Search

Introduction Cardiac surgery with cardiopulmonary bypass and cardioplegic arrest is known to be responsible for ischaemia and reperfusion organ injury. In a previous study, ProMPT, in patients undergoing coronary artery bypass or aortic valve surgery we demonstrated improved cardiac protection when supplementing the cardioplegia solution with propofol (6 mcg/ml). The aim of the ProMPT2 study is to determine whether higher levels of propofol added to the cardioplegia could result in increased cardiac protection. Methods and Analysis The ProMPT2 study is a multi-centre, parallel, three-group, randomised controlled trial in adults undergoing non-emergency isolated coronary artery bypass graft surgery with cardiopulmonary bypass. A total of 240 patients will be randomised in a 1:1:1 ratio to receive either cardioplegia supplementation with high dose of propofol (12 mcg/ml), low dose of propofol (6 mcg/ml) or placebo (saline). The primary outcome is myocardial injury, assessed by serial measurements of myocardial troponin T up to 48 hours after surgery. Secondary outcomes include biomarkers of renal function (creatinine) and metabolism (lactate). Ethics and Dissemination The trial received research ethics approval from South Central – Berkshire B Research Ethics Committee and Medicines and Healthcare products Regulatory Agency in September 2018. Any findings will be shared though peer-reviewed publications and presented at international and national meetings. Participants will be informed of results through patient organisations and newsletters. Trial Registration ISRCTN15255199. Registered in March 2019.

Background Given the variety in mitral valve (MV) pathology and associated surgical techniques, extended reality (XR) holds great potential to assist MV surgeons. This review aims to systematically evaluate the currently available evidence investigating the use of XR and associated technologies in MV surgery. Methods A systematic database search was conducted of original articles and case reports that explored the use of XR and MV surgery in EMBASE, MEDLINE, Cochrane database and Google Scholar, from inception to February 2022. Results Our search yielded 171 articles, of which 15 studies were included in this review, featuring 328 patients. Two main areas of application were identified: (i) pre-operative planning and (ii) predicting post-operative outcomes. The articles reporting outcomes relating to pre-operative planning were further categorised as exploring themes relevant to (i) mitral annular assessment; (ii) training; (iii) evaluation of surgical technique; (iv) surgical approach or plan and (v) selecting ring size or type. Preoperatively, XR has been shown to evaluate mitral annular pathology more accurately than echocardiography, informing the surgeon about the optimal surgical technique, approach and plan for a particular patient’s MV pathology. Furthermore, XR could simulate and aid ring size/type selection for MV annuloplasty, creating a personalized surgical plan. Additionally, XR could estimate the postoperative MV biomechanical and physiological characteristics, predicting and pre-empting post-operative complications. Conclusion XR demonstrated promising applications for assisting MV surgery, enhancing outcomes and patient-centred care, nevertheless, there remain the need for randomized studies to ascertain its feasibility, safety, and validity in clinical practice.

Our earlier work has shown inter‑disease and intra‑disease differences in the cardiac proteome between right (RV) and left (LV) ventricles of patients with aortic valve stenosis (AVS) or coronary artery disease (CAD). Whether disease remodeling also affects acute changes occuring in the proteome during surgical intervention is unknown. This study investigated the effects of cardioplegic arrest on cardiac proteins/phosphoproteins in LV and RV of CAD (n=6) and AVS (n=6) patients undergoing cardiac surgery. LV and RV biopsies were collected during surgery before ischemic cold blood cardioplegic arrest (pre) and 20 min after reperfusion (post). Tissues were snap frozen, proteins extracted, and the extracts were used for proteomic and phosphoproteomic analysis using Tandem Mass Tag (TMT) analysis. The results were analysed using QuickGO and Ingenuity Pathway Analysis softwares. For each comparision, our proteomic analysis identified more than 3,000 proteins which could be detected in both the pre and Post samples. Cardioplegic arrest and reperfusion were associated with significant differential expression of 24 (LV) and 120 (RV) proteins in the CAD patients, which were linked to mitochondrial function, inflammation and cardiac contraction. By contrast, AVS patients showed differential expression of only 3 LV proteins and 2 RV proteins, despite a significantly longer duration of ischaemic cardioplegic arrest. The relative expression of 41 phosphoproteins was significantly altered in CAD patients, with 18 phosphoproteins showing altered expression in AVS patients. Inflammatory pathways were implicated in the changes in phosphoprotein expression in both groups. Inter‑disease comparison for the same ventricular chamber at both timepoints revealed differences relating to inflammation and adrenergic and calcium signalling. In conclusion, the present study found that ischemic arrest and reperfusion trigger different changes in the proteomes and phosphoproteomes of LV and RV of CAD and AVS patients undergoing surgery, with markedly more changes in CAD patients despite a significantly shorter ischaemic period.

