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BACKGROUND: Thoracic endovascular repair (TEVAR) is considered the first-line therapy in the repair of acute complicated type B aortic dissection (AC-BAD). Given the difficulty of designing randomized trials in this surgical cohort, long-term outcome data is limited. This systematic review and meta-analysis provide a complete aggregation of reported long-term survival and freedom from reintervention of AC-BAD patients based on the existing literature. METHODS: Three databases were searched from date of database inception to January 2021. The relevant references were identified and baseline cohort characteristics, survival and freedom from reintervention were extracted. The primary endpoints were survival and freedom from reintervention, whilst secondary endpoints were post-operative outcomes such as cord ischemia and endoleak. Kaplan-Meier curves were digitized and aggregated as per established procedure. RESULTS: A total of 2,812 references were identified in the literature search for review, with 46 selected for inclusion. A total of 2,565 patients were identified, of which 1,920 (75%) were male. The mean age of the cohort was 59.8±5.8. Actuarial survival at 2, 4, 6 and 10 years was 87.5%, 83.2%, 78.5% and 69.7%, respectively. Freedom from all secondary reintervention at 2, 4, 6, 8 and 10 years was 74.7%, 69.1%, 65.7%, 63.9% and 60.9%, respectively. When accounting for study quality, actuarial survival at 2, 4, 6 and 8 years was 85.4%, 79.1%, 69.8% and 63.1%, respectively. Freedom from all secondary reintervention at 2, 4, 6 and 8 years was 73.2%, 67.6%, 63.7% (maintained), respectively. CONCLUSIONS: TEVAR is associated with promising long-term survival extended to 10 years, though rates of freedom from reintervention remain an ongoing point for improvement. Randomized controlled trials comparing endovascular with open repair in the setting of acute, complicated type B aortic dissection are needed.

Introduction Left ventricular (LV) thrombus is a complication of acute myocardial infarction and is associated with systemic thromboembolism. We describe a trans-aortic endoscopic approach to the removal of an LV thrombus in a patient undergoing concurrent coronary artery bypass grafting and aortic valve replacement. Case presentation A 47 year old male presented following an embolic middle cerebral artery stroke and underwent transthoracic echocardiography demonstrating a mobile LV thrombus. Additional investigation revealed a moderately stenosed bicispid aortic valve, two vessel coronary artery disease and ischemic cardiomyopathy. The patient underwent early surgery to reduce the risk of further embolic episodes. A trans-aortic approach was utilized with videoscopy and single shafted instrumentation to aide in removal of the thrombus. The patient then underwent aortic valve replacement and coronary artery bypass grafting. Conclusion We report an alternative technique for the removal of a left ventricular thrombus in a patient undergoing concurrent coronary and aortic valve surgery. The transaortic video-assisted approach provided excellent visualisation of the apex and near complete removal of the thrombus without damaging the surrounding trabeculae. The main benefit of this technique is sparing of LV tissue, thereby preserving left ventricular function.

Over the past two decades surgical approaches for mitral valve (MV) disease have evolved with the advent of minimally invasive techniques. Robotic mitral valve repair (RMVr) safety and efficacy has been well documented, however, mid- to long-term data are limited. The aim of this review was to provide a comprehensive analysis of the available mid- to long-term data for RMVr.Electronic searches of five databases were performed to identify all relevant studies reporting minimum five-year data on RMVr. Pre-defined primary outcomes of interest were overall survival, freedom from MV reoperation and from moderate or worse mitral regurgitation (MR) at five years or more post-RMVr. A meta-analysis of proportions or means was performed, utilizing a random effects model, to present the data. Kaplan-Meier curves were aggregated using reconstructed individual patient data.Nine studies totaling 3,300 patients undergoing RMVr were identified. Rates of overall survival at 1-, 5- and 10-year were 99.2%, 97.4% and 92.3%, respectively. Freedom from MV reoperation at eight-years post RMVr was 95.0%. Freedom from moderate or worse MR at seven years was 86.0%. Rates of early post-operative complications were low with only 0.2% all-cause mortality and 1.0% cerebrovascular accident. Reoperation for bleeding was low at 2.2% and successful RMVr was 99.8%. Mean intensive care unit and hospital stay were 22.4 hours and 5.2 days, respectively.RMVr is a safe procedure with low rates of early mortality and other complications. It can be performed with low complication rates in high volume, experienced centers. Evaluation of available mid-term data post-RMVr suggests favorable rates of overall survival, freedom from MV reoperation and from moderate or worse MR recurrence.

