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Background: 3-factor prothrombin complex concentrate (3F-PCC) may provide a valuable treatment option for coagulopathy in cardiac surgery patients. However, it may expose patients to increased risk of thromboembolic events. Accordingly, we compared the incidence of thromboembolic events between patients exposed to 3F-PCC and those receiving conventional therapy.Methods: Demographic, operative and postoperative data was obtained in a cohort of consecutive patients exposed to 3F-PCC and a contemporaneous control population. Propensity-score matching was performed for risk adjustment. Unadjusted and adjusted patient demographics and incidence of thromboembolism were compared.Results: Patients receiving 3F-PCC (PCC) were younger (mean age PCC: 64±14.2 vs. No PCC: 67.6±11.6, p=0.022), and less likely to have diabetes or previous myocardial infarction. PCC patients experienced more prolonged aortic cross clamp times (mean time in minutes PCC: 119.9±58.8 vs. No PCC: 92.3±54), more complex cardiac surgeries and were more likely to have received more fresh frozen plasma (FFP), cryoprecipitate and red blood cells. Despite this, both unadjusted and adjusted 30-day mortality and readmission rates were similar between groups. There were 9 (9.2%) and 34 (6.8%) (p=0.40) thromboembolic events in the unadjusted PCC and control groups respectively. Adjusted risk for thromboembolic event rates was also comparable (Odds ratio: 1.512, 95% Confidence Interval 0.401-5.7, p=0.541).Conclusions: 3-factor prothrombin complex concentrate was administered to patients at greater risk of complications including bleeding. Our initial experience suggests that the use of PCC does not appear to increase thromboembolic risks compared to conventional treatment. [ABSTRACT FROM AUTHOR]

Sternal wound infection (SWI) is one of the potential complications post cardiac surgery, and despite refined surgical techniques such as smaller incisions, antibiotic therapy, and optimised glycaemic control, the incidence rate is between <1% in elective cases with low risk factors and as high as 25% in patients with extensive risk factors. The presence of SWI will increase the perioperative morbidity and mortality rates and prolong the patient's hospital stay, therefore the prevention and diagnosis with appropriate management of such adverse outcomes at an early stage is important to prevent further progression as it can be fatal when the mediastinal structures are affected. Currently, the diagnosis typically consists of three main stages: clinical, biochemical including microbiology studies and imaging studies. In the current health care system, the use of computed tomography (CT) and magnetic resonance imaging (MRI) is valuable to define mediastinal abnormalities and can also help find the source of a descending infection. Management is through methods such as antibiotic therapy, surgical debridement, reconstruction with soft tissue flap coverage, sternal plating, and sternectomy. In this literature review, we aim to summarise current literature evidence behind appropriately diagnosing such a catastrophe. [ABSTRACT FROM AUTHOR]

Background: Due to the advancements in congenital cardiac surgery and interventional cardiology in the last 5 decades, more than 85% of congenital heart patients now survive to adulthood.Methods: This retrospective study included 135 Adult Congenital Heart Disease (ACHD) patients, who had cardiac surgery at Southampton General Hospital over 3 consecutive years. We also included 42 patients with a structurally normal heart who had cardiac surgery for acquired cardiac conditions as a control group. Preoperative, intraoperative and postoperative data were analysed in both groups to identify risk factors for morbidity and mortality.Results: In the ACHD group, in hospital mortality was 0.7%. In the control group no deaths were observed. Fifty-eight per cent of the ACHD patients had significantly higher perioperative morbidity with arrhythmias (26%), bleeding (3%), prolonged ventilation (11.3%) and renal replacement therapy 1.5%. In the non ACHD control group 32% (p=0.003) developed perioperative complications with arrhythmias (9.8%), bleeding (2.5%), prolonged ventilation (4.3%) and renal replacement therapy (2.5%). In ACHD patients total in-hospital stay was longer in patients with longer cardiopulmonary bypass (CPB) time (p=0.005), aortic cross clamp time (p=0.013) and higher preoperative alkaline phosphatase level (p=0.005). Early postoperative complications were higher in ACHD patients with longer cardiopulmonary bypass time (p=0.04) and presence of pulmonary artery hypertension (p=0.012).Conclusions: Even though the preoperative and operative characteristics are similar to both groups, the morbidity is more in ACHD group. Longer CBP time, aortic cross clamp time and presence of pulmonary hypertension are risk factors for higher morbidity in this group. [ABSTRACT FROM AUTHOR]

