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Objectives: Female gender and advanced age are regarded as independent risk factors for adverse outcomes after isolated coronary artery bypass grafting (CABG). There is paucity of evidence comparing outcomes of CABG between male and female octogenarians. We aimed to analyse in-hospital outcomes of isolated CABG in this cohort., Methods: All octogenarians that underwent isolated CABG, from January 2000 to October 2017, were included. A retrospective analysis of a prospectively collected cardiac surgery database (PATS; Dendrite Clinical Systems, Oxford, UK) was performed. A propensity score was generated for each patient from a multivariable logistic regression model based on 25 pre-treatment covariates. A total of 156 matching pairs were derived., Results: Five hundred and sixty-seven octogenarians underwent isolated CABG. This included 156 females (mean age 82.1 [SD: 0.9]) and 411 males (mean age 82.4 [SD: 2.1 years]). More males were current smokers (P = 0.002) with renal impairment (P = 0.041), chronic obstructive pulmonary disease (P = 0.048), history of cerebrovascular accident (P = 0.039) and peripheral vascular disease (P = 0.027) while more females had New York Heart Association class 4 (P = 0.02), left ventricular ejection fraction 30-49% (P = 0.038) and left ventricular ejection fraction <30% (P = 0.049). On-pump, CABG was performed in 140 males and 52 females (P = 0.921). There was no difference in in-hospital mortality (5.4% vs 6.4%; P = 0.840), stroke (0.9% vs 1.3%; P = 0.689), need for renal replacement therapy (17.0% vs 13.5%; P = 0.732), pulmonary complications (9.5% vs 8.3%; P = 0.746) and sternal wound infection (2.7% vs 2.6%; P = 0.882). The outcomes were comparable for the propensity-matched cohorts., Conclusions: No gender difference in outcomes was seen in octogenarians undergoing isolated CABG., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

A best evidence topic was constructed according to a structured protocol. The question addressed was 'Does perioperative furosemide usage reduce the need for renal replacement therapy in cardiac surgery patients?' Forty-seven papers were found using the reported search, of which 10 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. Current best available evidence to resolve the issue includes a systematic review and nine randomized controlled trials (RCTs). The systematic review of seven RCTs and one observational study has demonstrated that in patients who have undergone cardiac surgery, a more consistent and sustained diuresis is produced by a continuous infusion of furosemide compared with intermittent bolus doses of furosemide. However, there does not appear to be a significant difference in the total urine output or a change in serum electrolyte levels when furosemide is administered as a continuous infusion compared with intermittent bolus doses. Three RCTs recruiting neonatal and paediatric patients after open heart surgery also validated the safety and efficacy of furosemide infusion as well as intermittent bolus doses. Two of the five RCTS in adult cardiac surgery patients showed that furosemide infusion was associated with a reduced need for renal replacement therapy (RRT), while two RCTs failed to show any benefit and one reported an increased incidence of renal impairment. We conclude that continuous furosemide infusion in the perioperative period promotes a gentle and sustained diuresis in cardiac surgery patients. The evidence supporting the benefit of this strategy in terms of reducing the need for RRT is weak. At the same time, current best available evidence, albeit from small RCTs, suggests that the timely introduction of continuous furosemide infusion does not increase the incidence of renal impairment after cardiac surgery.

Hydroxyethyl starch (HES) solutions are commonly used for volume replacement in cardiac surgery patients. The degree of impairment of the haemostatic system depends on the molecular weight and substitution degree of HES solutions. It is claimed that as HES 130/0.4 (Voluven(®)) exhibits a lower in vitro molecular weight and a lower degree of hydroxyethyl substitution than HES 200/0.5 (HAES-steril(®)) therefore it has less impact on haemostasis. A best evidence topic in cardiac surgery was written according to a structured protocol to verify this statement. The question addressed was: in cardiac surgery patients does volume replacement with Voluven(®) impair coagulation less than other colloids? Using the reported search 12 papers, three in vitro and nine clinical studies, were found to represent the best evidence to answer the clinical question. The nine clinical studies were all randomised controlled trials. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The in vitro studies suggest that HES 130/0.4 has no significant effect on platelet variables, shows a faster clot formation process and a better clot retraction as compared with the other HES solutions. On the other hand, current best available evidence (level 1b) from clinical studies, limited by heterogeneity predominantly in terms of dosage of HES 130/0.4 administered and the sample size of individual trials, overwhelmingly suggests that HES 130/0.4 compared with HES 200/0.5 or gelatin-based volume replacement fluid affects coagulation to the same extent resulting in similar degree of blood loss. It can be concluded that contrary to in vitro studies HES 130/0.4 in clinical practice has comparable effects on blood loss after cardiac surgery.

