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Proning patients with acute respiratory distress syndrome (ARDS) has been associated with increased survival, although few data exist evaluating the safety and feasibility of proning patients with ARDS on extracorporeal membrane oxygenation (ECMO).A single-institution retrospective review of all patients with ARDS placed on ECMO between March 1 and May 31, 2020, was performed. All proning events were evaluated for complications, as well as change in compliance, sweep, oxygenation, and flow. The primary outcome of this study was the rate major morbidity associated with proning while on ECMO.In total, 30 patients were placed on ECMO for ARDS, with 12 patients (40%) proned while on ECMO. A total of 83 proning episodes occurred, with a median of 7 per patient (interquartile range, 3-9). No ECMO cannula-associated bleeding, cannula displacement, or endotracheal tune dislodgements occurred (0%). Oropharyngeal bleeding occurred twice (50%). Four patients were proned with chest tubes in place, and none had complications (0%). Lung compliance improved after proning in 70 events (84%), from a mean of 15.4 mL/mm Hg preproning to 20.6 mL/mm Hg postproning (Proning in patients with ARDS on ECMO is safe with an associated improvement in lung mechanics. With careful planning and coordination, these data support the practice of appropriately proning patients with severe ARDS, even if they are on ECMO.

Background: Independent peer review of mortality cases has potential to identify issues in cardiothoracic surgical patients. The Australian and New Zealand Audit of Surgical Mortality aims to improve surgical care through peer-reviewed assessment of all surgical mortality. The aim of this study was to describe common clinical management issues that contribute to patient mortality in a cohort of Australian cardiothoracic surgical patients. This approach may subsequently provide a basis for quality improvement. Methods: Cardiothoracic mortality reports to the Australian and New Zealand Audit of Surgical Mortality from February 2009 through December 2015 were reviewed. The surgeon report and assessor comments were coded to identify clinical management issues. These were divided into perioperative stages (preoperative, intraoperative, and postoperative), and at each stage a thematic analysis was performed. Results: Of the 908 cases analyzed, 1371 clinical management issues were identified. Postoperative issues were the most common (n = 552), followed by preoperative (n = 378) and intraoperative issues (n = 370). Communication issues were present at all 3 stages (n = 71). Overall the most common theme was intraoperative technical issues (n = 287). Many of these issues revolved around unintentional injury to anatomic structures during surgery and inadequate myocardial protection. Communication issues commonly related to surgical handover to the intensive care unit and lack of shared decision-making. Also common were consultant surgeons being unaware of patient deterioration or significant changes in management. Conclusions: The Australian and New Zealand Audit of Surgical Mortality provides valuable insights into issues affecting mortality in cardiothoracic patients. Potentially avoidable management issues play a large role in determining the outcome of these patients. Quality improvement initiatives targeting these areas may be valuable. Refereed/Peer-reviewed

Determine the long-term outcome and need for additional therapy after pulmonary endarterectomy (PEA) for segmental chronic thromboembolic pulmonary hypertension.Retrospective analysis of a prospective cohort of 401 consecutive Canadian patients undergoing PEA between August 2005 and March 2020 in Toronto. The outcome of segmental disease defined as Jamieson type 3 was compared with more proximal disease defined as Jamieson type 1 and 2. The cohort was divided into 3 intervals to analyze the trend over time: 2005-2010, 2011-2015, and 2016-2020.Type 3 disease accounted for 41% of patients undergoing PEA durig 2016-2020 compared with 7% in 2006-2010. Total pulmonary vascular resistance improved by 505 ± 485 dynes/s/cmPEA achieved excellent early and long-term results in segmental chronic thromboembolic pulmonary hypertension. However, patients with segmental disease are at increased risk of requiring additional therapy after PEA and should be carefully monitored.

Resection of sternal tumors can leave large defects, which exposes major mediastinal structures, and can affect respiratory mechanics. If feasible, resection is potentially a complex reconstructive challenge to restore normal and functional anatomy using conventional techniques. We report the first Australian use of a three-dimensional–printed titanium and PoreStar prosthesis in a 39-year-old woman for reconstruction after major surgical resection of the sternum for metastatic breast cancer. The patient successfully underwent excision of the sternum and costal cartilages as well as implantation of the prosthesis. We conclude that three-dimensional–printed prostheses are technically feasible to deliver excellent cosmetic result.