Background The COVID-19 pandemic has spread globally infecting and killing millions. Those with cardiovascular disease (CVD) are at higher risk of increased disease severity and mortality. We performed a systematic review and meta-analysis to estimate the rate of in-hospital mortality following different treatments on COVID-19 in patients with CVD. Methods Pertinent articles were identified from the PubMed, Google Scholar, Ovid MEDLINE, and Ovid EMBASE databases. This study protocol was registered under PROSPERO with the identifier CRD42020183057. Results Of the 1673 papers scrutinized, 46 were included in the review. Of the 2553 patients (mean age 63.9 ± 2.7 years/o; 57.2% male), the most frequent CVDs were coronary artery disease (9.09%) and peripheral arterial disease (5.4%) and the most frequent cardiovascular risk factors were hypertension (86.7%) and diabetes (23.7%). Most patients were on multiple treatments. 14 COVID-19 treatments were compared with controls. The pooled event rate for in-hospital mortality was 20% (95% confidence interval (CI): 11–33%); certain heterogeneity was observed across studies. Conclusions COVID-19 is associated with a high in-hospital mortality rate in patients with CVD. This study shows that previous CVD determines mortality, regardless of the type of COVID-19 administered therapy. Treatments for at-risk patients should be administered carefully and monitored closely until further data are available.

The landmark 2016 Minimal Invasive Extracorporeal Technologies International Society (MiECTiS) position paper promoted the creation of a common language between cardiac surgeons, anesthesiologists and perfusionists which led to the development of a stable framework that paved the way for the advancement of minimal invasive perfusion and related technologies. The current expert consensus document offers an update in areas for which new evidence has emerged. In the light of published literature, modular minimal invasive extracorporeal circulation (MiECC) has been established as a safe and effective perfusion technique that increases biocompatibility and ultimately ensures perfusion safety in all adult cardiac surgical procedures, including re-operations, aortic arch and emergency surgery. Moreover, it was recognized that incorporation of MiECC strategies advances minimal invasive cardiac surgery (MICS) by combining reduced surgical trauma with minimal physiologic derangements. Minimal Invasive Extracorporeal Technologies International Society considers MiECC as a physiologically-based multidisciplinary strategy for performing cardiac surgery that is associated with significant evidence-based clinical benefit that has accrued over the years. Widespread adoption of this technology is thus strongly advocated to obtain additional healthcare benefit while advancing patient care.

Introduction: Despite low mortality, cardiac surgery patients may experience serious life-threatening post-operative complications, often due to extracorporeal circulation and reperfusion. Miniaturised cardiopulmonary bypass (minimally invasive extracorporeal circulation) has been developed aiming to reduce the risk of post-operative complications arising with conventional extracorporeal circulation. Methods: The COMICS trial is a multi-centre, international, two-group parallel randomised controlled trial testing whether type II, III or IV minimally invasive extracorporeal circulation is effective and cost-effective compared to conventional extracorporeal circulation in patients undergoing elective or urgent coronary artery bypass grafting, aortic valve replacement or coronary artery bypass grafting + aortic valve replacement. Randomisation (1:1 ratio) is concealed and stratified by centre and surgical procedure. The primary outcome is a composite of 12 serious complications, objectively defined or adjudicated, 30 days after surgery. Secondary outcomes (at 30 days) include other serious adverse events (primary safety outcome), use of blood products, length of intensive care and hospital stay and generic health status (also at 90 days). Status of the trial: Two centres started recruiting on 08 May 2018; 10 are currently recruiting and 603 patients have been randomised (11 May 2020). The recruitment rate from 01 April 2019 to 31 March 2020 was 40-50 patients/month. About 80% have had coronary artery bypass grafting only. Adherence to allocation is good. Conclusions: The trial is feasible but criteria for progressing to a full trial were not met on time. The Trial Steering and Data Monitoring Committees have recommended that the trial should currently continue.

Background: Contemporary studies show that myocardial fibrosis worsens after mechanical unloading with left ventricular assist devices (LVADs). The exact mechanism underlying this phenomenon remains unknown. Mechanical unloading has however been associated with a reduction in microvascular lumenal diameter in the failing heart, suggesting a link with negative auto-regulatory effects on the collateral circulation. We hypothesise that coronary reperfusion after myocardial infarction ameliorates the deleterious effect of mechanical unloading on infarct size and interstitial fibrosis. Methods: Syngeneic male Lewis rats weighing 200 to 300g were studied. Myocardial infarction – acute (AMI) and chronic (CMI) - was induced by LAD ligation. Two groups were generated: a permanent ligation group (AMI and CMI) and a reperfusion - coronary circulation restored after 90 minutes - group (AMI/R and CMI/R). In each group hearts were either loaded (L) or unloaded (U). In the loaded subgroup, rats were recovered after coronary ligation. In the unloaded subgroup, the infarcted hearts were explanted after 90 minutes and transplanted into the abdomen of healthy recipients via heterotopic abdominal heart transplantation. Hearts were explanted on day 2, day 7, and 16wks. The recipient’s heart acted as control. Histological analysis and western blotting for αSMA and TGF-β1 (markers of fibrosis) were completed. Results: Ninety rats were studied. There was a significant increase in infarct ratio (IR) - infarct size/area at risk-, and interstitial fibrosis (IF) after mechanical unloading in the permanent ligation group at day 2 (AMI-L vs AMI-U p = 0.0073 (IR) and p = 0.0012 (IF)) and day 7 (AMI-L vs AMI-U p = 0.0166 (IR) and p = 0.0363 (IF)). After coronary reperfusion, there was no increase in IR or IF with mechanical unloading. At 16wks however, this protective effect of reperfusion was lost (CMI/R-L vs CMI/R-U p = 0.004 (IR) and p = 0.0024 (IF)). The expression profiles of αSMA and TGF-β1 correlated with the results above. Conclusion: These data suggest an association between the revascularisation of a less auto-regulated vessel and amelioration of the deleterious effect of mechanical unloading on the extracellular matrix with implications for LVAD induced recovery.

