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ObjectivesThere is a lack of high-quality data informing the optimal antithrombotic drug strategy following bioprosthetic heart valve replacement or valve repair. Disparity in recommendations from international guidelines reflects this. This study aimed to document current patterns of antithrombotic prescribing after heart valve surgery in the United Kingdom.MethodsAll UK consultant cardiac surgeons were e-mailed a custom-designed survey. The use of oral anticoagulant (OAC) and/or antiplatelet drugs following bioprosthetic aortic (AVR) or mitral valve replacement (MVR), or mitral valve repair (MVrep), for patients in sinus rhythm, without additional indications for antithrombotic medication, was assessed. Additionally, we evaluated anticoagulant choice following MVrep in patients with atrial fibrillation (AF).ResultsWe identified 260 UK consultant cardiac surgeons from 36 units, of whom 103 (40%) responded, with 33 units (92%) having at least one respondent. The greatest consensus was for patients undergoing bioprosthetic AVR, in which 76% of surgeons favour initial antiplatelet therapy and 53% prescribe lifelong treatment. Only 8% recommend initial OAC. After bioprosthetic MVR, 48% of surgeons use an initial OAC strategy (versus 42% antiplatelet), with 66% subsequently prescribing lifelong antiplatelet therapy. After MVrep, recommendations were lifelong antiplatelet agent alone (34%) or following 3 months OAC (20%), no antithrombotic agent (20%), or 3 months OAC (16%). After MVrep for patients with established AF, surgeons recommend warfarin (38%), a direct oral anticoagulant (37%) or have no preference between the two (25%).ConclusionThere is considerable variation in the use of antithrombotic drugs after heart valve surgery in the UK. This reflects the lack of high-quality evidence and underscores the need for randomised studies.KEY MESSAGESWhat is already known on this topic?The most appropriate antithrombotic drug regime following bioprosthetic heart valve replacement or mitral valve repair is not known. Contemporary practice in the UK has not been established.What this study addsThis study demonstrates wide variation in antithrombotic drug choice and duration following bioprosthetic heart valve replacement or mitral valve repair in the UK.How this study might affect research, practice, or policyRandomised studies are required to assess the most appropriate antithrombotic strategy after heart valve surgery.

Objectives Cardiac surgery has evolved significantly since the turn of the century. The objective of this study was to investigate trends in cardiac surgery activity and outcomes in the United Kingdom utilizing a mandatory national cardiac surgical clinical database in the context of a comprehensive public health care system (ie, the UK National Health Service). Methods Data for all cardiac surgery procedures performed between 2002 and 2016 were extracted from the UK National Adult Cardiac Surgery Audit database. Data are validated and cleaned using reproducible algorithms. Trends in activity and outcomes were analyzed by fiscal year using linear regression. Results A total of 534,067 procedures were performed during the study period with the number of cases per year peaking in 2008/2009 at 41,426. Despite an increase in patient age and mean logistic European System for Cardiac Operative Risk Evaluation score, the in-hospital mortality rate for all cardiac surgery has fallen from 4.0% to 2.8% (P Conclusions This study, which covers all cardiac surgery procedures performed in the United Kingdom for fiscal years between 2002 and 2016, demonstrates that despite an increase in patient risk profile, there has been a consistent reduction in in-hospital mortality. A number of other markers associated with quality have also improved.

OBJECTIVES Since the turn of the century, cardiac surgery has evolved quite notably. This study sought to investigate the trends in aortic valve surgery activity and subsequent outcomes in the UK by using a mandatory national cardiac surgical clinical database within the context of a comprehensive public healthcare system (National Health Service). METHODS The UK National Adult Cardiac Surgery Audit database provided data for aortic valve surgery procedures performed between 2002 and 2016, and the data were validated and cleaned using reproducible algorithms. The findings and trends in in activity and outcomes were then analysed by financial year. RESULTS During the study period, a total of 148 862 procedures were performed, with the number of cases per year peaking in 2014/2015 at 12 483. The mean in-hospital mortality rate for all aortic valve surgery has fallen from 5.6% to 3.4%, despite an increase in patient age and mean logistic EuroSCORE. While the number of isolated aortic valve replacements has remained stable at around 5000 per year, aortic valve replacement and coronary artery bypass graft have increased to over 3200 with transcatheter aortic valve implantation activity continuing to increase. CONCLUSIONS This study demonstrates that despite an increase in patient risk profile, there has been a consistent reduction in in-hospital mortality within all aortic valve surgery procedures performed in the UK over a 15-year period. Increasing catheter-based interventions have not yet resulted in a significant decrease in surgical aortic valve replacements in the UK.

