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Primary pulmonary artery (PA) sarcoma (PAS) is a rare disease with poor prognosis. Radical resection provides the best curative chances. Our 60-year old male patient underwent PAS excision with pericardial patch repair of the main PA in 2017, but required reoperation in 2019 due to recurrence. Total PA bifurcation replacement was performed using a handmade two-limbed bovine pericardial tube graft, which has not previously been described in the literature. This technique is safe and reproducible, and may offer a valuable alternative surgical strategy for this patient cohort. Our patient is still alive four years after initial presentation.

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.

Aims Operability of type A acute aortic dissections (TAAAD) is currently based on non-standardized decision-making process, and it lacks a disease-specific risk evaluation model that can predict mortality. We investigated patient, intraoperative data, surgeon, and centre-related variables for patients who underwent TAAAD in the UK. Methods and results We identified 4203 patients undergoing TAAAD surgery in the UK (2009–18), who were enrolled into the UK National Adult Cardiac Surgical Audit dataset. The primary outcome was operative mortality. A multivariable logistic regression analysis was performed with fast backward elimination of variables and the bootstrap-based optimism-correction was adopted to assess model performance. Variation related to hospital or surgeon effects were quantified by a generalized mixed linear model and risk-adjusted funnel plots by displaying the individual standardized mortality ratio against expected deaths. Final variables retained in the model were: age [odds ratio (OR) 1.02, 95% confidence interval (CI) 1.02–1.03; P, Graphical Abstract

Supplemental Digital Content is available in the text., Background: Aortic stenosis requires timely treatment with either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). This study aimed to investigate the indirect impact of coronavirus disease 2019 (COVID-19) on national SAVR and TAVR activity and outcomes. Methods: The UK TAVR Registry and the National Adult Cardiac Surgery Audit were used to identify all TAVR and SAVR procedures in England, between January 2017 and November 2020. The number of isolated aortic valve replacement (AVR), AVR+coronary artery bypass graft surgery, AVR+other surgery, and TAVR procedures per month was calculated. Separate negative binomial regression models were fit to monthly procedural counts, with functions of time as covariates, to estimate the expected change in activity during COVID-19. Results: We included 15 142 TAVR cases, 13 357 isolated AVR cases, 8550 AVR+coronary artery bypass graft cases, and 6773 AVR+other cases. Before March 2020 (UK lockdown), monthly TAVR activity was rising, with a slight decrease in the SAVR activity during 2019. We observed a rapid and significant drop in TAVR and SAVR activity during the COVID-19 pandemic, especially for elective cases. Cumulatively, over the period March to November 2020, we estimated an expected 4989 (95% CI, 4020–5959) cases of aortic stenosis who have not received treatment. Conclusions: This study has demonstrated a significant decrease in TAVR and SAVR activity in England following the COVID-19 outbreak. This situation should be monitored closely, to ensure that monthly activity rapidly returns to expected levels. There is potential for significant backlog in the near-to-medium term and potential for increased mortality in this population.

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 There are limited data on the impact of the COVID‐19 pandemic on left main (LM) coronary revascularisation activity, choice of revascularisation strategy, and post‐procedural outcomes. Methods All patients with LM disease (≥50% stenosis) undergoing coronary revascularisation in England between January 1, 2017 and August 19, 2020 were included (n = 22,235), stratified by time‐period (pre‐COVID: 01/01/2017–29/2/2020; COVID: 1/3/2020–19/8/2020) and revascularisation strategy (percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG). Logistic regression models were performed to examine odds ratio (OR) of 1) receipt of CABG (vs. PCI) and 2) in‐hospital and 30‐day postprocedural mortality, in the COVID‐19 period (vs. pre‐COVID). Results There was a decline of 1,354 LM revascularisation procedures between March 1, 2020 and July 31, 2020 compared with previous years' (2017–2019) averages (−48.8%). An increased utilization of PCI over CABG was observed in the COVID period (receipt of CABG vs. PCI: OR 0.46 [0.39, 0.53] compared with 2017), consistent across all age groups. No difference in adjusted in‐hospital or 30‐day mortality was observed between pre‐COVID and COVID periods for both PCI (odds ratio (OR): 0.72 [0.51. 1.02] and 0.83 [0.62, 1.11], respectively) and CABG (OR 0.98 [0.45, 2.14] and 1.51 [0.77, 2.98], respectively) groups. Conclusion LM revascularisation activity has significantly declined during the COVID period, with a shift towards PCI as the preferred strategy. Postprocedural mortality within each revascularisation group was similar in the pre‐COVID and COVID periods, reflecting maintenance in quality of outcomes during the pandemic. Future measures are required to safely restore LM revascularisation activity to pre‐COVID levels.

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 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.

BackgroundAortic stenosis requires timely treatment with either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). This study aimed to investigate the indirect impact of COVID-19 on national SAVR and TAVR activity and outcomes.MethodsThe UK TAVR Registry and the National Adult Cardiac Surgery Audit were used to identify all TAVR and SAVR procedures in England, between January 2017 and June 2020. The number of isolated AVR, AVR+coronary artery bypass graft (CABG) surgery, AVR+other surgery and TAVR procedures per month was calculated. Separate negative binomial regression models were fit to monthly procedural counts, with functions of time as covariates, to estimate the expected change in activity during COVID-19.ResultsWe included 13376 TAVR cases, 12328 isolated AVR cases, 7829 AVR+CABG cases, and 6014 AVR+Other cases. Prior to March 2020 (UK lockdown), monthly TAVR activity was rising, with a slight decrease in SAVR activity during 2019. We observed a rapid and significant drop in TAVR and SAVR activity during the COVID-19 pandemic, especially for elective cases. Cumulatively, over the period March to June 2020, we estimated an expected 2294 (95% CI 1872, 2716) cases of severe aortic stenosis who have not received treatment.ConclusionThis study has demonstrated a significant decrease in TAVR and SAVR activity in England following the COVID-19 outbreak. This situation should be monitored closely, to ensure that monthly activity rapidly returns to expected levels. There is potential for significant backlog in the near-to-medium term, and potential for increased mortality in this population.

