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Introduction: Depressive illness has a high prevalence in patients undergoing coronary artery bypass graft surgery (CABG). The first line treatment for depression are selective serotonin reuptake inhibitors (SSRIs) which inhibit serotonin reuptake in the presynaptic neuronal membrane and uptake by platelets, inhibiting subsequent serotonin-mediated platelet activation. This presents a theoretically increased risk of bleeding and subsequent postoperative mortality. This review aims to investigate the effects of SSRIs on postoperative bleeding, defined as the need for transfusions and re-operation for bleeding, as well as 30-day mortality in patients undergoing CABG., Method: Four hundred and thirty-seven papers were screened with seven meeting the full inclusion criteria., Results: Meta-analysis demonstrated that SSRI use increased the risk of red blood cell transfusion (odds ratio (OR) = 1.15; 95% confidence interval (CI): 1.06-1.26), but resulted in no difference in the rate of re-operation for bleeding (OR = 1.07; 95% CI: 0.66-1.74). SSRI use had no effect on the rates of platelet (OR = 0.93; 95% CI: 0.79-1.09) or fresh frozen plasma (OR = 0.96; 95% CI: 0.74-1.24) transfusion nor on the mortality rate (OR =1.03; 95 CI: 0.90-1.17)., Conclusion: This review demonstrates that SSRIs are largely safe in cardiac surgery as no increase in mortality was observed. However, there is a significantly raised chance of red blood cell transfusion. The heterogeneous nature of the current evidence base highlights the need for further research into SSRIs and whether any effect on patient outcomes in cardiac surgery occurs.

A high prevalence of depression is observed in patients undergoing cardiac surgery, and depression has been shown to be an independent predictor of morbidity and mortality in this patient population. Selective serotonin re-uptake inhibitors (SSRIs) are the first-line recommended therapy for depressive disorders, however due to their platelet inhibitory actions they have been associated with increased incidences of post-operative bleeding. This review has sought to address whether the use of SSRIs is associated with a higher rate of mortality, major adverse events or bleeding events following cardiac surgery. A retrospective literature search selected studies comparing the use of SSRIs with no SSRI use in patients undergoing cardiac surgery. Seven of the ten studies analysed reported no significant difference in mortality in SSRI users. Five of the seven studies reporting bleeding events demonstrated no significant difference in SSRI users. Three of the five studies reporting other significant morbidity demonstrated no significant difference in SSRI users. Our study demonstrates the safety of the use of SSRIs for the treatment of depressive disorders in patients undergoing cardiac surgery., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Aneurysms and dissections of the right-sided aortic arch are rare and published data are limited to a few case reports and small series. The optimal treatment strategy of this entity and the challenges associated with their management are not yet fully investigated and conclusive. We performed a systematic review of the literature to identify all patients who underwent surgical or endovascular intervention for right aortic arch aneurysms or dissections. The search was limited to the articles published only in English. We focused on presentation and critically assessed different management strategies and outcomes. We identified 74 studies that reported 99 patients undergoing surgical or endovascular intervention for a right aortic arch aneurysm or dissection. The median age was 61 years. The commonest presenting symptoms were chest or back pain and dysphagia. Eighty-eight patients had an aberrant left subclavian artery with only 11 patients having the mirror image variant of a right aortic arch. The commonest pathology was aneurysm arising from a Kommerell's diverticulum occurring in over 50% of the patients. Twenty-eight patients had dissections, 19 of these were Type B and 9 were Type A. Eighty-one patients had elective operations while 18 had emergency procedures. Sixty-seven patients underwent surgical treatment, 20 patients had hybrid surgical and endovascular procedures and 12 had totally endovascular procedure. There were 5 deaths, 4 of which were in patients undergoing emergency surgery and none in the endovascular repair group. Aneurysms and dissections of a right-sided aortic arch are rare. Advances in endovascular treatment and hybrid surgical and endovascular management are making this rare pathology amenable to these approaches and may confer improved outcomes compared with conventional extensive repair techniques., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Off-pump coronary artery bypass surgery has been a controversial area of debate and the outcome profile of the technique has been thoroughly investigated. Scepticism regarding the reported outcomes and the conduct of the randomized trials comparing this technique with conventional on-pump coronary artery bypass surgery has been widely voiced, and the technique of off-pump surgery remains as an infrequently adopted approach to myocardial revascularization worldwide. Criticisms of the technique are related to lower rates of complete revascularization and its unknown long-term consequences, the significant detrimental effects on mortality and major adverse events when emergency conversion is required, and the significant lack of long-term survival and morbidity data. The hybrid technique of myocardial revascularization on the beating heart with the use of cardiopulmonary bypass may theoretically provide the beneficial effects of off-pump surgery in terms of myocardial protection and organ protection, while providing the safety and stability of on-pump surgery to allow complete revascularization. Large randomized comparison to support evidence-based choices is currently lacking. In this article, we have meta-analysed the outcomes of on-pump beating heart surgery in comparison with off-pump surgery focusing on major adverse cardiovascular and cerebrovascular adverse events (MACCE) including mortality, stroke and myocardial infarction and the degree of revascularization and number of bypass grafts performed. It was demonstrated that the beating heart on-pump technique allows a significantly higher number of bypass grafts to be performed, resulting in significantly higher degree of revascularization. We have also demonstrated a slightly higher rate of 30-day mortality and MACCE with the technique although not at a statistically significant level. These results should be considered alongside the population risk profile, where a significantly higher risk cohort had undergone the beating heart on-pump technique. Long-term survival and morbidity figures are required to assess the impact of these findings in the coronary surgery patient population., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Coronary artery bypass graft surgery remains the main treatment modality for multivessel coronary artery disease and has consistently been demonstrated to have significantly lower rates of major adverse cardiac and cerebrovascular events in comparison to percutaneous coronary intervention. In this article we will explore the advances over time and the recent refinements in the techniques of surgical revascularization and how these contribute to the superior outcome profile associated with coronary artery bypass graft surgery. These include the current outcome status of coronary artery bypass grafting; the major landmark trials, registries and meta-analyses comparing coronary artery bypass grafting and percutaneous coronary intervention; the developments in coronary artery disease lesion classification; the techniques for the physiological assessment of coronary artery lesions; bypass grafting using arterial conduits; the role of off-pump coronary artery surgery; the outcomes of reoperative surgery; hybrid techniques for coronary revascularization; minimally invasive coronary artery surgery and finally robotic surgery.

