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Aims Recent clinical trials indicate that sodium-glucose cotransporter 2 (SGLT2) inhibitors improve cardiovascular outcomes in heart failure patients, but the underlying mechanisms remain unknown. We explored the direct effects of canagliflozin, an SGLT2 inhibitor with mild SGLT1 inhibitory effects, on myocardial redox signalling in humans. Methods and results Study 1 included 364 patients undergoing cardiac surgery. Right atrial appendage biopsies were harvested to quantify superoxide (O2.−) sources and the expression of inflammation, fibrosis, and myocardial stretch genes. In Study 2, atrial tissue from 51 patients was used ex vivo to study the direct effects of canagliflozin on NADPH oxidase activity and nitric oxide synthase (NOS) uncoupling. Differentiated H9C2 and primary human cardiomyocytes (hCM) were used to further characterize the underlying mechanisms (Study 3). SGLT1 was abundantly expressed in human atrial tissue and hCM, contrary to SGLT2. Myocardial SGLT1 expression was positively associated with O2.− production and pro-fibrotic, pro-inflammatory, and wall stretch gene expression. Canagliflozin reduced NADPH oxidase activity via AMP kinase (AMPK)/Rac1signalling and improved NOS coupling via increased tetrahydrobiopterin bioavailability ex vivo and in vitro. These were attenuated by knocking down SGLT1 in hCM. Canagliflozin had striking ex vivo transcriptomic effects on myocardial redox signalling, suppressing apoptotic and inflammatory pathways in hCM. Conclusions We demonstrate for the first time that canagliflozin suppresses myocardial NADPH oxidase activity and improves NOS coupling via SGLT1/AMPK/Rac1 signalling, leading to global anti-inflammatory and anti-apoptotic effects in the human myocardium. These findings reveal a novel mechanism contributing to the beneficial cardiac effects of canagliflozin., Graphical Abstract Proposed mechanism of canagliflozin-induced improvement of myocardial redox state. Canagliflozin increases intracellular AMP/ATP ratio through inhibition of SGLT1, which can activate AMPK/NOS signalling and increase NO that suppresses pro-inflammatory signalling. AMPK activation also inhibits activation of Rac1 and membrane translocation of Rac1 and p47phox, which decrease NADPH oxidase activity and superoxide (O2.−) production, attenuates inflammatory and apoptotic pathways and increasing the bioavailability of tetrahydrobiopterin (BH4), a key factor for NOS coupling.

Contains fulltext : 286832.pdf (Publisher’s version ) (Open Access) BACKGROUND: Direct evaluation of vascular inflammation in patients with COVID-19 would facilitate more efficient trials of new treatments and identify patients at risk of long-term complications who might respond to treatment. We aimed to develop a novel artificial intelligence (AI)-assisted image analysis platform that quantifies cytokine-driven vascular inflammation from routine CT angiograms, and sought to validate its prognostic value in COVID-19. METHODS: For this prospective outcomes validation study, we developed a radiotranscriptomic platform that uses RNA sequencing data from human internal mammary artery biopsies to develop novel radiomic signatures of vascular inflammation from CT angiography images. We then used this platform to train a radiotranscriptomic signature (C19-RS), derived from the perivascular space around the aorta and the internal mammary artery, to best describe cytokine-driven vascular inflammation. The prognostic value of C19-RS was validated externally in 435 patients (331 from study arm 3 and 104 from study arm 4) admitted to hospital with or without COVID-19, undergoing clinically indicated pulmonary CT angiography, in three UK National Health Service (NHS) trusts (Oxford, Leicester, and Bath). We evaluated the diagnostic and prognostic value of C19-RS for death in hospital due to COVID-19, did sensitivity analyses based on dexamethasone treatment, and investigated the correlation of C19-RS with systemic transcriptomic changes. FINDINGS: Patients with COVID-19 had higher C19-RS than those without (adjusted odds ratio [OR] 2·97 [95% CI 1·43-6·27], p=0·0038), and those infected with the B.1.1.7 (alpha) SARS-CoV-2 variant had higher C19-RS values than those infected with the wild-type SARS-CoV-2 variant (adjusted OR 1·89 [95% CI 1·17-3·20] per SD, p=0·012). C19-RS had prognostic value for in-hospital mortality in COVID-19 in two testing cohorts (high [≥6·99] vs low [

