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Aortic aneurysms, which may dissect or rupture acutely and be lethal, can be a part of multisystem disorders that have a heritable basis. We report four patients with deficiency of selenocysteine-containing proteins due to selenocysteine Insertion Sequence Binding Protein 2 (SECISBP2) mutations who show early-onset, progressive, aneurysmal dilatation of the ascending aorta due to cystic medial necrosis. Zebrafish and male mice with global or vascular smooth muscle cell (VSMC)-targeted disruption of Secisbp2 respectively show similar aortopathy. Aortas from patients and animal models exhibit raised cellular reactive oxygen species, oxidative DNA damage and VSMC apoptosis. Antioxidant exposure or chelation of iron prevents oxidative damage in patient’s cells and aortopathy in the zebrafish model. Our observations suggest a key role for oxidative stress and cell death, including via ferroptosis, in mediating aortic degeneration.Aortic aneurysms have a heritable basis. Here, the authors report that a selenoprotein deficiency disorder due to mutations in SECISBP2, causes oxidative stress-mediated aortic cell death, predisposing to thoracic aortic aneurysm formation. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES The Amaze trial showed that adding atrial fibrillation (AF) surgery to cardiac operations increased return to sinus rhythm (SR) without impact on quality of life or survival at 2 years. We report outcomes to 5 years. METHODS In a multicentre, phase III, pragmatic, double-blind, randomized controlled superiority trial, cardiac surgery patients with >3 months of AF were randomized 1:1 to adjunct AF surgery or control. Primary outcomes of 1-year SR restoration and 2-year quality-adjusted survival were already reported. This study reports on rhythm, survival, quality-adjusted survival, stroke, medication and safety to 5 years. RESULTS Between 2009 and 2014, 352 patients were randomized. By 5 years 79 died, 58 withdrew, 34 were lost to follow-up and the remaining 182 provided data. AF surgery significantly increased the odds of remaining in SR at 5 years {odds ratio = 2.98 [95% confidence interval (CI) 1.23, 7.17], P  = 0.015}. There was a non-significant decrease in stroke incidence [odds ratio = 0.605 (95% CI 0.284, 1.287), P  = 0.19], but no improved survival [5-year survival: AF surgery 77.3% (95% CI 71.1%, 83.5%), controls 77.8% (95% CI 71.7%, 84.0%), P  = 0.85]. Quality-adjusted survival difference was negligible (−0.03; 95% CI −0.33, 0.27, P  = 0.85). The composite of survival free of stroke and AF was better in the AF surgery group [odds ratio = 2.34 (95% CI 1.03, 5.31)]. There were no other differences. CONCLUSIONS Adjunct AF surgery confers a higher rate of SR to 5 years and a better composite outcome of survival free of stroke and AF but has no impact on overall or quality-adjusted survival or other clinical outcomes. Clinical trial registration number ISRCTN82731440. [ABSTRACT FROM AUTHOR]

OBJECTIVES Atrial fibrillation (AF) reduces survival and quality of life (QoL). It can be treated at the time of major cardiac surgery using ablation procedures ranging from simple pulmonary vein isolation to a full maze procedure. The aim of this study is to evaluate the impact of adjunct AF surgery as currently performed on sinus rhythm (SR) restoration, survival, QoL and cost-effectiveness. METHODS In a multicentre, Phase III, pragmatic, double-blinded, parallel-armed randomized controlled trial, 352 cardiac surgery patients with >3 months of documented AF were randomized to surgery with or without adjunct maze or similar AF ablation between 2009 and 2014. Primary outcomes were SR restoration at 1 year and quality-adjusted life years at 2 years. Secondary outcomes included SR at 2 years, overall and stroke-free survival, medication, QoL, cost-effectiveness and safety. RESULTS More ablation patients were in SR at 1 year [odds ratio (OR) 2.06, 95% confidence interval (CI) 1.20–3.54; P  = 0.009]. At 2 years, the OR increased to 3.24 (95% CI 1.76–5.96). Quality-adjusted life years were similar at 2 years (ablation − control −0.025, P  = 0.6319). Significantly fewer ablation patients were anticoagulated from 6 months postoperatively. Stroke rates were 5.7% (ablation) and 9.1% (control) (P  = 0.3083). There was no significant difference in stroke-free survival [hazard ratio (HR) = 0.99, 95% CI 0.64–1.53; P  = 0.949] nor in serious adverse events, operative or overall survival, cardioversion, pacemaker implantation, New York Heart Association, EQ-5D-3L and SF-36. The mean additional ablation cost per patient was £3533 (95% CI £1321–£5746). Cost-effectiveness was not demonstrated at 2 years. CONCLUSIONS Adjunct AF surgery is safe and increases SR restoration and costs but not survival or QoL up to 2 years. A continued follow-up will provide information on these outcomes in the longer term. Study registration ISRCTN82731440 (project number 07/01/34). [ABSTRACT FROM AUTHOR]