Background: Surgical repair of the mitral valve has long been the established therapy for degenerative mitral regurgitation (MR). Newer transcatheter methods over the last decade, such as the MitraClip, serve to restore mitral function with reduced procedural burden and enhanced recovery. This study aims to compare the shortterm and midterm outcomes of MitraClip insertion with surgical repair for MR. Methods: A systematic review of the literature was conducted for studies comparing outcomes between surgical repair and MitraClip. The initial search returned 1850 titles, from which 12 studies satisfied the inclusion criteria (one randomized controlled trial and 11 retrospective studies). Results: The final analysis comprised 4219 patients (MitraClip 1210; surgery 3009). Operative mortality was not different between the groups (odds ratio [OR] = 1.63, 95% confidence interval [CI]: [0.63−4.23]; p = .317). Length of hospital stay was significantly shorter in the MitraClip group (standardized mean difference [SMD] = 0.882, 95% CI: [0.77–0.99]; p 90%; p

OBJECTIVES The objective was to review national trends in activity and hospital outcomes in older patients having cardiac surgery over a 15-year time period. METHODS Data were collected prospectively and uploaded to the National Institute for Cardiovascular Outcomes Research electronically. Data were validated, cleaned and processed using reproducible algorithms. Mortality was death in hospital after index operation. RESULTS A total of 227 442 cardiac procedures were recorded in patients aged ≥70 years of which 46 354 were in those aged ≥80 years. Overall patients aged ≥70 years represented 43% of all adult cardiac surgery in the most recent study year. The annual proportion of surgery in patients ≥80 years increased from 4.1% to 10.8% between the first and last study years. There has been a significant linear increase in octogenarian valve [β 67.44, 95% confidence interval (CI) 55.04 to 79.83, P CONCLUSIONS This study represents the largest complete validated national dataset of cardiac surgery in the entire population of older patients. Octogenarians represent 11% of adult patients having cardiac surgery by the end of the study period, a three-fold increase from the start. In-hospital mortality in patients aged ≥80 years halved during study period to only 4% despite high logistic EuroSCORE of 15%. Cardiac surgery in octogenarians places a higher demand on resources, however, with an increased postoperative length of stay.

Background Multiple industries and organisations are afflicted by and respond to institutional crises daily. As surgeons, we respond to crisis frequently and individually such as with critically unwell patients or in mass casualty scenarios; but rarely, do we encounter institutional or multi-institutional crisis with multiple actors as we have seen with the COVID-19 pan-demic. Businesses, private industry and the financial sector have been in a more precar-ious position regarding crisis and consequently have developed rapid response strate-gies employing foresight to reduce risk to assets and financial liquidity. Moreover, large nationalised governmental organisations such as the military have strategies in place ow-ing to a rapidly evolving geopolitical climate with the expectation of immediate new chal-lenges either in the negotiating room or indeed the field of conflict. Despite both nation-alised and privatised healthcare systems existing, both appeared ill-prepared for the COVID-19 global crisis. Methods A narrative review of the literature was undertaken exploring the approach to crisis man-agement and models used in organisations exposed to institutional crises outside the field of medicine. Results There are many parallels between the organisational management of private business institutions, large military organisations and surgical organisational management in healthcare. Models from management consultancies and the armed forces were ex-plored discussed and adapted for the surgical leader providing a framework through which the surgical leader can bring about an successful response to an institutional crisis and ensure future resilience. Conclusion We believe that healthcare, and surgeons (as leaders) in particular, can learn from these other organisations and industries to engage appropriate generic operational plans and contingencies in preparation for whatever further crises may arise in the future, both near and distant. As such, following a review of the literature, we have explored a number of models we believe are adaptable for the surgical community to ensure we remain a dy-namically responsive and ever prepared profession.

OBJECTIVES The aim of this study was to review the UK national trends in activity and outcome in coronary artery bypass graft (CABG) over a 15-year period (2002–2016). METHODS Validated data collected (2002–2016) and uploaded to National Institute for Cardiovascular Outcomes Research were used to generate summary data from the National Adult Cardiac Surgery Audit Database for the analysis. Logistic European System of Cardiac Operative Risk Evaluation was used for risk stratification with recalibration applied for governance. Data were analysed by financial year and presented as numerical, categorical, %, mean and standard deviation where appropriate. Mortality was recorded as death in hospital at any time after index CABG operation. RESULTS A total of 347 626 CABG procedures (282 883 isolated CABG, 61 109 CABG and valve and 4132 redo CABG) were recorded. Over this period annual activity reduced from 66.6% of workload to 41.7%. The mean age for isolated CABG was 65.7 years. The mean log European System of Cardiac Operative Risk Evaluation was 3.1, 5.9 and 23.2 for elective, urgent and emergency isolated CABG, respectively. There was a decline in the observed mortality for all procedures. Overall mortality for isolated CABG surgery is now 1.0% and only 0.6% for elective operations. CONCLUSIONS Quality of care and risk-adjusted mortality rates have consistently improved over the last 15 years despite the increasing risk profile of patients. There have been a consistent decline in overall case volumes and a three-fold increase in elderly cases.

OBJECTIVES Mitral and tricuspid ring annuloplasty dehiscence with consequent recurrent valve regurgitation is a rare but challenging procedural failure. The incidence and predisposing risk factors for annuloplasty ring dehiscence include technical and pathological ones. METHODS A systematic database search with pooled analysis was conducted of original articles that only included dehiscence rate of mitral and tricuspid ring in EMBASE, MEDLINE, Cochrane database and Google Scholar, from inception to November 2020. The outcomes included were dehiscence rate in mitral and tricuspid, type of ring implanted, dehiscence rate by pathology and by ring size and shape. RESULTS Our search yielded 821 relevant studies. Thirty-three studies met the inclusion criteria with a total of 10 340 patients (6543 mitral, 1414 tricuspid) of which 87 (mitral) and 30 (tricuspid) had dehiscence. Overall, dehiscence rate was 1.43%, diagnosed at a median of 4.5 ± 1.0 months postoperatively. A significant difference in mitral dehiscence rate was found by ring type (semi-rigid 1.86%, rigid 2.32%; flexible 0.43%; P CONCLUSIONS Although rigid, semi-rigid and flexible annuloplasty rings provide acceptable valve repair outcomes, mitral annuloplasty ring dehiscence is clinically more common among rigid rings. Understanding the multifactorial nature of ring dehiscence will help in identifying the patients at high risk and improve their clinical outcomes.

