Joseph Zacharias

Mid-term outcomes for Endoscopic versus Open Vein Harvest: a case control study

BackgroundSaphenous vein remains the most common conduit for coronary artery bypass grafting with increasing uptake of minimally invasive harvesting techniques. While Endoscopic Vein Harvest (EVH) has been demonstrated to improve early morbidity compared to Open Vein Harvest (OVH), recent literature suggests that this may be at the expense of graft patency at one year and survival at three years.MethodsWe undertook a retrospective single-centre, single-surgeon, case-control study of EVH (n = 89) and OVH (n = 182). The primary endpoint was death with secondary endpoints including acute coronary syndrome, revascularisation or other major adverse cardiac events. Freedom from angina, wound complications and self-rated health status were also assessed. Where repeat angiography had been performed, this was reviewed.ResultsBoth groups were well matched demographically and for peri-operative characteristics. All cause mortality was 2/89 (2%) and 11/182 (6%) in the EVH and OVH groups respectively. This was shown by Cox Log-Rank analysis to be non-significant (p = 0.65), even if adjusting for inpatient mortality (p = 0.74). There was no difference in the rates of freedom from angina (p = 1.00), re-admission (p = 0.78) or need for further anti-anginals (p = 1.00). There was a significant reduction in the incidence of leg wound infections and complications in the endoscopic group (EVH: 7%; OVH: 28%; p = 0.0008) and the skew of high patient self-rated health scores in the EVH group (61% compared to 52% in the open group) approached statistical significance (p = 0.06).ConclusionsWhile aware of the limitations of this small retrospective study, we are heartened by the preliminary results and consider our data to be justification for continuing to provide patients the opportunity to have minimally invasive conduit harvest in our centre. More robust evidence is still required to elucidate the implications of endoscopic techniques on conduit patency and patient outcome, but until the results of a large, prospective and randomised trial are available, we believe we can confidently offer our patients the option and benefits of EVH.

A simple reproducible method of preventing lobar torsion

Torsion of remaining lobes after pulmonary resection is a potentially serious complication with high reported morbidity and mortality. A range of additional procedures has been described, we have used a simple, effective, quick and easy to reproduce minor procedure to prevents torsion.

A Prospective Audit of Endoscopic Vein Harvesting for Coronary Artery Bypass Surgery

INTRODUCTION The objectives of this study were to: (i) assess the feasibility of minimally invasive endoscopic harvesting of the long saphenous vein or radial artery for use as conduit during coronary artery bypass surgery in the NHS setting; and (ii) investigate the results of endoscopic vein harvesting with regards to postoperative complications, ability to mobilise, and patient satisfaction. PATIENTS AND METHODS In this prospective audit, 25 consecutive patients, aged 52-90 years, undergoing either coronary artery bypass grafting alone or together with valve surgery or atrial fibrillation ablation were studied. All data were entered in purpose-designed proforma. Pre-operative risk factors including increasing age, diabetes, peripheral vascular disease, obesity, renal impairment, tobacco consumption and steroid use were documented. Time taken for harvest and conversion to traditional open vein harvest, quality of harvested vein in terms of number of repairs and vein damage were recorded. Postoperatively, we recorded harvest site wound complications, number of days to mobilise and total hospital stay. Pain score and patient satisfaction were also assessed. RESULTS There was one death due to myocardial infarction; another patient had postoperative cerebrovascular accident. A total of 43 lengths of grafts were harvested, 41 were long saphenous vein and two radial artery. Vein harvest time reduced significantly from a maximum of 94 min to 34 min for two lengths of long saphenous vein. Three patients required conversion from endoscopic vein harvesting to open vein harvest. The only postoperative complication directly related to endoscopic harvesting was bruising along the tunnel created by the passage of the instruments. None of the patients had any wound complication; none required antibiotics or wound debridement. Mean time to mobilise was 3.4 days. All patients who underwent successful endoscopic vein harvesting expressed satisfaction with regards to postoperative pain and cosmetic result. CONCLUSIONS Competence and ability to harvest conduit in an acceptable time frame are obtainable after a relatively low number of cases. The procedure is associated with a low number of postoperative complications and very high patient satisfaction.