Background: Atelectasis is a significant complication after cardiac surgery. The current study was designed to assess the significance of atelectasis after bilateral internal thoracic artery (BITA) harvest.Methods: The ICU admission chest x-ray of 565 patients undergoing BITA was reviewed. Linear regression modelling was used to assess the relationship between atelectasis and oxygenation as well as patient variables to length of ventilation and length of stay in the Intensive Care Unit (ICU).Results: Eighty-nine patients (15.8%) had Grade 2/3 atelectasis which was significantly more common on the left as compared to the right (left 0.149 95% CI [0.119-0.178], right 0.027 95% CI [0.013-0.040], p<0.001). Grade 2/3 atelectasis on the right was associated with a significant drop in the pO2 (p=0.001) and the per cent O2-fractional O2 (PF) ratio (p=0.002). Factors associated with increased ventilation time included presence of Grade 2/3 atelectasis (p=0.001) and peripheral vascular disease (PVD) (p<0.001), both of which were predictors of prolonged ICU length of stay (p=0.002 and p<0.001 respectively).Conclusions: Early atelectasis is related to impaired oxygenation, prolonged ventilation and prolonged ICU stay. Future research should focus on strategies to minimise atelectasis and to determine if these changes translate into better patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Cognitive decline post-cardiac surgery is of clinical concern. To better understand it a sensitive and specific measure of post-surgery brain impairment is required. The cerebral territory most likely to be adversely affected by surgery is the posterior "watershed" territory. Methods: We have designed a psychophysical task involving reading letters defined by motion aimed at measuring the integrity of a cortical area (MT) located in this territory. Patients undergoing coronary artery bypass grafting (CABG) and a healthy control group were given the psychophysical test twice, pre- and post-surgery for the patient group. Results: There was no overall difference in performance between the surgery group and the control group at either pre- or post-surgery testing. However, multivariate analysis of surgical variables such as body temperature and embolic load to the brain as measured by Transcranial Doppler showed that patients with warmer core temperatures and higher embolic loads performed significantly worse on the motion defined letter reading tasks than those with more favourable surgical variables. Conclusions: These results demonstrate that high embolic load and warm core body temperatures lead to poor motion perception post-cardiac surgery, implying damage to the posterior watershed cortex. [ABSTRACT FROM AUTHOR]

Background: To determine predictors of mortality after surgical management of post-infarction ventricular septal rupture repair.Methods: A total of 63 patients (73.2%, mean age 67.22±7.71 years, male:female ratio; 35:28) underwent open heart surgery for post-infarction ventricular septal rupture repair. Patient demographics, operative data and postoperative parameters were analysed to reveal predictors of early mortality and long-term survival.Results: In-hospital mortality was 54.0% (34/63). Time from myocardial infarction to operation ≤ 14 days (OR: 4.10, 95% CI 1.16-14.46, p=0.02), systolic pulmonary artery pressure > 45 mmHg (OR: 4.14, 95% CI 1.110-15.496, p=0.03) and age (years) (OR: 1.09, 95% CI 1.002-1.194, p=0.04) were found to be independent predictors of in-hospital mortality. In multivariate Cox regression analysis, presence of pulmonary oedema on admission (HR: 4.95, 95% CI 1.58-15.54, p=0.006), age (years) (HR: 1.09, 95% CI 1.009-1.180, p= 0.02) and cross-clamp time <60 min (HR: 3.93, 95% CI 1.13-13.64, p=0.03) were found to be independent predictors of long-term survival. Within a follow-up of a median of 60.0 months, five-year survival rate was 67±9.0%.Conclusion: In line with the previous studies, our study demonstrated the benefits of delaying the repair for post-infarction ventricular septal rupture to allow adequate myocardial healing if haemodynamic status of the patient allows. [ABSTRACT FROM AUTHOR]