A risk prediction model is a mathematical equation that uses patient risk factor data to estimate the probability of a patient experiencing a healthcare outcome. Risk prediction models are widely studied in the cardiothoracic surgical literature with most developed using logistic regression. For a risk prediction model to be useful, it must have adequate discrimination, calibration, face validity and clinical usefulness. A basic understanding of the advantages and potential limitations of risk prediction models is vital before applying them in clinical practice. This article provides a brief overview for the clinician on the various issues to be considered when developing or validating a risk prediction model. An example of how to develop a simple model is also included. [ABSTRACT FROM AUTHOR]

Concomitant surgery for atrial fibrillation is a conceptually and clinically difficult area of cardiac surgical decision making. This review introduces the pathophysiological background, provides insight and guidance for cardiac surgeons on some of the conflicting evidence and claims, and explores the fields in which further research may help elucidate a cardiac surgical clinical strategy for tackling this common and potentially lethal form of arrhythmia. [ABSTRACT FROM AUTHOR]

When machine learning modelling techniques first became available, we tested them, as far back as 2006, against the original EuroSCORE [[3]] model. The study also found that machine learning techniques were associated with a modest improvement in risk model discrimination, with an area under ROC curve of around 0.834 compared with around 0.817 for the original EuroSCORE II model. Keywords: Risk assessment; EuroSCORE; Artificial intelligence; Logistic regression; Machine learning EN Risk assessment EuroSCORE Artificial intelligence Logistic regression Machine learning 1 1 1 07/04/23 20230601 NES 230601 In this issue, Sinha I et al. i [[1]] present a comparison between risk modelling carried out using EuroSCORE II and using machine learning or artificial intelligence techniques. [Extracted from the article]

OBJECTIVES: Risks of cardiac surgery in patients with poor [ejection fraction (EF) ≤ 30%] and very poor left ventricular (LV) function (EF ≤ 20%) may be considered high due to increased mortality. We examine our results in this cohort of patients. METHODS: Data were prospectively collected and retrospectively analysed from 4491 consecutive patients referred for cardiac surgery over 18 years ( July 1993-June 2012). Univariate predictors of in-hospital postoperative mortality were analysed by the appropriate tests. Variables with P < 0.1 were entered into multivariable logistic-regression model to identify predictors of in-hospital postoperative mortality, with data presented as odds ratios; P < 0.05 was statistically significant. Data on long-term survival and cardiac-specific mortality were obtained from the UK Office for National Statistics; the date of last follow-up was 13 October 2013 for the alive patients. Univariate predictors influencing cardiac death were determined by log-rank method. Variables with P < 0.1 were entered into multivariable Cox regression model to determine independent predictors of long-term survival, with data presented as hazard ratios; P < 0.05 was statistically significant. RESULTS: Cardiac surgery was performed on 3890 consecutive patients (74.7% male, age 68.7 ± 8.1 years); 601 patients did not undergo surgery. Postoperative hospital mortality was 2.9% (n = 112/3890). Predictors of postoperative hospital mortality included age ≥ 70 years, female sex, hypertension, LVEF < 50%, neurological dysfunction, previous cardiac surgery, early time period 1993-1997, emergency procedures and triple procedures. All patients were followed until the date of last follow-up or date of death, with a median follow-up of 8.1 ± 7.6 years and a total follow-up of 33 208 years. There were 533 (13.7%) postoperative early and late deaths from cardiac causes. Predictors of long-term survival free from cardiac death included LVEF > 50%. Predictors of postoperative cardiac deaths in the long-term follow-up included older age, diabetes, neurological dysfunction, LVEF < 50%, non-coronary artery bypass surgery, early time period of surgery (1993- 1997) and redo-cardiac surgery. CONCLUSIONS: Cardiac surgery provides long-term survival benefit in all subsets of LV function, including advanced LV dysfunction. [ABSTRACT FROM AUTHOR]