Introduction: A notable reduction in major adverse cardiovascular events and cardiovascular mortality was observed in several cardiovascular studies via treatment with liraglutide, which have been suggested to be mediated through several mechanisms including inhibition of oxidative stress. Hypothesis: We hypothesised that treatment with liraglutide reduces oxidative stress via modulating circulating levels of long-chain ceramides. Methods: We measured vascular superoxide production using lucigenin-enhanced chemiluminescence and levels of circulating ceramides using LC-MS/MS in 633 participants of the Oxford Heart Vessels and Fat (OxHVF) cohort. We also measured 33 sphingolipid species (SPL) in plasma from 32 obese individuals (average BMI 33.5±2.5kg/m 2 at inclusion) participating in a randomized clinical trial (RCT) of low calorie diet and liraglutide. Results: We found a significant association between superoxide production by internal mammary arteries (IMA) and circulating levels of long-chain ceramides (C16:0, C17:0, C18:0, C18:1) (A-D) . In the RCT, all participants adhered to an 8-week low-calorie diet (800 kcal/day) (E) , during which they lost 9.9±6.0 kg of body weight exhibiting a significant reduction in BMI ( p (F) . Following this initial phase, the patients were randomised to liraglutide treatment (1.2 mg daily) or no treatment, for a period of 52 weeks. Liraglutide treatment differentially affected several SPL species compared to the control group despite no significant changes in BMI in any of the two groups (G-J) . Conclusions: In this study, we observed for the first time in human a regulatory effect of liraglutide on the circulating levels of long-chain ceramides that are shown to be associated with vascular oxidative stress suggesting a promising mechanistic link that justifies further exploration.

Introduction: The biology of human vascular wall is implicated in cardiovascular pathology. We applied discovery transcriptomics to internal mammary arteries (IMAs) obtained from cardiac surgery patients, to identify pathways that can be treated therapeutically. Methods: Weighted correlation network analysis was conducted in sequencing data from IMAs RNA in 205 patients (Arm 1). Association with future incidence of major adverse cardiovascular events [MACE: cardiovascular death (CVD), non-fatal myocardial infarction or stroke, or new-onset heart failure] was assessed with Cox regression models (adjusted for age, sex, hypertension, dyslipidaemia, diabetes mellitus, and plasma TNFa). Arm 2 included 497 patients in whom segments of IMA were used for ex-vivo quantification of NADPH-stimulated superoxide by lucigenin chemiluminescence. Results: We identified 10 coexpressed gene ‘modules’ in the human arterial wall, through unsupervised transcriptomic analysis. The “red” module was found to cluster with arterial NADPH oxidase activity, while its eigengene values had the most significant correlation ( a ). Patients with high eigengene values for the “red” module showed a 3-fold higher risk of MACE ( b ), and enrichment analysis revealed top pathways ( c ). The Study Arm 2 population was followed up for a median of 6.35 years [IQR: 3.97-8.38], with 50 CVD and 101 MACE. High NADPH oxidases activity was independently predictive of cardiovascular mortality ( d ) and MACE (adj. hazard ratio 1.58 [1.07-2.36], p=0.02). Conclusion: We demonstrate that arterial oxidative stress leads to high risk of MACE in patients with atherosclerosis. We also identify a novel, redox-related arterial transcriptomic signature that predicts long-term cardiovascular risk. Pathways related with oxidative stress, or glucose metabolism or Hypoxia-Inducible Factor-1 in the human arterial wall, may be rational therapeutic targets to reduce cardiovascular risk in secondary prevention.

Background To compare early outcomes of mitral valve repair versus replacement in elderly patients with degenerative mitral valve disease. Methods A retrospective review of prospectively collected clinical data of patients over 75 years of age, who underwent mitral valve surgery for degenerative disease, between 2010 and 2013, was carried out. Those undergoing mitral valve repair and replacement were propensity matched to adjust for baseline clinical differences. Results A total 260 patients were identified: mitral valve repair was undertaken in 145 and replacement in 115 patients. After propensity matching, 78 patients were included in each group. In the entire, unmatched population, in-hospital mortality was significantly higher in those undergoing replacement compared with those undergoing repair (9.6% vs 1.4%, p=0.003). In-hospital death occurred in six (7.7%) of the propensity matched replacement group and none in the repair group (p=0.012). Amongst the propensity matched groups, probability of survival at 1, 2 and 3 years were 0.94, 0.90 and 0.86 respectively for the repair group and 0.85, 0.77 and 0.69 for the replacement group: the HR for death between replacement and repair is 2.5 (1.2-5.4), p=0.012. Conclusions Within the limitations imposed by retrospective analyses, our study demonstrates that, in elderly patients with degenerative disease of the mitral valve, repair is associated with improved short-term and mid-term outcomes compared with mitral valve replacement.