OBJECTIVES The risk of brain injury following surgery for type A aortic dissection (TAAD) remains substantial and no consensus has still been reached on which neuroprotective technique should be preferred. We aimed to investigate the association between neuroprotective strategies and clinical outcomes following TAAD repair. METHODS Using the UK National Adult Cardiac Surgical Audit, we identified 1929 patients undergoing surgery for TAAD (2011–2018). Deep hypothermic circulatory arrest (DHCA) only, unilateral (uACP), bilateral antegrade cerebral perfusion (bACP) and retrograde cerebral perfusion were used in 830, 117, 760 and 222 patients, respectively. The primary end point was a composite of death and/or cerebrovascular accident (CVA). Generalized linear mixed model was used to adjust the effect of neuroprotective strategies for other confounders. RESULTS The use of bACP was associated with longer circulatory arrest (CA) compared to other strategies. There was a trend towards lower incidence of death and/or CVA using uACP only for shorter CA. In particular, primary end point rate was 27.7% overall and 26.5%, 12.5%, 28.0% and 22.9% for CA, Management of type A acute aortic dissection (TAAD) remains a challenge.

BackgroundNo firm recommendations are currently available to guide decision making for patients requiring cardiac surgery during the COVID-19 pandemic. Systematic appraisal of national expert consensus can be used to generate interim recommendations until data from clinical observations will become available. Hence, we aimed to collect and quantitatively appraise nationwide UK senior surgeons’ opinion on clinical decision making for patients requiring cardiac surgery during the COVID-19 pandemic.MethodsWe mailed a web-based questionnaire to all consultant cardiac surgeons through the Society for Cardiothoracic Surgery in Great Britain and Ireland (SCTS) mailing list on the 17th April 2020 and we pre-determined to close the survey on the 21st April 2020. This survey was primarily designed to gather information on UK surgeons’ opinion using 12 items. Strong consensus was predefined as an opinion shared by at least 60% of responding consultants.ResultsA total of 86 consultant surgeons undertook the survey. All UK cardiac units were represented by at least one consultant. Strong consensus was achieved for the following key questions:1) before hospital admission every patient should receive nasopharyngeal swab, PCR and chest CT; 2) the use of full PPE should to be adopted in every case by the theatre team regardless patient’s COVID-19 status; 3) the risk of COVID-19 exposure for patients undergoing heart surgery should be considered moderate to high and likely to increase mortality if it occurs; 4) cardiac procedure should be decided based on ad-hoc multidisciplinary team discussion for every patient. The majority believed that both aortic and mitral surgery should be considered in selected cases. The role of CABG surgery during the pandemic was more controversial.ConclusionsIn the current unprecedented scenario, the present survey provides information for generating interim recommendations until data from clinical observations will become available.Perspective statementSystematic appraisal of national expert consensus can be used to generate interim recommendations for patients undergoing cardiac surgery during COVID-19 pandemic until data from clinical observations will become available.Central messageNo firm recommendations are currently available to guide decision making for patients requiring cardiac surgery during the pandemic. This can translate into significant variability in clinical practice and patients’ outcomes across cardiac units. Systematic appraisal of national expert consensus can represent a rapid and efficient instrument to provide support to heath policy makers and other stakeholders in generating interim recommendations until data from clinical observations will become available.

The purpose of this document is to update the existing joint British Societies recommendations on multidisciplinary meetings (MDMs) published in 2015 to reflect changes in practice. We aim to provide guidance on the structure and function of MDMs which should be taking place in every cardiac surgical centre. Out of scope are MDMs that do not require the routine presence of a cardiac surgeon such as electrophysiology MDMs and those which are not provided in every centre, such as complex aortic surgery.

ObjectivesTo date the reported outcomes of surgical aortic valve replacement (SAVR) are mainly in the settings of trials comparing it with evolving transcatheter aortic valve implantation. We set out to examine characteristics and outcomes in people who underwent SAVR reflecting a national cohort and therefore ‘real-world’ practice.DesignRetrospective analysis of prospectively collected data of consecutive people who underwent SAVR with or without coronary artery bypass graft (CABG) surgery between April 2013 and March 2018 in the UK. This included elective, urgent and emergency operations. Participants’ demographics, preoperative risk factors, operative data, in-hospital mortality, postoperative complications and effect of the addition of CABG to SAVR were analysed.Setting27 (90%) tertiary cardiac surgical centres in the UK submitted their data for analysis.Participants31 277 people with AVR were identified. 19 670 (62.9%) had only SAVR and 11 607 (37.1%) had AVR+CABG.ResultsIn-hospital mortality for isolated SAVR was 1.9% (95% CI 1.6% to 2.1%) and was 2.4% for AVR+CABG. Mortality by age category for SAVR only were: 75 years=2.2%. For SAVR+CABG these were; 2.2%, 1.8% and 3.1%. For different categories of EuroSCORE, mortality for SAVR in low risk people was 1.3%, in intermediate risk 1% and for high risk 3.9%. 74.3% of the operations were elective, 24% urgent and 1.7% emergency/salvage. The incidences of resternotomy for bleeding and stroke were 3.9% and 1.1%, respectively. Multivariable analyses provided no evidence that concomitant CABG influenced outcome. However, urgency of the operation, poor ventricular function, higher EuroSCORE and longer cross clamp and cardiopulmonary bypass times adversely affected outcomes.ConclusionsSurgical SAVR±CABG has low mortality risk and a low level of complications in the UK in people of all ages and risk factors. These results should inform consideration of treatment options in people with aortic valve disease.