Background: Beating-heart on-pump coronary artery bypass grafting (BH-ONCAB) offers a hybrid coronary revascularization technique that may confer the benefits of an "off-pump" operation while maintaining the hemodynamic stability and mechanical support of conventional on-pump CABG (C-ONCAB). This study aimed to identify whether BH-ONCAB confers a morbidity or mortality benefit over C-ONCAB in the immediate and midterm postoperative period., Methods: A systematic literature review identified 13 studies incorporating 3,930 patients (937 BH-ONCAB; 2,993 C-ONCAB) fulfilling our inclusion criteria. Outcomes were meta-analyzed using random-effects modelling. Between-study heterogeneity was investigated through quality assessment, subgroup, and risk of bias analysis., Results: No difference was seen in overall 30-day mortality (13 studies; odds ratio, 0.60; 95% confidence interval, 0.32 to 1.14; p = 0.12), or midterm survival (5 studies; hazard ratio, 0.65; 95% confidence interval, 0.22 to 1.88; p = 0.43) between BH-ONCAB and C-ONCAB. BH-ONCAB was associated with significantly fewer postoperative myocardial infarction events (odds ratio, 0.32; 95% confidence interval, 0.11 to 0.92; p = 0.03); however, no significant difference was observed in other postoperative morbidity outcomes. Intraoperatively, BH-ONCAB resulted in significantly less intraaortic balloon pump use, shorter cardiopulmonary bypass time, and less blood loss. The number of anastomoses and vessels grafted were not significantly different between BH-ONCAB and C-ONCAB., Conclusions: BH-ONCAB is a safe and comparable alternative to C-ONCAB in terms of early mortality and late survival. Furthermore, BH-ONCAB may confer a particular advantage in preventing perioperative myocardial infarction and reducing overall blood loss. Future work should focus on larger matched studies and multicenter randomized controlled trials that risk-stratify patients according to preoperative ventricular function and renal insufficiency to allow us to optimize our surgical revascularization strategy in these high-risk patients., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A best evidence topic was written according to a structured protocol. The question addressed was whether on-pump beating heart coronary artery bypass (BH-ONCAB) surgery has a different outcome profile in comparison to off-pump coronary artery bypass (OPCAB). A total of 205 papers were found by systematic search of which 7 provided the largest and most recent outcome analysis comparing BH-ONCAB with OPCAB, and represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results were tabulated. Reported outcome measures included mortality, stroke, myocardial infarction, renal failure, myocardial damage, change in ejection fraction, number of bypass grafts and completeness of revascularization. With the exception of one study that favoured the off-pump technique, our review did not demonstrate a statistically significant difference in terms of mortality between the groups. We did not identify a statistically significant difference in any reported morbidity outcomes. However, there was a trend towards better outcomes for the on-pump beating heart technique, despite a higher risk profile in terms of age, ejection fraction and burden of coronary disease in this group. Consistent statistically significant differences between the groups were the mean number of grafts performed and the completeness of revascularization, both of which were higher with the on-pump beating heart technique. Limitations to the current evidence include the finding that most of the current data arise from specialist off-pump surgeons or centres that would usually only carry out BH-ONCAB in the higher risk patients where the added safety of cardiopulmonary bypass is desired., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