Objective The primary objective was to investigate the long-term survival of patients who underwent single-vessel coronary revascularization with minimally invasive direct coronary artery bypass surgery with or without hybrid revascularization. The secondary outcome measures were repeat revascularization either by coronary artery bypass grafting or by percutaneous coronary intervention and the incidence of myocardial infarction or recurrent angina. Methods This is a retrospective study of prospectively collected data of patients who underwent minimally invasive direct coronary artery bypass procedure in our center between January 2001 and December 2015. Procedures were performed either through small left anterolateral thoracotomy or lower midline sternotomy. Results A total of 182 patients were identified: 100 underwent minimally invasive direct coronary artery bypass to the left anterior descending artery and 82 underwent hybrid revascularization (percutaneous coronary intervention to coronary arteries other than the left anterior descending artery along with minimally invasive direct coronary artery bypass to the left anterior descending artery). The mean ± SD age was 62 ± 10.1 years. Preoperatively 82% were male, and 72.5% patients had good left ventricular function. The median follow-up period was 10.9 years. There was no inhospital or 30-day mortality. The 10-year actuarial survival was 84.8%. Freedom from repeat revascularization was 98.9% at 1 year and 89.9% at 10 years. At follow-up, freedom from myocardial infarction was 96.7% whereas freedom from angina was 92.9%. Conclusions Within the limitations imposed by retrospective analyses, our study demonstrates excellent long-term outcome in patients undergoing minimally invasive direct coronary artery bypass with or without hybrid revascularization. For isolated left anterior descending artery disease minimally invasive direct coronary artery bypass should be considered, whereas hybrid revascularization (percutaneous coronary intervention and minimally invasive direct coronary artery bypass) should be considered for multivessel disease.

ObjectivesTo date the reported outcomes of surgical aortic valve replacement (SAVR) are mainly in the settings of trials comparing it with evolving transcatheter aortic valve implantation. We set out to examine characteristics and outcomes in people who underwent SAVR reflecting a national cohort and therefore ‘real-world’ practice.DesignRetrospective analysis of prospectively collected data of consecutive people who underwent SAVR with or without coronary artery bypass graft (CABG) surgery between April 2013 and March 2018 in the UK. This included elective, urgent and emergency operations. Participants’ demographics, preoperative risk factors, operative data, in-hospital mortality, postoperative complications and effect of the addition of CABG to SAVR were analysed.Setting27 (90%) tertiary cardiac surgical centres in the UK submitted their data for analysis.Participants31 277 people with AVR were identified. 19 670 (62.9%) had only SAVR and 11 607 (37.1%) had AVR+CABG.ResultsIn-hospital mortality for isolated SAVR was 1.9% (95% CI 1.6% to 2.1%) and was 2.4% for AVR+CABG. Mortality by age category for SAVR only were: 75 years=2.2%. For SAVR+CABG these were; 2.2%, 1.8% and 3.1%. For different categories of EuroSCORE, mortality for SAVR in low risk people was 1.3%, in intermediate risk 1% and for high risk 3.9%. 74.3% of the operations were elective, 24% urgent and 1.7% emergency/salvage. The incidences of resternotomy for bleeding and stroke were 3.9% and 1.1%, respectively. Multivariable analyses provided no evidence that concomitant CABG influenced outcome. However, urgency of the operation, poor ventricular function, higher EuroSCORE and longer cross clamp and cardiopulmonary bypass times adversely affected outcomes.ConclusionsSurgical SAVR±CABG has low mortality risk and a low level of complications in the UK in people of all ages and risk factors. These results should inform consideration of treatment options in people with aortic valve disease.