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.

ObjectiveTo compare clinical and health economic outcomes after manubrium-limited mini-sternotomy (intervention) and conventional median sternotomy (usual care).DesignA single-blind, randomised controlled trial.SettingSingle centre UK National Health Service tertiary hospital.ParticipantsAdult patients undergoing aortic valve replacement (AVR) surgery.InterventionsIntervention was manubrium-limited mini-sternotomy performed using a 5–7 cm midline incision. Usual care was median sternotomy performed using a midline incision from the sternal notch to the xiphisternum.Primary and secondary outcome measuresThe primary outcome was the proportion of patients who received a red cell transfusion postoperatively and within 7 days of index surgery. Secondary outcomes included proportion of patients receiving a non-red cell blood component transfusion and number of units transfused within 7 days and during index hospital stay, quality of life and cost-effectiveness analyses.Results270 patients were randomised, received surgery and contributed to the intention to treat analysis. No difference between mini and conventional sternotomy in red-cell transfusion within 7 days was found; 23/135 patients in each arm received a transfusion, OR 1.0 (95% CI 0.5 to 2.0) and risk difference 0.0 (95% CI −0.1 to 0.1). Mini-sternotomy reduced chest drain losses (mean 181.6 mL (SD 138.7) vs conventional, mean 306·9 mL (SD 348.6)); this did not reduce red-cell transfusions. Mean valve size and postoperative valve function were comparable between mini-sternotomy and conventional groups; 23 mm vs 24 mm and 6/134 moderate or severe aortic regurgitation vs 3/130, respectively. Mini-sternotomy resulted in longer bypass (82.7 min (SD 23.5) vs 59.6 min (SD 15.1)) and cross-clamp times (64.1 min (SD 17.1) vs 46·3 min (SD 10.7)). Conventional sternotomy was more cost-effective with only a 5.8% probability of mini-sternotomy being cost-effective at a willingness to pay of £20 000/QALY (Quality Adjusted Life Years).ConclusionsAVR via mini-sternotomy did not reduce red blood cell transfusion within 7 days following surgery when compared with conventional sternotomy.Trial registration numberISRCTN29567910; Results.

Objectives To evaluate the feasibility and safety of direct transcatheter aortic valve implantation (TAVI) by the transfemoral approach without balloon pre-dilatation using the Edwards SapienXT valve. Background TAVI is established in selected high-risk patients with severe aortic stenosis. Balloon aortic valvuloplasty (BAV) is recommended prior to valve implantation, but may contribute to procedural risk. It is unknown whether this is necessary for successful passage and deployment of the device. Methods 81 patients (mean age 84 [95%CI:82–85.8], 62% male, median EuroScore 22.8% [95%CI:20.5–27]) undergoing transfemoral TAVI (35 by direct implantation [direct group]; 46 with balloon pre-dilatation [balloon group]) between 2010 and 2013 were analyzed for efficacy and safety endpoints. Results Procedural success was 100%. Pre and post-procedural peak gradients in the direct group were 66mmHg (95%CI:59–72.8) and 14mmHg (95%CI:12–17.8)(P

Background: While Aortic Valve Replacement (AVR) outcomes have improved, morbidity remains significant. Need for transfusion is a key indicator of quality; transfusions are linked to prolonged hospital stay and increased mortality. Over one third of patients undergoing AVR via conventional median sternotomy require post-operative red-cell transfusion. Methods: MAVRIC was a single centre, single blind, randomised controlled trial, comparing AVR via manubrium-limited mini-sternotomy (intervention) and conventional median sternotomy (usual care) to assess the impact on post-operative red-cell transfusion. Patients were stratified by baseline logistic EuroSCORE and haemoglobin and followed for 12 weeks. The primary outcome was proportion of patients receiving red-cell transfusion within 7 days of index surgery. Findings: 271 patients were randomised using a central computer system with concealed allocation; 270 received surgery and contributed to the intention to treat analysis. No difference between intervention and usual care in red-cell transfusion within 7 days was found; 23/135 patients in each arm received a transfusion, odds ratio 1·0 (95% CI: 0·5, 2·0) and risk difference 0·0 (95% CI: -0·1, 0·1). Intervention reduced chest drain losses (mean 181·6ml (SD 138·7) vs usual care mean 306·9ml (SD 348·6)); this did not reduce red-cell transfusions. Mean valve size and postoperative valve function were comparable between intervention and usual care; 23mm vs 24mm, and 6/134 moderate or severe aortic regurgitation vs 3/130, respectively. Mini-sternotomy resulted in longer bypass times (82·7 minutes (SD 23·5) vs 59·6 minutes (SD 15·1)) and cross clamp times (64·1 minutes (SD 17·1) vs 46·3 minutes (SD 10·7)). Conventional sternotomy was more cost-effective with only a 5·8% probability of ministernotomy being cost-effective at a willingness to pay of £20,000/QALY. Interpretation: AVR via manubrium-limited mini-sternotomy did not reduce red blood cell transfusion within 7 days following index surgery when compared to conventional sternotomy. Clinical Trial Number: International Standard Randomised Controlled Trial Number (ISRCTN) ISRCTN29567910. Registered on 3 February 2014. Funding Statement: The trial was funded by the NIHR Research for Patient Benefit Programme (grant number PB-PG-1112-29035). GJM is supported by the British Heart Foundation (CH/12/1/29419) and the NIHR Leicester Biomedical Research Centre. Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: This protocol and all trial-related documents were originally approved by the National Research Ethics Service Committee, North East - Newcastle & North Tyneside 1 in March 2014 (IRAS Project 137295; REC Reference 14/NE/0005). Since initial approval, three amendments have been made and approved; thus, this is version 5 of the protocol. Written informed consent will be obtained from all participants. The trial will be run according to the principles of ICH-GCP and in accordance with relevant UK legislation and the protocol.