A best evidence topic in congenital cardiac surgery was written according to a structured protocol. The question addressed was whether neonatal thymectomy in patients undergoing cardiac surgery has any adverse immunological consequences. Altogether 164 papers were found using the reported search, of which nine papers represented 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 were tabulated. The thymus is the major production site of T cells, whose stocks are built-up during foetal and early postnatal life. However, its function diminishes after the first years of life, and although thymic output is maintained into adulthood, the thymus mostly degenerates into fatty tissue in elderly adults. To date, there has been no general consensus with regard to the importance of this organ during childhood and adulthood. As a consequence, during cardiac surgery in neonates, partial or total thymectomy is routinely performed to enable better access to the heart and great vessels to correct congenital heart defects, suggesting that it may be dispensable during childhood and adulthood. Interestingly, current best available evidence from nine case-control studies suggests that neonatal thymectomy affects peripheral T-cell populations both in the short- as well as long-term and results in premature immunosenescence. However, the impact of these changes on the risk of infectious diseases or malignancy has not been thoroughly evaluated by any of these studies. Maintenance of a registry of patients undergoing neonatal thymectomy and further studies to assess the functional or clinical consequences of this practice would be valuable.

A best evidence topic in cardiac surgery was written, according to a structured protocol. The question addressed was: in young patients with rheumatic aortic regurgitation compared to non-rheumatics is a Ross operation associated with increased incidence of autograft failure? The pulmonary autograft with its inherent advantages of viable autologous transplant, central laminar flow, freedom from prosthetic valve complications, side effects of anticoagulation, and growth potential is considered a well-accepted option for aortic valve replacement in young patients. However, the use of a pulmonary autograft in young patients with rheumatic aortic valve disease is controversial. We analyse existing evidence to determine the suitability of the pulmonary autograft as a substitute for the diseased aortic valve in patients with rheumatic disease. Altogether 901 papers were found using the reported search terms, from which eight represented the best evidence to answer the clinical question. In addition, a meta-analysis also superficially addressed this issue. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All eight publications were from two institutions with one reporting outcomes for a Ross operation vs. mechanical valve implantation and two compared results of the Ross operation in rheumatic vs. non-rheumatic aortic valve disease. We conclude that the current available evidence suggests that pulmonary autograft is susceptible to rheumatic involvement. Use of pulmonary autograft in young patients (<30 years) with rheumatic aortic regurgitation and concomitant mitral regurgitation requires a cautious approach as there is an impaired autograft durability in this subgroup of patients.