Background Risk models play an important role in stratification of patients for cardiac surgery, but their prognostic utilities for post-operative complications are rarely studied. We compared the EuroSCORE, EuroSCORE II, Society of Thoracic Surgeon's (STS) Score and an Australasian model (Aus-AVR Score) for predicting morbidities after aortic valve replacement (AVR), and also evaluated seven STS complications models in this context. Methods We retrospectively calculated risk scores for 620 consecutive patients undergoing isolated AVR at Auckland City Hospital during 2005-2012, assessing their discrimination and calibration for post-operative complications. Results Amongst mortality scores, the EuroSCORE was the best at discriminating stroke (c-statistic 0.845); the EuroSCORE II at deep sternal wound infection (c=0.748); and the STS Score at composite morbidity or mortality (c=0.666), renal failure (c=0.634), ventilation>24 hours (c=0.732), return to theatre (c=0.577) and prolonged hospital stay >14 days post-operatively (c=0.707). The individual STS complications models had a marginally higher c-statistic (c=0.634-0.846) for all complications except mediastinitis, and had good calibration (Hosmer-Lemeshow test P-value 0.123-0.915) for all complications. Conclusion The STS Score was best overall at discriminating post-operative complications and their composite for AVR . All STS complications models except for deep sternal wound infection had good discrimination and calibration for post-operative complications. [ABSTRACT FROM AUTHOR]

Background Neurologic injury is common after cardiac surgery and disruption of the blood brain barrier (BBB) has been proposed as a contributing factor. We sought to study BBB characteristics in a rodent model of cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA). Methods Adult rats were subjected to CPB/DHCA or to sham surgery. Analysis included Western blotting of relevant BBB proteins in addition to in vivo brain magnetic resonance imaging (MRI) with a clinically used low-molecular contrast agent. Results While quantitative analysis of BBB proteins revealed similar expression levels, MRI showed evidence of BBB disruption after CPB/DHCA compared to sham surgery. Conclusions Combining molecular BBB analysis and MRI technology in a rodent model is a highly translatable approach to study adverse neurologic outcomes following CPB/DHCA. [ABSTRACT FROM AUTHOR]

Objective: To review the risk factors, complications and follow-up of Indigenous patients post cardiac surgery. Methods: This was a retrospective study of Indigenous patients who underwent cardiac surgery at an Australian tertiary hospital between 2002 and 2009. Patients’ medical notes were reviewed and data collected and analysed. Results: There were 220 Indigenous patients who had cardiac surgery. Non-elective surgery was performed in 45.0% (99/220). A history of smoking was reported by 76.8% (169/220). The most common operation was coronary artery bypass grafting with a mean age of 55 years. Of the 71 valve operations, 31.0% had rheumatic heart disease. Mechanical valves were given to 56.3% (40/71) of patients with a mean age of 45 years. The rate of peri-operative bleeding requiring blood transfusion or reoperation was 8.6% (19/220) and 28-day mortality was 0.45% (1/220). Of the patients with mechanical valves, 10.0% (4/40) did not present for outpatient review. Late anticoagulation related complications were haemorrhagic stroke 7.5% (3/40) and ischaemic bowel 2.5% (1/40). Late mortality was 9.5% (21/220). Late anticoagulation related deaths were in 1.8% (4/220), of whom 0.9% (2/220) had mechanical valves. Conclusions: The mean age of 52 years at which Indigenous patients have cardiac surgery is significantly low compared to non-Indigenous patients. Indigenous patients have multiple risk factors for cardiac disease and with a large number requiring emergency surgery. Although surgical outcome in the short term is favourable, a large number of patients are lost to follow-up. The use of mechanical valve and warfarin should be individualised. Strategic post-operative follow-up mechanisms are needed to address these issues. [Copyright &y& Elsevier]

Phrenic nerve injury is a well-recognised complication of cardiac surgery that can lead to disabling effects from diaphragmatic dysfunction, especially in children and patients with a history of chronic obstructive airway disease. Various mechanisms of injury have been recognised including hypothermia, mechanical trauma and possibly ischaemia. A clear understanding of these mechanisms is important in order to modify surgical techniques to prevent this serious complication of cardiac surgery. [Copyright &y& Elsevier]