Aim Examination of potentially avoidable issues in surgical deaths can provide a basis for quality improvement. Perioperative technical factors in cardiac surgery may lead or contribute to patient mortality. Using data from a well-established and comprehensive national surgical mortality audit, we aimed to identify and describe clinical management issues leading to mortality in Australian cardiac surgical patients. Methods Retrospective analysis of a cardiac surgical dataset from the Australian and New Zealand Audit of Surgical Mortality (February 2009 to December 2015) was undertaken. Clinical management issues related to technical factors were analyzed using a thematic analysis approach. Technical clinical management issues were categorized based on the most common themes, followed by qualitative analysis of each theme. Results We identified 256 patients with least one technical management issues (total 270). Injury to structures was the most common theme ( n = 115, 44.9%), followed by unaddressed surgical pathology ( n = 39, 15.2%) and inadequate myocardial protection ( n = 34, 13.2%). More specifically, the most common structural injury involved the right ventricle, with the aorta and femoral vessels also commonly injured. The most common unaddressed surgical pathology was incomplete coronary revascularization, followed by systolic anterior motion of the mitral valve during mitral repair. Graft failure occurred during coronary artery bypass graft surgery, with a poor target vessel being a common issue. Conclusion Technical factors in cardiac surgery resulting in potentially avoidable mortality constitute an important subset of deaths. These findings can inform various stakeholders to improve the quality and safety of surgical care.

Giant thymic cysts are a rare clinical entity evolving from smaller benign thymic cysts over many years. Benign thymic cysts account for approximately 3% of all mediastinal masses. There is a paucity of literature regarding benign thymic cyst management, especially when dealing with giant cysts. This can lead to potential confusion amongst clinicians on how to best treat these patients. We report the successful diagnosis and treatment of a 76 year-old female with a giant, benign thymic cyst. This cyst was discovered incidentally and after consultation of the literature it was found management strategies regarding this condition are scarce. After careful consideration of surgical principles, patient preference and potential complications of a conservative approach, the successful surgical removal of a 1.8 kg cyst took place. The patient improved symptomatically with improved exercise tolerance and lung function tests. This case demonstrates the benefits of giant thymic cyst removal thus confirming diagnosis, reducing potential serious complications and improving patient quality of life.

Background Multiple case studies have suggested that video-assisted thoracoscopic sympathectomy (VATS) reduces the occurrence and frequency of symptoms in long QT syndrome (LQTS) [1] , [2] , [3] . To date there has not been a literature review to report on the short-term and long-term outcomes of this procedure. Our primary aims are to review the literature findings on the clinical outcomes of VATS sympathectomy for long QT and present a local centre case report on the outcomes of T2-T5 sympathectomy. Methods Relevant articles were identified by a systematic search of PubMed, Cochrane and Scopus databases, from November 1985 to October 2015. A total of 520 patients from 21 publications were included for analysis and discussion in three main areas: presenting symptoms and indication for surgery, perioperative complications, and patient quality of life following surgery. Our case study reviews a 49-year-old female with recently diagnosed long QT syndrome and intolerance to beta blocker therapy successfully managed with T2-T5 thoracic sympathectomy. Results The most common presenting indication for operative management of long QT syndrome was syncope (208/520 patients) and tachyarrhythmia (207/520 patients). T1-T5 left sympathectomy was performed in 15/21 published reports (332/520 patients) with partial stellate removal or in its entirety. Follow-up of patients ranged from 1 month to 11 years. Four patients died in the postoperative period, from fatal arrhythmias. The most common postoperative findings were no symptoms (64/520 patients); tachyarrhythmia (55/520 patients), syncope (45/520 patients), and Horner’s syndrome (13/520 patients with 27 patients reporting associated symptoms). Thirteen cases reported on the QTc changes post sympathectomy and 9/13 cases involving 220/520 patients showed marked QTc reduction following surgery. Mean preoperative QTc was 558 ms and median 559 ms. Mean postoperative QTc was 476 ms and median 466 ms. Our patient showed a marked reduction in QTc following surgery, with no evidence of arrhythmias and reduced beta blocker dependence. Conclusions Surgical management of LQTS has historically involved a left cervicothoracic stellectomy removing stellate ganglia and typically part of the left thoracic sympathetic chain resulting in reduction in symptoms but increasing the risk of Horner’s syndrome and intermittent temperature changes [4] , [5] . Surgical resection of the thoracic ganglia alone for management of LQTS is scarce in the literature. Short-term follow-up in our case study following a T2-T5 sympathectomy revealed reduction in symptoms, no requirement for beta blocker therapy and reduced QTc interval. Further follow-up using greater patient numbers will further support T2-T5 sympathectomy as an option for surgical management of LQTS.

