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Engineering infrastructure is provided at high cost and is expected to have a useful operational life of decades. However, it is clear that the future is uncertain. Traditional approaches to designing and operating urban storm drainage assets have relied on past performance of natural systems and the ability to extrapolate this performance, together with that of the assets across the usable lifetime. Whether or not climate change is going to significantly alter future weather patterns in Europe, it is clear that it is now incumbent on designers and operators of storm drainage systems to prepare for greater uncertainty in the effectiveness of storm drainage systems. A recent UK Government study considered the potential effects of climate and socio-economic change in the UK in terms of four future scenarios and what the implications are for the performance of existing storm drainage facilities. In this paper the modelling that was undertaken to try to quantify the changes in risk, together with the effectiveness of responses in managing that risk, are described. It shows that flood risks may increase by a factor of almost 30 times and that traditional engineering measures alone are unlikely to be able to provide protection. [ABSTRACT FROM AUTHOR]

Steps leading to development of the Environmental Protection Agency's effluent limitation guidelines for the textile industry are reviewed. Through a cooperative effort, the textile industry obtained the latest available information on the nature of its process effluent and on effective treatment technology. Industry and EPA scientists worked closely together to develop a responsible, workable solution. The textile industry has demonstrated responsible leadership that should set an example for other industries. [ABSTRACT FROM AUTHOR]

A redo sternotomy, aortic root, and arch replacement in a patient following previous complex surgical and endovascular type A aortic dissection repair is presented in this video case report. Shortly after having the initial type A aortic dissection repair with replacement of the ascending aorta, the patient developed severe visceral malperfusion due to a compressed distal true lumen and underwent emergency endovascular repair with ascending arch and descending thoracic aorta stents and chimney grafts for the aortic arch vessels as well as fenestration of the intimal flap of the abdominal aorta. Unfortunately, the patient developed permanent paraplegia and progressive symptomatic severe aortic regurgitation. The patient underwent a redo sternotomy, aortic root, and arch replacement with explantation of the ascending stent graft and chimney stent grafts. Antegrade cerebral perfusion was maintained throughout the procedure. The aortic arch was replaced using a Terumo Aortic Plexus multibranched graft distally anastomosed to the endovascular stent graft, and the innominate and left common carotid arteries were reimplanted onto the graft. The aortic root was replaced with a Bioconduit graft, using a modified Cabrol technique to reimplant the left coronary artery. A satisfactory postoperative course and computed tomography imaging highlight the feasibility of this highly complex aortic arch repair with careful preoperative planning., (© The Author 2022. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background The COVID-19 pandemic continues to devastate communities all over the world. The aim of this study was to evaluate the efficacy and safety of the test agent as a prophylaxis against SARS-CoV-2 infection in a population of high-risk healthcare workers. Methods The study was a multi-centre, prospective, double blind, randomized, placebo-controlled trial. Key eligibility criteria included absence of significant co-morbidity and no previous SARS-CoV-2 infection or vaccination. Participants were randomised to either the active agent nasal spray or placebo using computer generated random number tables. The nasal spray was administered 3 times daily over a 45 day course. The primary end point was the percentage of subjects who tested positive for IgGS (anti-spike, immunoglobulin G specific to the spike protein of SARS-CoV-2) at day 45. Results Between 16th April 2021 and 26th July 2021, 556 participants were analysed for the primary endpoint (275 Test; 281 Placebo). The test agent significantly reduced SARS-CoV-2 infection compared to placebo [36 cases (13.1%) Vs 97 cases (34.5%); OR 0.29 (95% CI; 0.18-0.45), p < 0.0001]. Fewer clinical symptoms were also seen in the test group [57 cases (17.6%) vs 112 cases (34.6%); OR 0.40, (95% CI; 0.27-0.59), p < 0.0001]. No harmful effects were associated with taking the test agent. Conclusion The test agent significantly reduced SARS-CoV-2 infection in healthcare workers, with 62% fewer infections when compared to placebo. It was found to be safe and well tolerated and offers a novel treatment option for prophylaxis against SARS-CoV-2 infection., Competing Interests: Declaration of Competing Interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. JAS, LS, AD, KED, SGD, MAM, AM, RM, DR, AJR, and RU are shareholders of Raphael Labs LTD. JS is the managing director of Swales Pharma Consulting providing consulting services for a range of pharmaceutical companies. AJM and AR sit on the advisory board of Raphael labs., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Mycotic pseudoaneurysms of the ascending aorta are a rare and devastating complication of previous cardiac surgery., Case Presentation: We present an unusual case of a fungal mycotic pseudoaneurysm secondary to an aortic suture line successfully repaired under deep hypothermic circulatory arrest., Conclusions: Patients with mycotic pseudoaneurysms of the aorta require a multidisciplinary team approach to prevent devastating complications that may occur in these complex surgical cases., (© 2022. The Author(s).)

