Gopal Soppa

Impact of European Society of Cardiology and European Association for Cardiothoracic Surgery Guidelines on Myocardial Revascularization on the activity of percutaneous coronary intervention and coronary artery bypass graft surgery for stable coronary artery disease.

OBJECTIVE Joint guidelines on myocardial revascularization were published by the European Society of Cardiology and European Association for Cardiothoracic Surgery: Patients with left main stem, proximal left anterior descending, or 3-vessel disease should be discussed with a surgeon before revascularization, and ad hoc percutaneous coronary intervention has no elective indication in these categories. We assess the impact of the guidelines on referral patterns to a cardiac surgery service at a large-volume cardiac center in the United Kingdom. METHODS Joint guidelines were published in August 2010. All patients with severe disease undergoing percutaneous coronary intervention at one institution were identified 6 months before (January to June 2010) and 6 months after (January to June 2011) their introduction. Decision-making and surgical referral were determined from minutes of multidisciplinary meeting. RESULTS A total of 197 patients underwent elective percutaneous coronary intervention pre-guidelines, of whom 62 had severe disease. Only 6 patients (9%) were discussed at a multidisciplinary meeting before intervention. After introduction of the guidelines, elective percutaneous coronary interventions were performed in 164 patients, of whom 42 had surgical disease. Only 8 patients (17%) were discussed at a multidisciplinary meeting before intervention (P = not significant). Follow-up was a median of 480 (380-514) days for the pre-guideline group and 104 (31-183) days for the post-guideline group. Ad hoc percutaneous coronary intervention in surgical disease occurred in 8 patients (14%) pre-guidelines and was unchanged for 9 patients (26%) post-guidelines (P = not significant). CONCLUSIONS Despite recommendation by both cardiology and cardiac surgical bodies and widespread publicity, a significant number of patients in this single-center study are not receiving optimal treatment recommended by these guidelines.

Early experience with the transaortic approach for transcatheter aortic valve implantation

the orifice. Posterior veins are also referred to as inferolateral collaterals and left posterior veins. The coronary sinus venograms obtained during the treatment of patient 2 were not preserved. Echocardiograms demonstrate the lead entering the coronary sinus but do not define the final venous location. It is likely that the vein used in the treatment of patient 1 was a posterior vein, whereas the vein used in the treatment of patient 2 was a posterior or middle cardiac vein. Because the primary objective of lead insertion in these patients was ventricular pacing and not cardiac resynchronization therapy, the precise location of the veins involved is primarily of academic interest.

Trainees can learn minimally invasive aortic valve replacement without compromising safety

OBJECTIVES Minimally invasive aortic valve replacement (Mini-AVR) is a technically advanced procedure. However, it results in equivalent operative mortality, less bleeding and reduced intensive care/hospital stay when compared with conventional AVR. Our aim was to assess the impact of trainee performance on short-term outcomes of patients undergoing elective and urgent Mini-AVR where a significant proportion were performed by trainees. METHODS All patients undergoing non-emergency, elective and urgent, isolated Mini-AVR between September 2005 and December 2012 were studied. Operative details and short-term outcomes, with particular attention to trainee performance, were analysed. RESULTS During the study period, there were 205 Mini-AVR with a median age of 67 years (range 29-86); 74 (36%) operations were performed by trainees. The overall median cross-clamp and bypass times were 42 (range 33-63) and 59 min (range 59-94) for the attending surgeon and 52 (range 42-63) and 71 min (range 59-94) for the trainee (P = 0.03). Five Mini-AVR patients (2.4%) required conversion to full sternotomy for ascending aortic replacement, right ventricular bleeding, coronary artery bypass graft surgery and failure to cardiovert. None of these cases were performed by trainees. Median lengths of intensive care and hospital stay were 1 and 5 days and were not different for attending surgeon and trainee. Only 1 (0.5%) patient died in hospital. CONCLUSIONS Mini-AVR can be performed with a low conversion rate and hospital stay and taught to trainees without compromising safety.

High-Volume Practice by a Single Specialized Team Reduces Mortality and Morbidity of Elective and Urgent Aortic Root Replacement.