On-pump coronary artery surgery remains the gold standard treatment for multi-vessel disease. The technique of off-pump surgery has evolved since its first use; however, currently less than 20% of all cases worldwide are performed this way. This poor uptake has been both the cause and the effect of widespread scepticism regarding the validity of the data on the technique, as well as criticism regarding the conversion-related adverse outcomes, graft patency and completeness of revascularisation. Consequently, there has been focus on patient selection from subgroups most likely to benefit from the technique. Re-operative patients, by virtue of their advanced age, complex co-morbidities and the technical challenges of re-operation, fall into this category. In this review, the authors will discuss the outcomes of off-pump surgery in comparison to on-pump, explore the potential beneficial effects of off-pump in re-operative surgery and formulate a decision-making strategy in patients undergoing reoperative coronary artery surgery.

Off-pump coronary artery bypass surgery (OPCAB) has been hypothesised to be beneficial in the high-risk patient population undergoing re-operative coronary artery bypass graft surgery (CABG). In addition, this technique has been demonstrated to provide subtle benefits in end-organ function including heart, lungs and kidney. The aims of this study were to assess whether OPCAB is associated with a lower incidence of major adverse cardiovascular and cerebrovascular events (MACCE) and other adverse outcomes in re-operative coronary surgery. Twelve studies, incorporating 3471 patients were identified by systematic literature review. These were meta-analysed using random-effects modelling. Primary endpoints were MACCE and other adverse outcomes including myocardial infarction, stroke, renal dysfunction, low cardiac output state, respiratory failure and atrial fibrillation. A significantly lower incidence of myocardial infarction, stroke, renal dysfunction, low cardiac output state, respiratory failure and atrial fibrillation was observed with OPCAB (OR 0.58; 95% CI (confidence interval) [0.39-0.87]; OR 0.37; 95% CI [0.17-0.79]; OR 0.39; 95% CI [0.24-0.63]; OR 0.14; 95% CI [0.04-0.56]; OR 0.36; 95% CI [0.24-0.54]; OR 0.41; 95% CI [0.22-0.77] respectively). Sub-group analysis using sample size, matching score and quality score was consistent with and reflected these significant findings. Off-pump coronary artery bypass grafting reduces peri-operative and short-term major adverse outcomes in patients undergoing re-operative surgery. Consequently we conclude that OPCAB provides superior organ protection and a safer outcome profile in re-operative CABG.

Objectives: Obstruction of the main coronary trunks, although rare among the general pediatric population, remains an important complication of the arterial switch operation (ASO). Surgical patch angioplasty (SPA) is a technique whereby myocardial revascularization is achieved through direct ostial enlargement, restoring antegrade coronary flow, avoiding competitive flow, and preserving conduit material. This study investigates the indications, techniques, and outcomes of SPA in the pediatric population., Methods: A systematic literature review identified 15 studies incorporating 92 patients. The primary outcome of interest was 30-day mortality. Secondary outcomes included 30-day major adverse cardiac and cerebrovascular events, mortality at last follow-up, reintervention rate, symptomatic status, angiographic patency, and myocardial perfusion status at last follow-up., Results: The SPA was most frequently performed to treat ostial occlusion as a complication of the ASO (73.9%). Of the procedures, 77.2% involved the left main stem, 8.7% the left anterior descending artery, and 14.1% the right coronary artery. Saphenous vein was the commonest patch type (60.9%) followed by autologous pericardium (23.9%). Of the procedures, 96.7% were considered successful with an uneventful postoperative recovery. Overall hospital mortality was 2.2%. At a mean of 39 months of follow-up, 84.8% of the patients were asymptomatic, 51.1% of the repairs were angiographically patent, 9.8% had myocardial perfusion defects, and 6.5% required repeat revascularization., Conclusion: Current evidence suggests that SPA shows encouraging outcomes in a pediatric population and, with increasing experience, may provide a definitive solution to coronary artery occlusion.