A best evidence topic in congenital cardiac surgery was written according to a structured protocol. The question addressed was: in hypoplastic left heart patients is Sano shunt compared with modified Blalock-Taussig (mBT) shunt associated with deleterious effects on ventricular performance? Sano shunt modification of Norwood procedure involves construction of a right ventricle to pulmonary artery (RV-PA) conduit as an alternative source of pulmonary blood flow. Compared with the mBT shunt, the RV-PA conduit provides a more stable haemodynamic state in the immediate postoperative period and is reported to be associated with lower interstage mortality. However, concerns regarding the impact of ventriculotomy on short- and long-term performance of single ventricle have been expressed. Altogether 101 papers were found using the reported search terms, from which seven 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. None of the echocardiographic or clinical outcome studies showed poor ventricular performance after ventriculotomy of the systemic RV for construction of Sano shunt. A small autopsy study of 11 patients showed greater remodelling of the ventricular myocardial extracellular matrix in patients with RV-PA conduit with potential implications for poor ventricular performance. We conclude that the current available evidence, although weak, does not show any adverse effects of ventriculotomy on ventricular performance in patients with Sano shunt in the short- and medium-term. However, all the existing studies are limited by small numbers, non-randomised design and retrospective nature with failure of correlation of echocardiographic indices to clinical outcomes. It is expected that the Pediatric Heart Network randomised controlled trial will address this important issue.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether bi-ventricular pacing, also referred to as cardiac resynchronisation therapy (CRT), improves survival and quality of life in patients with severe (NYHA III/IV) symptomatic heart failure. Cardiac pacing can be achieved by stimulation of the right ventricle, left ventricle (LV) or by bi-ventricular pacing. This best evidence topic considers only bi-ventricular pacing. This involves placement of pacing leads in the right ventricle, epicardially on the LV with a lead typically placed in a branch of the coronary sinus and, unless the patient is in permanent atrial fibrillation, in the right atrium. Bi-ventricular pacing allows the optimisation of atrio-ventricular timing and resynchronisation of septal and postero-lateral left ventricular contraction. Symptomatic heart failure has a high morbidity and a poor prognosis. Patients with dyspnoea at rest or on minimal exertion (NYHA III/IV) are at high risk of death due to progressive heart failure, while those with less severe symptoms are more likely to experience sudden cardiac death. Up to 50% of patients with NYHA class III/IV symptoms have a prolonged QRS duration (>120 ms) on 12-lead ECG (usually in a LBBB pattern). This intra-ventricular conduction delay is a surrogate marker of mechanical dyssynchrony (an uncoordinated regional contraction-relaxation pattern) and is associated with reduced cardiac output and increased mortality. Bi-ventricular pacing can reduce the delay in activation of the LV free wall found in many patients with LV systolic dysfunction, thereby improving mechanical synchrony and cardiac output. It may also reduce pre-systolic mitral regurgitation. Three hundred and fifty-six papers were identified using the search method outlined, nine randomised controlled trials and a meta-analysis in addition to published guidelines presented the best evidence to answer the clinical question. Current best available evidence suggests that in patients with left ventricular systolic dysfunction (LVEF or=120 ms), and NYHA class III or IV symptoms despite optimal pharmacological therapy, bi-ventricular pacing significantly reduces the number of hospitalisations from heart failure, improves functional status (NYHA class, peak oxygen uptake and exercise tolerance) and improves health related quality of life. The CARE-HF study also demonstrated a reduction in mortality from progressive heart failure and all-cause mortality.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether, for patients undergoing coronary artery bypass grafting at higher risk of stroke, the single cross-clamp (SC) technique is of benefit in reducing the incidence of stroke. Using the reported search 458 papers were identified. Six randomised controlled trials (RCTs), of which one was a duplicate publication, represented the best evidence on the subject. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated for these. We conclude that current best available evidence, from six RCTs randomising 490 patients, suggests that there is no benefit of SC technique over multiple cross-clamp (MC) technique in terms of reduction in the incidence of stroke (SC=2/206 vs. MC=7/284; P=ns) although there is some advantage of SC technique in causing less neuropsychological deficits and release of serum S-100 protein, a surrogate marker of cerebral injury.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the omission of angiotensin converting inhibitors (ACEI)/angiotensin II receptor antagonists (AIIA) before cardiac surgery leads to avoidance of postoperative vasodilation. Using the reported search 421 papers were identified. Eleven papers including three randomised controlled trials (RCTs) represented the best evidence on the subject. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated for these. Whereas the three small RCTs on this topic provided conflicting evidence, the remaining seven large cohort and case-control studies confirmed that preoperative ACEI therapy resulted in postoperative low systemic vascular resistance (SVR)/vasoplegia. Only two small RCTs with conflicting conclusions specifically addressed the issue of omitting ACEI/AIIA before cardiac surgery. We conclude that preoperative administration of ACEI/AIIA in patients undergoing cardiac surgery contributes to lowering of SVR/vasoplegia postoperatively thereby making omission of ACEI/AIIA before cardiac surgery a rational strategy to avoid postoperative vasodilation. However, the current available evidence to support this strategy is weak.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether, in patients with mitral regurgitation secondary to degenerative mitral valve disease requiring mitral valve repair with an annuloplasty ring, a flexible ring is superior to a semi-rigid or rigid ring in terms of improvement in symptoms and survival. Using the reported search 478 papers were identified. Twelve papers of which seven were echocardiographic studies and five clinical studies, including two randomised controlled trials (RCTs), represented the best evidence on the subject. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated for these. We conclude that current best available evidence suggests that, in patients with a flexible annuloplasty ring compared to patients with a semi-rigid/rigid annuloplasty ring, the improvement in LV systolic function as reported by all the seven sophisticated echocardiographic studies with a total of 266 patients does not translate into better clinical outcomes as five clinical studies with a total of 941 patients, including two RCTs, report comparable clinical outcomes for patients with mitral regurgitation secondary to degenerative mitral valve disease requiring mitral valve repair with an annuloplasty ring.