Objectives: During the worldwide COVID-19 pandemic, elective cardiac surgery was suspended to provide ICU beds for COVID-19 patients and those requiring urgent cardiac surgery. The aim of this study is to assess the effect of the pandemic on outcomes of patients awaiting elective cardiac surgery., Design: A multi-centre prospective cohort study., Setting: The elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres., Participants: Patients on the elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres., Main Outcome Measures: Primary outcome was surgery, percutaneous therapy or death at one year., Methods: Data were collected prospectively on patients on the elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres. Primary outcome was surgery, percutaneous therapy or death at one year. Demographic data and outcomes were obtained from local electronic records, anonymised and submitted securely to the lead centre for analysis., Results: On 1 March 2020, there were 1099 patients on the elective waiting list for cardiac surgery. On 1 March 2021, 83% (n = 916) had met a primary outcome. Of these, 840 (92%) had surgery after a median of 195 (118-262) days on waiting list, 34 (3%) declined an offer of surgery, 23 (3%) had percutaneous intervention, 12 (1%) died, 7 (0.6%) were removed from the waiting list. The remainder of patients, 183 (17%) remained on the elective waiting list., Conclusions: This study has shown, for the first time, significant delays to treatment of patients awaiting elective cardiac surgery. Although there was a low risk of mortality or urgent intervention, important unmeasured adverse outcomes such as quality of life or increased perioperative risk may be associated with prolonged waiting times.

BACKGROUNDEpicardial adipose tissue (EAT) directly overlies the myocardium, with changes in its morphology and volume associated with myriad cardiovascular and metabolic diseases. However, EAT's immune structure and cellular characterization remain incompletely described. We aimed to define the immune phenotype of EAT in humans and compare such profiles across lean, obese, and diabetic patients.METHODSWe recruited 152 patients undergoing open-chest coronary artery bypass grafting (CABG), valve repair/replacement (VR) surgery, or combined CABG/VR. Patients' clinical and biochemical data and EAT, subcutaneous adipose tissue (SAT), and preoperative blood samples were collected. Immune cell profiling was evaluated by flow cytometry and complemented by gene expression studies of immune mediators. Bulk RNA-Seq was performed in EAT across metabolic profiles to assess whole-transcriptome changes observed in lean, obese, and diabetic groups.RESULTSFlow cytometry analysis demonstrated EAT was highly enriched in adaptive immune (T and B) cells. Although overweight/obese and diabetic patients had similar EAT cellular profiles to lean control patients, the EAT exhibited significantly (P ≤ 0.01) raised expression of immune mediators, including IL-1, IL-6, TNF-α, and IFN-γ. These changes were not observed in SAT or blood. Neither underlying coronary artery disease nor the presence of hypertension significantly altered the immune profiles observed. Bulk RNA-Seq demonstrated significant alterations in metabolic and inflammatory pathways in the EAT of overweight/obese patients compared with lean controls.CONCLUSIONAdaptive immune cells are the predominant immune cell constituent in human EAT and SAT. The presence of underlying cardiometabolic conditions, specifically obesity and diabetes, rather than cardiac disease phenotype appears to alter the inflammatory profile of EAT. Obese states markedly alter EAT metabolic and inflammatory signaling genes, underlining the impact of obesity on the EAT transcriptome profile.FUNDINGBarts Charity MGU0413, Abbott, Medical Research Council MR/T008059/1, and British Heart Foundation FS/13/49/30421 and PG/16/79/32419.