As the general population ages the incidence of degenerative valve disease is increasing. This is reflected by the changing workload of cardiac surgeons, indicated by the rising number of heart valve operations. Improved imaging techniques facilitate diagnosis, surveillance and guide surgical management in correcting the underlying defect. Patients with valvular heart disease require close follow-up and monitoring for changes in symptomatology, valve and ventricular function. Medical therapy is limited to antibiotic prophylaxis against endocarditis. Surgery is the mainstay of treatment for symptomatic and severe lesions, and is associated with excellent haemodynamic improvements and long-term outcomes. The timing of valve surgery is critical in order to avoid irreversible consequences of ventricular dysfunction or pulmonary hypertension.

Right ventricular (RV) remodelling may be an important determinant of clinical outcome in patients undergoing mitral valve surgery for mitral regurgitation. In the present study we hypothesised that, compared to valve replacement, mitral valve repair for degenerative mitral regurgitation may result in better RV remodelling, as assessed by real-time, three-dimensional echocardiography (RT3DE).Forty unselected patients with degenerative mitral valve regurgitation were recruited prospectively. Two-dimensional (2DE) and RT3DE studies were performed prior to surgery and 6 months postoperatively. RV volumes, stroke volume, ejection fraction and mass, as well as RV pressures were calculated. Regression analysis was used to demonstrate the effect of surgical mitral repair and replacement on reverse RV remodelling.Twenty-one patients underwent mitral valve repair and 19 valve replacement. Mean age was 59.5 ± 15.4 years. Five patients who underwent repair (23.8%) developed recurrent MR within 6 months postoperatively. RV systolic pressure was reduced from 39.3 ± 11.9 mmHg, to 25.4 ± 8.3 mmHg after surgery (p=0.027). Compared to preoperative volumes, 6 months after surgery there was a significant reduction in RV diastolic volume and stroke volume (from 106.4 ± 16.3 ml to 80.4 ± 12.1 ml and from 69.2 ± 15.4 ml to 52.2 ± 14.1 ml, respectively, p0.001), and an increase in RV ejection fraction (from 54.5 ± 9.2% to 67.3 ± 8.5%, p0.001). Over a 6-month follow-up period there were no deaths. Overall, the functional class was significantly improved in 39/40 patients (97.5%) but there was no difference between the repair and replacement groups. Using a multivariate regression analysis model including all parameters composing RV remodelling postoperatively, mitral valve repair was the strongest predictor of reverse RV remodelling (reduction of RV end-diastolic volume, p0.01; reduction of RV mass, p0.01; reduction of tricuspid regurgitant velocity, p=0.019).Mitral valve repair leads to more favourable reverse RV remodelling, assessed by RT3DE, compared to valve replacement. This may have important clinical implications.

To characterize contemporary long-term results of AVR as a function of type of prosthesis and subsequent competing risks. 5470 consecutive patients had AVR ± CABG at 3 centers between 1993–2006. Microsimulation survival models were developed combining perioperative mortality estimates from multivariable modeling of individual patient data, UK survival and random effects meta-analyses of valve-related events. Outputs were predicted and event-free life expectancy, and lifetime event rates according to patient characteristics of age, sex, creatinine, valve type, and concomitant CABG. In multivariable analysis long-term survival was significantly influenced by age (hazard ratio, HR, 1.52 per 10-year increment), male sex (HR 1.20), bioprosthesis (HR 1.25) and pre-operative creatinine, but not by concomitant CABG. Recipients of bioprostheses had longer average life expectancy for implant ages from 59 onwards in both men (see figure ) and women. The improvement in event-free survival for mechanical prostheses was greater at younger ages (3.4 years for implant age 50) and extended to implant age 65. Concomitant CABG increased operative mortality but conferred only slightly shorter life expectancy and event-free life expectancy than for those having AVR alone. Creatinine also had only a small absolute effect on outcomes. Structural bioprosthetic valve degeneration was the most common long-term complication. Predictions from simulation models were in excellent agreement with UK Heart Valve Registry survival data. Aortic bioprostheses could be implanted in many UK patients aged 59–65 without significant long-term hazards.