Background Lung cancers managed surgically with curative intent are sometimes upstaged postoperatively. The potential contributions from surgical waiting time and primary tumour 18F-FDG avidity on positron emission tomography (PET)/computed tomography (CT) are unknown. Methods We reviewed the records of 153 Royal Adelaide Hospital surgical patients with primary lung cancers from 2013 to 2016 who had preoperative staging combining CT, 18F-FDG PET/CT and biopsy. Subjects were divided into two cohorts: postoperative Tumour, Node, Metastases (TNM) upstaged (US) and not upstaged (UN). The parameters of standardised uptake value (SUV max), pre-scan blood glucose level (BGL), the time interval between staging and surgery were analysed using a two-tailed Mann-Whitney U test. Results Subjects were aged 31 to 85 years; 75 were male. Ninety-three had adenocarcinoma (AC), 42 had squamous cell carcinoma (SCC). Sixty-four were upstaged after surgery, 40 AC and 18 SCC. For AC, US SUV max was significantly higher (mean US 6.4 (SD 4.6) vs. UN 4.6 (SD 3.4), p = 0.03) but not time to surgery (mean US 55 (SEM 7.1) vs. UN 71 (SEM 14.8) days p = 0.74). Upstaged were mainly T (imaging and histopathology discordance) and N (unexpected mediastinal or hilar nodal metastases). For SCC, US vs. UN SUV max (mean US 12.0 (SD 5.6) vs. UN 9.4 (SD 5.6), p = 0.08) and time to surgery (mean US 48 (SEM 5.3) vs. UN 47 (SEM 5.0) days p = 0.66) were not significantly different. Standardised uptake value max and surgical waiting time were not analysed for other tumour types due to small numbers. Pre-PET BGL US vs. UN was not significantly different for all (p = 0.52), AC (p = 0.32) and SCC (p = 0.37) subjects, thus not a confounding factor. Conclusions For lung cancers assigned to curative surgery, high primary tumour SUV max of AC but not SCC may predict surgical upstaging with implications for 18F-FDG PET/CT nodal assessments. Surgical waiting time appears not to be a predictor for both tumour types.

Background Little is known about the outcome of cardiac surgery in patients with a prior history of malignancy. Our aim was to investigate in our unit the population of patients with a known malignancy and compare their outcomes to a matched population without malignancy. Methods We identified all patients who underwent cardiac surgery at the Alfred Hospital between February 2002 and December 2009 with malignancy. Cases were matched to 216 controls based on age, gender, major medical comorbidities and type of surgery. A univariate analysis was performed with Fishers exact test and χ 2 test. Results 83/4474 patients were identified with malignancy. Sixty-four (77%) were male. Mean age of the patients with malignancy was 66.7 years, and 67.4 in the control group. 68.7% had a solid organ tumour, and 31.3% had a haematological malignancy. There were no significant between-group differences in hospital or 30-day mortality. However, there were significantly higher rates of transfusion (79.5% vs 49%, p p =0.0009), pneumonia (14.5% vs 6%, p =0.035), septicaemia (8.4% vs 1.9%, p =0.018), arrhythmias (42.2% vs. 33.8%, p =0.047) and anticoagulant complications (7.2% vs 0%, p =0.008) in patients with malignancies. Conclusion Patients who present for cardiac surgery having had prior treatment for cancer are at particular risk for complications. However, these patients can be operated upon with acceptable risk. There is no difference in the short term mortality. Therefore, for selected patients who are undergoing curative treatment for their malignancy, or are in remission, cardiac surgery is not contraindicated.