Outcomes following aortic valve replacement (AVR) surgery are generally excellent, with in-hospital observed mortality in the United Kingdom of 1.5% for first-time elective procedures [(1)][1]. These results are not observed in all populations; in high-risk groups, conventional surgery risks

Background Vascular complications from transfemoral (TF) secondary access during transcatheter aortic valve implantation (TAVI) are common. We compare our experience of transradial (TR) versus transfemoral secondary access during TAVI and describe techniques for performing iliofemoral arterial intervention from the transradial approach. Methods All TAVI procedures with a single secondary access were included. Demographics, procedural details and 30-day outcomes were recorded. VARC-2 criteria were used for procedural complications. Procedures with TF primary access were stratified by the site of secondary arterial access. Results Single secondary access was used in 199 cases, of which 20 were performed via non-TF access. Of the 179 TF primary access cases, 115 (64%) used TR secondary access and 64 (36%) used TF secondary access. In the TR cohort percutaneous vascular intervention was performed from the transradial approach in 19 cases (17%). Emergent TF secondary access was not required in any case. There were no differences in procedural time, radiation dose, contrast use, bleeding complications, stroke or mortality between the groups. There was one secondary access complication in the TF cohort and none in the TR cohort. Conclusions Transradial (TR) secondary access during TAVI is safe and feasible and may reduce the secondary access site vascular complication rate. With appropriate equipment, most peripheral vascular complications can be managed entirely via TR access avoiding unplanned femoral arterial access. TR secondary access should be considered the default approach for non-TF TAVI cases and can be considered for all TF cases as long as dedicated equipment is available.

Background Aortic valve replacement is one of the most common cardiac surgical procedures performed worldwide. Conventional aortic valve replacement surgery is performed via a median sternotomy; the sternum is divided completely from the sternal notch to the xiphisternum. Minimally invasive aortic valve replacement, using a new technique called manubrium-limited ministernotomy, divides only the manubrium from the sternal notch to 1 cm below the manubrio-sternal junction. More than one third of patients undergoing conventional sternotomy develop clinically significant bleeding requiring post-operative red blood cell transfusion. Case series data suggest a potentially clinically significant difference in red blood cell transfusion requirements between the two techniques. Given the implications for National Health Service resources and patient outcomes, a definitive trial is needed. Methods/design This is a single-centre, single-blind, randomised controlled trial comparing aortic valve replacement surgery using manubrium-limited ministernotomy (intervention) and conventional median sternotomy (usual care). Two hundred and seventy patients will be randomised in a 1:1 ratio between the intervention and control arms, stratified by baseline logistic EuroSCORE and haemoglobin value. Patients will be followed for 12 weeks from discharge following their index operation. The primary outcome is the proportion of patients who receive a red blood cell transfusion post-operatively within 7 days of surgery. Secondary outcomes include red blood cell and blood product transfusions, blood loss, re-operation rates, sternal wound pain, quality of life, markers of inflammatory response, hospital discharge, health care utilisation, cost and cost effectiveness and adverse events. Discussion This is the first trial to examine aortic valve replacement via manubrium-limited ministernotomy versus conventional sternotomy when comparing red blood cell transfusion rates following surgery. Surgical trials present significant challenges; strengths of this trial include a rigorous research design, standardised surgery performed by experienced consultant cardiothoracic surgeons, an agreed anaesthetic regimen, patient blinding and consultant-led patient recruitment. The MAVRIC trial will demonstrate that complex surgical trials can be delivered to exemplary standards and provide the community with the knowledge required to inform future care for patients requiring aortic valve replacement surgery. Trial registration International Standard Randomised Controlled Trial Number (ISRCTN) ISRCTN29567910. Registered on 3 February 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1768-4) contains supplementary material, which is available to authorized users.

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.

Dynamic left ventricular outflow tract obstruction is a rare but important complication of myocardial infarction. It occurs acutely and may mimic the presentation of papillary muscle rupture or acquired ventricular septal defect. Unlike these mechanical complications, it does not require circulatory support or cardiac surgical intervention. Recognition is critical because it typically responds to volume loading and beta blockade. We report a case who displayed many classical features of this condition.