BACKGROUND Elective aortic root replacement (ARR), or the Bentall procedure, is associated with significant mortality and complications. Recent studies have shown that high procedure volume has an inverse association with postoperative mortality. The outcomes of patients undergoing elective/urgent ARR by a single, high-volume surgical team were assessed in this study. METHODS Patients undergoing nonemergency, elective/urgent ARR for non-Marfan aortic root dilatation, from October 2005 to March 2011, were studied. Valve-preserving procedures, extra-anatomic bypass, and arch and descending aortic repairs were excluded. Patient demographics, operative details, and postoperative outcomes were collected prospectively. Surgical techniques included central cannulation and cardiopulmonary bypass (CPB) at 35°C. Following aneurysm excision, a composite valve-conduit reconstruction with coronary button reimplantation was performed. Tissue glue, Teflon pledgets, and blood products were seldom used. Patients were followed locally at 8 weeks, 6 months, and annually thereafter with echocardiography and computed tomographic (CT) scanning. RESULTS From October 2005 to March 2011, 163 ARRs were performed. Of these, 131 (80%) were isolated first time procedures (four in pregnant women), six were redo (4%), and in 26 (16%) ARR was combined with concomitant valve or coronary artery revascularization procedures. Median age was 63 years (range 19-84). Median cross-clamp and CPB times were 73 (range 69-87) and 86 minutes (range 85-126), respectively. There was one in-hospital death (mortality = 0.6%), one patient underwent resternotomy for bleeding, two required hemofiltration, and there were no strokes. Median hospital stay was 6 days (range 5-11). Median follow-up was 2.9 years (range 6 months-4.3 years) with 100% freedom from reoperation. There was no late distal ascending aorta/arch dilatation. There were two late deaths (1.2%) due to pneumonia and stroke. CONCLUSIONS High-volume surgery, with minimal use of hemostatic adjuncts and sustained follow-up, leads to excellent outcomes, with low morbidity and mortality following ARR.

Aortic Root Surgery: Does High Surgical Volume and a Consistent Perioperative Approach Improve Outcome?

There is evidence that high surgical volume and team consistency improve outcomes. Mortality of 4%-12% for aortic root surgery has been reported in the United States and UK. We aim to assess outcomes of patients undergoing aortic root surgery by a consistent, high-volume team. Data on patients undergoing elective or urgent aortic root replacement (ARR) were collected prospectively. Patients undergoing emergency surgery were excluded. A standardized perioperative approach was maintained and was achieved by delivering training to team members, including surgical trainees, anesthetic, nursing, and perfusion staff, whenever there was a change of team. Between 2005 and 2014, 344 patients underwent ARR. Median age was 59 years (18-86) and 74% were men. Procedures included ARR (biological [186; 54%] or mechanical [101; 29.4%]) and valve sparing root replacement, remodeling technique (57; 16.6%). A total of 42 patients (12.2%) underwent concomitant procedures. There were 4 (1.2%) in-hospital deaths and no incidence of stroke. In total, 3 (0.9%) required resternotomy for bleeding and 8 (2.3%) required hemofiltration. Follow-up was complete for 94% of patients with median intensive care unit and hospital stays of 1 and 6 days, respectively. Follow-up was complete for 94% of patients at a median of 5.6 years with 98% freedom from reoperation and prosthetic valve dysfunction. There was 90% freedom from aortic insufficiency at 7 years in the valve sparing root replacement, remodeling technique cohort. We have demonstrated that high surgical volume and standardized care improves outcomes in aortic root surgery. Maintaining a consistent perioperative approach ensures team members are aware and well rehearsed in their roles, thereby improving outcomes.

Functional status and survival after prolonged intensive care unit stay following cardiac surgery

OBJECTIVES The clinical outcomes of patients discharged after prolonged postoperative intensive care unit (ICU) stay following cardiac surgery are unclear. The aim of this study was to assess survival and functional status in patients whose ICU stay exceeded 5 or 10 days in a tertiary cardiac surgical unit. METHODS Patients undergoing adult cardiac surgery between October 2008 and October 2010 who stayed in an ICU for 5-10 days (Group A) or >10 days (Group B) were studied. Demographics, operative details and postoperative data were prospectively collected. The follow-up of all patients was performed by telephone questionnaire. Functional status was assessed using the Karnofsky performance score by only one investigator for uniformity of scoring. For those patients who could not be contacted, the electronic patient records and data from the UK Office for National Statistics were reviewed to determine mortality. RESULTS Between 2008 and 2010, 2250 patients underwent adult cardiac surgery. Of these, 108 (4.7%) patients stayed >5 days (Group A, n = 53 and Group B, n = 55) in the ICU, having undergone various adult cardiac surgical procedures. The mean logistic EuroSCORE was 13 (range 1.5-86) for Group A and 16 (range 1-78) for Group B (P = 0.11). The mean ICU stay was 7 (range 6-8 days) for Group A and 21 (range 10-78 days) for Group B. Death in ICU occurred in 7 (13%) Group A patients and 11 (20%) Group B patients (P = 0.34). The median follow-up of patients who survived to the hospital discharge was 30 (range 13-38 months). Of the 90 survivors discharged from the hospital, there were 13 (25%) late deaths in Group A and 26 (47%) in Group B (P = 0.02). All survivors were contacted for the assessment of their functional status. The mean Karnofsky scores for Group A and Group B were 87 (range 70-100%) and 77.3% (range 40-100%), respectively, indicating satisfactory functional status. CONCLUSIONS Patients who have a prolonged ICU stay following cardiac surgery have high early and late mortalities. However, the functional status of the survivors is satisfactory after 1 year and beyond.