A best evidence topic was written according to a structured protocol. The question addressed was regarding the indication and timing of the use of cardiopulmonary bypass (CPB), following severe hypothermic cardiac arrest. A total of 284 papers were found using the reported searches, of which nine represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were survival, rewarming speed, incidence of arrhythmia during rewarming, resolution of full neurological function, long-term neurological function, evidence of damage on neurological imaging and venous metabolic parameters in hypothermic patients. The most recent of the best evidence studies, a retrospective comparative study of 68 patients, demonstrated CPB rewarming to be far superior to conventional methods of rewarming, with mortality rates of 15.8 and 53.3%, respectively. Another study of similar size, comparing CPB with extracorporeal membrane oxygenation (ECMO) for rewarming, revealed superior survival rates with ECMO, 75 vs 34%. A systematic review of 68 patients demonstrated an overall survival of 60%, and 80% of survivors returning to a previous level of activity. Two smaller observational studies reported survival rates of 73.1 and 45.5%, respectively. A retrospective study analysing long-term neurological outcomes of survivors reported normal history and physical examination in 93.3%, normal neurovascular ultrasound in 100%, normal neuropsychological findings in 93.3% and normal brain magnetic resonance imaging in 86.7%. A small comparative study demonstrated a significant survival benefit when CPB was preceded with emergency thoracotomy, internal cardiac massage and warm mediastinal irrigation compared with CPB alone. We conclude that, following deep hypothermic circulatory arrest, the urgent use of cardiopulmonary bypass is widely indicated for rewarming where it has been shown to provide good survival and neurological outcomes far superior in comparison with conventional methods of rewarming.

A best evidence topic was written according to a structured protocol. The question addressed was whether there is a surgeon or hospital volume-outcome relationship in patients undergoing off-pump coronary artery bypass surgery. A total of 281 papers were found using the reported searches, of which six represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. The studies found analysed the outcomes of off-pump coronary artery bypass surgery in relation to surgeon or hospital volume and evaluated the presence of a volume-outcome relationship. Reported measures included mortality and major adverse cardiovascular and cerebrovascular events. The methodological quality and strength of each study for exploring volume-outcome relationships were quantitatively assessed using a predefined scoring system. Three studies analysed surgeon volume and three studies analysed hospital volume. The two largest and most recent studies presented a significant volume-outcome relationship in mortality and postoperative complications. Perhaps owing to the smaller sample size, this significant relationship in mortality was not observed in the four smaller studies; however, one of these studies demonstrated a significantly positive relationship for postoperative complications and another study demonstrated a similar significant relationship for the number of grafts and the degree of completeness of revascularization. While the volume-outcome relationship in coronary artery bypass graft surgery is very well-documented, the technically challenging nature of off-pump surgery, the length of the learning curve associated with the operation and the higher risk profile of patients undergoing off-pump surgery in comparison with routine on-pump surgery render these results difficult to interpret. Although our review does support the idea of a volume-outcome relationship in off-pump coronary artery bypass surgery, this relationship may not be so clearly defined and requires further analysis by higher-quality studies.

A best evidence topic was written according to a structured protocol. The question addressed was whether cardiopulmonary bypass can be used safely with satisfactory maternal and foetal outcomes in pregnant patients undergoing cardiac surgery. A total of 679 papers were found using the reported searches of which 14 represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were maternal and foetal mortality and complications, mode of delivery, cardiopulmonary bypass and aortic cross-clamp times, perfusate flow rate and temperature and maternal NYHA functional class. The most recent of the best evidence studies, a retrospective observational study of 21 pregnant patients reported early and late maternal mortalities of 4.8 and 14.3%, respectively, and a foetal mortality of 14.3%. Median cardiopulmonary bypass and aortic cross-clamp times were 53 and 35 min, respectively, and the median bypass temperature was 37°C. Three larger retrospective reviews of the literature reported maternal mortality rates of 2.9-5.1% and foetal mortality rates of 19-29%. Mean cardiopulmonary bypass times ranged from 50.5 to 77.8 min. Another retrospective observational study reported maternal mortality of 13.3% and foetal mortality of 38.5%. Mean cardiopulmonary bypass and aortic cross-clamp times were 89.1 and 62.8 min, respectively, with a mean bypass temperature of 31.8°C. A retrospective case series reported no maternal mortality and one case of foetal mortality. Median cardiopulmonary bypass and aortic cross-clamp times were 101 and 88 min, respectively. Eight case reports described 10 patients undergoing cardiopulmonary bypass. There were no reports of maternal mortality and one report of foetal mortality. Mean cardiopulmonary bypass and aortic cross-clamp times were 105 and 50 min, respectively. We conclude that while the use of cardiopulmonary bypass during pregnancy poses a high risk for both the mother and the foetus, the use of high-flow, high-pressure, pulsatile, normothermic bypass and continuous foetal and uterine monitoring can allow cardiac surgery with the use of cardiopulmonary bypass to be performed with the greatest control of risk in the pregnant patient.