Robotic-assisted mitral valve surgery (RMVS) is becoming an increasingly performed procedure in cardiac surgery, however, its true safety and efficacy compared to the gold standard conventional sternotomy approach [conventional sternotomy mitral valve surgery (CSMVS)] remains debated. The aim of this meta-analysis was to provide a comprehensive analysis of all available literature comparing RMVS to CSMVS.An electronic search of five databases was performed to identify all relevant studies comparing RMVS to CSMVS. Pre-defined primary outcomes of interest included all-cause mortality, cerebrovascular accidents (CVA) and re-operation for bleeding. Secondary outcomes of interest included cross clamp time, cardiopulmonary bypass (CPB) time, intensive care unit (ICU) and hospital length of stay (LOS), post-operative atrial fibrillation (POAF) and red blood cell (RBC) transfusion.The search strategy identified fourteen studies qualifying for inclusion in this meta-analysis comparing RMVS to CSMVS. The outcomes of 6,341 patients (2,804 RMVS and 3,537 CSMVS) were included. RMVS had significantly lower mortality when compared to CSMVS group in both the unmatched [odds ratio (OR) 0.33; 95% confidence interval (CI): 0.19-0.57; P0.001] and matched cohorts (OR 0.35; 95% CI: 0.15-0.80; P=0.01). There was no significant difference in rates of CVA or re-operation for bleeding between the two groups in either the entire included cohort or matched patients. CSMVS had significantly shorter cross clamp time by 28 minutes (95% CI: 19.30-37.32; P0.001) and CPB time by 49 minutes (95% CI: 36.16-61.01; P0.001) which remained significantly shorter in the matched cohorts. RMVS had shorter ICU [mean difference (MD) 26 hours; 95% CI: -34.31 to -18.52; P0.001] and hospital LOS (MD 2 days; 95% CI: -2.66 to -1.37; P0.001), which were again both significantly shorter in the matched cohort. RMVS group also had fewer RBC transfusions (OR 0.44; 95% CI: 0.28-0.70; P0.001).Current evidence on comparative outcomes of RMVS and CSMVS is limited with only low-quality studies currently available. This present meta-analysis suggests that RMVS may have lower mortality and shorter ICU and hospital LOS, however CSMVS may be associated with significantly shorter cross clamp and CPB times. Further analysis of high-quality studies with randomized data is required to verify these results.

Background:Acute Type A Aortic Dissection (TAAD) represents a cardiothoracic emergency and should be managed without delay. Western Australia is an expansive state with a network of regional centres and cardiothoracic centres located in the capital Perth. The aim of this study is to assess the differences in presentation and outcomes between rural and urban patients undergoing emergent repair for an acute TAAD. Methods: We performed a retrospective analysis of all patients undergoing emergent repair of a TAAD at Fiona Stanley Hospital between 2015 to 2020. A number of variables associated with the patient’s geography, physiology, and postoperative outcome were assessed. Univariate and multivariate logistical regression analysis was performed to evaluate significant differences between the cohorts. Results:A total of 64 patients underwent emergent repair of a TAAD between 2015 – 2020. The overall 30-day mortality rate was 20%. The 30-day mortality rate in the rural cohort was higher than the urban cohort (30% vs 16%) however this was not statistically significant. The rural cohort faced a higher median time to surgery (12 vs 6 hours, P = 0.002) and are likely to require transfer between more than two centres (7 vs 1, P = 0.001). Rural patients were also more likely to require resuscitation perioperatively (OR 4.33, P = 0.013) and more likely to require return to theatre post operatively (OR 7.60, P = 0.002). Both return to theatre and multi-hospital transfer were associated with rural status in multivariate analysis. ConclusionRural patients wait twice as long for definitive surgery as their urban counterparts and require multi-hospital transfer. Rural patients are more likely to present in a critical peri-operative state requiring resuscitation, and have a significantly higher risk of returning to theatre post operatively.