Objective: Pulmonary endarterectomy is the best treatment for patients with chronic thromboembolic pulmonary hypertension. Traditionally pulmonary endarterectomy has been performed utilising deep hypothermic circulatory arrest to provide a bloodless field, but some recent reports have challenged this concept. We reviewed our experience with selective antegrade cerebral perfusion as the initial strategy of controlling bronchial collateral flow to avoid complete circulatory arrest in patients undergoing pulmonary endarterectomy. Methods: A retrospective review of all patients meeting the above criteria between July 2003 and June 2006. Selective antegrade cerebral perfusion at 20 8C was usedasthe initial meansof reducingbloodflowto theoperativefield.Results:One hundredandfifty-onepatients (83male, 68female, mean age56 16years) were operatedonusing thisstrategy. ThepreoperativeNewYork HeartAssociationclass distributionshowed themajorityto be in class III or IV (142 of 151). At initial assessment, mean pulmonary artery pressure was 49 12 mmHg and mean pulmonary vascular resistance was 851 391 dynes s cm 5 . Selective antegrade cerebral perfusion was required in 145 for a total period of 63 24 min. Thirteen (9%) patients required conversion to deep hypothermic arrest for completion of the operation. In-hospital mortality was 22 (15%). There were no instances of focal neurological deficit. Prearranged clinical follow-up for 3 and 12 months was 97% complete with one late death by 3 months and one more by 12 months. The majority were in New York Heart Association class I or II at 3 months (102 of 115) and 12 months (65 of 74). At 3-month follow-up the mean pulmonary artery pressure was 27 10 mmHg and pulmonary vascular resistance was 304 220 dynes s cm 5 . Conclusions: Overall results improved with era and institutional experience. The use of selective antegrade cerebral perfusion for pulmonary endarterectomy appears to be technically feasible in the majority of patients and is an alternative to complete circulatory arrest. To clarify its role further, comparison with deep hypothermic circulatory arrest in a randomised controlled trial is necessary. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

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.

Ectopic thyroid is a rare embryogenic anomaly that occurs during its migration from foramen caecum to its pretracheal position. An intracardiac ectopic location is even rarer and found most commonly in the right ventricular outflow tract in sporadic reports. While surgery in symptomatic patients seems appropriate, resection of non-neoplastic ectopic tissue remains a clinical equipoise. Its occurrence is often unsuspected by clinicians, but its possibility should be considered due to its typical location in the right ventricular outflow tract. Unlike true neoplastic intracardiac tumour which mandates surgical resection, both surgical and non-surgical approach may be considered for an intracardiac ectopic thyroid mass.

This contribution focuses on the anatomy of the coronary artery, pathology investigations, indications and preparations for surgery, operative technique, outcome and possible complications, and surgical treatment of ‘inoperable’ coronary artery disease.

Endothelin (ET) may have both detrimental (reduced coronary flow) and beneficial effects (positive inotrope, reduced arrhythmogenesis) following ischaemia. We examined the effects of ET on cardiac function during reperfusion following prolonged hypothermic cardioplegic arrest in a protocol mimicking cardiac transplantation. Isolated working rat hearts were perfused with Krebs buffer to which increasing concentrations of ET-1 or sarafotoxin S6c had been added. Identical experiments were performed after 4h of cardioplegic arrest at 4°C. Under pre-ischaemic conditions ET-1 caused a dose-dependent decrease in cardiac function compared with controls. In contrast, following ischaemia low doses of ET-1 (10-10 M) caused a significant and beneficial increase in cardiac output (109.1% versus 81.3%), dP/dt i.e. the rate of change of pressure with time (94.7% versus 75.6%) and stroke volume (100.3% versus 77.5%) compared with controls (P

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.

Objective: Endothelin plays a role in the regulation of basal coronary tone. We hypothesized that low coronary reflow and reduced cardiac function after prolonged ischemia may be due to increased release of endogenous endothelin. Methods: Using an isolated perfused rat heart, we examined the effect of the addition of various endothelin antagonists during reperfusion after 4 hours of cardioplegic arrest at 4°C. Hearts were freeze-clamped at the end of reperfusion for analysis of high-energy phosphate levels. Results are expressed as the percentages of preischemic values. Results: The addition of bosentan or Ro61-0612 (nonselective endothelin antagonists) resulted in a significant increase in the recovery of coronary flow after 30 minutes of reperfusion (100.9% vs 85.3% [P =.03] and 122.4% vs 83.7% [P

The role of the endothelium in the control of coronary flow has been demonstrated. Results of recent studies, both on animals and on humans, suggest that endogenous endothelin also plays an important role in basal coronary tone. Disease processes such as ischaemia-reperfusion injury, congestive heart failure, hypertension and atherosclerosis may be contributed to by an imbalance in, or excess of, release of endothelin. With the discovery of newer endothelin antagonists and endothelin converting enzyme inhibitors, especially with fewer hepatic side effects, there is the potential for much future research into novel therapeutic management of these common cardiovascular disorders.