A best evidence topic was written according to a structured protocol. The question addressed was whether smoking cessation prior to cardiac surgery would result in a greater freedom from postoperative complications. A total of 564 papers were found using the reported searches, of which five represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were operative mortality, pulmonary complications, infective complications, neurological complications, transfusion requirements, duration of ventilation, intensive care unit and hospital stay, intensive care unit re-admission, postoperative gas exchange parameters and postoperative pulmonary function. The largest of the best evidence studies demonstrated a significant reduction in pulmonary complications in non-smokers (P < 0.001); however, there was an increased requirement for transfusion in this cohort (P = 0.002). There were non-significant reductions in neurological complications, infective complications and re-admissions to intensive care. Another large cohort study demonstrated significant reductions in non-smokers in mortality (P < 0.0001), pulmonary complications (P = 0.0002), infection (P < 0.0007), intensive care unit re-admission (P = 0.0002), duration of mechanical ventilation (P = 0.026) and intensive care unit stay (P = 0.002). A larger cohort study again demonstrated significant reductions in non-smokers in pulmonary complications (P < 0.002), duration of mechanical ventilation (P < 0.012) and intensive care unit stay (P < 0.005). A smaller prospective cohort study reported significantly raised PaO(2) (P = 0.0091) and reduced PaCO(2) (P < 0.0001) levels in the non-smokers as well as improved FVC and FEV(1) (P < 0.0001). There were also reductions in duration of intubation (P < 0.0001), intensive care unit stay (P < 0.0001) and hospital stay (P < 0.0013). Another small cohort study reporting outcomes of heart transplantation demonstrated significant improvement in non-smokers in terms of survival (P = 0.031), duration of intubation (P = 0.05) and intensive care unit stay (P = 0.021). We conclude that there is strong evidence demonstrating superior outcomes in non-smokers following cardiac surgery and advocate the necessity of smoking cessation as soon as possible prior to cardiac surgery.

Isolated ostial stenosis of the left main coronary artery (LMCA) is rare, occurring in <1% of the patients undergoing coronary angiography. Surgical patch angioplasty (SPA) offers an alternative to conventional coronary artery bypass grafting (CABG) in such cases and is advantageous in restoring more physiological myocardial perfusion, maintaining ostial patency and preserving conduit material. However, a number of early technical failures and high perioperative mortality have limited the generalized uptake of this procedure, and only recently have advances in myocardial protection and novel surgical approaches to the LMCA resulted in a resurgence of the technique. A systematic literature search identified 45 studies incorporating 478 patients undergoing SPA. A variety of patch materials were used, including the pericardium, saphenous vein and internal mammary and pulmonary arteries. Patients were followed up for a mean of 54.4 months. The 30-day mortality was 1.7% and cardiac specific mortality 3.3% at last follow-up. Encouragingly, 92.4% of reported cases (n = 182) showed complete angiographic patency at last follow-up. Our results indicate that SPA may be a viable alternative to CABG in the surgical management of isolated ostial LMCA stenosis. However, no randomized trials have been performed, and it is clear that careful patient selection is essential in minimizing morbidity and mortality in the short- and long-term. Further research is required to allow a direct comparison of SPA to techniques with a more substantial evidence base such as CABG and percutaneous coronary intervention, and to define the optimal patch graft material, elucidating that any beneficial effects arterial patches may have on long-term patency.