It is now 50 years since the development of the first pericardial valve in 1971. In this time significant progress has been made in refining valve design aimed at improving the longevity of the prostheses. This article reviews the current literature regarding the longevity of pericardial heart valves in the aortic position. Side by side comparisons of freedom from structural valve degeneration are made for the valves most commonly used in clinical practice today, including stented, stentless, and sutureless valves. Strategies to reduce structural valve degeneration are also discussed including methods of tissue fixation and anti-calcification, ways to minimise mechanical stress on the valve, and the role of patient prosthesis mismatch., (© 2021 The Authors. Journal of Cardiac Surgery Published by Wiley Periodicals LLC.)

We report a rare case of infective endocarditis complicated by postoperative splenic rupture. A patient underwent urgent mitral valve replacement for infective endocarditis believed to be associated with a recent spinal surgical intervention. The patient developed haemodynamic compromise on the third day postoperatively. Computed tomography showed a splenic rupture as the cause. The patient underwent emergency radiological intervention with coil embolization avoiding the need for a splenectomy and was discharged home., (© 2020 Wiley Periodicals LLC.)

Objective: In the United Kingdom, the coronavirus disease 2019 (COVID-19) pandemic has led to the cessation of elective surgery. However, there remains a need to provide urgent and emergency cardiac and thoracic surgery as well as to continue time-critical thoracic cancer surgery. This study describes our early experience of implementing a protocol to safely deliver major cardiac and thoracic surgery in the midst of the pandemic., Methods: Data on all patients undergoing cardiothoracic surgery at a single tertiary referral center in London were prospectively collated during the first 7 weeks of lockdown in the United Kingdom. A comprehensive protocol was implemented to maintain a COVID-19-free environment including the preoperative screening of all patients, the use of full personal protective equipment in areas with aerosol-generating procedures, and separate treatment pathways for patients with and without the virus., Results: A total of 156 patients underwent major cardiac and thoracic surgery over the study period. Operative mortality was 9% in the cardiac patients and 1.4% in thoracic patients. The preoperative COVID-19 protocol implemented resulted in 18 patients testing positive for COVID-19 infection and 13 patients having their surgery delayed. No patients who were negative for COVID-19 infection on preoperative screening tested positive postoperatively. However, 1 thoracic patient tested positive on intraoperative bronchoalveolar lavage., Conclusions: Our early experience demonstrates that it is possible to perform major cardiac and thoracic surgery with low operative mortality and zero development of postoperative COVID-19 infection., (© 2020 The Authors.)