Background NADPH oxidase activity is a major source of superoxide anions (O2·−) in the human myocardium, linked with adverse short-term clinical outcomes after cardiac surgery, but its prognostic value for the long-term clinical outcome of these patients is unknown. Purpose To explore the association between NADPH oxidase activity in the human myocardium and the clinical outcome of patients undergoing cardiac surgery. Methods A total of 216 patients from the Oxford Heart Vessels and Fat (OxHVF) cohort were enrolled. Myocardial tissue samples were collected during cardiac surgery and used for RNA isolation and myocardial O2·− quantification using lucigenin-enhanced chemiluminescence (5μmol/L). The specific contribution of NADPH oxidase activity to myocardial O2·− production was quantified as the Vas287021 (40 μmol/L)-inhibitable signal following NADPH (100μmol/L) stimulation (Vas2870 is a NADPH oxidases inhibitor). Malonyldialdehyde and hsCRP levels were measured in plasma isolated from peripheral blood collected pre-operatively. Patients were followed-up for a mean of 2.9±1.4 years for the primary endpoint of cardiovascular mortality. Results Myocardial NADPH oxidase activity was not correlated with systemic oxidative stress (evidenced by malonyldialdehyde, panel A) or systemic inflammation (reflected by hsCRP levels, panel B). NADPH oxidase activity was significantly higher in the cardiovascular death group (panel C) and was associated with cardiovascular (HR [95% CI]: 1.53 [1.10–2.13], p=0.01 per SD increase) but not all-cause mortality (HR [95% CI]: 1.32 [0.96–1.80], p=0.08 per SD increase). This association remained significant after adjustment for EuroscoreII (HR [95% CI]: 1.80 [1.14–2.82], p=0.01 per SD increase). For an optimal cut-off value of 7,920 RLU/sec/mg tissue, patient survival was significantly poorer in the high vs. low NADPH oxidase activity subgroup (panel D). Adding NADPH oxidase activity to the baseline clinical model significantly improved model's performance (panel E). Interestingly, myocardial NOX gene expression levels didn't show any significance in mortality prediction, highlighting the fact that NADPH oxidase activity, rather than enzyme levels, is the key outcomes regulator. Conclusion Increased NADPH oxidase activity in the human myocardium independently predicts high cardiovascular mortality in patients with advanced coronary atherosclerosis. Targeting NADPH oxidase in the human heart may be a rational therapeutic approach. Acknowledgement/Funding BHF, EPSRC

Background We sought to determine the incidence of hospital death due to surgical compromise of the coronary ostia in aortic valve replacement. The mechanism of coronary ostium blockage was also investigated. Methods A retrospective review was conducted of prospectively collected clinical data and autopsy findings in 322 patients who died in hospital after aortic valve replacement with or without concomitant procedures in a single institution from January 1998 to March 2013. Results Over the 15-year period, more than 17 surgeons performed 7507 aortic valve replacements with or without other procedures. The mean age of the patients was 70.8 ± 11.78 years and 63% were male. Bioprosthetic valves were used in 75%, mechanical valves in 24.7%, and homografts in only 0.3%. Early mortality for all patients (combined, emergency, and redo procedures) was 4.29% (mean logistic EuroSCORE 10.7). There were 322 deaths after procedures involving the aortic valve. Autopsy examinations were carried out in all patients and showed that 3.4% ( n = 11) of deaths were at least partly attributed to encroachment on one or both coronary ostia. Causes of ostial compromise included the valve sutures, the valve sewing ring, and the aortotomy suture line. Conclusions Coronary ostial compromise in aortic valve replacement is a very rare but real problem occurring in at least 0.15% of aortic valve replacements and contributing to or directly causing one in every 29 aortic valve replacement deaths. Surgeons should have a high level of awareness of the risk of this rare but fatal and avoidable complication.

The Ross procedure is an alternative option for young and middle-aged patients needing aortic valve replacement. We present an interesting case where the patient had a preexisting aortic homograft that was implanted because of previous infective endocarditis with aortic root abscess. The patient presented with biological degeneration of the homograft with resultant severe stenosis as well as insufficiency. We performed a redo root surgery to replace the homograft with the Ross procedure by using the autograft inclusion into a vascular graft technique. The dissection was carried out by performing external dissection of the aortic root. Redo root replacement is a difficult procedure, however external root dissection is a safe and easy technique that can be used in such a difficult scenario.