A best evidence topic was written according to a structured protocol in order to identify the mode of anticoagulation that has the best safety profile for both the mother and the foetus in pregnant patients with mechanical prosthetic heart valves. A total of 281 papers were identified using the reported search, of which eight represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. The reported measures were foetal mortality, maternal mortality, congenital abnormalities and embryopathy, and maternal thromboembolic and haemorrhagic complications. The medical orthodoxy has warned of the combination of oral anticoagulation and pregnancy due to the well-documented warfarin embryopathy. Yet only one of the reported papers identified a greater incidence of foetal aberrations among warfarin use, with the highest reported rate being 6.4% and two of the assessed papers reporting no embryopathy at all. Foetal mortality with oral anticoagulation use ranged from 1.52 to 76%. All reported publications demonstrated a superior maternal outcome with warfarin use, with a range of thromboembolic events from 0 to 10% in comparison with 4 to 48% where heparin was used. Thus, it is concluded that warfarin is a more durable anticoagulant with a better maternal outcome despite it carrying a greater foetal risk. Although, in contrast to previous teaching, the risks of embryopathy are not the major drawback of oral anticoagulation. Heparin is consistently less effective, but may be preferred for the superior foetal outcome. Heparin usage during the first trimester reduces the foetal risk but is still associated with an adverse maternal outcome. While the focus for clinicians looking after pregnant women with mechanical heart valves may be to prevent maternal thromboembolic complications, the overriding concern for many women is to avoid any harm to their unborn child, even when this places their health at risk. Thus women with mechanical heart valves must be fully informed of the risks involved with different anticoagulation for an informed decision to be made.

A best evidence topic was written according to a structured protocol. The question addressed was whether routine chest radiography is indicated following chest drain removal in patients undergoing cardiothoracic surgery. A total of 356 papers were found using the reported searches; of which, 6 represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were mean duration of drains left in situ, timing of drain removal, pathology detected on chest radiographs (CXRs), interventions following imaging and clinical assessment, complications in patients not undergoing routine CXRs and the cost saving of omitting routine CXRs. One large cohort study reported the detection of pathology in 79% of clinically indicated CXRs in comparison to 40% of routine CXRs (P = 0.005). Ninety-five per cent of the non-routine CXR cohort remained asymptomatic and required no intervention. One large observational study reported the detection of new pneumothoraces in 9.3% of patients, 70.3% of which were barely perceptible. Intervention following CXR was required in 0.25% and only one medium-sized pneumothorax would have been potentially missed without CXR. Another large observational study reported intervention following CXR in 1.9% and the presence of relevant clinical signs and symptoms to be a significant predictor of major intervention (P < 0.01). A smaller observational study reported no pathology detected or intervention following CXR in 98% and the cost saving of omitting a single CXR at £10 000 per annum. Another small observational study reported only 7% of CXRs to be clinically indicated with a false-positive rate of 100%, and a false-negative rate of 7% in CXRs not clinically indicated. The smallest study reported no complications in the non-CXR cohort and only one patient undergoing intervention in the routine CXR cohort. We conclude that there is evidence that routine post drain removal CXR provides no diagnostic or therapeutic advantage over clinically indicated CXR or simple clinical assessment. The best evidence studies reported the detection of pathology on routine CXR ranging from 2 to 40% compared with 79% in clinically indicated CXRs (P = 0.005). Whilst the rate of intervention following routine CXR was as high as 4% in the smallest study, clinical signs and symptoms suggestive of pathology were a significant predictor of major re-intervention (P < 0.01).

A best evidence topic was written according to a structured protocol. The question addressed was whether sutureless aortic valves have a clinical and haemodynamic benefit in high-risk patients with aortic valve disease. A total of 307 papers were found using the reported searches; of which, six represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. The studies found analysed the outcomes of sutureless aortic valve implantation in high-risk patients undergoing aortic valve replacement. Reported measures included mortality; post-operative complications namely stroke, renal failure, endocarditis and bleeding; valve deployment, cardiopulmonary bypass (CPB) and aortic cross-clamp (ACC) times; echocardiographic assessment of paravalvular leaks (PVLs) and valve haemodynamics; and symptomatic functional class. Hospital mortality ranged between 3.1 and 12.5% and long-term mortality ranged between 3.1 and 10%. Incidence of PVL was found to be between 0.0 and 11%. Stroke was observed in 0.7%, renal failure in 3.1%, prosthetic valve endocarditis in 2.1-3.1% and major bleeding in 3.1%. The valve deployment time was 9-21 min, CPB time 35-111 min and ACC time 17-70 min. Short-term mean and peak valve gradients were in the ranges of 10-11 and 18-22 mmHg, respectively, reducing to 8-9 and 16.4-19 mmHg, respectively, at follow-up. Owing to the lack of comparative studies analysing the outcomes of sutureless and conventional aortic valves, we compared these results with the recently published PARTNER Trial (Transcatheter vs. Surgical Aortic-Valve Replacement in High-Risk Patients), and it can be shown that the outcomes of sutureless aortic valves compare favourably with conventional valves in terms of mortality, neurological deficit, renal failure and post-operative bleeding. However, there is increased incidence of endocarditis and PVLs, together with raised mean valve gradients, perhaps owing to the mechanical properties and deployment techniques of sutureless aortic valves.