Objectives: The authors aimed to adapt a practice advisory for the prevention of atrial fibrillation after cardiac surgery (AFACS) recently published in this journal into the authors' local perioperative protocols, implementing the recommendations, with a focus on early postoperative (re)introduction of β-blockers and overcoming frequent guideline implementation barriers., Design: Development of a prevention care bundle and repeated audit after a model of improvement approach with retrospective analysis., Setting: Single center (tertiary academic hospital)., Participants: A total of 384 patients in 2 cohorts of consecutive patients undergoing open cardiac surgery before and after hospital-wide implementation of a care bundle., Interventions: After auditing the standard of care in the authors' center, an AFACS prevention care bundle was designed and implemented, consisting of a graphic tool with 5 pillars based on current evidence for the early postoperative phase. Multidisciplinary teaching and training of staff were delivered, and a second audit was conducted after the implementation period., Measurements and Main Results: Significantly more patients received postoperative β-blockers after care bundle implementation (82.7% pre- v 91.3% post-bundle, p = 0.019), with a higher proportion on day 1 (36.7% pre- v 67% post-bundle, p < 0.001), indicating a successful uptake. The incidence of AFACS was significantly reduced from 35.4% to 23.3% (p = 0.009), with a particularly marked reduction in the age group 65- to 75- years and for isolated aortic valve and coronary artery bypass graft surgery., Conclusion: An AFACS prevention care bundle improved adherence to current guidelines with regard to early β-blocker administration and significantly reduced the incidence of atrial fibrillation after cardiac surgery., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The coronavirus 2019 (COVID-19) pandemic has disrupted patient care across the NHS. Following the suspension of elective surgery, priority was placed in providing urgent and emergency surgery for patients with no alternative treatment. We aim to assess the outcomes of patients undergoing cardiac surgery who have COVID-19 infection diagnosed in the early postoperative period. We identified 9 patients who developed COVID-19 infection following cardiac surgery. These patients had a significant length of hospital stay and extremely poor outcomes with mortality of 44%. In conclusion, the outcome of cardiac surgical patients who contracted COVID-19 infection perioperatively is extremely poor. In order to offer cardiac surgery, units must implement rigorous protocols aimed at maintaining a COVID-19 protective environment to minimize additional life-threatening complications related to this virus infection., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

We describe a case of an adult patient with embolization of a varicocele coil (7 × 70 mm) to the right ventricle. We review the multimodality imaging techniques used to identify location and the importance of a multidisciplinary approach in determining management. ( Level of Difficulty: Advanced. )., Competing Interests: All authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2020 The Authors.)

Over the last 4 months, the novel coronavirus, SARS-CoV-2, has caused a significant economic, political, and public health impact on a global scale. The natural history of the disease and surge in the need for invasive ventilation has required the provision of intensive care beds in London to be reallocated. NHS England have proposed the formation of a Pan-London Emergency Cardiac surgery (PLECS) service to provide urgent and emergency cardiac surgery for the whole of London. In this initial report, we outline our experience of setting up and delivering a pan-regional service for the delivery of urgent and emergency cardiac surgery with a focus on maintaining a COVID-free in-hospital environment. In doing so, we hope that other regions can use this as a starting point in developing their own region-specific pathways if the spread of coronavirus necessitates similar measures be put in place across the United Kingdom., (© 2020 Wiley Periodicals LLC.)

Despite being recognised over a century ago, the aetiology and pathogenesis of large vessel vasculitis (LVV) still remains elusive. Takayasu's arteritis (TA) and giant cell arteritis (GCA) represent the two major categories of LVV, each with distinctive clinical features. Over the last 10 years an increased understanding of the immunopathogenesis of the inflammatory cascade within the aortic wall has revived the view that LVVs may represent subtypes of the same pathological process, with implications in the treatment of this disease. In this review, the histological, genetic and immunopathological features of TA and GCA will be discussed and the evidence for a common underlying disease mechanism examined. Novel markers of disease activity and therapies based on advances in our understanding of the immunopathogenesis of these conditions will also be discussed.

Thoracic aortic aneurysm (TAA) represents a major cause of mortality and morbidity in Western countries. The natural history of TAA is indolent, with patients usually being asymptomatic until a catastrophic event such as rupture or dissection ensues. As such, early diagnosis is crucial and the search is ongoing for a biomarker that can indicate the presence of TAA with sufficient accuracy to act as a screening tool. To date, no such marker has been developed for the diagnosis of non-familial or 'sporadic' TAA. However, our increased understanding of the pathogenesis of both familial and sporadic TAA has suggested potential candidates for diagnostic biomarkers. Many markers/pathways have been shown to have differential activity levels or expression in the aortic tissue of TAA. However, priority is given to markers that have shown differential levels in blood plasma, as blood tests represent the easiest route for mass screening for TAA. This review aims to evaluate the efficacy of clinical tests already in use in diagnosing TAA, explore novel proposed biomarkers and identify key areas of future interest.