The influence of prolonged intensive care stay on quality of life, recovery, and clinical outcomes following cardiac surgery: A prospective cohort study

Objective To examine the influence of prolonged intensive care unit (ICU) stay on quality of life and recovery following cardiac surgery. Methods Quality of life was assessed using the Short Form 36 Health Survey (SF36). The Postoperative Quality of Recovery Scale was used to assess quality of recovery, disability, and cognition after ICU discharge over 12 months’ follow‐up. Prolonged ICU stay was defined as ≥3 postoperative days. Mortality and major adverse cardiac and cerebrovascular events were recorded up to 12 months. Results For quality of life, the physical component improved over time in both groups (P < .01 for both groups), as did the mental component (P < .01 for both groups). The long ICU group had lower physical and mental components over time (both P values < .01), but by 12 months the values were similar. The overall quality of recovery was lower for the long ICU group (P < .01). Likewise, we found higher rates of recovery in the normal ICU group than in the long ICU group in terms of emotive recovery (P < .01), activities of daily living (P < .01), and cognitive recovery (P = .03) but no differences in terms of physiologic (P = .91), nociceptive (P = .89), and satisfaction with anesthetic care (P = .91). Major adverse cardiac and cerebrovascular events (P < .01), 30‐day mortality (P < .01), and length of ward stay (P < .01) were all higher with prolonged ICU stay. Conclusions Patients with prolonged ICU stay have lower quality of life scores; however, they achieve similar midterm quality of recovery, but with reduced survival, increased major adverse cardiac and cerebrovascular events, and longer hospital length of stay.

A Survey of Cardiothoracic Surgical Training in the United Kingdom: Realities of a 6-Year Integrated Training Program

BACKGROUND In recent years, cardiothoracic (CT) surgical training has faced several challenges, including a reduction in working hours and trainees favoring shorter training programs. We carried out a national survey in the United Kingdom (UK) to assess the CT 6-year training program. METHODS All CT trainees in the UK (n = 121) were sent an online survey. This was combined with a debate at the Society for CT Surgery of Great Britain and Ireland. RESULTS Ninety-one (75.2%) of all trainees responded. Despite 56 (68.1%) being rostered for more than a 48-hour week, 31 (34.1%) of all trainees work an extra 10 hours. The majority (56, 61.5%) thought that on-calls and night duty are useful. Just over half of the trainees (47, 51.6%) spend at least 2 full days in the operating room, but 79 (86.8%) thought that this is too little and would spend voluntary time operating. Simulation of operations is thought to be useful; however, few thought that this should take more precedence in their training program. The majority of trainees thought that the current assessment of surgical training is suboptimal and does not examine surgical skill. Similarly, the majority thought that a defined number of operations is required before qualification. CONCLUSIONS Trainees remain committed to their profession and are willing to dedicate more time perfecting their art. They believe that despite wanting extra operating experience, they will be ready for independent practice at the completion of their training. It rests with training bodies to find alternative assessments for surgical ability and to define experience at the exit point of training.

Analysis of aortic area/height ratio in patients with thoracic aortic aneurysm and Type A dissection†

OBJECTIVES Significant proportions of aortic dissections occur at aortic diameters <5.5 cm. By indexing aortic area to height and correlating with absolute aortic diameter, we sought to identify those aneurysm patients with aortic diameters <5.5 cm who do not meet current size thresholds for surgery, yet with corresponding abnormal indexed aortic areas (IAAs) >10 cm2/m, are at increased risk of aortic complications. METHODS IAAs were calculated at 3 aortic locations in 187 aneurysm and 66 dissection patients operated on between 2010 and 2016 at our tertiary aortic centre. Proportions of patients with IAA >10 cm2/m, mean IAAs corresponding to aortic diameters <4.0 cm, 4.0-4.5 cm, 4.5-5.0 cm, 5.0-5.5 cm and >5.5 cm, and mean aortic diameters corresponding to IAAs 10-12 cm2/m, 12-14 cm2/m and >14 cm2/m were determined. RESULTS Proportions of patients with abnormal IAAs were similar in both groups. In all, 49.1% of aneurysm patients with aortic diameters 4.5-5.0 cm, and 98.5% with aortic diameters 5.0-5.5 cm had abnormal IAAs. Out of 200 separate aneurysms with IAAs >10 cm2/m between the mid-sinus and mid-ascending aorta, 139 (69.5%) would not warrant surgery according to existing guidelines. CONCLUSIONS Using the IAA, we identified a significant proportion of patients with thoracic aortic aneurysms who are at increased risk of aortic complications, despite current aortic guidelines not endorsing surgical intervention in this group. Our data suggests the IAA may be useful in preoperative risk evaluation and as a criterion for surgery.

Spontaneous coronary artery dissection in a 38-year-old: stenting and/or surgery?

Spontaneous coronary artery dissection is a rare but important differential diagnosis in fit young women presenting with chest pain.