Background Little is known about variations in care and outcomes of patients undergoing surgical repair for type A aortic dissection(TAAD). We aim to investigate decade-long trends in TAAD surgical repair in England. Methods Retrospective review of the National Adult Cardiac Surgery Audit, which prospectively collects demographic and peri‑operative information for all major adult cardiac surgery procedures performed in the UK. We identified patients undergoing surgery for TAAD from January 2009-December 2018, reviewed trends in operative frequency, patient demographics, and mortality. Findings Over the 10-year period,3,680 TAAD patients underwent surgical repair in England. A doubling in the overall number of operations conducted in England was observed (235 cases in 2009 to 510 in 2018). Number of procedures per hospital per year also doubled(9 in 2009 to 23 in 2018). Overall, in-hospital mortality was 17.4% with a trend toward lower mortality in recent years(23% in 2009 to 14.7% in 2018). There was a significant variation in operative mortality between hospitals and surgeons. We also found that most patients presented towards the middle of the week and during winter. Interpretation Surgery is the only treatment for acute TAAD but is associated with high mortality. Prompt diagnosis and referral to a specialist center is paramount. The number of operations conducted in England has doubled in 10 years and the associated survival has improved. Variations exist in service provision with a trend towards better survival in high volume centers. Funding British Heart Foundation and NIHR Biomedical Research center(University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol).

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was should limb revascularization take priority over dissection repair in acute type A aortic dissection (ATAAD) presenting as isolated acute limb ischaemia? Altogether 133 papers were found using the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Six studies showed that aortic repair alone resulted in the reperfusion of 60-100% of ischaemic lower limbs and recommended a strategy prioritizing aortic repair. In those with persistent isolated limb ischaemia post-aortic repair, expeditious peripheral revascularization procedures produced excellent patient outcomes comparable to those of ATAAD patients without malperfusion syndromes. In the remaining study, aortic repair was delayed in order to prioritize percutaneous reperfusion therapy aimed at treating the peripheral malperfusion. However, this resulted in one-third of patients not surviving to aortic surgery. We conclude that delaying aortic repair for limb reperfusion procedures results in unacceptably high mortality rates and that repair alone results in high reperfusion rates of ischaemic limbs. We therefore strongly recommend that aortic repair be the primary therapy for ATAAD patients even when limb ischaemia is the presenting feature. Limbs should be reassessed immediately after aortic repair and revascularization procedures undertaken urgently if any pulse deficits remain.

OBJECTIVES The first transcatheter aortic valve implantation (TAVI) in England and Wales was performed in 2007. This study presents the subsequent national activity and outcomes for both TAVI and aortic valve replacement (AVR). METHODS Data for all AVR and TAVI procedures between January 2006 and December 2012 in England and Wales were included. The number of procedures, patient characteristics, in-hospital and 30-day mortality, postoperative length of stay (PLOS) and survival were analysed separately for: isolated AVR; AVR + coronary artery bypass graft (CABG) surgery; AVR + other surgery and TAVI. RESULTS The number of TAVIs increased from 66 in 2007 (0.8% of all implants) to 1186 in 2012 (10.9% of all implants). AVR activity also increased over the study period. TAVI patients were older and had a higher mean logistic EuroSCORE than all AVR groups. The 30-day mortality rates were 2.1% for isolated AVR, 3.9% for AVR + CABG, 7.7% for AVR + other surgery and 6.2% for TAVI. In-hospital mortality has significantly improved for all groups. The 5-year survival rates were 82.6% for isolated AVR, 81.7% for AVR + CABG, 74.5% for AVR + other surgery and 46.1% for TAVI. The median PLOS after TAVI was similar to that of isolated AVR but shorter than that of the other AVR groups. CONCLUSIONS Since the introduction of TAVI, there has been an increase in both TAVI and AVR activity. TAVIs now represent over 10% of all aortic valve implants. There are distinct differences between procedural groups with respect to patient risk factors. Outcomes for all procedural groups have improved, but long-term TAVI results are required before its role in the treatment of aortic stenosis can be fully defined.

Background— The calibration of several cardiac clinical prediction models has deteriorated over time. We compare different model fitting approaches for in-hospital mortality after cardiac surgery that adjust for cross-sectional case mix in a heterogeneous patient population. Methods and Results— Data from >300 000 consecutive cardiac surgery procedures performed at all National Health Service and some private hospitals in England and Wales between April 2001 and March 2011 were extracted from the National Institute for Cardiovascular Outcomes Research clinical registry. The study outcome was in-hospital mortality. Model approaches included not updating, periodic refitting, rolling window, and dynamic logistic regression. Covariate adjustment was made in each model using variables included in the logistic European System for Cardiac Operative Risk Evaluation model. The association between in-hospital mortality and some variables changed with time. Notably, the intercept coefficient has been steadily decreasing during the study period, consistent with decreasing observed mortality. Some risk factors, such as operative urgency and postinfarct ventricular septal defect, have been relatively stable over time, whereas other risk factors, such as left ventricular function and surgery on the thoracic aorta, have been associated with lower risk relative to the static model. Conclusions— Dynamic models or periodic model refitting is necessary to counteract calibration drift. A dynamic modeling framework that uses contemporary and available historic data can provide a continuously smooth update mechanism that also allows for inferences to be made on individual risk factors. Better models that withstand the effects of time give advantages for governance, quality improvement, and patient-level decision making.

