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The aim of the study was to assess the degree of aerosolisation in different chest drainage systems according to different air leak volumes, in a simulated environment. This novel simulation model was designed to produce an air leak by passing air through and agitating a fluorescent fluid. The air leak volume and amount of fluorescent fluid were tested in various combinations and aerosolisation was assessed at 10-minute intervals using the ultraviolet light. The following chest drainage systems were compared: (1) single-chamber chest drainage system, (2) 3-compartment wet-dry suction chest drainage system, (3) digital drainage and monitoring system. The impact of suction (−2 and −4 kPa) in generating aerosolised particles was tested as well. A total number of 187 of 10-minute interval measurements were performed. The single-chamber chest drainage system generated the largest number of aerosolised particles at different air leak volumes and drainage output. The 3-compartment wet-dry suction system and the digital drainage and monitoring system did not generate any identifiable aerosolised particles at any of the air leak or drain output volumes considered. Suction applied to the chest drainage systems did not have an effect on aerosolisation. Aerosol generation in the simulated air-leak model demonstrated the potential risk of SARS-CoV-2 spread in the clinical setting. Full personal protective equipment must be used in patients with an air leak. Single-chamber chest drainage system generates the highest rate of aerosolised particles and it should not be used as an open system in patients with an air leak., Graphical Abstract Image, graphical abstract

Background: In the contemporary era of drug-eluting stents (DES) the issue of optimal revascularization strategy for patients with isolated disease of the left anterior descending (LAD) artery has gained more significance. We aimed to evaluate the current best evidence on the subject by performing a systematic review and meta-analysis of the studies comparing minimally invasive direct coronary artery bypass (MIDCAB) grafting with DES in patients with isolated LAD disease. Methods: A literature search was conducted from 1966 through March 2018 using MEDLINE, EMBASE, and other scientific databases to identify relevant articles. Analyzed outcomes included all-cause mortality, myocardial infarction (MI), major adverse cardiac and cerebrovascular events (MACCE) and target vessel revascularization (TVR). The random effects model was used to calculate the outcomes of both binary and continuous data to control any heterogeneity between the studies. Heterogeneity amongst the trials was determined by means of the Cochran Q value and quantified using the I 2 inconsistency test. All P values were 2-sided and a 5% level was considered significant. Results: A total of 7,710 patients from 12 studies were identified. There was no significant difference in mortality rate [pooled odds ratio (OR) =0.92; 95% confidence interval (CI), 0.65 to 1.32; P=0.66], MI rate (pooled OR =1.13, 95% CI, 0.62 to 2.06; P=0.69) or MACCE (pooled OR =1.31; 95% CI, 0.58 to 2.95; P=0.52). However, TVR rate was significantly more for patients having percutaneous intervention with DES (pooled OR =0.27; 95% CI, 0.16 to 0.45; P

Patients with multi-vessel coronary artery disease and poor left ventricular (LV) function (ejection fraction [EF] 30%) requiring revascularization are considered 'high-risk'. Limited long-term survival data exists comparing percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DES) versus surgery for this cohort of patients.We retrospectively reviewed our data for 321 patients with EF30% who underwent multi-vessel revascularization from January 2005 to December 2015 using Cox regression analyses and inverse probability treatment weighted (IPTW) methods. We stratified patients that underwent surgical revascularization into on-pump coronary artery bypass grafting (CABG) and off-pump CABG and analyzed all-cause mortality at 10 years compared to PCI.214 patients underwent CABG (n [on-pump CABG] = 94; n [off-pump CABG] = 120) and 107 patients had PCI with second generation DES. PCI with DES had higher 10-year mortality compared with on-pump CABG (Hazard ratio [HR] = 1.86, 95% confidence interval [CI] = 1.46-2.42; p 0.001) and off-pump CABG (HR = 2.32, 95% CI = 1.75-3.15; p 0.001). This was confirmed in IPTW analyses. When adjusting for both measured and unmeasured factors using instrumental variable analyses, PCI with DES had higher 10-year mortality compared with on-pump CABG (Δ = 13.5, 95% CI = 3.2-24.5; p = 0.012) and off-pump CABG (Δ = 16.1, 95% CI = 5.9-25.8; p 0.001).Surgical revascularization, preferably off-pump CABG, results in better long-term survival compared with PCI using second generation DES for patients with multi-vessel coronary artery disease and poor left ventricular function. Randomized controlled trials in this patient group should be undertaken.