Objectives: The aim of our study was to investigate the effects of pulsatile cardiopulmonary bypass (CPB) on renal function and the need for haemofiltration in patients with preoperative renal impairment undergoing cardiac surgery. Methods: Clinical data were collected prospectively for patients undergoing cardiac surgery with pulsatile CPB (Group A, n=66) and compared to matched patients with standard non-pulsatile CPB (Group B, n=66). Patients included in the study had mild renal impairment and at least moderate risk from surgery as defined by logistic EuroSCORE. Emergency operations were excluded. Results: Patients in Groups A and B had similar age (71 ± 10 versus 70 ± 10 years), sex distribution, mean preoperative renal function (creatinine clearance 63.9 ± 28 versus 67.7 ± 27.3 ml/min) and overall risk profile as predicted by the logistic EuroSCORE (8 ± 8.3 versus 11.05±13.3, p=0.122). Intraoperative variables were comparable with respect to bypass and cross-clamp times (96 ± 37 minutes and 64 ± 28 minutes versus 103 ± 40 minutes and 70 ± 33 minutes in Groups A and B, respectively). A smaller proportion of patients in Group A (4.5% versus 15%, p=0.076) required haemofiltration in the postoperative period. Postoperative mortality was low in both groups (Group A 1.54% versus Group B 3.03%, p=1.00). Conclusion: Within the limitations imposed by retrospective analyses, our study demonstrates that pulsatile CPB may confer a reno-protective effect in higher-risk patients with pre-existing mild renal dysfunction undergoing cardiac surgery. [ABSTRACT FROM AUTHOR]

We also found that there appears to be an ablation "dose-response" in achieving return to sinus rhythm, with the greatest step-up achieved when the left atrial lesion set includes the mitral isthmus lesion. Keywords: Arrhythmia; Cardiac surgery; Ablation; 5-Year follow-up EN Arrhythmia Cardiac surgery Ablation 5-Year follow-up 1 1 1 02/07/23 20230101 NES 230101 We thank Dr Garcia-Villarreal [[1]] for his comment on our article in which he questions the rate of return to stable sinus rhythm in the Amaze trial [[2]]. We therefore agree with Dr Garcia-Villarreal that concomitant atrial fibrillation surgery should ideally be as complete as possible, and there may be an argument for concentrating such surgery in the hands of interested and experienced surgeons. [Extracted from the article]

Objectives: We reviewed our results and experience over a 14-year period to identify predictors of outcome following surgical repair of postinfarction ventricular septal rupture.Methods: A retrospective review was carried over a 14-year period. All patients had surgical repair of a postinfarction ventricular septal rupture. Patient demographics, perioperative variables, and survival data were collected. Logistic regression identified independent predictors of 30-day mortality. Multivariate analysis determined the effects of independent risk factors on survival.Results: Surgery for postinfarction ventricular septal rupture was carried out on 59 patients. The median age was 69 years, and 69% were male. In 54% of patients, the ventricular septal rupture was anterior, and 75% had concomitant coronary artery bypass grafting. Mortality was 39% at 30 days. Age was the most important predictor of 30-day and long-term outcome. Logistic regression analysis identified age, preoperative ventilation, and female sex as significant predictors of 30-day mortality. Cardiogenic shock, preoperative ventilation, and advanced age were associated with reduced medium-term survival. Surprisingly, anterior ventricular septal rupture was associated with reduced long-term survival. Concomitant coronary artery bypass grafting did not influence 30-day or long-term outcome.Conclusions: Despite advances, the surgical mortality from ventricular septal rupture remains high. Age remains the most important predictor of outcome, and concomitant coronary artery bypass grafting does not appear to have a demonstrable benefit. Interestingly, anterior ventricular septal rupture had poorer long-term outcome than inferior ventricular septal rupture. [ABSTRACT FROM AUTHOR]

Quality monitoring in medicine was a neglected field until the last two decades. Doctors traditionally did their best, but how good that was could not be evaluated. This situation remains in some areas of medicine, but specialties with clearly-defined interventions and outcomes have progressed in quality of care evaluation, and cardiac surgery leads the way. Measuring the risk of an intervention allows prediction of the outcome and is essential for quality monitoring: without knowing the predicted outcome, the actual outcome cannot be evaluated. Cardiac surgery risk models like EuroSCORE and others have been adopted worldwide, so that measuring risk-adjusted performance is now an integral part of the delivery of good cardiac surgical care. When mortality for a procedure is higher for one surgeon (or hospital) than another, this can be due to one of three reasons, or a combination of the three: the difference is due to chance, or variation in risk profile, or better and safer service. We now have the tools to distinguish between the above factors. We can also observe performance over time: cusum curves plot the performance of surgeons and hospitals by showing hypothetical 'lives saved'. This provides early warning of deterioration in performance before a problem reaches statistical significance. With the appropriate tools, it is possible not only to identify a problem, but also to anticipate and thus prevent a problem from happening. Monitoring clinical performance is an exciting and rewarding field for future development, and one that will yield real improvements in patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Cardiac surgery is widely believed to be an excessively high-risk intervention for very elderly patients with coronary artery or valvular disease. However, as life expectancy and the prospect of sustained quality of life into older age increase, this assumption should be challenged so that surgery is not denied to patients who may derive significant symptomatic benefit with acceptable levels of operative risk. Objective: To evaluate outcomes from cardiac surgery in nonagenarian patients. Design: Analysis of prospectively collected single-centre data and review of outcomes reported in the literature. Results: Twenty-three patients (13 males) aged 90 years or more underwent open cardiac surgery between 1998 and 2007. Four patients died within 30 days of surgery (surgical mortality 17.4%) and all-cause in-hospital morbidity was 74%. Actuarial survival at 1 and 5 years was estimated at 72 and 54%, respectively. Comparison of patients’ survival against age-matched life tables for the English population found a standardised mortality ratio of 0.57 (95% CI: 0.24–0.99; one-sample log-rank test χ2 = 3.93; p < 0.05) representing a significant survival benefit associated with surgery. The majority of patients reported symptomatic improvement reflected by significant decreases in angina and dyspnoea scores. Six single-centre series of nonagenarians and 3 reviews from national databases in the US and UK were identified in the literature. Pooled surgical mortality was 12.7% (95% CI: 8.7–17.3%) with no significant heterogeneity (χ2 = 4.12; p = 0.77; I2 = 0). Conclusion: Cardiac surgery in the elderly carries higher operative risk than in younger patients. However, in selected nonagenarians, surgery can be performed with acceptable morbidity and early mortality, and patients gain significant symptomatic relief and survival benefit. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