Abstract: Surgical therapies have represented the primary evidence-based intervention to alter the natural history of valvular heart disease (VHD), however, the increasing incidence of patients at high surgical risk due to age and related co-morbid conditions has given rise to the need for alternative strategies. Thus, percutaneous approaches to VHD therapy have emerged as an important therapeutic option. Cardiovascular imaging plays a critical role in patient screening for percutaneous valvular interventions, during the procedure itself, and as part of follow-up for the identification of implant success/failure and complications. The technical demands on imaging in this context are highly specific. Although imaging has a significant role in the broader evaluation of valvular heart disease mechanism and severity, the purpose of this paper is to summarise the particular goals of cardiovascular imaging in the work-up for, during, and in the follow-up of percutaneous valvular intervention. [Copyright &y& Elsevier]

Background: Deep sternal wound infection (DSWI) is a rare but severe complication following cardiac surgery. Our study investigated the risk factors and treatment options for patients who developed DSWI at our institution between May 1988 and April 2008. Method: Data was collected prospectively in a database and information on demographics reviewed retrospectively on 5649 patients who underwent cardiac surgery during this period. Results: The incidence of DSWI was 34/5649 (0.6%). These patients were older (mean age 66.1 vs. 64.5), more likely to die (in hospital mortality 11.8% vs. non DSWI group 1.8%) and had longer hospital stays (DSWI group mean stay 25 days vs. non DSWI group 9 days). Using Fisher''s exact test the risk predictors for DSWI determined at our institution included diabetes managed with oral medications (p =0.021), previous cardiac surgery (p =0.038), BMI≥30 (p =0.041), LVEF≤30 (p =0.010), IABP usage (p =0.028) and homologous blood usage (p <0.001). Most commonly bilateral pectoralis major muscle flap (BPMMF) was used for treatment of DSWI (11/30, 36.7%). Conclusion: Ultimately our data was comparable to published data in the literature on known risk predictors. [Copyright &y& Elsevier]

Background: We sought to compare overall mortality with neonatal outcomes over a five year period to define risk factors for mortality and service development priorities. Methods: A retrospective cohort study of surgical outcomes following repair or palliation of structural congenital heart defects January 2005–2010. We defined mortality according to contemporary international guidelines and classified surgical procedures using the Risk Adjustment in Congenital Heart Surgery (RACHS-1) score. The effect of age and weight at operation on mortality and annual variation in case-complexity and surgeon case-mix were assessed. Subgroup analysis was performed in patients who were ≤30 days at operation (neonates). Results: Overall mortality within 30 days of operation or prior to hospital discharge was 1.3 and 1.9%, respectively. Mortality was higher in neonates (6.8%) and low birth weight infants (≤2.5kg) (12.1%). Mortality was similar in bypass versus non-bypass procedures (odds ratio 0.74, p =0.425). Annual mortality rates were consistent despite a marked increase in case-complexity. Neonates overall required longer periods of intensive care support and were more likely to suffer serious complications compared to older children. Age, weight and RACHS-1 score were independent risk factors for mortality on multivariate analysis. In neonates undergoing bypass procedures, only RACHS-1 score was a significant risk factor. Conclusions: This study provides an accurate and contemporary audit of mortality risk associated with congenital heart surgery. Outcomes compare favourably to international benchmarks but highlight the risks of morbidity and mortality associated with neonatal cardiac surgery. [Copyright &y& Elsevier]