BACKGROUND—There is a perceived conflict between the need for service provision and surgical training within the National Health Service (NHS). Trainee surgeons tend to be slower (thereby reducing theatre throughput), and may have more complications (increasing hospital stay and costs). OBJECTIVE—To quantify the effect of training on outcome and costs. DESIGN—Data on 2740 consecutive isolated coronary artery bypass (CABG) operations were analysed retrospectively. Redo and emergency procedures were excluded. The seniority of the operating surgeon was related to operating times, risk stratified outcome, and overall hospital costs. SETTING—Regional cardiothoracic surgery unit. MAIN OUTCOME MEASURES—Postoperative mortality; hospital costs. RESULTS—Consultants, senior trainees, intermediate trainees, and junior trainees performed 1524, 759, 434, and 23 procedures, respectively. Trainees at the three different levels were directly supervised by a consultant in 55%, 95%, and 100% of cases. The unadjusted mortalities were 3.2%, 2.0%, 2.3%, and 4.3%, respectively (NS). There were no significant differences between the groups with respect to time in the intensive care unit and length of hospital stay. The mean cost per patient was £6619, £6572, £6494, and £6404 (NS). CONCLUSIONS—Trainees performed 44.4% of all CABG operations. There was no detrimental effect on patient outcome, length of hospital stay, or overall hospital costs. There need be little conflict between service and training needs, even in hospitals with extensive training programmes. Keywords: coronary artery bypass surgery; training; costs

We investigated the effects of endothelin-1 (ET-1) on growth of cultured human coronary artery smooth muscle cells (cSMC). ET-1 alone stimulated DNA synthesis in growth-arrested cSMC as measured by [3H]thymidine incorporation, with a maximum 63 +/- 23% increase above control by 10(-7) M (P0.05). ET-1 (10(-7) M) also stimulated increases in cyclin D1 protein levels after 24 h, and in absolute cell number after 4 days. Furthermore, ET-1 stimulated protein synthesis (maximum 73 +/- 32% increase in [3H]leucine incorporation by 10(-7) M (P0.05)), as well as triggering intracellular calcium transients in human cSMC, as visualised under fura-2 fluorescence microscopy. The selective ET(A) receptor antagonist BQ123 inhibited the increases in DNA synthesis, cell number, protein synthesis and intracellular calcium concentration in response to ET-1, whereas the ET(B) receptor antagonist BQ788 had no such effects. Furthermore, the ET(B) agonist sarafotoxin 6c had no effect on cSMC DNA synthesis. In addition, co-incubation of ET-1 with threshold concentrations of the growth factors, platelet-derived growth factor-BB (PDGF-BB), basic fibroblast growth factor (bFGF) and epidermal growth factor (EGF), resulted in pronounced synergistic increases in DNA synthesis over that observed with the factors alone. In conclusion, we have shown that ET-1 stimulates proliferation of human cSMC via the ET(A) receptor and is also a co-mitogen with the growth factors tested. These findings indicate a role for ET-1 in the development of coronary intimal hyperplasia in man.

Ageing is known to be associated with changes within the heart. We investigated whether the coronary response to endothelin-1 (ET) and sarafotoxin S6c (S6c) is altered with increasing age, before and after cardioplegic arrest.Using an isolated rat heart model, increasing concentrations of ET and S6c were administered to rats of different ages (group I = one month; group II = five months; group III = 21 months). An identical series of experiments was performed following the addition of indomethacin and NG-nitro-L-arginine methyl ester (L-NAME) to the Krebs perfusion fluid. In a third series of experiments, increasing doses of ET-1 were added to hearts following 4 h of cardioplegic arrest at 4 degrees C.Coronary flows are expressed as a percentage of initial coronary flow +/- SEM. There was a greater decrease in coronary flow in the older rats for all doses of ET-1. ET-1 (10(-9) M) reduced coronary flows to 72.8 +/- 3.7, 53.2 +/- 6.7 and 56.5 +/- 10.7% for groups I-III respectively (P = 0.01 I vs. II; P = 0.1 I vs. III). A similar response to ET-1 was seen in hearts perfused with indomethacin and L-NAME when compared to those perfused without (P = NS). Perfusion with ET-1 (10(-9) M) following 4 h of cardioplegic arrest reduced coronary flows to 40.5 +/- 4.9, 26.8 +/- 4.8 and 24.1 +/- 3.9%, respectively (P = 0.08 I vs. II; P = 0.03 I vs. III). Perfusion with S6c (10(-10) M) produced coronary flows of 93.3 +/- 5.5, 77.0 +/- 3.5 and 73.9 +/- 3.9% for groups I-III, respectively (P = 0.03 I vs. II; P = 0.01 I vs. III). Perfusion with S6c (10(-9) M) in the presence of L-NAME and indomethacin reduced coronary flows to 85.7 +/- 3.0, 81.6 +/- 2.2 and 74.6 +/- 3.6% (P = NS I vs. II; P = 0.03 I vs. III).The coronary vasoconstrictor response to ET-1 and S6c increases with age. The increased vasoconstriction in response to ET-1 is independent of the decrease in NO release seen with ageing.

1. Coronary vascular tone is a vital factor that regulates the delivery of oxygen to cardiac muscle. We tested the hypothesis that basal coronary tone may depend on the release of an endogenous vasoconstrictor peptide, endothelin (ET). 2. Using an isolated, Krebs solution-perfused rat heart we measured the changes in coronary flow following the administration over a 30 min period of the ET antagonists Ro61-0612 (mixed ETA/ETB), PD155080 (ETA) and BQ788 (ETB). 3. In a second series of experiments, hearts were randomly assigned to perfusion with plain Krebs solution, or with Krebs solution to which L-NAME and/or indomethacin had been added. The effect on coronary flow following the addition of Ro61-0612 was then measured. 4. Perfusion with Ro61-0612 (10-4 M) alone increased coronary flow by 57.8 % vs. control (P = 0.00001). PD155080 (10-4 M) increased coronary flow by 28.9 % (P = 0.009), whereas BQ788 had no effect on coronary flow. 5. In the second series of experiments, Ro61-0612 increased coronary flow by 6.6 +/- 0.8 ml min-1 in hearts perfused with plain Krebs solution, by 3.8 +/- 0.8 ml min-1 in hearts to which both L-NAME and indomethacin had been added, by 3.3 +/- 0.7 ml min-1 in hearts to which L-NAME had been added, and by 6. 9 +/- 0.5 ml min-1 in hearts to which indomethacin had been added to the Krebs buffer. 6. In hearts perfused with Krebs solution alone, nitric oxide (NO) release into the coronary sinus increased from 219. 8 to 544.9 pmol min-1 g-1 following the addition of Ro61-0612 (P = 0. 06). There was no detectable release of NO from hearts perfused with L-NAME alone or in combination with indomethacin either before or after the addition of Ro61-0612. 7. We conclude that endogenous ET plays a role in coronary tone mediated via ETA receptors. This vasodilatation is partially due to an increase in endogenous NO release. However, a significant vasodilatation is still seen following the inhibition of NO synthesis. We propose that basal coronary tone depends on a balance between the endogenous release of vasodilators such as NO and vasoconstrictors such as ET.