Despite evidence from several randomized controlled trials and observational studies validating short-term safety and efficacy of off-pump coronary artery bypass grafting (CABG), concerns persist regarding the impact of off-pump CABG on long-term survival and freedom from reintervention. This persistent scepticism regarding off-pump CABG prompted us to review our practice of CABG over the last 20 years with a view to comparing the impact of off-pump and on-pump CABG on short-term and long-term outcomes in a high-volume off-pump coronary surgery centre.We retrospectively analysed prospectively collected data from the Patients Analysis and Tracking System database (Dendrite Clinical Systems, Oxford, UK) for all isolated first-time CABG procedures with at least 2 grafts performed at our institution from January 1996 to September 2017. Over the study period, 5995 off-pump CABG and 4875 on-pump CABG were performed by surgeons with exclusive off-pump and on-pump practices, respectively. Multivariable logistic regression and the Cox model were used to investigate the effect of off-pump versus on-pump procedures on short-term outcomes and long-term survival. Propensity score matching was used to compare the 2 matched groups.Off-pump CABG was associated with a lower risk for 30-day mortality [odds ratio (OR) 0.42, 95% confidence interval (CI) 0.32-0.55; P 0.001], reintubation/tracheostomy (OR 0.58, 95% CI 0.47-0.72; P 0.001) and re-exploration for bleeding (OR 0.48, 95% CI 0.37-0.62; P 0.001). The benefit in terms of operative deaths from off-pump was significant in those with Society of Cardio-Thoracic Surgery logistic EuroSCORE2 (interaction P = 0.04). When compared with on-pump CABG, off-pump CABG did not significantly reduce the risk of stroke (OR 0.96, 95% CI 0.88-1.12; P = 0.20) and postoperative haemofiltration (OR 0.98, 95% CI 0.86-1.20; P = 0.35). At the median follow-up of 12 years (interquartile range 6-17, max 21), off-pump CABG did not affect late survival [log rank P = 0.24; hazard ratio (HR) 0.95, 95% CI 0.89-1.02] or the need for reintervention (log rank P = 0.12; HR 1.19, 95% CI 0.95-1.48).This large volume, single-centre study with the longest reported follow-up confirms that off-pump CABG performed by experienced surgeons, who perform only off-pump procedures in a high-volume off-pump coronary surgery centre, is associated with lower risk of operative deaths, fewer postoperative complications and similar 20-year survival and freedom from reintervention rates compared with on-pump CABG.

Objectives Minimally invasive cardiac valve surgery is safe, effective and increasingly popular. It is performed worldwide with the use of either external aortic clamping or endoaortic balloon occlusion. Methods We conducted a literature search using MEDLINE, EMBASE, Scopus and Web of Science. Primary outcomes included aortic dissection, conversion to sternotomy, mortality, stroke and cross-clamp time. Secondary outcomes included atrial fibrillation, acute kidney injury, reoperation for bleeding, cardiopulmonary bypass times, myocardial infarction, use of intra-aortic balloon pump and length of hospital stay. The random effects model was used to calculate the outcomes of both binary and continuous data. Results Thirty retrospective studies were included in the meta-analysis. The incidence of aortic dissection (pooled odds ratio = 3.88, 95% confidence interval = 1.06-14.18; P =0.04) and conversion to sternotomy (pooled odds ratio = 3.07, 95% confidence interval = 1.33-7.10; P = 0.009) was higher in the endoaortic balloon occlusion group than in the external aortic clamping group, in whom a direct comparison was possible. The remaining observational studies did not show any significant differences in either group. There was no significant difference in 30-day mortality (P = 0.37), stroke (P = 0.26), cross-clamp time (P = 0.20), atrial fibrillation (P = 0.18), acute kidney injury (P = 0.49), reoperation for bleeding (P = 0.24), cardiopulmonary bypass time (P = 0.06), myocardial infarction (P = 0.74), use of intra-aortic balloon pump (P = 0.11) or length of hospital stay (P = 0.47). Conclusions External aortic clamping may be safer than endoaortic balloon occlusion with respect to aortic dissection and conversion to sternotomy. However, mortality, length of stay, stroke, cross-clamp time and other cardiovascular complication rates were similar between the 2 techniques.

Seven unsaturated-zone solute-transport models were tested with two data sets to select models for use by the Agricultural Chemical Team of the U.S. Geological Survey's National Water-Quality Assessment Program. The data sets were from a bromide tracer test near Merced, California, and an atrazine study in the White River Basin, Indiana. In this study the models are designated either as complex or simple based on the water flux algorithm. The complex models, HYDRUS2D, LEACHP, RZWQM, and VS2DT, use Richards' equation to simulate water flux and are well suited to process understanding. The simple models, CALF, GLEAMS, and PRZM, use a tipping-bucket algorithm and are more amenable to extrapolation because they require fewer input parameters. The purpose of this report is not to endorse a particular model, but to describe useful features, potential capabilities, and possible limitations that emerged from working with the model input data sets. More rigorous assessment of model applicability involves proper calibration, which was beyond the scope of this study.