Objective: To describe monitoring of four years’ isolated coronary artery bypass surgery outcomes and complications at The Prince Charles Hospital, Brisbane, Australia. Methods: Analysis of Cardiac Surgical Register database using tabulations, funnel plots and random-effects (Bayesian shrinkage) analysis for aggregated data. Combined CUSUM and cumulative observed minus expected (modified VLAD) charts and combined CUSUM and cumulative funnel plots used for individual observation sequential data and binomial control charts and generalised additive models (GAMs) for quarterly sequential data. Risk adjustment employed re-calibrated EuroSCORE. Results: There were 2575 procedures with an unadjusted in-hospital mortality rate of 1.17%. Mean age was 65 years and 21% of patients were female; 43.6% were elective procedures. Median ventilation time was 10 hours and median length of stay in intensive care (ICU) was 23 hours. Return to theatre for bleeding occurred in 3% of cases. Return to theatre for surgical site infection occurred in 0.4% of cases; 4% were re-do procedures. Permanent stroke or neurological deficit occurred in 1%, perioperative myocardial infarction in 0.8%, arrest in 1.2%, renal failure in 1.6% and ICU return in 2.3% of cases. Conclusions: Complication rates and mortality were comparable with similar units. Use of random-effects (Bayesian shrinkage) analysis for aggregated data is encouraged together with generalised additive models (GAMs) and combined CUSUM and cumulative observed minus expected (modified VLAD) charts for sequential data. [Copyright &y& Elsevier]

Introduction: Although anaemia is associated with an adverse prognosis in congestive heart failure (HF), the cause of the anaemia and its relationship to non-cardiac and cardiac complications needs to be better defined, particularly in a general community population. Methods: Clinical data were collected prospectively from 959 patients hospitalised with HF. Results: Thirty-eight percent (n =369) had anaemia (Hb<120g/L), which was normochromic normocytic in 87.8%. Of those who had haematinic studies, 15.5% had a confirmed haematinic deficiency. Anaemic patients were of similar age to non-anaemic (79 vs 77 years) but were more likely to have elevated creatinine (48 vs 29%, p <0.001), hyponatremia (20 vs 15%, p =0.05), and LVEF>40% (49 vs 39%, p =0.004), and less likely to receive ACE inhibitors (72 vs 78%, p =0.04). At 12 months, anaemic patients had higher HF readmission rates (22.4 vs 15.7%, p =0.01), more multiple non-HF readmissions (12.4 vs 6.3%, p =0.001) and a higher mortality (16.4% vs 10.5%, p =0.01). Conclusion: Anaemia is common (38%) in community patients hospitalised with HF, and is associated with increased HF and non-HF readmissions, and increased mortality. A haematinic deficiency was identified in 15.5% of patients. Anaemia is a common, multifactorial, but potentially treatable cause of adverse outcome in HF. [ABSTRACT FROM AUTHOR]

Abstract: The first percutaneous transcatheter aortic valve implantation (TAVI) was performed in 2002 by Alain Cribier with over 10,000 valve implants since. Despite this, as with all new technologies we remain on a learning curve and continue to encounter new challenges and complications. We report a case of acute structural valve failure treated successfully with a second valve in valve implantation of transcatheter aortic valve in a patient who had severe aortic stenosis (AS) complicated by a severely unfolded aorta. [Copyright &y& Elsevier]

Objective: Perioperative therapy with antioxidants and metabolic substrates has the potential to reduce oxidative stress and improve recovery from cardiac surgery, particularly in elderly and high risk cases. The aim of this study was to assess the effect of perioperative metabolic therapy at a biochemical, clinical and economic level in cardiac surgical patients. Methods: Patients (n =117, mean age 65±1.0 years, 74% male) undergoing elective coronary artery bypass graft (CABG) and/or valve surgery in 2004–2006 were randomised to receive in double blinded fashion, while on the waiting list for surgery (approximately two months) and one month after surgery, either metabolic therapy (coenzyme Q10, magnesium orotate, lipoic acid, omega-3 fatty acids and selenium) or placebo. Biochemical and clinical outcomes were assessed. Results: Cardiac surgery increased oxidative stress and decreased plasma levels of key antioxidants. Metabolic therapy for a mean of 76±7.5 days increased antioxidant levels preoperatively so that the adverse effect of surgery on redox status was attenuated. Metabolic therapy reduced plasma troponin I, 24 hours postoperatively from 1.5 (1.2–1.8) (geometric mean 95% CI) μg/L, to 2.1 (1.8–2.6) μg/L (P =0.003) and shortened the mean length of postoperative hospital stay by 1.2 days from 8.1 (7.5–8.7) to 6.9 (6.4–7.4) days (P =0.004) and reduced hospital costs. Metabolic therapy was inexpensive and had no clinically significant side effects. Conclusions: Perioperative metabolic therapy for cardiac surgery is safe and inexpensive and is associated with improved redox status, reduced myocardial damage, and shortened length of postoperative hospital stay. [Copyright &y& Elsevier]

