Amer Harky

Acute type A aortic dissection in the United Kingdom: Surgeon volume-outcome relation

Objectives Surgery for acute type A aortic dissection (ATAD) carries a high risk of operative mortality. We examined the surgeon volume‐outcome relation with respect to in‐hospital mortality for patients presenting with this pathology in the United Kingdom. Method Between April 2007 and March 2013, 1550 ATAD procedures were identified from the National Institute for Cardiovascular Outcomes Research database. A total of 249 responsible consultant cardiac surgeons from the United Kingdom recorded 1 or more of these procedures in their surgical activity over this period. We describe the patient population and mortality rates, focusing on the relationship between surgeon volume and in‐hospital mortality. Results The mean annual volume of procedures per surgeon during the 6‐year period ranged from 1 to 6.6. The overall in‐hospital mortality rate was 18.3% (283/1550). A mortality improvement at the 95% level was observed with a risk‐adjusted mean annual volume >4.5. Surgeons with a mean annual volume <4 over the study period had significantly higher in‐hospital mortality rates in comparison with surgeons with a mean annual volume ≥4 (19.3% vs 12.6%; P = .015). Conclusions Patients with ATAD who are operated on by lower‐volume surgeons experience higher levels of in‐hospital mortality. Directing these patients to higher‐volume surgeons may be a strategy to reduce in‐hospital mortality.

Mitral valve repair or replacement in native valve endocarditis? Systematic review and meta-analysis

The objective of this study is to review the morbidity and mortality associated with mitral valve repair versus replacement in infective endocarditis patients.

Is there a prospect for hybrid aortic arch surgery

The surge of endovascular repair of aortic aneurysm in current modern aortic surgery practice has been the key for surgical management of elective cases of thoracic aortic aneurysms. This has paved way for the combined hybrid approach to be amongst the armamentarium for the management of aortic arch disease. The pivotal understanding of the aortic arch natural history coupled with device technology advancement allowed surgeons insight into delivery of hybrid surgery with acceptable morbidity and mortality results. This review article provides current insights into hybrid technique of aortic arch aneurysm repair and the evidences behind its applicability to arch surgery. It is aimed to highlight the challenges encountered for this innovative approach and correlate its challenges to those that are met by the conventional open aortic arch repair.

Is ministernotomy superior to right anterior minithoracotomy in minimally invasive aortic valve replacement

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

Ruptured isolated descending thoracic aortic aneurysm: open or endovascular repair?

Descending thoracic aortic aneurysm management has gained momentum and became a topic of many debates at international levels since the evolution of endovascular repair. Ruptured descending thoracic aortic aneurysm is a clinical emergency which is associated with high mortality and morbidity rates if not managed properly. Prior to thoracic endovascular aortic repair (TEVAR), open repair (OR) was the gold standard management, however since the evolution of TEVAR, this has changed. Several centers have reported many of their experiences and published that TEVAR can provide equal or even better perioperative outcomes when compared to OR, although the evidences can be of only short term and could be biased at different levels at the time of publication. This review article is aimed to examine current literature evidences behind the use of TEVAR vs. OR and the reported comparative clinical outcomes.

Brain protection in aortic arch aneurysm: antegrade or retrograde?

During open aortic arch repair, there is an interruption of cerebral perfusion and to prevent neurological sequelae, the hypothermic circulatory arrest has been established to provide sufficient brain protection coupled with adjuncts including retrograde and antegrade cerebral perfusion. To date, brain protection during open aortic arch repair is a contested topic as to which provides superior brain protection with little evidence existing to suggest supremacy of one modality over the other. This article reviews current literature reflecting on key and emerging studies in brain protection and their associated outcomes in patients undergoing open aortic arch surgery.

Varying Evidence on Deep Hypothermic Circulatory Arrest in Thoracic Aortic Aneurysm Surgery

Cardiovascular surgeons have long debated the safe duration of deep hypothermic circulatory arrest during thoracic aortic aneurysm surgery. The rationale for using adjunctive cerebral perfusion (or not) is to achieve the best technical aortic repair with the lowest risk of morbidity and death. In this literature review, we highlight the debates surrounding these issues, evaluate the disparate findings on deep hypothermic circulatory arrest durations and temperatures, and consider the usefulness of adjunctive perfusion.

Should the mitral valve be repaired for moderate ischemic mitral regurgitation at the time of revascularization surgery

Ischemic mitral regurgitation (IMR) is associated with increased mortality and recurrent congestive heart failure following coronary artery bypass graft (CABG) surgery. While mitral surgery should be undertaken for severe MR during CABG, the treatment of moderate IMR remains controversial. We conducted a meta‐analysis to determine the outcomes of CABG alone and combine with mitral valve repair (MVr) in moderate IMR.

Is there a role for biomarkers in thoracic aortic aneurysm disease

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

Aortic arch aneurysm surgery: what is the gold standard temperature in the absence of randomized data?

In the absence randomized data for assessing the best and optimal temperature for managing open aortic arch surgery patients, cerebral protection method is still performed through hypothermic circulatory arrest with or without the use of adjuncts. A recent consensus has emerged setting to define the temperature levels. In an attempt, this was aimed to establish a solid ground for future trials in aortic arch surgery. This article reviews the current literature and the evidences behind using different temperature methods and their outcomes in patients undergoing open aortic arch surgery.