The true incidence of bicuspid valve-related aortic dissection (AD) is extremely difficult to ascertain. This review aimed to provide the reported cumulative incidence of bicuspid aortic valve (BAV)-related AD in actively monitored study populations.Four electronic databases were used to perform literature searches. A meta-analysis of proportions or means were performed for categorical and continuous variables, as appropriate. Survival data was calculated from the aggregation of Kaplan-Meier (KM) curves from the included studies, where reported.A total of 4,330 patients were identified in eleven studies. A cumulative incidence of bicuspid valve-related AD of 0.6% across a median follow-up time of 9 years was identified. Actuarial survival across this monitored population at 1, 3, 5 and 10 years was 97.2%, 96.7%, 92.45%, and 81.1%, respectively.This systematic review and meta-analysis identified a low incidence of AD across the examined follow-up period. Large, prospective studies involving early identification of bicuspid valve pathology, recruitment, and follow-up of BAV cohorts with comparison to the baseline population are required to most accurately determine the outcomes of these patients.

Background Cardiac surgery is associated with a high rate of blood use. The aim of this study is to identify preoperative patient factors associated with allogeneic Red Blood Cell (RBC) or non-Red Blood Cell (NRBC) use in cardiac surgery. Methods All adult cardiac surgical procedures conducted at a single Western Australian institution were retrospectively analysed. Data was collected from the Australia and New Zealand Cardiac Surgery Database from 2015 to 2018. A number of preoperative factors were identified, relating to past medical history or preoperative cardiac status. Outcome 1 was defined as the use of one or more RBC products intra or post-operatively. Outcome 2 was defined as the use of one or more NRBC products intra or post-operatively. Multivariate logistical regression analysis was done to assess for the association between preoperative factors and allogeneic blood product use. Results A total of 1595 patients were included in this study, of which 1488 underwent a Coronary Artery Bypass Graft, Valve or a combined procedure. Patients on dialysis preoperatively and those who had preoperative cardiogenic shock demonstrated the greatest risk of requiring RBC transfusion with an odds ratio of 5.643 (95% CI 1.305–24.40) and 3.257 (95% 1.801–5.882) respectively. Patients who had preoperative cardiogenic shock demonstrated the greatest risk of requiring NRBC transfusion with an odds ratio of 3.473 (95% CI 1.970–6.135). Patients who have had a previous cardiothoracic intervention are at increased risk of both RBC and NRBC transfusion, with adjusted odds ratios of 1.774 (95% CI 1.353–2.325) and 2.370 (95% CI 1.748–3.215) respectively. Conclusion A number of factors relating to past medical history or preoperative cardiac status are implicated with increased allogeneic blood product use in cardiac surgery. Identifying high-risk patients in a preoperative setting can enable us enrol them in a blood conservation program, therefore minimizing the risk of exposure to blood transfusion.