OBJECTIVES: Death in low-risk cardiac surgical patients provides a simple and accessible method by which modifiable causes of death can be identified. In the first FIASCO study published in 2009, local potentially modifiable causes of preventable death in low-risk patients with a logistic EuroSCORE of 0–2 undergoing cardiac surgery were inadequate myocardial protection and lack of clarity in the chain of responsibility. As a result, myocardial protection was improved, and a formalized system introduced to ensure clarity of the chain of responsibility in the care of all cardiac surgical patients. The purpose of the current study was to re-audit outcomes in low-risk patients to see if improvements have been achieved. METHODS: Patients with a logistic EuroSCORE of 0–2 who had cardiac surgery from January 2006 to August 2012 were included. Data were prospectively collected and retrospectively analysed. The case notes of patients who died in hospital were subject to internal and external review and classified according to preventability. RESULTS: Two thousand five hundred and forty-nine patients with a logistic EuroSCORE of 0–2 underwent cardiac surgery during the study period. Seven deaths occurred in truly low-risk patients, giving a mortality of 0.27%. Of the seven, three were considered preventable and four non-preventable. Mortality was marginally lower than in our previous study (0.37%), and no death occurred as a result of inadequate myocardial protection or communication failures. CONCLUSION: We postulate that the regular study of such events in all institutions may unmask systemic errors that can be remedied to prevent or reduce future occurrences. We encourage all units to use this methodology to detect any similarly modifiable factors in their practice.

Objectives: The aim of our study was to investigate the effects of pulsatile cardiopulmonary bypass (CPB) on renal function and the need for haemofiltration in patients with preoperative renal impairment undergoing cardiac surgery. Methods: Clinical data were collected prospectively for patients undergoing cardiac surgery with pulsatile CPB (Group A, n=66) and compared to matched patients with standard non-pulsatile CPB (Group B, n=66). Patients included in the study had mild renal impairment and at least moderate risk from surgery as defined by logistic EuroSCORE. Emergency operations were excluded. Results: Patients in Groups A and B had similar age (71 ± 10 versus 70 ± 10 years), sex distribution, mean preoperative renal function (creatinine clearance 63.9 ± 28 versus 67.7 ± 27.3 ml/min) and overall risk profile as predicted by the logistic EuroSCORE (8 ± 8.3 versus 11.05±13.3, p=0.122). Intraoperative variables were comparable with respect to bypass and cross-clamp times (96 ± 37 minutes and 64 ± 28 minutes versus 103 ± 40 minutes and 70 ± 33 minutes in Groups A and B, respectively). A smaller proportion of patients in Group A (4.5% versus 15%, p=0.076) required haemofiltration in the postoperative period. Postoperative mortality was low in both groups (Group A 1.54% versus Group B 3.03%, p=1.00). Conclusion: Within the limitations imposed by retrospective analyses, our study demonstrates that pulsatile CPB may confer a reno-protective effect in higher-risk patients with pre-existing mild renal dysfunction undergoing cardiac surgery.

Cardiac failure may occur after repair of type A aortic dissections and contributes significantly to mortality. The use of an intraaortic balloon pump (IABP) for circulatory support in these patients is traditionally considered contraindicated because of concerns over extension of the residual dissection flap or aortic rupture. We propose that the use of an IABP may be appropriate and safe to improve cardiac function in patients after type A dissection repair. The two cases presented here contribute to increasing the body of evidence to support the appropriate use of IABP in these patients.

Between April 2001 and December 2005, data were collected prospectively from 2,320 consecutive patients who underwent first-time coronary artery bypass. Logistic multiple regression analyses were carried out to determine the independent predictors of gastrointestinal complications and death. There were 65 major gastrointestinal complications identified in 65 (2.8%) patients: paralytic ileus in 15, mesenteric ischemia in 12, upper gastrointestinal hemorrhage in 16, lower gastrointestinal hemorrhage in 8, small bowel obstruction in 5, pseudoobstruction in 5, and others in 4. The 30-day mortality was 21.5% (14 patients). Female sex, preoperative creatinine >200 µmol·L−1, previous gastrointestinal pathology, low cardiac output, readmission to the intensive care unit, postoperative pulmonary complications, arrhythmias, hemofiltration, and reoperation were independent predictors of major gastrointestinal complications. Independent risk factors for death were readmission to the intensive care unit, the need for hemofiltration, reoperation, and ischemic bowel. Careful hemodynamic control and optimization of perioperative organ perfusion are important to minimize the mortality associated with major gastrointestinal complications after coronary artery bypass.

Anatomical segmentectomy has emerged as the procedure of choice for early-stage non-small-cell lung cancer, especially in the presence of poor cardiopulmonary reserve. The most common postoperative complications are pneumonia, persistent air leak, and rarely, vascular compromise of the remaining lobe. We report the case of a 74-year-old woman who underwent thoracotomy and left upper lobe trisegmentectomy for T1bN0Mo squamous cell carcinoma and subsequently developed infarction and hepatization of the remaining lingula. A completion left upper lobectomy was performed and the patient made a full recovery.