Objecti6e: Heat stress and induction of heat shock proteins confer protection against myocardial ischemia-reperfusion injury; however the precise mechanisms of this effect remain unknown. We investigated the influence of heat stress on metabolic and functional recovery after cardioplegic arrest, in a protocol mimicking clinical donor heart preservation. Methods: Langendorff perfused rat hearts in control group (C, n6) and heat stressed (24 h prior to experiment) group (HS, n 6) were subjected to 4 h of ischemia at 4°C following cardioplegic arrest (St. Thomas’ No. 1). 31 P nuclear magnetic resonance spectroscopy was used to follow changes in ATP, phosphocreatine and inorganic phosphate concentrations during the pre-ischemic, ischemic and reperfusion periods. Myocardial adenine nucleotide levels in hearts at the end of experiments and purine catabolite release in coronary effluent during reperfusion, were evaluated using high performance liquid chromatography. Mechanical function in the pre-ischemic and reperfusion periods was evaluated using an intraventricular balloon. Western immunoblotting was used to quantitate HSP70 expression. Results: Although baseline concentrations of ATP and phosphocreatine were similar in C and HS groups, the rate of high-energy phosphate depletion was attenuated during the early phase of ischemia in HS groups. On reperfusion, recovery of ATP was 10‐20% greater in HS versus C groups; phosphocreatine levels also recovered better in the HS group, transiently reaching levels 40% higher in HS versus C groups. The concentrations of adenine nucleotides in hearts were significantly higher in the HS versus C groups. These changes were associated with an attenuation of total purine catabolite release in the coronary effluent in HS versus C groups. A significant improvement in relative recovery of developed pressure was shown in HS versus C groups in the post-ischemic periods. Conclusions: Heat stress causes beneficial changes in high-energy phosphate metabolism in the rat heart subjected to cardioplegic arrest and ischemia. Improved mechanical recovery in HS versus C groups was associated with a decreased rate of high-energy phosphate depletion and increased recovery of ATP and phosphocreatine levels during reperfusion. Changes in energy metabolism may play a role in the mechanism of cardioprotection by heat stress during prolonged hypothermic cardiac arrest. © 1998 Elsevier Science B.V. All rights reserved.

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 best evidence topic was written in cardiothoracic surgery based on a structured protocol. The question addressed was whether ultrasound mapping of the long saphenous vein (LSV) might reduce leg wound complications by reducing unnecessary leg incisions due to poor quality veins. Altogether, 32 abstracts were identified from the search, from which 5 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. Surgical site infections can be extremely distressing for patients, and it is estimated that treating a surgical wound can cost up to £1554 each. Ultrasound mapping of the LSV has been reported to be an accurate way of assessing vein quality preoperatively, reducing unnecessary surgical dissection, theatre time and cost to both the patient and the health service. We identified four studies that showed that ultrasound scanning preoperatively could accurately predict the anatomy and quality of the LSV (correlation coefficient 0.87). One paper showed that ultrasound scanning reduced length of incision (P = 0.005), harvest time (P = 0.04) and hospital stay and reduced morbidity (although not statistically significant). However, one study found that it could not accurately predict vein wall changes. Evidence from the papers supports the use of preoperative ultrasound assessment of the saphenous vein. Benefits to the patient include a smaller scar, reduced harvest time and minimizing unnecessary incisions.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was which side of the operating table you should stand on when carrying out surgical revascularization on a patient with dextrocardia. Altogether 40 papers were found using the reported search, of which 19 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. The side on which the operating surgeon stood was mentioned in 20 out of the 24 cases. Surgery was carried out from the conventional right side of the patient in 5 cases, while in 10 cases, it was carried out from the left side. The surgeon needed to switch sides to facilitate surgery in three cases. In addition, the right internal mammary artery (RIMA) was anastomosed to the left anterior descending artery (LAD) in 16 cases. Of these, surgery was carried out from the left side in 11 cases. The left internal mammary artery (LIMA) to LAD anastomosis was carried out in two cases, one of which was a free LIMA graft. In six cases, only vein grafts were used. Fourteen cases were carried out using cardiopulmonary bypass while 10 cases were carried out as off-pump cases with one conversion. The majority of patients were operated on from the left of the table. More cases were performed with the RIMA as the conduit of choice to the LAD.