For ease of use and to aid precision, left-handed instruments are invaluable to the left-handed surgeon. Although they exist, they are not available in many surgical centres. As a result, most operating theatre staff (including many left-handers) have little knowledge of their value or even application. With specific reference to cardiac surgery, this article addresses the ways in which they differ, why they are needed and what is required - with tips on use. Electronic supplementary material The online version of this article (doi:10.1186/s13019-016-0497-9) contains supplementary material, which is available to authorized users.

We report the early failure of two tissue valves within hours of surgery due to the accumulation of cellular debris in two different institutions in the United Kingdom. The valves were both found at explant to be covered in a cellular material - possibly fibrin. From clinical experience and careful review of the literature we have found no other reports of such early valve failure due to the build up of material on the structure of the valve. This rare occurrence needs to be reported in the literature to forewarn clinicians of an early complication that may not be recognized yet.

Background We investigated the long-term outcome of coronary artery bypass grafting both in terms of survival and quality of life. Methods Ten-year postsurgery survival was collated on patients undergoing coronary artery bypass grafting from 1994 to 1996, and quality of life was assessed using EQ-5D and a quality-of-life thermometer. We analyzed data from 1,180 patients. Mean age was 61 years, and 79% had triple-vessel disease. Results Thirty-day mortality was 3.3% (1.8% elective). Mean time to censorship for survivors was 9.9 years (range, 8.1 to 12.3 years). Ten-year survival was 66% across all patients, 70% for elective patients. Ten-year cardiac survival was 82%. Percutaneous intervention was required in 25 patients in the subsequent 10 years (2%), and only 4 required redo coronary artery bypass grafting (0.3%); 59% of patients reported no angina, and 88% of patients had grade II angina or better. Of 621 patients who were assessed for quality of life at 10 years, 530 (85%) had a quality of life within a 95% confidence interval of the score found in the general population with similar age. Poor quality of life was reported in 91 patients (14.7%). Significant predictors of poor long-term quality of life were current smoking, Canadian Cardiovascular Society grade III or IV, redo operation, female sex, diabetes, peripheral vascular disease, more than 2 days in intensive care, and chronic obstructive pulmonary disease. Twenty-five percent of patients with poor EQ-5D outcome had grade IV angina. Interestingly, age did not correlate with poor outcome, and administration of blood, arterial revascularization, left mainstem disease, or cross-clamp fibrillation had no impact on survival or outcome. Conclusions Coronary artery bypass grafting is associated with excellent 10-year survival and quality of life.

For ease of use and to aid precision, left-handed instruments are invaluable to the left-handed surgeon. Although they exist, they are not available in many surgical centres. As a result, most operating theatre staff (including many left-handers) have little knowledge of their value or even application.

OBJECTIVES Sternal stability is essential to prevent serious infective complications after sternotomy. This paper examines whether nitinol thermoreactive clips reduce sternal wound infection rates in obese patients [body mass index (BMI) ≥30] compared with sternal wires. METHODS All patients with BMI ≥30 undergoing cardiac surgery via median sternotomy between February 2008 and February 2013 in our institution were divided into two groups depending on sternal closure technique-sternal wires or thermoreactive clips. Comparison was made using propensity-matched analysis with sternal wound infection as the primary outcome. RESULTS Of 1371 patients, 826 (60%) had thermoreactive clips and 545 (40%) sternal wires. The sternal wires group was older (mean age 66.62 ± 10.1 vs 64.35 ± 9.8 years, P = 0.00) with a greater proportion of females (39 vs 26%, P = 0.00). In unmatched group comparison, both superficial sternal wound infection (thermoreactive clips 4% vs wires 3%) and deep infection (thermoreactive clips 3% vs wires 0.6%, P = 0.00) were more common in the thermoreactive clips group. More patients in the thermoreactive clips group required debridement and a larger number had vacuum-assisted closure [thermoreactive clips 10 patients (1%) vs sternal wires 2 (0.4%)]. Propensity-matching yielded two groups of 356 patients. There was no difference in sternal wound infection rates [thermoreactive clips 19 patients (5%) vs sternal wires 15 (4%), P = 0.58] or deep sternal infection rates [thermoreactive clips 9 patients (3%) vs sternal wires 3 (1%), P = 0.11]. CONCLUSIONS Thermoreactive clips did not have an advantage in the prevention of superficial or deep sternal wound infection in obese patients undergoing sternotomy.