We report three cases of symptomatic stenosis of the great vessels or supra-aortic trunks successfully treated surgically with aorto-subclavian and aorto-innominate bypass. Two were performed via manubriotomy and a third case via standard median sternotomy because of concomitant coronary revascularisation. There was complete symptomatic relief on follow-up, and radiological imaging confirmed good flow in the grafts and post-stenotic arteries. [ABSTRACT FROM AUTHOR]

Background: The success of a Fontan circulation depends on several factors including low pulmonary vascular resistance. Pulmonary vascular resistance rises in response to hypoxia. Hypoxia is associated with altitude. Therefore, we wondered whether altitude is a risk factor for early failure after the Fontan operation. The aim was to test this hypothesis. Methods: Data were obtained from all published series of 'total cavopulmonary' Fontan operations since 1990. The early failure rate from each series and the altitude of the respective cities were recorded. Early failure was defined as death, takedown of Fontan, or transplantation during the same hospital admission. The association between altitude and failure rate was investigated by rank correlation and logistic regression. Results: 24 series were identified from centres situated at altitudes ranging from sea level to 520 metres. The plot of failure rate versus altitude suggests that failure rate increases with altitude. Logistic regression did not fit the data adequately. This was possibly due to the influence of unmeasured and unknown factors affecting the results, as well as the fact that centres were not randomly chosen but were self-selected by virtue of publishing their results. However, Spearman's rank correlation was 0.74 (p = 0.001). Conclusion: The early outcome of the Fontan circulation appears to be adversely affected by altitude. [ABSTRACT FROM AUTHOR]

Abstract Objectives To investigate attitudes of cardiac surgeons and anaesthetists towards working immediately after an intraoperative death and to establish whether an intraoperative death affects the outcome of subsequent surgery. Design Questionnaire on attitudes to working after an intraoperative death and matched cohort study. Setting UK adult cardiac surgery centres and regional cardiothoracic surgical centre. Participants 371 consultant cardiac surgeons and anaesthetists in the United Kingdom were asked to complete a questionnaire, and seven surgeons from one centre who continued to operate after intraoperative death. Main outcome measures Outcome for 233 patients operated on by a surgeon who had experienced an intraoperative death within the preceding 48 hours compared with outcome of 932 matched controls. Hospital mortality and length of stay as a surrogate for hospital morbidity. Results The questionnaire response rate was 76%. Around a quarter of surgeons and anaesthetists thought they should stop work after an intraoperative death and most wanted guidelines on this subject. Overall, there was no increased mortality in patients operated on in the 48 hours after an intraoperative death. However, mortality was higher if the preceding intraoperative death was in an emergency or high risk case. Survivors operated on within 48 hours after an intraoperative death had longer stay in intensive care (odds ratio 1.64, 95% confidence interval 1.08 to 2.52, P = 0.02) and longer stay in hospital (relative change 1.15, 1.03 to 1.24, P = 0.02). Conclusion Mortality is not increased in operations performed in the immediate aftermath of an intraoperative death, but survivors have longer stays in intensive care and on the hospital ward. [ABSTRACT FROM AUTHOR]

The article offers information on atrial fibrillation and the restoration of sinus rhythm. Topics include the survival rates of the surgery, the management of quality of life, and the use of randomized control trials. The article also discusses the coronary artery bypass grafting technique for patients.

An editorial is presented, in which the author discusses risk scores and evaluation of patients having total arterial coronary revascularization. Topics discussed include risk factors that contribute to the models' power of discrimination, overestimation of mortality for the mode, and specialty of cardiac surgery.

Presents a letter to the editor describing a case of transpulmonary pacing lead.