OBJECTIVE: The purpose of this study was to establish the safety and feasibility of a recently adopted policy to type and screen (TS) (group and save) only for selected patients who had low likelihood of transfusion requirement. METHODS: The TS only policy was applied to patients undergoing first-time elective lobectomy with Hb of >11 g/dl, aged

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

Background: The purpose of this study was to compare early and late results of redo-CABG with (redo-ONCAB) and without (redo-OPCAB) cardiopulmonary bypass. Methods: From April 2001 to September 2006 redo-CABG was performed in 110 patients (redo-ONCAB = 50 and redoOPCAB = 60). Applying the propensity score, 43 OPCAB patients were matched with 43 ONCAB patients. The mean EuroScore was 5 4.7 and 5 3.4forredo-ONCABandredo-OPCAB,respectively(p = 0.5).Thenumberofdiseasedcoronaryarterieswas3 0.5and2 0.8inredo-ONCAB andredo-OPCAB,respectively(p < 0.01).Results:TwelvepatientsunderwentOPCABthroughanteriorthoracotomywhiletherestofthepatients (n = 74) underwent median sternotomy. Mean number of grafts performed was 3 0.8 in redo-ONCAB and 2 0.6 in redo-OPCAB (p < 0.05). The need for postoperative insertion of intra-aortic balloon pump (IABP) was higher (p = 0.02) in redo-ONCAB (n = 9, 21%) than redo-OPCAB (n =1 , 2%). The duration of postoperative ventilation was 55 98.7 h for redo-ONCAB and 10 12.8 h for redo-OPCAB (p = 0.008). No differences were found in the incidence of other postoperative complications. The 30-day mortality rate was 6.9% for redo-ONCAB (n = 3) and 2.3% redo-OPCAB (n =1 ;p = NS). Meanfollow-up forredo-ONCABwas 30 21.3months(range0.1—63months)andthatof redo-OPCABwas37 19.2months(0.1— 62.5 months). Actuarial survival at 5 years was 87 5.5% for redo-ONCAB and 95 3.2% for redo-OPCAB (p = 0.17). Event-free survival was 71 8.0% for redo-ONCAB and 78 7.2% for redo-OPCAB (p = 0.32). Conclusion: OPCAB is an acceptable strategy in selected patients requiring redo-CABG. Employing a strategy of OPCAB for those patients with 2 or fewer lesions and ONCAB for those with more diffuse disease, redo-OPCAB and redo-ONCAB have similar early and late outcomes. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Background: Surgery for pulmonary aspergillosis is infrequent and often challenging. Risk assessment is imprecise and new antifungals may ameliorate some surgical risks. We evaluated the medical and surgical management of these patients, including perioperative and postoperative antifungal therapy. Methods: Retrospective study of patients who underwent surgery for pulmonary aspergillosis between September 1996 and September 2011. Results: 30 patients underwent surgery with 23 having a preoperative tissue diagnosis while 7 were confirmed post-resection. The median age was 57 years (17–78). The commonest presenting symptoms were cough (40%, n = 12) and haemoptysis (43%, n = 13). Twelve (40%) patients had simple aspergilloma (including 2 with Aspergillus nodules) while the remaining 18 (60%) had chronic cavitary pulmonary aspergillosis (CCPA) (complex aspergilloma). Most of the patients had underlying lung disease: tuberculosis (20%, n = 6), asthma (26%, n = 8) and COPD (20%, n = 6). The procedures included lobectomy 50% (n = 15), pneumonectomy 10% (n = 3), sublobar resection 27% (n = 8), decortication 7% (n = 2), segmentectomy 3% (n = 1), thoracoplasty 3% (n = 1), bullectomy and pleurectomy 3% (n = 1), 6% (n = 2) lung transplantation for associated disease. Median hospital stay was 9.5 days (3–37). There was no operative and 30 day mortality. Main complications were prolonged air leak (n = 7, 23%), empyema (n = 6, 20%), respiratory failure requiring tracheostomy /reintubation (n = 4, 13%). Recurrence of CCPA was noted in 8 patients (26%), most having prior CCPA (75%). Taurolidine 2% was active against all 9 A. fumigatus isolates and used for pleural decontamination during surgery. Conclusions: Surgery in patients with chronic pulmonary aspergillosis offered good outcomes with an acceptable morbidity in a difficult clinical situation; recurrence is problematic.