Emergency redo surgery is rare, but may be required in patients with conditions such as endocarditis, unstable angina and acute aortic dissection. To date there are no published data on the outcome of these difficult patients. Prospective consecutive data were collected from a single institution on 65 patients (51 male) undergoing coronary artery bypass grafts (27), mitral valve replacement or repair (13), aortic valve replacement (7), aortic surgery (13), and other (combined procedures) (5). Indications for surgery were unstable angina (12), endocarditis (11), resuscitation/catheter lab complications (11), torn prosthetic leaflet (6), aortic dissection (4), paraprosthetic leak (2), other (19). Mean ITU stay was 45 h (0-284) and hospital stay was 13.3 days (0-68). There were 14 intra-operative deaths and 14 further in-hospital deaths (overall mortality 43%). Predicted mortality rates were 26% (Parsonnet), 11% (EuroSCORE) and 31% (EuroSCORE logistic). Mean hospital cost per patient was 18,299 euros (or 32,147 euros per hospital survivor). In conclusion, the mortality in these difficult patients is very high, however, often no other treatment option is available. More sophisticated models, such as EuroSCORE logistic, may allow better prediction of risk in very high risk cases.

To determine current practice regarding the use of epicardial pacing wires by cardiothoracic surgeons in the U.K.

We describe the case of a 76-year old female who presented with a Type A aortic dissection requiring repair with an interposition graft and aortic valve replacement. Post-operatively she had clinical features and computerised tomographic images suggestive of a pulmonary embolus and died 24 hours later. The extremely rare finding of intramural thrombus occluding the right pulmonary artery was seen at post mortem.

Objectives: The role of post-mortem following thoracic surgery has not been previously studied. Most importantly, the clinical diagnosis of thoracic surgical mortality cannot be certain unless post-mortem analysis has been performed. Methods: Consecutive post-mortem data were collected on 110 patients between 1992 and 2001 (66.3% of all in-hospital thoracic surgical deaths). Clinically attributed causes of death were compared with post-mortem findings. Results: A total of 4302 thoracic operations were performed during the 10-year period, with overall mortality 3.8%. The mean age was 63.6 years (range 21‐ 87) with 73.6% male. In the 110 patients undergoing post-mortem examination, the operations performed were pneumonectomy 24.5%, lobectomy 14.5%, oesophagectomy 12.7%, lung biopsy 8.2%, pleurectomy/bullectomy 6.4%, decortication 4.5%, lung volume reduction 1.8%, other thoracic 13.6%, other oesophageal 9.1%, and other procedures 4.5%. The mean time to death was 12.5 days (range 0 ‐ 85). The causes of death were respiratory 47.3%, cardiac 16.4%, multiple organ failure 8.2%, sepsis 6.4%, gastrointestinal 4.5%, haemorrhage/technical failure 10%, and others 7.3%. Post-mortem revealed an unsuspected cause of death in 34 (31%) patients, comprising pulmonary 17, cardiac 5, gastrointestinal 3, haemorrhage/technical failure 2, multiple organ failure 2 and other 5. Conclusion: Post-mortem determined unsuspected diagnoses in a high proportion of patients undergoing thoracic surgery. Post-mortem continues to be the ‘gold standard’ method for attributing the cause of death. Accurate outcome data following thoracic surgery are essential for proper audit, and hence for improvements in clinical practice to occur. q 2003 Elsevier Science B.V. All rights reserved.

Endothelin-1 (ET-1) is believed to play an important role in cardiac ischaemia/reperfusion injury. ET-1 is synthesized from preproET-1 by the action of ET-converting enzyme (ECE). It is unclear to what extent the ET system is activated following prolonged ischaemia. In this study we used a model mimicking the conditions of the donor heart during transplantation. Isolated rat hearts perfused with Krebs–Henseleit buffer were subjected to 30min of normothermic perfusion, then 4h of cardioplegic arrest at 4°C with St Thomas' Hospital solution, followed by reperfusion for 2h. Hearts were freeze-clamped at different time points during the protocol. Using quantitative reverse transcription–PCR, relative levels of ET-1 and ECE mRNA expression were measured and compared with a housekeeping gene (ribosomal protein L32). During reperfusion there was a consistent decrease in coronary flow to approx. 85–90% of pre-ischaemic flow. There was no significant alteration in preproET-1 mRNA expression during 2h of reperfusion. However, ECE mRNA expression was increased by 77.5% at 1h and by 74.6% at 2h following ischaemia compared with pre-ischaemic values (P

Objectives: Cardioplegic arrest during cardiac surgery induces severe abnormalities of the pyruvate metabolism, which may affect functional recovery of the heart. We aimed to evaluate the effect of pyruvate and dichloroacetate administration during reperfusion on recovery of mechanical function and energy metabolism in the heart subjected to prolonged cardioplegic arrest. Methods: Four groups of rat hearts perfused in working mode were subjected to cardioplegic arrest (St. Thomas’ No. 1), 4 h of ischaemia at 88C and reperfusion with either Krebs buffer alone (C) or with 2.8 mM pyruvate (P), with 1 mM dichloroacetate (D), or with a combination of both (PD). Mechanical function was recorded before cardioplegic arrest and at the end of experiments. In groups C and PD, additional experiments were performed using 31 P nuclear magnetic resonance spectroscopy in non-working Langendorff mode to evaluate cardiac high-energy phosphate concentration changes throughout the experiment. Results: Improved recovery of cardiac output (% of the preischaemic value ^ SEM, na 9‐12) was observed in all three treated groups (65.7 ^ 4.3, 59.5 ^ 5.2 and 59.5 ^ 5.3% in PD, P and D, respectively) as compared with C (42.2 ^ 4.6%; P , 0:05). Recovery of coronary flow was improved from 66.4 ^ 3.8 in C to 94.9 ^ 8.6% in PD (P , 0:05). The phosphocreatine recovery rate in the first minutes of reperfusion was increased from 9.9 ^ 1.5 in C to 31.5 ^ 4.3 mmol/min per g dry wt in PD (P , 0:001). No differences were observed in ATP or phosphocreatine concentrations at the end of experiment. Conclusions: The administration of pyruvate and dichloroacetate improves the recovery of mechanical function following hypothermic ischaemia. Accelerated restoration of the energy equilibrium in the initial phase of reperfusion may underlie the metabolic mechanism of this effect. q 2001 Elsevier Science B.V. All rights reserved.