Minimally invasive surgical approaches for aortic valve replacement (AVR) are growing in popularity in an attempt to decrease morbidity from conventional surgery. We have adopted a technique that divides only the manubrium and spares the body of the sternum. We sought to determine whether patients benefit from this less-invasive approach.We retrospectively analysed our prospectively maintained database to review all isolated aortic valve replacements performed in an 18-month period from November 2011 to April 2013.One hundred and ninety-one patients were identified, 98 underwent manubrium-limited sternotomy (Mini-AVR) and 93 had a conventional median sternotomy (AVR). The two groups were well matched for preoperative variables and risk (mean logistic EuroSCORE mini-AVR 7.15 vs AVR 6.55, P = 0.47). Mean cardiopulmonary bypass and aortic cross-clamp times were 10 and 6 min longer, respectively, in the mini-AVR group (mean values 88 vs 78 min, P = 0.00040, and 66 vs 60 min, P = 0.0078, respectively). Mini-AVR patients had significantly less postoperative blood loss, 332 vs 513 ml, P = 0.00021, and were less likely to require blood products (fresh-frozen plasma and platelets), 24 vs 36%, P = 0.042. Postoperative complications and length of stay were similar (discharge on or before Day 4; mini-AVR 15 vs AVR 8%, P = 0.17). Valve outcome (paravalvular leak mini-AVR 2 vs AVR 1%, P = 1.00) and survival (mini-AVR 99 vs AVR 97%, P = 0.36) were equal.A manubrium-limited approach maintains outcomes achieved for aortic valve replacement by conventional sternotomy while significantly reducing postoperative blood loss and transfusion of blood products.

s / International Journal of Surgery 11 (2013) 589e685 613 ABSTRACTS Conclusion: The results were accessible, useable and reliable, shown by the LIDA tool. The information required a high level of education, shown by the Gunning-Fog Index and Flesch Readability Score. The best three websites for patient self-education about mitral valve replacement are: http://www.drugs.com/cg/mitral-valve-replacementinpatient-care.html, http://www.nhs.uk/conditions/Aorticvalvereplace ment/Pages/Whatisitpage.aspx, http://www.bhf.org.uk/heart-health/ treatments/valve-heart-surgery.aspx 0683: STARTING & EVALUATING A ROBOT-ASSISTED VATS PROGRAMME: PILOT PHASE Sandra Gelvez-Zapata, Maral Rouhani, Rachel Kuo, Priya Sastry, Aman S. Coonar. Papaworth Hospital, Cambridge, UK. Aim: The Freehand TM robot scope holder has been recently released. We sought to assess the feasibility of implementing and using this robotassisted telescope holder in VATS. This is first use in thoracic surgery. Methods: Following dry-lab training of the consultant and theatre team by an experienced trainer we introduced the system into the operating room. Non-lobectomy patients were considered for robot-assisted VATS (RVATS). 27 consecutive VATS patients were selected. 22 procedures were completed by R-VATS. The procedures were 9 wedge resections, 7 pneumothorax, 2 lung volume resections (LVRS), 3 empyema and 1 pleurectomy for mesothelioma. Results: Surgical time (including on table-robot positioning): 50 115 min (mean 82). Total operating room time (including robot set-up/take down): 65 140min (mean 111). R-VATcases by consultant with assistant available but hands-off: 21/22. R-VAT cases by trainee with consultant scrubbed:1/ 22 Conclusions: Dry-lab preparation allowed robot position to be optimized. Implementation was rapid and safe. Consideration of robot placement and port position is critical. The robot gave a stable, non-wandering view. Assistants observed the procedure, but were not required to participate. Since these procedures can be conducted by a single operator there are manpower implications. Operative and theatre times are acceptable. 0801: THERMO-REACTIVE CLIPS DO NOT PREVENT STERNAL WOUND INFECTION IN OBESE PATIENTS AFTER CARDIAC SURGERY Clare Burdett, Simon Kendall, Joel Dunning, Andrew Owens, Andrew Goodwin, Steve Hunter, Jonathan Ferguson, Tracey Smailes, Cheng-Hon Yap, Enoch Akowuah. James Cook University Hospital

A 25-year-old man presented with acute pleuritic chest pain and dyspnoea with type I respiratory failure. Past medical history comprised of mild asthma and surgical correction of pectus excavatum 9 years prior by elevation of the sternum and stabilization over a Lorenz Pectus bar. Examination demonstrated tachypnoea, pan-systolic murmur at the left lower sternal edge and giant V-wave jugular venous …

Preoperative investigation in adult cardiac surgery assesses the indication for surgery, allows the clinician to inform the patient of the risks and benefits of surgery and indicates the timing of surgery. This contribution aims to provide a review of the common investigations for adults undergoing cardiac surgery.

We present an unusual complication caused by a dialysis catheter inserted through the internal jugular vein into the central venous system. The 49-year-old male patient developed a right atrial thrombus, which became infected with Staphylococcus aureus, resulting in septic pulmonary embolism and septicemic shock. The thrombus was excised on cardiopulmonary bypass. The patient made an uneventful recovery.