Cerebral Metastases in Patients with Left Atrial Myxoma.

We describe two cases of cardiac myxomas with cerebral metastases and review the literature on this subject. doi: 10.1111/jocs.12727 (J Card Surg 2016;31:289–293)

Salvage therapy with topical antifungal for Aspergillus fumigatus empyema complicating extrapleural pneumonectomy

We describe an unusual case of Aspergillus fumigatus empyema and bronchopleural fistulae after extrapleural pneumonectomy (EPP) and chemoradiotherapy (CRT), which was treated successfully under salvage conditions with debridement, an innovative topical antifungal application and supplemented systemic antifungal therapy and which went on for a definitive surgical procedure. Combinations of CRT and EPP have been recommended in a select group of patients with malignant mesothelioma. Irrespective of the combination, EPP is associated with mortality in the range of 4-15% and a complication rate as high as 62%.

Mitral valve repair after a right pneumonectomy: a minimally invasive approach

A 31-year old man was admitted to our unit with severe mitral regurgitation secondary to infective endocarditis on a background of a right pneumonectomy performed 8 years previously for a central carcinoid tumour. A previous right thoracotomy for lung resection is considered a contraindication to a minimal access approach to the mitral valve. Following the right pneumonectomy, a left-to-right displacement of the mediastinum had occurred. We report our experience on performing a mitral valve repair through a right mini-thoracotomy in a patient who had undergone a right pneumonectomy. In this case, three-dimensional computed tomography reconstructions were used to guide our surgical approach. We hope that this case presentation will help further broaden the applicability of a thru-port approach to this rare subgroup of patients.

Penetrating ulcer of the aortic arch presenting with hemoptysis.

CLINICAL SUMMARY A 58-year-old nonsmoker presented with a 6-month history of hemoptysis and a 1-month history of left-sided chest pain. He was known to have poorly controlled hypertension. Physical examination was unremarkable. Chest radiographic analysis showed a lesion in the left lung apex lying against the aortic arch. Contrast computed tomographic (CT) scanning demonstrated continuity between the lesion and the aortic lumen. Positron emission tomographic analysis confirmed high uptake in the lesion, and the patient was referred to us as having a case of lung cancer with extension into the aorta (Figure 1). However, multislice CT analysis with 3-dimensional reconstruction clarified the presence of a PAU in the arch leaking into the lung, with surrounding hematoma (Figure 2). The patient continued to experience pain, and we proceeded to surgical intervention. Hypothermic (24 C) cardiopulmonary bypass was established between the right atrium and the right subclavian artery. Myocardial protection was with intermittent antegrade cold blood cardioplegia. The ulcer was full of clot and penetrating into the lung. The clot was sent for culture. The base of the ulcer extended to the descending aorta, adhering to the left lung and the phrenic nerve. Dissection to free the descending aorta was impossible. The aortic wall was thickened, inflamed, and friable. The ulcer was excised, and the aortic defect was patched with Dacron. Because of the poor quality of aortic tissue, the bleeding from the suture line could not be controlled, and therefore the arch was replaced with a Dacron (Golscal, Sulzer Vascutek, UK) graft, leaving an elephant trunk in the descending aorta. An island of aorta containing the innominate and left common carotid arteries was reimplanted onto the arch. The patient was weaned off cardio-

Can cardiothoracic surgeons provide a safe and effective thoracic surgery service

There is a trend to separate Thoracic surgery from the Cardiothoracic surgical divisions. One of the main persuasive argument is the evidence in support of increased resection rate and effective delivery of thoracic surgical services. In such context we reviewed the outcome of thoracic surgical practice in our region where a cardiothoracic surgeons service was standard.