Background Clinical attribution of the cause of death can be misleading, with the only true outcome measure being post-mortem analysis. Despite this there is very little published data on post-mortems following cardiac surgery. Methods Prospective consecutive post-mortem data were collected on 167 patients (84.4% of all in-hospital cardiac surgical deaths) in a single institution. Clinical diagnoses were compared with post-mortem findings. Results The mean age at death was 69.8 with 67.6% male. The proportion undergoing coronary artery bypass graft (CABG) alone was 52.1%, valve surgery 18.6%, valve+CABG 19.2% and other procedures 10.1%. The mean time to death was 7.9 days (range 0-87). The causes of death were cardiac 67.7%, gastrointestinal 9.6%, respiratory 8.4%, haemorrhage/technical failure 4.8%, stroke (cerebrovascular accident) 3.6%, multiorgan failure 3.0%, sepsis 1.8%, malignancy 0. 6% and trauma 0.6%. Post-mortem revealed an unsuspected cause of death in 19 (11.4%). These were gastrointestinal (infarction nine, perforation two), cardiac three, adult respiratory distress syndrome two, technical two and pulmonary embolus one. In addition, an unsuspected lung cancer was found in 1 patient who died of cardiac causes. When cardiac deaths were compared with non-cardiac causes the Parsonnet score was higher 20.0 (+/-1.4) vs. 15.3 (+/-1.6), P=0. 07; and a greater proportion tended to have poor ejection fractions (34 vs. 15%), P=0.12. There was no significant difference between the groups in terms of age, sex, operation, hypertension, diabetes, creatinine and body mass. Conclusions Post-mortem can determine unsuspected diagnoses in a significant proportion of cases. Pre-operative risk factors do not correlate with eventual cause of death. Post-mortem still has an important role to play in cardiac surgery.

Since endothelins were discovered by Yanasigawa in 1988 it has been recognised that they may have an important role in lung pathophysiology. Despite their biological importance as vasoconstrictors the physiological role of endothelin has not yet been defined within the lungs. This review explores their role in acute and chronic disease. During acute inflammation and ischaemia–reperfusion injury cytokines may induce release of endothelin. This is important in the realm of acute lung injury and during surgical procedures such as cardiopulmonary operations including lung resections and transplantation. Complications of surgery including primary organ failure resulting in poor gas exchange as well as increased pulmonary vascular resistance have been linked to the presence of excessive endothelin. Endothelin may have an important role in transplantation biology. The complex process leading to successful lung transplantation includes optimising the donor with brain death, harvesting the lungs, managing acute and chronic rejection, and protecting the vital organs from toxic effects of immunosuppressants. During chronic disease processes, the mitotic action of endothelin may be important in vascular and airway remodelling by means of smooth muscle cell proliferation. We also explore recent advances in drug development, animal models and future directions for research.

Objective: The effect of age on metabolism and mechanical recovery of the heart after cardioplegic arrest is important, but remains a relatively unexplored subject. In this study, functional recovery and nucleotide levels were compared in the heart at different ages subjected to prolonged hypothermic cardioplegic arrest. Methods: Three different age groups of rats: 1 (A); 4 (B); and 16 months (C) were perfused in working mode and subjected to cardioplegic arrest (St. Thomas’ No. 1) and ischemia for 4 h at 4°C, followed by reperfusion for 35 min. Cardiac function (cardiac output and aortic pressure) was recorded before and after ischemia. Another series of hearts in all three age groups underwent 5 min of normoxic perfusion to obtain pre-ischemic baseline metabolite concentrations. Hearts were freeze-clamped at the end of each experiment and used for determination of nucleotide and creatine metabolites by HPLC. Results: The post-ischemic recovery (% of the pre-ischemic value) of the cardiac power was 48.997.8% for group A, which was significantly higher than the functional recovery of group B (24.19 3.5%) or C (21.494.7%, PB0.05, respectively). There was no difference in ATP or the total adenine nucleotide or creatine metabolite concentrations between the three age groups. In contrast, both GTP and the total guanine nucleotide concentration was highest in A (PB0.05). Total guanylate pool was 1.5290.10 1 mmol:g dry wt. in A, as compared to B (1.059 0.04) or C (1.129 0.04). NAD was significantly higher in B (4.190.1, PB0.05), when compared to A (3.69 0.1) and C (3.89 0.1). Conclusion: Best post-ischemic functional recovery after cardioplegic arrest was observed in the 1-month-old hearts (A) and was associated with highest guanine nucleotide concentration; preservation of guanine nucleotide pool in the youngest hearts may be an important mechanism for improved cardioprotection due to the important role of GTP in signalling pathways. © 1998 Elsevier Science B.V. All rights reserved.