Aims We sought to assess the haemodynamic profile of the Freedom stentless aortic valve compared with a stented bioprosthesis in a randomized controlled trial using echocardiography. Methods and results Sixty patients (mean age 73 years) undergoing bioprosthetic aortic valve replacement (AVR) were randomized to either Sorin Freedom stentless ( n = 31) or Sorin More stented ( n = 29) valves. The primary endpoints were left ventricular mass index (LVMI) reduction at 6 and 12-months. We also assessed post-operative effective orifice area index (EOAI), aortic gradient and operative time. There were no significant differences in baseline characteristics. The stentless valve was associated with a lower post-operative gradient [PG 17 (12) vs. 31 (13) mmHg, P < 0.0001] and greater EOAI [1.1 (0.3) vs. 0.8 (0.2) cm2/m2, P < 0.0001]. A highly significant reduction in LVMI occurred by 6 months in both groups, but LVMI was significantly lower in the stentless group [LVMI 119 (39) vs. 135 (30) g/m2, P = 0.05]. However, there was continued regression of left ventricular hypertrophy (LVH) in the stented but not in the stentless group, resulting in no significant difference in LVMI at 12 months [119 (36) vs. 126 (31) g/m2, P = 0.42]. Conclusion The use of the Sorin Freedom stentless bioprosthesis for AVR results in lower PG and greater EOA when compared with a Sorin More stented valve. This is associated with earlier regression of LVH.

Objective: Currentdrug treatment for atrialfibrillationis suboptimaland percutaneous catheter-based ablation techniques may be associated with complications. The aim of this study is to assess the cost-effectiveness of (1) high-intensity focused ultrasound (HIFU)-assisted surgical ablation,(2) the classic ‘cutand sew’maze procedure and(3) percutaneous ablation, all concomitant to cardiac surgery(e.g. CABG, valverepair) in comparison with non-interventional (drug) treatment. Methods: A Markov model was developed to predict the cost-effectiveness of the interventional approaches. The model consisted of four disease states (sinus rhythm without complications, atrial fibrillation without complications, stroke and death), allowing for 3-monthly transitions between these states and using direct UK costs from the National Health Service perspective. Clinical input data are obtained from literature and cost input data from National Health Service sources and literature. Five-year total and incremental costs are calculated. Incremental effects are expressed in quality-adjusted-life-years-gained (QALYG). Results: All interventional treatments show good incremental cost-effectiveness ratios in all atrial fibrillation types, compared to drug treatment. For classic maze the incremental cost-effectiveness ratio compared to non-interventional atrial fibrillation treatment varies from 1343 to 3471 GBP/ QALYG, for HIFU-assisted surgical ablation from 4005 to 7448 GBP/QALYG and for percutaneous ablation from 7041 to 17,372 GBP/QALYG depending on the atrial fibrillation type. Sensitivity analyses showed the robustness of the data. Conclusions: Performing a classic maze procedure or HIFU-assisted surgical ablation concomitant to a scheduled CABG or valve procedure is highly cost-effective. Performing a percutaneous ablation in a subsequent procedure is also cost-effective, but to a lower extent. Both the maze procedure and the HIFU-assisted surgical ablation are cheaper and more effective than percutaneous ablation in a subsequent procedure. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Stentless aortic bioprostheses have been advocated as being superior to conventional bioprosthetic valves, with benefits including superior left ventricular mass regression and larger effective orifice area. Several high-quality randomized studies now exist on this topic, and we sought to summarize them by meta-analysis.The literature was searched from 1995 to 2006, in MEDLINE, EMBASE, CRISP, metaRegister of Controlled Trials, and the Cochrane database. Experts were also contacted and reference lists searched. Studies were combined using the inverse variance fixed-effects model. Heterogeneity was assessed and a sensitivity analysis performed. Publication bias was also investigated.Ten studies were identified that included 919 patients in which the Freedom (Sorin Biomedica Cardio, Via Crescentino, Italy), Freestyle (Medtronic, Minneapolis, MN), Prima Plus (Edwards Life Sciences, Irvine, CA) and the Toronto and Biocor (St Jude Medical, St. Paul, MN) valves were used. The mean aortic valve gradient was lower in the stentless groups, with a weighted mean difference (WMD) of -3.57 mm Hg (95% confidence interval [CI], -4.36 to -2.78; p0.01). The left ventricular mass index was significantly lower in the stentless groups at 6 months (WMD, -6.42; 95% CI, -11.63 to -1.21; p = 0.02), but this improvement disappeared after 12 months (WMD, 1.19; 95% CI, -4.15 to 6.53; p = 0.66). The weighted mean increase in cross-clamp time was 23 minutes, and the increase in bypass time was 29 minutes with a stentless valve.This meta-analysis showed that stentless aortic valves provide an improved level of left ventricular mass regression at 6 months, reduced aortic gradients, and an improved effective orifice area index, at the expense of a 23-minute longer cross-clamp time and a 29-minute longer bypass time.

Objective: Following cardiac surgery, patients are transferred from the operating theatre to intensive care. This clinical environment has one nurse per patient and facilities for mechanical ventilation. Patients are kept in this setting until the following day. This practice has been challenged with early extubation of patients. At our institution we have established a fast-track policy including the following features: (1) patient selection; (2) operating list scheduling with fast-track patients first; (3) anaesthetic tailored to early extubation; (4) methodical procedure with warm cardiopulmonary bypass; (5) removal of the arterial line; (6) transfer from intensive care to a separate high dependency unit (‘step-down’) on the day of operation, where the ratio of nurse to patient is one to three and there are no ventilatory facilities and no invasive monitoring; or (7) to keep these patients on ICU but decrease the nurse to patient ratio. Method: The case notes of 572 patients who predominantly had myocardial revascularisation, undergoing this process from July 1996 to July 2000 at our institution were reviewed. Results: Mean EUROSCORE for the study group was 1.42. The 30-day mortality rate for the study group was 0.34%, mean intensive care time was 5 h 52 min, mean time to extubation was 3 h 10 min, mean readmission rate to intensive care was 0.34% and mean hospital stay from day of operation (inclusive) was 5.65 days. This process increased our throughput by 14.6% (compared to standard practices). Comment: This study demonstrates that transfer of appropriate patients to a high dependency area from intensive care following cardiac surgery is safe. It allows intensive care beds to be used by more than one patient each day and allows significant cost savings by reducing the nursing ratio per patient. q 2003 Elsevier B.V. All rights reserved.