Objectives: Infective endocarditis is a disease with high mortality and morbidity. The primary outcome of this study is to assess factors associated with in-hospital mortality in patients undergoing valvular surgery for infective endocarditis. The secondary outcome of this study is to assess the incidence and factors associated with post-operative morbidity; namely post-operative stroke, renal failure and dialysis, complete heart block and return to theatre for bleeding or tamponade. Methods Between the years of 2015 to 2019, a total of 89 patients underwent surgery for infective endocarditis at Fiona Stanley Hospital. Data was collected from the Australia and New Zealand Cardiac Surgery Database from 2015 to 2019 as well as patients electronic medical record (EMR). A number of preoperative and perioperative factors were assessed in relation to patient mortality and morbidity. Univariate and multivariate logistical regression analysis was done to assess for the association between factors and in-hospital mortality and morbidity Results: A total of 89 patients underwent surgery for infective endocarditis, affecting 101 valves. The mean age of patients was 53.7. A total of 79 patients had a positive blood culture pre-operatively, with Staphylococcus Aureus being the most frequently cultured organism (39%). Fourteen patients (16%) were deemed emergent and underwent surgery within 24 hours of review. A total of five patients died within their hospital stay postoperatively. Variables significantly associated with mortality on univariate analysis were intravenous drug use, emergent surgery, perioperative dialysis, perioperative inotropes, cardiopulmonary bypass (CPB) time and cross clamp time (CCT). Only CBP time was significantly associated with mortality on multivariate analysis. A total of 19 patients (21%) required hemodialysis after surgery, 10 patients sustained a postoperative stroke (11%), 15 patients required to return to theatre (17%) and 11 patients developed a complete heart block post operatively (12%). Conclusion There are a number of factors associated with mortality and morbidity in patients undergoing surgery with infective endocarditis. Our study demonstrates a lower mortality rate in these patients than previously quoted in literature. Exposure of prolonged CBP times was the only factor significantly associated with increased mortality on multivariate analysis, although a critical perioperative state was highly significant on univariate analysis.

Rehabilitation following burns is integral to improving physical and psychological outcomes. Interactive video game consoles are emerging as therapeutic adjuncts due to their ease of use, affordability, and interactive gameplay. The Xbox Kinect™ has advantage over similar consoles, with controller free interaction utilising three dimensional motion capture software. Player movements during gameplay have been shown to be comparable to completing daily tasks and therefore the Xbox Kinect™ has potential for use as a rehabilitation tool.The objectives of this pilot study were to compare the efficacy of the Xbox Kinect™ with conventional physiotherapy as an adjunctive tool to promote activity and, to explore their efficacy in influencing functionality and pain.A randomised controlled clinical trial design was used. Intervention group participants were asked to complete two daily 30min exercise sessions consisting of 15min of self-directed physiotherapy exercise followed by 15min of Xbox Kinect™ activities, based on location of burn. Control group participants were asked to complete two daily 30min exercise sessions of self-directed physiotherapy exercises involving two 15min sets of exercises, standardised for location of burn. Participants were recruited for a maximum of 7 days. Outcomes assessed included daily activity time, treatment satisfaction, upper limb disability, pain, and self-reported fear of movement (kinesiophobia).A sample of 30 burn patients admitted to Royal Perth Hospital was randomised into intervention and control groups. The intervention group demonstrated significantly greater total activity time compared to control group (median 49.4 and 26.7min respectively, p0.0001), irrespective of total burns surface area (TBSA). Significantly greater satisfaction scores were also demonstrated in the intervention group compared to controls (median 8.53 vs 7.8 respectively, p0.0001). There was no evidence to support differences between group measures for upper limb disability, pain and fear avoidance of movement.The Xbox Kinect™ is a useful tool in increasing rehabilitation exercise time and patient satisfaction compared to conventional physiotherapy without indication of concurrent negative effects on patient recovery.

There is a sustained interest worldwide for liquid biofuels that form a numerous and very contrasting family. Among biofuels, bio-ethanol is a natural candidate in regions such as Brazil and India, where similar petroleum-based fuels such as naphtha have been utilized as gas turbine fuels. While biodiesel is very similar to middle distillates (gasoil), ethanol has some commonalities with volatile petroleum fuels in terms of physical data; however, the small alcohol molecule displays a markedly distinct combustion behavior. As part of a development program devoted to biofuels and in collaboration with the major Indian utility Reliance Energy, GE Energy has carried out a preliminary characterization of the combustion of an extensive range of naphtha/bio-ethanol blends with up to 95% ethanol. This test was performed in Spring 2008 on a Frame 6B equipped with standard combustors at the Goa power plant, state of Goa, India. All blends showed excellent combustion performances, low NOx emissions and virtually zero emissions of carbon monoxide (CO), unburned hydrocarbons (UHC) and sulphur oxides (Sox).Copyright © 2009 by ASME