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether neoadjuvant chemotherapy improves survival in patients with resectable oesophageal cancer. Altogether 685 papers were identified using the below mentioned search. Nine represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses were tabulated. We conclude that combining neoadjuvant chemotherapy with surgery for resectable thoracic oesophageal cancer has theoretical appeal and may offer a modest survival advantage compared to surgery alone. The most recent meta-analysis and the largest randomised trial of 804 patients demonstrated an absolute survival advantage of around 7-9% at two years which just reached statistical significance. Benefit was less clear for squamous cell carcinoma than adenocarcinoma and the second largest randomised trial did not demonstrate a significant benefit.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether vacuum-assisted closure (VAC) should be routinely used for management of deep sternal wound infection after cardiac surgery. Altogether, 198 papers were identified using the reported search. A further three relevant papers were identified by hand searching reference lists. Thirteen papers represented the best evidence on the topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that VAC provides a viable and efficacious adjunctive method by which to treat postoperative wound infection after cardiac surgery. It is especially useful for managing sternal osteomyelitis in high-risk patients and is an attractive option as a first-line therapy in this group of patients. However, currently the evidence to endorse its routine use for management of deep sternal wound infection after cardiac surgery is weak. A randomised controlled trial comparing VAC therapy with the conventional treatment is mandatory to validate its safety, efficacy, and cost effectiveness as a routine first-line therapy for management of deep sternal wound infection after cardiac surgery.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether warfarin should be routinely prescribed for the first three months after a bioprosthetic valve replacement either for the aortic or mitral position. Altogether 620 papers were identified using the below-mentioned search. In addition, all major international guidelines were included. Fifteen papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses were tabulated. We conclude that all guidelines, the available evidence and current practice support the use of warfarin at an INR of 2-3 for 3 months for bioprosthetic mitral valve replacement (MVR). However, it must be acknowledged that this recommendation is based on only a small number of non-randomized cohort studies and on expert consensus. For patients without high risk factors undergoing a bioprosthetic aortic valve replacement (AVR), the European Society of Cardiology (ESC), the American College of Chest Physicians (ACCP) and the Scottish Intercollegiate Guidelines Network (SIGN) all recommend warfarin for 3 months after surgery. However, the American Heart Association (AHA/ACC) guidelines and the British Society for Haematology (BSH) regard aspirin alone as adequate therapy. In addition, two large surveys show that the majority of surgeons worldwide now use only antiplatelet therapy. The evidence from clinical studies to support the use of warfarin post-bioprosthetic AVR is very weak and out-dated, and therefore, we feel that it is certainly safe to use antiplatelet therapy alone post-bioprosthetic AVR.

A best evidence topic in pediatric cardiac surgery was written according to a structured protocol. The question addressed was whether sildenafil was effective in treating postoperative pulmonary hypertension after pediatric heart surgery. Altogether 28 papers were found using the reported search, of which three represented 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 were tabulated. We conclude that oral sildenafil may be useful in reducing pulmonary vascular resistance and can be considered for treatment of postoperative pulmonary hypertension after pediatric heart surgery. However, evidence from a large, multicenter, randomized controlled trial is needed to validate the safety and efficacy of sildenafil for use in postoperative pediatric cardiac surgical patients.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether skeletonised internal mammary artery (IMA) is better than pedicle IMA in coronary artery bypass grafting? Altogether 106 papers were found using the reported search, of which 12 presented 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 skeletonisation increases the length of conduit by around 3 cm and may also increase flow and conduit diameter. Skeletonisation should be the technique of choice for diabetics in whom BIMA harvest is desired, but at the expense of an extra 15-20 min per operation, no convincing outcome benefits have been shown for single IMA harvest.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether off-pump coronary artery surgery reduces the incidence of postoperative atrial fibrillation. Altogether 107 papers were found using the reported search, of which 18 presented 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 off-pump coronary artery surgery significantly reduces the incidence of postoperative atrial fibrillation with a number needed to treat of 20 to prevent one case of AF.