Objective: To investigate the feasibility and safety of using a laryngeal mask airway (LMA) compared with a cuffed oral endotracheal tube (COETT) for atrial fibrillation (AF) ablation with transesophageal echocardiography (TEE)., Design: Prospective, cohort study., Setting: A single-center inner-city hospital., Participants: The study comprised adult patients undergoing elective AF ablation with periprocedural TEE over a 3-year period., Interventions: Patients were treated with either an LMA or a COETT before undergoing a standardized protocol for TEE and AF ablation., Measurements and Main Results: The primary outcome was the need for conversion from an LMA to a COETT. Between January 2014 and January 2017, 346 patients underwent AF ablation. Of those, 126 procedures were performed with a COETT (36.4%) and 220 (63.6%) with an LMA. There were no differences between groups in terms of baseline characteristics, including age, sex, body mass index, and American Society of Anesthesiologists grade. An adequate airway seal was unable to be maintained in 3 patients in the LMA group (1.4%), and those patients were converted to a COETT. No episodes of airway complications occurred in either group. No difference was found in mean propofol (2%) dose between COETT and LMA (385 mg/h v 374 mg/h; p = 0.127). However, the mean remifentanil dose (100 µg/mL) was reduced significantly in the LMA group compared with the COETT group at 355 µg/h and 939 µg/h, respectively (p < 0.001)., Conclusions: LMA use is safe and feasible in the vast majority of patients undergoing AF ablation with TEE and is an acceptable alternative to COETT. A significantly reduced rate of remifentanil was required to maintain anesthesia in the LMA group., (Copyright © 2017 Elsevier Inc. All rights reserved.)

A best evidence topic was constructed according to a structured protocol. The question addressed was whether, in patients undergoing minimally invasive aortic valve replacement (AVR), right anterior thoracotomy (RT) or mini-sternotomy (MS) was superior in terms of postoperative outcome? A total of 840 publications were found using the reported search. Of these, 6 represented the best available 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. In all, except 1 study, the primary outcome was early mortality, ranging from in-hospital mortality to 90 days postoperatively. The remaining study was a cost-benefit analysis. Four studies were non-randomized observational studies, one of which was multicentre. Two were meta-analyses of studies comparing minithoracotomy or MS with conventional sternotomy for AVR, rather than direct comparisons of the 2 minimal access techniques. We conclude that there is a lack of high-quality evidence comparing RT and MS for minimally invasive AVR, with no randomized controlled trials to date. The available evidence shows no difference in early mortality between RT and MS for surgical AVR. In studies that directly compared RT and MS, RT was found to be associated with reduced length of hospital stay, despite longer cardiopulmonary bypass times and cross-clamp times. One study reported groin complications (10.8%) with the RT group, where peripheral cannulation was used, while the other 5 studies did not comment on groin complications associated with peripheral cannulation. In the only cost-benefit analysis, RT was found to carry considerably more cost than MS over and above conventional AVR., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Ischaemic optic neuropathy is a rare but serious complication post cardiopulmonary bypass in cardiac surgery patients. It presents with visual loss either unilaterally or bilaterally, and it can be anterior or posterior in type depending on the segment of the optic nerve involved. In non-ocular surgery patients, the most common type is called non-arteritic ischaemic optic neuropathy. We report a case of bilateral non-arteritic ischaemic optic neuropathy following coronary artery bypass grafting and mitral valve surgeries and review the published literature for the aetiology, management and prognosis of this rare complication., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Management of aortic valve disease and, in particular, aortic valve stenosis has evolved through the course of time from medical management and balloon valvuloplasty to the presumed gold-standard surgical intervention. However, with the advent of surgical innovation, intra- and postoperative patients monitoring, understanding of hemodynamic dysfunction, and choices of prosthesis, conventional surgical aortic valve replacements are currently being challenged in particular in moderate- and high-risk patients. Although the long-term results and survival are not robustly available, the durability of the new prosthesis, repair, and the freedom from reoperation remain debatable. In this review, we aim to highlight the surgical innovation attained, choices of aortic valve prosthesis, and also dwell on the current evidence, practice, and trend steered to managing patients with aortic valve stenosis., (Copyright © 2017 Elsevier Inc. All rights reserved.)

