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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: is vaginal delivery or caesarean section (CS) the safer mode of delivery in patients with adult congenital heart disease? Of the 119 studies, 13 papers represented the best evidence on the topic. Recommendations are based on 29 262 patients. Those having undergone successful corrective or palliative cardiac surgery for congenital heart disease, in addition to patients with unoperated congenital heart disease are a high-risk obstetric population. Heart disease is a leading cause of maternal mortality in the USA and the UK. Traditionally, CS was regarded as the mode of delivery of choice for high-risk patients, but growing experience in this field has now made this advice appear controversial. Patients are stratified into high- and low-risk, depending on the degree of heart failure symptoms [New York Heart Association (NYHA) class]. All studies demonstrated adverse outcomes in ACHD patients compared with normal age-matched controls. This pertained to a higher overall risk of maternal cardiac death, neonatal death, preterm birth, fetal growth restriction and longer hospital stay. On univariate regression analysis, the variables that imparted the highest risk to mother and foetus, were right ventricular failure, pulmonary regurgitation and pulmonary hypertension (P < 0.001). Induction of labour was deemed safe and was not associated with higher CS rates. There was no increase in maternal or neonatal complications in patients who were NYHA class I and II at labour. Patients who were NYHA class III and IV at labour had higher complication rates with adverse feto-maternal outcomes (P < 0.0001) and longer intensive care unit and hospital stay (Spearman's correlation 0.326, P = 0.007). The largest cohort from the USA (26 973 ACHD births) demonstrated that ventricular septal defect was associated with the highest risk of maternal death and complications (P < 0.05). The data would indicate that patients NYHA class I and II symptoms are suitable for VD. For most NYHA III and IV patients a trail of labour is safe with expedited delivery under good analgesic control as dictated by obstetric needs. Due to high complication risks, CS may be indicated in a proportion of patients.

A best evidence topic was written according to a structured protocol. The question addressed was whether patients undergoing coronary bypass grafting and mitral intervention for moderate to severe ischaemic mitral regurgitation are best treated with mitral repair or replacement. Five hundred and fifty papers were found using the reported search. Based on the 14 non-randomised studies judged to represent best evidence, we concluded that whilst there is some evidence that the operative mortality may be less following mitral valve repair, long-term data are equivocal. Even with contemporary techniques, recurrent mitral regurgitation is not uncommon following repair. Replacement was more frequently performed for patients with greater co-morbidity. Whilst two studies attempted to control for this using propensity analysis, in the majority of studies this introduced considerable bias. No data was available on long-term functional outcomes and quality of life. As there is currently insufficient evidence to inform clinical practice, a randomised trial is warranted in this important area.

A best evidence topic in cardiovascular surgery was written according to a structured protocol. The question addressed was whether asymptomatic significant carotid artery stenosis (ASCAS) warrants carotid endarterectomy (CEA) in patients undergoing cardiac surgery. 128 Papers were found using the reported search, of these 10 presented represent the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that low risk, younger patients with a significant asymptomatic carotid artery stenosis should be considered for carotid endarterectomy at some stage. There is, however, no strong evidence that this must be performed prior to, or during CABG.