A best-evidence topic was written according to a structured protocol. The question addressed was whether mechanical pleurodesis results in better outcomes in comparison with chemical pleurodesis in patients undergoing surgery for recurrent primary spontaneous pneumothorax. A total of 542 papers were found using the reported searches, of which 6 represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. The studies found compared the outcomes of mechanical and chemical pleurodesis and also focused on the outcomes of the different methods of mechanical pleurodesis: pleural abrasion and pleurectomy. Reported measures were operative mortality, mean operation time, post-operative bleeding, persistent air leaks, chest drain duration, pain levels, pneumonia, respiratory failure, wound infection, pulmonary function, re-exploration for bleeding and air leak, hospital stay, recurrence and re-operation for recurrence. One large cohort study compared the outcomes of mechanical and chemical talc pleurodesis and reported a significant reduction in recurrence with talc pleurodesis in comparison with pleurectomy (1.79 vs. 9.15%, P = 0.00018). Another large cohort study, analysing pleural abrasion, pleurectomy and talc pleurodesis, both in isolation and in combination with apical bullectomy, reported the highest rate of recurrence in bullectomy plus abrasion patients (1.4%) followed by bullectomy plus talc pleurodesis patients (0.4%). No recurrence was seen with other techniques. The reported freedom from surgery at 10-year follow-up was 98.9% with talc pleurodesis, 97.5% with pleurectomy and 96.4% with pleural abrasion, however, with no statistical significance. A prospective randomized study, a retrospective case series review and two smaller cohort studies compared the outcomes of pleural abrasion and pleurectomy as different techniques of mechanical pleurodesis and reported statistically significant shorter operation times, lower rates of post-operative bleeding, re-exploration and pain observed with pleural abrasion and lower rates of recurrence with pleurectomy. Three studies reported the outcomes of apical bullectomy or wedge resection with recurrence rates ranging from 0.4 to 6.2%. We conclude that there is a very similar outcome profile in the comparison of mechanical and chemical pleurodesis, with modest evidence suggesting lower rates of recurrence with chemical talc pleurodesis.

We present the case of a 70-year-old man with three synchronous histologically different primary tumours in the same lobe. He initially presented with an intermittent productive cough, dyspnoea and non-specific abdominal pains. Radiological investigation revealed three areas of high-intensity fludeoxyglucose uptake of varying size within the right upper lobe. He underwent thoracoscopic right upper lobectomy. Histological analysis confirmed the three lesions to be undifferentiated squamous cell carcinoma, adenocarcinoma and atypical adenomatous hyperplasia. The reclassification of the T descriptors of the tumour-node-metastasis staging of a lung cancer has lead to the transition of classification of tumour nodules in the ipsilateral primary tumour lobe from T4 to T3. In the case of our patient, this has lead to the downstaging of the tumour allowing consideration for surgical management.

A best evidence topic was written according to a structured protocol. The question addressed was whether harvesting the saphenous vein (SV) as a conduit for coronary artery bypass grafting (CABG) using a no-touch technique would result in better patency rates. This technique involves the harvest of the SV with a pedicle of peri-vascular tissue left intact and the avoidance of distension of the vein prior to anastomosis. A total of 405 papers were found using the reported searches of which eight represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. The studies found analysed the ultrastructural and mechanical properties of the endothelium and vessel walls of the two harvesting techniques; the protein and enzymatic expression and activity observed; the early atherosclerotic changes detected; and the overall patency of the grafts during short- and long-term angiographical follow-up. Three small prospectively randomised studies compared the patency of grafts harvested using the two techniques and found significant improvements in graft patency using the no-touch harvesting technique in comparison to both the conventional technique and more importantly comparable to the left internal thoracic artery (LITA) patency. The most favourable difference was that of graft patency after 8.5 years of follow-up [90% vs. 76% (P = 0.01), LITA patency 90%], and incidence of graft stenosis [11% vs. 25% (P = 0.006)]. These findings were supported by the demonstrated improvements in the cellular integrity of the vessels and the reduction in the mechanisms leading to graft failure seen in the no-touch harvested SV grafts. These morphological and cellular analyses were carried by five small comparative studies, demonstrating improved endothelial integrity and reduced injury, decelerated atherosclerotic processes, intact adventitial collagen layers, increase in the total area of vasa vasorum, elevated endothelial nitric oxide synthase expression and activity, and increased peri-vascular leptin levels and activity. We conclude that there are clear enhancements in vessel wall properties at a cellular level and angiographical evidence of superior graft patency when the no-touch SV harvesting technique is employed.