A best evidence topic was written according to a structured protocol. The question addressed was whether endoscopic vein harvesting (EVH) is equivalent to open vein harvesting in terms of graft patency for patients undergoing coronary artery bypass surgery. A total of 417 articles were found using the reported search, of which 4 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 articles are tabulated. Reported outcomes were vein graft failure or patency on coronary angiography or computed tomography angiography at early, mid and long-term follow-up. Of the non-randomized studies reviewed, those with greater patient numbers and longer follow-up periods showed reduced patency rates in the EVH group. Two small early randomized controlled trials demonstrated equivalent patency rates at up to 6 months follow-up. However, a more recent randomized controlled trial showed reduced patency with EVH in 63 patients at a median follow-up of 6.3 years. We conclude that high-quality evidence for the effects of harvesting method on vein graft patency is lacking, with no large randomized trials performed to date. The current evidence suggests that although rates of vein graft failure seem to be similar within the first 6 months following surgery, EVH is associated with reduced graft patency from 12 months onwards., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

A best evidence topic was constructed according to a structured protocol. The question addressed was whether (18)F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) aids the diagnosis of prosthetic valve endocarditis (PVE)? A total of 107 publications were found using the reported search, of which 6 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 reported outcome of all studies was a final diagnosis of confirmed endocarditis on follow-up. All the six studies were non-randomized, single-centre, observational studies and thus represented level 3 evidence. The diagnostic capability of PET/CT for PVE was compared with that of the modified Duke Criteria and echocardiography, and reported in terms of sensitivity, specificity and positive and negative predictive values. All studies demonstrated an increased sensitivity for the diagnosis of PVE when PET/CT was combined with the modified Duke Criteria on admission. A higher SUVmax on PET was found to be significantly associated with a confirmed diagnosis of endocarditis and an additional diagnostic benefit of PET/CT angiography over conventional PET/non-enhanced CT is reported due to improved anatomical resolution. However, PET/CT was found to be unreliable in the early postoperative period due to its inability to distinguish between infection and residual postoperative inflammatory changes. PET/CT was also found to be poor at diagnosing cases of native valve endocarditis. We conclude that PET/CT aids in the diagnosis of PVE when combined with the modified Duke Criteria on admission by increasing the diagnostic sensitivity. The diagnostic ability of PET/CT can be potentiated by the use of PET/CTA; however, its use may be unreliable in the early postoperative period or in native valve endocarditis., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Pleural effusions as part of the yellow nail syndrome (YNS) can often be recurrent, requiring multiple thoracocentesis. The optimal surgical treatment of such recurrent effusions remains unclear and various methods including thoracoscopic pleurodesis, pleuroperitioneal shunts and pleurectomy have been described. We report two cases of recurrent pleural effusions in YNS, the first case with bilateral effusions and the second with right-sided effusions treated 2 months apart from bilateral long-term tunnelled catheters and thoracoscopic pleurectomy and compare the results of the two treatment strategies.

We report a rare case of a laparoscopic splenectomy performed for a carcinoid metastasis. The patient represented with pleuritic left-sided chest pain from pleural deposits 9 years following resection of a primary lung carcinoid tumour. They were found to have a 4.7 cm splenic lesion on CT with a probable left acetabular metastasis demonstrated on Gallium PET scan. The patient underwent laparoscopic splenectomy for debulking treatment of the splenic lesion that was confirmed to be a splenic metastasis of the resected carcinoid lung tumour. Following an uncomplicated recovery, the patient was discharged on the second postoperative day. On discharge, she received adjuvant therapy with Lutetium 177 DOTATATE. This is the first report of a carcinoid splenic metastasis successfully treated with laparoscopic splenectomy.