parallel functional studies, the recovery of LVDP after 35 min ischemia and 60 min of reperfusion was 43 +/- 7% in the ischemic control group, 61 +/- 3% (P<0.05) in the preconditioned group and 42 +/- 6% in the hypercarbic group. Thus, translocation of alphaB-crystallin and/or is not of-itself sufficient to induce cardioprotection. Using a phospho-specific antibody, we have demonstrated that preconditioning not only translocates alphaB-crystallin but also increases its phosphorylation at Ser-59 by 9.7-fold compared to aerobic controls (1616 +/- 402 v 166 +/- 28 units respectively). In contrast, hypercarbia while eliciting a comparable translocation, failed to alter the phosphorylation state of alphaB-crystallin. Preconditioning-induced phosphorylation was significantly attenuated by 50 microM genistein (by 61%), 10 microM SB203580 (by 91%) and 10 microM bisindolylmaleimide (by 68%), but not by 10 microM PD98059 (by 4%). Our findings are consistent with the possibility that ischemic preconditioning may be mediated by phosphorylation and translocation of constitutive low molecular weight stress proteins, particularly alphaB-crystallin.

Recurrence of stage I thymoma 32 years after total excision

Malignant thymomas are invasive and recur frequently, but noninvasive thymomas rarely do so. We report on a case of recurrent thymoma in a 50-year-old white man, 32 years after total excision of a stage I thymoma. We stress the importance of long-term follow-up in all patients.

Ischemic preconditioning in immature myocardium

BACKGROUND

Protection by ischemic preconditioning (PC) has not been studied extensively in immature hearts. We studied the developmental differences in the ability of the rat heart to precondition with ischemia.

METHODS AND RESULTS

Hearts from 4-, 7-, 14-, and 21-day-old and adult (approximately 50-day-old) rats were aerobically perfused in Langendorff mode before a PC stimulus of either (1) 3-minute ischemia (I), 3-minute reperfusion (R), 5-minute I, 5-minute R, or (2) 4 cycles of 5-minute I and 5-minute R, before a prolonged I (chosen to give 30% to 40% recovery) and 60-minute R. LVDP recovery was expressed as percent of baseline reading (after 20-minute aerobic perfusion). Protection was seen after protocol 1 in 14- and 21-day-old and adult hearts (45 +/- 5%, 53 +/- 7%, and 58 +/- 5% versus 30 +/- 4%, 29 +/- 3%, and 32 +/- 2% in controls, respectively) but not in 4- and 7-day (neonatal) hearts; neonatal hearts were also not protected in protocol 2. To determine whether this inability of neonatal hearts to precondition was due to insufficient duration of the PC cycle, they were subjected to increased I durations up to 20 minutes before 5-minute R, prolonged I (90 minutes and 60-minute R) (protocol 3); protection was not seen. To determine whether the inability to precondition was due to an excessively prolonged ischemic duration, neonatal hearts were subjected to only 45 minutes of prolonged I (protocol 4); again, PC protection was not evident.

CONCLUSIONS

Protection by PC develops after 7 days; the inability of neonatal hearts (< 7 days old) to precondition is not due to insufficient stimulus or extended ischemia.

Venous gangrene of the lower limbs following aortic valve replacement for native valve endocarditis

Bacterial endocarditis is a complex disease associated with high morbidity and mortality with complications that include acute heart failure and arterial embolism. Venous thrombosis of the lower limbs is not uncommon following all forms of surgery, but infrequent following cardiac surgery, and rarely progresses to venous gangrene. We report a case of bilateral lower-limb venous gangrene, in a 49-year-old female who underwent aortic valve replacement for native valve endocarditis. The possible aetiology of this complication is discussed.

Re-do cardiac surgery in patients over 70 years old

OBJECTIVE

This study was conducted in order to determine the outcome of cardiac re-operations in patients over the age of 70.

METHODS

All patients who underwent 're-do' cardiac surgery at our institution, between January 1987 and October 1995 were identified. The case notes of patients over the age of 70 were reviewed retrospectively and follow-up was by telephone.

RESULTS

A total of 687 re-do operations were performed during this 8 years and 9 months period. Operations, 110 (16%) were on patients aged 70 years and over (CABG 54, MVR 32, AVR 9, AVR + MVR 5, MVR + CABG 4, AVR + CABG 3, repair of paraprosthetic leak 2 and closure of VSD 1). Operations, 63 (57%) were elective and 42 (38%) were urgent. The median age was 73 years (range 70-82) and 64 patients (58%) were male. Pre-operatively, 78 patients (72%) were NYHA functional class III/IV and 55 (50%) had angiographically impaired left ventricular function (ejection fraction < 50%). The overall operative mortality was 7% (8/110). Median ITU stay was one night (range 1-21) and hospital stay was 7 days (range 5-35). Major in-hospital complications included resternotomy in five patients (5%), permanent stroke in three (3%), renal failure requiring haemodialysis in two (2%) and heart block requiring permanent pacing in two (2%). At a median follow-up of 34 months (range 2-101), 69 of the 77 patients alive at follow-up (90%) were NYHA functional class I/II.

CONCLUSIONS

'Re-do' cardiac surgery in patients over the age of 70 carries an acceptable operative morbidity and mortality with a good functional improvement at medium term follow-up.

Retrograde pulmonary embolectomy by flushing of the pulmonary veins

A glue embolization of a cerebral arteriovenous malformation in a 3-year-old boy was complicated by a massive pulmonary embolus due to glue entering the venous circulation. Attempted pulmonary embolectomy via pulmonary arteriotomy after emergency cardiopulmonary bypass was unsuccessful. However, retrograde flushing of the pulmonary veins with cold saline solution produced large quantities of embolus through the pulmonary arteriotomy. Bypass was discontinued uneventfully with no residual cardiopulmonary problems.

Action of Grignard reagents on N-Alkylidene- and N-Arylmethylene-aminophthalimides

N-Alkylidene- and N-arylmethylene-aminophthalimides react with organomagnesium halides to give different products depending upon the nature of the Grignard reagent. Thus the reaction may proceed by addition of two moles of the reagent to give (2) or (3) or it may proceed through addition and cleavage of the molecule to give phthalazin-1-ones (5). These phthalazin-1-ones can also be obtained in much better yields by the action of Grignard reagents on N- aminophthalimide. Structures are based on infrared and ultraviolet spectra and the synthesis of authentic samples in some cases.

Microdetermination of the azide group in organic compounds

A simple, rapid and accurate micro-method for the analysis of mono- and diazide organic compounds is described. It is based on the Curtius rearrangement reaction. Glacial acetic acid is found to be the best decomposition medium. The acyl azide function yields two nitrogen atoms per azide group, but the diazides investigated ultimately give five nitrogen atoms per group on oxidation of their decomposition products, with acidified cerium(IV) sulphate solution. The decomposition time varies from 10 min for monoazides to 20 min for diazides. Accurate results were obtained for a representative series of 18 mono-and diazides.