Andrew Goodwin

Should you stand on the left or the right of a patient with dextrocardia who needs coronary surgery

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was which side of the operating table you should stand on when carrying out surgical revascularization on a patient with dextrocardia. Altogether 40 papers were found using the reported search, of which 19 represented the best 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. The side on which the operating surgeon stood was mentioned in 20 out of the 24 cases. Surgery was carried out from the conventional right side of the patient in 5 cases, while in 10 cases, it was carried out from the left side. The surgeon needed to switch sides to facilitate surgery in three cases. In addition, the right internal mammary artery (RIMA) was anastomosed to the left anterior descending artery (LAD) in 16 cases. Of these, surgery was carried out from the left side in 11 cases. The left internal mammary artery (LIMA) to LAD anastomosis was carried out in two cases, one of which was a free LIMA graft. In six cases, only vein grafts were used. Fourteen cases were carried out using cardiopulmonary bypass while 10 cases were carried out as off-pump cases with one conversion. The majority of patients were operated on from the left of the table. More cases were performed with the RIMA as the conduit of choice to the LAD.

Direct transfemoral transcatheter aortic valve implantation without balloon pre‐dilatation using the Edwards Sapien XT valve

To evaluate the feasibility and safety of direct transcatheter aortic valve implantation (TAVI) by the transfemoral approach without balloon pre‐dilatation using the Edwards SapienXT valve.

Manubrium-limited sternotomy decreases blood loss after aortic valve replacement surgery

OBJECTIVES Minimally invasive surgical approaches for aortic valve replacement (AVR) are growing in popularity in an attempt to decrease morbidity from conventional surgery. We have adopted a technique that divides only the manubrium and spares the body of the sternum. We sought to determine whether patients benefit from this less-invasive approach. METHODS We retrospectively analysed our prospectively maintained database to review all isolated aortic valve replacements performed in an 18-month period from November 2011 to April 2013. RESULTS One hundred and ninety-one patients were identified, 98 underwent manubrium-limited sternotomy (Mini-AVR) and 93 had a conventional median sternotomy (AVR). The two groups were well matched for preoperative variables and risk (mean logistic EuroSCORE mini-AVR 7.15 vs AVR 6.55, P = 0.47). Mean cardiopulmonary bypass and aortic cross-clamp times were 10 and 6 min longer, respectively, in the mini-AVR group (mean values 88 vs 78 min, P = 0.00040, and 66 vs 60 min, P = 0.0078, respectively). Mini-AVR patients had significantly less postoperative blood loss, 332 vs 513 ml, P = 0.00021, and were less likely to require blood products (fresh-frozen plasma and platelets), 24 vs 36%, P = 0.042. Postoperative complications and length of stay were similar (discharge on or before Day 4; mini-AVR 15 vs AVR 8%, P = 0.17). Valve outcome (paravalvular leak mini-AVR 2 vs AVR 1%, P = 1.00) and survival (mini-AVR 99 vs AVR 97%, P = 0.36) were equal. CONCLUSIONS A manubrium-limited approach maintains outcomes achieved for aortic valve replacement by conventional sternotomy while significantly reducing postoperative blood loss and transfusion of blood products.

Right ventricular outflow tract tumour: an unsuspected intracardiac ectopic thyroid mass

Ectopic thyroid is a rare embryogenic anomaly that occurs during its migration from foramen caecum to its pretracheal position. An intracardiac ectopic location is even rarer and found most commonly in the right ventricular outflow tract in sporadic reports. While surgery in symptomatic patients seems appropriate, resection of non-neoplastic ectopic tissue remains a clinical equipoise. Its occurrence is often unsuspected by clinicians, but its possibility should be considered due to its typical location in the right ventricular outflow tract. Unlike true neoplastic intracardiac tumour which mandates surgical resection, both surgical and non-surgical approach may be considered for an intracardiac ectopic thyroid mass.

Left-handed surgical instruments - a guide for cardiac surgeons.

For ease of use and to aid precision, left-handed instruments are invaluable to the left-handed surgeon. Although they exist, they are not available in many surgical centres. As a result, most operating theatre staff (including many left-handers) have little knowledge of their value or even application. With specific reference to cardiac surgery, this article addresses the ways in which they differ, why they are needed and what is required - with tips on use.