Background: Postoperative occurrence of AF has been associated with less favourable outcomes in patients undergoing cardiac surgery and may result in increased postoperative morbidity and mortality. Objectives: A focused clinical question was designed and a meta-analysis of published studies was performed to identify the effect of preoperative use of statins on the occurrence of AF after cardiac surgery. Methods: Using the Medline database, the Cochrane clinical trials database and online clinical trial databases, we reviewed all RCTs and observational studies examining the effect of statins on AF occurrence following cardiac surgery. We searched for the literature published before April 2009 and earlier. Results: This analysis identified six studies (observational studies) which examined the effect of preoperative use of statins on AF occurrence following cardiac surgery, involving 10,165 patients. Contradictory to most of previous studies, the overall outcomes suggested that the statins group did not have a significant decrease in AF occurrence following cardiac surgery comparing to control group (P =0.19). Conclusions: The preoperative medication of statins showed no significant decrease in AF occurrence following cardiac surgery in this meta-analysis result. More prospective studies and researches are needed to explore and demonstrate the accurate mechanism and effect of statins on postoperative AF. [Copyright &y& Elsevier]

Background: Renal impairment is a major risk factor for cardiovascular disease. This study addressed clinical predictors of outcome following cardiac surgery, focusing on pre-operative renal dysfunction. Methods: All patients undergoing cardiac surgery at Austin Health from June 1, 2001 to June 30, 2006, were included in the analysis. Logistic regression models were used to evaluate clinical factors predicting “operative mortality” and common post-operative complications. Results: The operative mortality was 1.36% for coronary artery bypass grafting (CABG) alone (n =1027), 5.07% for valve surgery alone (n =217), 4.43% for combined CABG and valve surgery (n =158) and 11.11% for other cardiac surgical procedures (n =270). Amongst CABG alone patients, pre-operative renal impairment was a strong predictor of operative mortality, with a 35–43% increased risk of death (p =0.005) for every 10ml/min/1.73m2 that the glomerular filtration rate was lower. Peripheral vascular disease, recent myocardial infarction and congestive cardiac failure also predicted operative mortality. Pre-operative renal impairment also increased the rate of various post-operative complications, as well as duration of admission. Conclusion: Renal dysfunction is significantly associated with increased mortality and morbidity following cardiac surgery and necessitates careful consideration in risk benefit analysis when considering cardiac surgery. [Copyright &y& Elsevier]

Rarely aneurysmal dilatation of saphenous vein grafts following coronary artery bypass surgery may be complicated by fistulae which communicate with cardiac chambers. We describe our attempt to close a fistula which entered the right atrium by deploying covered stents within the graft. [Copyright &y& Elsevier]

Thrombotic cutaneous gangrene is a rare complication of heparin-induced thrombocytopaenia after cardiac surgery. We report a case and discuss management issues with cardiopulmonary bypass for cardiac surgery in this condition. [Copyright &y& Elsevier]

Background: With the increasing use of OPCAB, potentially devastating thromboembolic events, including graft thrombosis may become increasingly evident. We present a study of the quantitative and temporal differences of the coagulation system, fibrinolysis and platelet activation after coronary artery surgery with or without cardiopulmonary bypass. Methods: Patients undergoing on-pump CABG (n =10) or OPCAB (n =10) had six blood samples taken before surgery and up to 24h post-operatively. Activation of the coagulation cascade (tissue factor pathway—factor VIIa), endothelial injury (von Willebrand Factor antigen), thrombin generation (prothrombin fragments FI+II), fibrinolysis (decreased plasminogen levels), fibrin degradation (D-Dimer), platelet counts and platelet activation (soluble P-selectin) were quantified. Results: CABG caused earlier and more significant generation of thrombin, however OPCAB caused a late and sustained generation of thrombin. CABG caused intraoperative activation of fibrinolysis and fibrin degradation, however, at 24h these parameters were equally elevated in both groups. Platelet activation was significant in the CABG group, but did not occur in the OPCAB group. Conclusions: Late thrombin generation and reduced fibrinolysis in the presence of intact, functioning platelets may contribute to adverse thromboembolic events after OPCAB surgery. Thromboembolic prophylaxis and anti-platelet therapy may need to be more aggressive after OPCAB surgery. [Copyright &y& Elsevier]