Background: Sarcoplasmic reticulum calcium ATPase 2a (SERCA2a) gene therapy improves mechanical function in heart failure and is under evaluation in a clinical trial. A critical question is whether SERCA2a gene therapy predisposes to increased sarcoplasmic reticulum calcium (SR Ca(2+)) leak, cellular triggered activity, and ventricular arrhythmias in the failing heart., Methods and Results: We studied the influence of SERCA2a gene therapy on ventricular arrhythmogenesis in a rat chronic heart failure model. ECG telemetry studies revealed a significant antiarrhythmic effect of SERCA2a gene therapy with reduction of both spontaneous and catecholamine-induced arrhythmias in vivo. SERCA2a gene therapy also reduced susceptibility to reentry arrhythmias in ex vivo programmed electrical stimulation studies. Subcellular Ca(2+) homeostasis and spontaneous SR Ca(2+) leak characteristics were measured in failing cardiomyocytes transfected in vivo with a novel AAV9.SERCA2a vector. SR Ca(2+) leak was reduced after SERCA2a gene therapy, with reversal of the greater spark mass observed in the failing myocytes, despite normalization of SR Ca(2+) load. SERCA2a reduced ryanodine receptor phosphorylation, thereby resetting SR Ca(2+) leak threshold, leading to reduced triggered activity in vitro. Both indirect effects of reverse remodeling and direct SERCA2a effects appear to underlie the antiarrhythmic action., Conclusions: SERCA2a gene therapy stabilizes SR Ca(2+) load, reduces ryanodine receptor phosphorylation and decreases SR Ca(2+) leak, and reduces cellular triggered activity in vitro and spontaneous and catecholamine-induced ventricular arrhythmias in vivo in failing hearts. SERCA2a gene therapy did not therefore predispose to arrhythmias and may represent a novel antiarrhythmic strategy in heart failure.

Objectives and Design: Traumatic thoracic aortic injuries are serious and may be associated with high morbidity and mortality. Endovascular stent grafting is now an established treatment option which often requires proximal landing zone extension through left subclavian artery (LSA) origin coverage. This in turn can lead to downstream ischaemic complications which may be lessened by LSA revascularisation. This study investigates the consequence of LSA coverage and potential benefit of revascularisation., Materials and Methods: Systematic literature review of studies between 1997 and 2010 identified 94 studies incorporating 1704 patients. Chronological trends in LSA management practice for trauma were sought. Designated outcomes of interest were prevalences of left arm ischaemia, stroke, spinal cord ischaemia, endoleak, stent migration, need for additional procedure and mortality. These outcomes were compared in patients with and without LSA coverage (taking account of the degree of coverage). The impact of revascularisation on these outcomes was also explored. Statistical analysis included examination with Chi-Square or Fisher's tests as appropriate., Results: Isolated total LSA coverage without revascularisation increases the prevalence of left arm ischaemia [prevalence of 4.06% versus 0.0% (p < 0.001)]; stroke [prevalence of 1.19% versus 0.23% (p = 0.025)]; and need for additional procedure [prevalence of 2.86% versus 0.86% (p = 0.004). In contrast there were no reported cases of stroke, spinal cord ischaemia, endoleak, stent migration or mortality when the LSA origin was only partially covered. When the LSA territory was revascularised, again no cases of left arm ischaemia, stroke, spinal cord ischaemia, endoleak, or mortality were reported., Conclusion: Current evidence suggests that LSA coverage in patients undergoing endovascular stent grafting of the thoracic aorta for trauma should be avoided where possible to avoid ensuing downstream ischaemic complications. When coverage is anatomically necessary, partial coverage is better than complete in terms of avoiding these complications and revascularisation may be considered, however these decisions must be made in the context of the individual patient scenario., (Copyright © 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)