Could routine saphenous vein ultrasound mapping reduce leg wound complications in patients undergoing coronary artery bypass grafting

A best evidence topic was written in cardiothoracic surgery based on a structured protocol. The question addressed was whether ultrasound mapping of the long saphenous vein (LSV) might reduce leg wound complications by reducing unnecessary leg incisions due to poor quality veins. Altogether, 32 abstracts were identified from the search, from which 5 represented the best 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. Surgical site infections can be extremely distressing for patients, and it is estimated that treating a surgical wound can cost up to £1554 each. Ultrasound mapping of the LSV has been reported to be an accurate way of assessing vein quality preoperatively, reducing unnecessary surgical dissection, theatre time and cost to both the patient and the health service. We identified four studies that showed that ultrasound scanning preoperatively could accurately predict the anatomy and quality of the LSV (correlation coefficient 0.87). One paper showed that ultrasound scanning reduced length of incision (P = 0.005), harvest time (P = 0.04) and hospital stay and reduced morbidity (although not statistically significant). However, one study found that it could not accurately predict vein wall changes. Evidence from the papers supports the use of preoperative ultrasound assessment of the saphenous vein. Benefits to the patient include a smaller scar, reduced harvest time and minimizing unnecessary incisions.

Left-handed cardiac surgery: tips from set up to closure for trainees and their trainers

There are certain obstacles which left-handed surgeons can face when training but these are not necessary and often perpetuated by a lack of knowledge. Most have been encountered and overcome at some point but unless recorded and disseminated they will have to be resolved repeatedly by each trainee and their trainers. This article highlights difficulties that the left-hander may encounter in cardiac surgery and gives practical operative advice for both trainees and their trainers to help overcome them.

Left-handed Surgical Instruments - A Guide for Cardiothoracic Surgeons

For ease of use and to aid precision, left-handed instruments are invaluable to the left-handed surgeon. Although they exist, they are not available in many surgical centres. As a result, most operating theatre staff (including many left-handers) have little knowledge of their value or even application.

Left ventricular outflow tract obstruction following an uncomplicated primary percutaneous coronary intervention: a recognized but rare cause of cardiogenic shock:

Dynamic left ventricular outflow tract obstruction is a rare but important complication of myocardial infarction. It occurs acutely and may mimic the presentation of papillary muscle rupture or acquired ventricular septal defect. Unlike these mechanical complications, it does not require circulatory support or cardiac surgical intervention. Recognition is critical because it typically responds to volume loading and beta blockade. We report a case who displayed many classical features of this condition.

Transradial Secondary Access to Guide Valve Implantation and Manage Peripheral Vascular Complications During Transcatheter Aortic Valve Implantation

BACKGROUND Vascular complications from transfemoral (TF) secondary access during transcatheter aortic valve implantation (TAVI) are common. We compare our experience of transradial (TR) versus transfemoral secondary access during TAVI and describe techniques for performing iliofemoral arterial intervention from the transradial approach. METHODS All TAVI procedures with a single secondary access were included. Demographics, procedural details and 30-day outcomes were recorded. VARC-2 criteria were used for procedural complications. Procedures with TF primary access were stratified by the site of secondary arterial access. RESULTS Single secondary access was used in 199 cases, of which 20 were performed via non-TF access. Of the 179 TF primary access cases, 115 (64%) used TR secondary access and 64 (36%) used TF secondary access. In the TR cohort percutaneous vascular intervention was performed from the transradial approach in 19 cases (17%). Emergent TF secondary access was not required in any case. There were no differences in procedural time, radiation dose, contrast use, bleeding complications, stroke or mortality between the groups. There was one secondary access complication in the TF cohort and none in the TR cohort. CONCLUSIONS Transradial (TR) secondary access during TAVI is safe and feasible and may reduce the secondary access site vascular complication rate. With appropriate equipment, most peripheral vascular complications can be managed entirely via TR access avoiding unplanned femoral arterial access. TR secondary access should be considered the default approach for non-TF TAVI cases and can be considered for all TF cases as long as dedicated equipment is available.