Background: The current American College of Cardiology (ACC) guidelines recommend that elective percutaneous coronary interventions (PCI) should not be performed in institutions without on-site cardiac surgery. We sought to determine the safety of PCI without cardiac surgical support on-site and specifically the safety of complex elective procedures. The results of the first 1000 procedures performed at our institution, which is a rural centre 80km from the nearest cardiac surgical facility, are reported. Methods: Between September 2002 and April 2006 a total of 1000 procedures were performed in 893 patients at our institution. Patients included both high and low risk cohorts. Clinical and procedural outcomes were recorded and analysed. Results: Of the 921 elective and 79 emergency primary PCI procedures performed, 1138 vessels were treated and 1429 stents deployed. A 95% procedural success rate was recorded. Complex PCI was performed with multi-vessel PCI in 13%, bifurcation PCI in 8%, chronic total occlusions (CTO) in 5%, saphenous vein graft interventions in 5%, unprotected left main interventions in 0.8% and rotational atherectomy in 0.8% of all procedures performed. Of the cohort, 75.3% of the lesions treated were either American College of Cardiology (ACC)/American Heart Association (AHA) type B or C lesions. In the primary PCI group, three deaths and three sub-acute stent occlusions occurred. In the elective group, the following major complications occurred: one death, three sub-acute stent occlusions, one case of contrast nephropathy requiring short-term dialysis, two cases of cardiac tamponade, two significant femoral pseudo-aneurysms and one misplaced stent. Acute myocardial infarction occurred in 21 patients. There were no urgent transfers for CABG surgery to salvage a complication of PCI. Conclusion: PCI including high risk elective procedures can safely be performed without on-site cardiac surgery by experienced high volume operators. [Copyright &y& Elsevier]

Objectives: Various modifications have been proposed to the original Cox''s Maze procedure due to concerns about the long bypass and cross clamp times. The efficacy of these procedures has been studied and reported. We conducted a randomised prospective study to compare three procedures, differing in extent, of ablation in patients in atrial fibrillation who were undergoing surgery for rheumatic valvular heart disease. These procedures utilised radiofrequency in the bipolar mode. The extent of ablation was (1) biatrial (replication of the Cox Maze) (2) left atrial portion of the Cox Maze and (3) pulmonary vein isolation along with a control group (the No Maze group). Conversion rate to sinus rhythm was studied over a mid-term follow-up period. Methods: A total of 160 patients were studied with 40 patients in each group. Antiarrhythmic drugs were not used in the three months preceding surgery and for seven days postoperatively. The patients underwent surgery for their valve disease along with the ablative procedure as per randomisation using radiofrequency microbipolar coagulation and cryoablation. They were followed up and were evaluated for symptomatic improvement, rhythm with ECG documentation and 2D echocardiography. Results: Follow-up was available for 133 patients. Mid-term results showed that sinus rhythm was restored in 62.5% patients of Biatrial Maze group and 57.5% in the Left Atrial Maze. In the Pulmonary Vein Isolation Maze group, 67.5% patients converted to NSR whereas in the No Maze group only 20% patients were in sinus rhythm (p value for all the groups was 0.001 when compared to the No Maze group). The incidence of other arrhythmias was not significant and there were no other major complications. All the patients in sinus rhythm at follow-up were in NYHA functional class I–II and showed good effort tolerance. Conclusions: Results achieved with the three ablative procedures are comparable. Therefore lesser procedures viz. Left Atrial Maze and the Pulmonary Vein Isolation Maze procedures must be studied further with the additional use of antiarrhythmic drugs. [Copyright &y& Elsevier]