shock (HS) and acute pancreatitis (AP) is associated with multiple organ dysfunction syndrome (MODS) and death. Most common in MODS are cardiac and pulmonary dysfunction.The ‘gut-lymphhypothesis’ states thatMODSisdue to the releaseof toxic factors fromthe intestine intomesenteric lymph (ML). Significant composition changes to ML are associated with acute pancreatitis and other CI’s. ML is delivered to the systemic circulation via the thoracic duct and en route bypasses the liver avoidingpotential detoxification, beforefirst encountering the heart and then lungs. The aim of this study was to determine the effect of HS and AP conditioned ML on cardiac function and the effect of external drainage of ML. Methods: Groups (n=8 / group) of normal rats and those with taurocholate induced severe AP, a model of critical illness, had either no lymphatic intervention or thoracic duct (TD) ligation with external ML drainage (to protect the hearts from exposure to ML). After 6 hours the heart was removed from both groups for ex vivo functional measurements, including cardiac output and ventricular contractility (+dP/dt), relaxation (-dP/dt). In a separate experiment ML was collected from normal rats and those with HS and AP and infused into ex vivo perfused working hearts from donor normal rats to assess the impact on cardiac function. Results: Significant cardiac dysfunction was found in the hearts removed from rats with established AP alone (no lymphatic intervention) compared to the control group (p

other prosthesis types. Over 6000 individual patients were included in the selected case series’. Mean patient age ranged from 64.0 to 76.0 years. 48.1% of patients were in New York Heart Association class 3–4 pre-operatively; the majority (75.7%) of cases used the subcoronary implantation technique. Operativemortality ranged from 1.8% to 9.6%, and five-year actuarial survival ranged from 71 3.0% to greater than 90.0%. Post-operative neurological event and prosthetic endocarditis rates ranged from 0% to 6.5% and 0.7% to 2.0% (respectively). Discussion: Despite a lack of randomised studies, in those identified the FSB performed comparably against alternative prosthesis options regarding inhospital mortality, long-term survival and reduction in left ventricular mass index. Included case series demonstrated robust post-operative outcomes in both the short and long-term also.With longer-term clinical and echocardiographic follow-up of the FSB, additional outcomes will assist in confirming its place in aortic valve and root surgery.

Introduction: Infective endocarditis (IE) is a life threatening infection, requiring surgical intervention in around half of all cases. Recommendations regarding surgical management are, however, based on limited data. We aimed to investigate patient and bacterial characteristics as well as outcomes associated with surgically treated aortic valve IE in an Australian tertiary hospital. Methods: The study institution’s Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) database was searched for all patients who underwent aortic valve surgery with active IE between 2001 and 2011. Patients were excluded if other valves were affected. Additional data were obtained by reviewing medical records and investigation results. Results: There were 35 patients in this cohort, all of whom underwent aortic valve replacement. Mean age was 50 18 years, 86% (30/35) were male and 31% (11/35) had a history of IV drug use. There were 12 cases (34%) of Staphylococcus aureus (2/12 were MRSA), seven cases of viridans Streptococci (20%) and six cases of Enterococcus faecalis (17%) IE. Mean time from admission to surgery was 17 31 days. Overall 30-day mortality was 20% (7/35), three deaths occurred in patients with S. aureus infections (25% of S. aureus patients). Twelve operations were performed as an emergency procedure and five of these patients died within 30days of surgery (42%). Discussion: Surgery for active aortic valve IE is associated with substantial mortality, especially when performed as an emergency procedure. Staphylococcus aureus is the commonest causative bacteria in patients requiring surgery at our institution and has a high mortality rate.

ObjectiveThe aims of this study were first to analyze neurocognitive outcomes of patients after open-chamber cardiac surgery to determine whether carbon dioxide pericardial insufflation reduces incidence of neurocognitive decline (primary end point) as measured 6 weeks postoperatively and second to assess the utility of carbon dioxide insufflation in cardiac chamber deairing as assessed by transesophageal echocardiography.MethodsA multicenter, prospective, double-blind, randomized, controlled trial compared neurocognitive outcomes in patients undergoing open-chamber (left-sided) cardiac surgery who were assigned carbon dioxide insufflation or placebo (control group) in addition to standardized mechanical deairing maneuvers.ResultsOne hundred twenty-five patients underwent surgery and were randomly allocated. Neurocognitive testing showed no clinically significant differences in z scores between preoperative and postoperative testing. Linear regression was used to identify factors associated with neurocognitive decline. Factors most strongly associated with neurocognitive decline were hypercholesterolemia, aortic atheroma grade, and coronary artery disease. There was significantly more intracardiac gas noted on intraoperative transesophageal echocardiography in all cardiac chambers (left atrium, left ventricle, and aorta) at all measured times (after crossclamp removal, during weaning from cardiopulmonary bypass, and at declaration of adequate deairing by the anesthetist) in the control group than in the carbon dioxide group (P