Over 6 years of a single surgeon experience, 3 patients had left ventricle rupture following mitral valve replacement, despite preserving the posterior leaflet. The valve was re-replaced on bypass in all patients. Intraaortic balloon pump was inserted electively before coming off bypass. There were no intraoperative deaths, reexploration, or excessive bleeding. An intraaortic balloon pump is an ideal adjuvant to left ventricle repair for ruptured ventricle following mitral valve replacement on cardiopulmonary bypass.

A 14-year-old white boy presented with syncope and a left carotid bruit. Arch aortogram showed narrowing of the distal aortic arch, left carotid stenosis, and small left subclavian and vertebral arteries. When aortic arch replacement was carried out a vertical septum was found in the distal arch. Histologic examination suggested this was ductal in origin.

Background . Valve durability has been a major concern with bioprostheses, and the Tissuemed (Aspire) porcine bioprosthesis was designed to provide a solution to structural valve failure. Because bioprostheses tend to fail by 8 years, the aim of our study was to determine its midterm durability and performance. Methods . We reviewed 506 prostheses that were implanted in 493 patients (287 men; mean age 73 ± 6 years) between 1991 and 1999. Preoperatively 316 (68%) patients were in New York Heart Association class III or IV. There were 417 (85%) aortic, 61 (12%) mitral, 13 (2.6%) aortic and mitral, and two (0.4%) tricuspid procedures. Concomitant procedures were performed in 163 (33%) patients. Follow-up was complete in 488 (98.9%) patients with a total cumulative follow-up of 1,402 patient-years. Results . The 30-day mortality in this elderly population was 10% (95% confidence interval, 8 to 13), with no early valve-related deaths. Patients' survival at 8 years was 46% ± 7%. This was influenced by the following factors: (1) the patient's age, being worse for those 70 years or older ( p = 0.005); (2) those in New York Heart Association functional class III and IV ( p = 0.004); (3) those in atrial fibrillation before the operation ( p = 0.006); (4) those with poor left ventricular function ( p = 0.009); and (5) those who had a previous cardiac operation ( p = 0.003). Valve-related complications (expressed as percent per patient-year) were thromboembolism at 0.9%/patient-year; major hemorrhage at 1.4%/patient-year; bacterial endocarditis at 0.4%/patient-year; nonstructural dysfunction at 0.2%/patient-year, and reoperation at 0.2%/patient-year. At 8 years, freedom from thromboembolism was 93% ± 7%, major hemorrhage, 90% ± 4%, nonstructural dysfunction, 99% ± 1%, structural valve failure, 100%, and reoperation, 99% ± 1%. At follow-up, 98% of survivors were in New York Heart Association class I or II. Conclusions . Our study suggests that at 8 years, the Tissuemed (Aspire) porcine bioprosthesis is durable and has satisfactory performance with low complication rates.

Here we describe an unusual case of giant cell myocarditis (GCM) found in the left atrial appendage. Giant cell myocarditis is a rare entity in itself, while isolated left atrial GCM has only been reported on a few occasions. We describe a patient who underwent mitral valve replacement for rheumatic mitral stenosis and excision of a grossly abnormal, thickened, and enlarged left atrial appendage. Histological examination confirmed the presence of GCM.

Objectives: To evaluate the role of routine chest X-rays in the management of patients post cardiac surgery. Methods: 340 adult patients undergoing cardiac surgery were studied in three consecutive groups (A, B, C) of 100 patients each. Forty patients were excluded due to the intensive care stay greater than 36 h (n= 35), or early mortality within 36 h (n = 5). Chest X-rays were performed according to three different protocols. in Groups A and B. In group C there were no routine chest X-rays during the entire postoperative period. In all three groups chest X-rays were performed where clinically indicated. Group A had three routine chest X-rays post-operation. Group B had one routine chest X-ray on day 4 post-operation. Group C had chest X-rays only when indicated. The X-rays were evaluated in terms of their assistance value and the resultant number of interventions. Results: The three groups were similar preoperatively for age, sex, preoperative left ventricular function, presence of chronic obstructive airway disease and type of operation performed. The total number of chest X-rays in groups A, B and C were 304, 133 and 36, respectively. The number of chest X-rays leading to interventions were five, four and four in groups A, B and C, respectively. Chest X-rays that helped in management were 36, 28, and 28, respectively, in the same groups. There was no mortality or morbidity attributable to non-performance of routine chest X-ray. Conclusions: Routine chest X-rays post-cardiac surgery are of very little value and patients are adequately managed by performing chest X-rays only when clinically indicated. There was no increased mortality or morbidity attributed to lack of routine chest X-rays in any of these groups. We recommend performing chest X-rays only when clinically indicated in satisfactorily recovering adult cardiac surgical patients.