Advances in cardiovascular interventional techniques have allowed percutaneous treatment of conditions that either previously required open operations or have not been amenable to treatment. Conditions such as atrial and ventricular septal defects and patent foramen ovale are now amenable to percutaneous closure using implantable devices. A number of strategies have evolved to reduce the risk of stroke such as percutaneous occlusion of the left atrial appendage for patients in atrial fibrillation. Valvular heart disease and complications of its repair are approachable via the percutaneous route. Percutaneous pulmonary and aortic valve replacements have been performed in humans. There are evolving techniques for repair of the mitral valve and of prosthetic paravalvular leaks using devices such as the Amplatzer septal occluder to repair the defects without the need for repeat open heart surgery. Hypertrophic cardiomyopathy with left ventricular outflow tract obstruction can now be approached using alcohol septal ablation with results comparable to the surgical technique. These advances have occurred as a result of improvement in the design of the devices used as well as a better understanding of the pathophysiology of conditions. Many of these techniques are in evolution and in this paper we review some of the recent developments in this dynamic area of interventional cardiology. [Copyright &y& Elsevier]

We present a case of right pneumonectomy after induction chemotherapy complicated by a large bronchopleural fistula and empyema two weeks after surgery. The patient was treated surgically by transsternal transpericardial bronchopleural fistula closure and open window thoracoplasty. Thereafter, two new fistulae developed, one in the right main bronchial stump and one in the accessory tracheal bronchus. The two Amplatzer devices that were originally designed for transcatheter closure of cardiac defects were successfully used for closure of the bronchopleural fistulae. [Copyright &y& Elsevier]

Postoperative pulmonary hypertensive crisis (PHC) caused by an inverted left atrial appendage (ILAA) is a rare complication following cardiac surgery. We present a case of 23 day-old male infant who developed postoperative PHC attacks after undergoing cardiopulmonary bypass (CPB) surgery for repair of the coactation of aorta. A hyperechogenic left atrial mass was detected via bedside transthoracic echocardiography (TTE), which was identified as an ILAA and corrected following repeat surgery. In this case, both the negative pressure in vent catheter and the long left atrial appendage (LAA) with a narrow base led to an irreversible ILAA. As in this neonate, ILAA had significant influence on the left atrial volume and caused PHC since the ILAA was located on the mitral valve orifice and interfered with the blood flow through the valve. Therefore, we recommend that the vent catheter should be turned off before removing to avoid this potential complication. Additionally, LAA should be carefully inspected after CPB surgery, and intra-operative and post-operative transoesophageal echocardiography (TEE) should be performed to detect ILAA intraoperatively so as to avoid the reoperation. When an ILAA is diagnosed postoperatively, whether conservative treatment or surgery will depend on the balance of benefit and risk for a particular patient. [ABSTRACT FROM AUTHOR]

Peripheral cannulation for cardiopulmonary bypass is increasingly used for minimally invasive and re-operative cardiac surgery. Transoesophageal echo (TOE) is used routinely to guide placement of the peripheral venous cannula in the right atrium/superior vena cava (SVC). We here present a case where despite use of TOE, placement of the venous cannula led to perforation of the right ventricular apex. We describe the surgical management of the problem and highlight strategies to avoid this complication. [ABSTRACT FROM AUTHOR]

Use of percutaneous devices for closure of atrial septal defects (ASD) continues to increase owing to relative safety and ease of implementation compared with traditional surgical repair. Complications such as perforation and displacement requiring surgical intervention have been reported. We describe a case of perforation with intracardiac fistula formation, with an underlying mechanism likely to be similar to the few cases previously described, occurring during medium term follow up after ASD device closure. Appropriate case selection can reduce the incidence of this complication with caution taken in ASD cases with deficient aortic and superior rims. [Copyright &y& Elsevier]

Left internal mammary artery to pulmonary vasculature fistulas are rare complications following coronary artery bypass grafting surgery. In symptomatic cases, management may either be conservative, or involve coil embolisation or surgical ligation of the fistula. We describe a 52-year-old male patient who suffered from an acute coronary syndrome due to significant stenosis of the right coronary artery 12 years after coronary artery bypass grafting surgery. Coronary angiography accidentally revealed a fistulous connection between the left internal mammary artery and the left pulmonary vasculature. The patient underwent percutaneous coronary intervention for his right coronary artery and was managed conservatively for his fistula. [Copyright &y& Elsevier]