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Introduction: Strengthening The Reporting Of Cohort Studies in Surgery (STROCSS) guidelines were developed in 2017 in order to improve the reporting quality of observational studies in surgery and updated in 2019. In order to maintain relevance and continue upholding good reporting quality among observational studies in surgery, we aimed to update STROCSS 2019 guidelines., Methods: A STROCSS 2021 steering group was formed to come up with proposals to update STROCSS 2019 guidelines. An expert panel of researchers assessed these proposals and judged whether they should become part of STROCSS 2021 guidelines or not, through a Delphi consensus exercise., Results: 42 people (89%) completed the DELPHI survey and hence participated in the development of STROCSS 2021 guidelines. All items received a score between 7 and 9 by greater than 70% of the participants, indicating a high level of agreement among the DELPHI group members with the proposed changes to all the items., Conclusion: We present updated STROCSS 2021 guidelines to ensure ongoing good reporting quality among observational studies in surgery., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Valve disease carries a huge burden globally and the number of heart valve procedures are projected to increase from the current 300 000 to 800 000 annually by 2050. Since its genesis 50 years ago, pericardial heart valve has moved leaps and bounds to ever more ingenious designs and manufacturing methods with parallel developments in cardiology and cardiovascular surgical treatments. This feat has only been possible through close collaboration of many scientific disciplines in the fields of engineering, material sciences, basic tissue biology, medicine and surgery. As the pace of change continues to accelerate, we ask the readers to go back with us in time to understand developments in design and function of pericardial heart valves. This descriptive review seeks to focus on the qualities of pericardial heart valves, the advantages, successes and failures encapsulating the evolution of surgically implanted pericardial heart valves over the past five decades. We present the data on comparison of the pericardial heart valves to porcine valves, discuss structural valve deterioration and the future of heart valve treatments., (Copyright © 2021 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: Patients with multi-vessel coronary artery disease and poor left ventricular (LV) function (ejection fraction [EF] < 30%) requiring revascularization are considered 'high-risk'. Limited long-term survival data exists comparing percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DES) versus surgery for this cohort of patients., Methods: We retrospectively reviewed our data for 321 patients with EF < 30% who underwent multi-vessel revascularization from January 2005 to December 2015 using Cox regression analyses and inverse probability treatment weighted (IPTW) methods. We stratified patients that underwent surgical revascularization into on-pump coronary artery bypass grafting (CABG) and off-pump CABG and analyzed all-cause mortality at 10 years compared to PCI., Results: 214 patients underwent CABG (n [on-pump CABG] = 94; n [off-pump CABG] = 120) and 107 patients had PCI with second generation DES. PCI with DES had higher 10-year mortality compared with on-pump CABG (Hazard ratio [HR] = 1.86, 95% confidence interval [CI] = 1.46-2.42; p < 0.001) and off-pump CABG (HR = 2.32, 95% CI = 1.75-3.15; p < 0.001). This was confirmed in IPTW analyses. When adjusting for both measured and unmeasured factors using instrumental variable analyses, PCI with DES had higher 10-year mortality compared with on-pump CABG (Δ = 13.5, 95% CI = 3.2-24.5; p = 0.012) and off-pump CABG (Δ = 16.1, 95% CI = 5.9-25.8; p < 0.001)., Conclusion: Surgical revascularization, preferably off-pump CABG, results in better long-term survival compared with PCI using second generation DES for patients with multi-vessel coronary artery disease and poor left ventricular function. Randomized controlled trials in this patient group should be undertaken., Competing Interests: Declaration of competing interest None., (Copyright © 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Competing Interests: Declaration of competing interest None.

Objective: Endoscopic vein harvesting (EVH) is growing in popularity and is the method of choice in many centers worldwide as it is associated with lower complication rates compared to the open vein harvesting. The aim of this study was to determine the current use of EVH during coronary artery bypass grafting among cardiac surgeons in United Kingdom and identify the main concerns that limit the use of this technique., Methods: We developed an online survey with 16 questions about the use of EVH. An invitation to participate was sent to all the adult cardiac surgeons currently in practice in United Kingdom., Results: A total of 139 surgeons (52%) of 267 currently in practice across 48 different hospitals completed the survey. Twenty five percent of responding surgeons always use EVH while 44% use it for <10% cases. Forty eight percent of responders regard EVH as an expensive technique and 90% believe that EVH is associated with fewer leg wound issues. Seventy five percent of responding surgeons will use it for their patients due to no leg wound issues while 25% believe that the concerns about patency of EVH are genuine., Conclusion: The majority of UK cardiac surgeons responding to this survey will preferentially consider EVH for obese and diabetic patients and are convinced by its beneficial impact in reducing leg wound complications. However, the reported routine use of EVH is low. Concerns about cost and patency of the endoscopically harvested vein are the possible barriers for universal adoption of EVH in the United Kingdom., (Copyright © 2019 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: Currently, surgeons are unable to estimate whether the survival benefit from bilateral internal mammary artery (BIMA) grafting outweighs the increased deep sternal infection (DSWI) risk in the individual cases. As a consequence BIMA grafting is still largely underutilized. We aimed to develop and validate a scoring system to predict the individual risk for DSWI and 10 year survival probability to guide surgeons in decision making process for the use of BIMA over single internal mammary artery (SIMA)., Methods: Fast backward elimination on predictors was performed using Lawless and Singhal method. BIMA score was reported as a partial nomogram that can be used to manually obtain predicted individual risk of DSWI and 10 year survival probability from the regression models. Bootstrapping validation of the regression models was performed., Results: The study population consisted of 5234 patients of which a total of 960 (18%) received BIMA and the remaining 4274 (82%) underwent conventional strategy using SIMA. A total of 119 patients experienced DSWI (2.3%). A total of 489 deaths were recorded after a median follow-up time of 5.68 years (interquartile range 2.7-8.8, range 0-12.1). BIMA grafting was found to have effect on both risk of DSWI and 10 year survival probability and was included into partial nomograms. Bootstrapping validation confirmed a good discriminative power of the models., Conclusion: The BIMA score provides an impartial assessment of the decision making process for clinicians to establish the optimum revascularization strategy for individual patients., (Copyright © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: Coronary artery bypass grafting (CABG) is being increasingly offered to octogenarians. Both on- and off-pump CABG are reported as effective surgical revascularization strategies for octogenarians by single institution studies. However, the issue of superiority of one strategy over the other for octogenarians remains unresolved due to limited sample size of these studies. A meta-analysis of studies comparing outcomes of on- and off-pump CABG in octogenarians was undertaken to address the issue., Methods: A literature search was conducted from 1966 through September 2016 using MEDLINE, EMBASE, Scopus and Web of Science to identify relevant articles. Primary outcomes of interest included in-hospital mortality and stroke. Secondary outcomes of interest were atrial fibrillation, acute renal failure, reoperation for bleeding, deep sternal wound infection, myocardial infarction, intensive therapy unit (ITU) stay and hospital stay. The random effects model was used to calculate the outcomes of both binary and continuous data to control any heterogeneity between the studies. Heterogeneity amongst the trials was determined by means of the Cochran Q value and quantified using the I 2 inconsistency test. All p-values were 2-sided and a 5% level was considered significant., Results: Sixteen retrospective studies (18,685 on-pump patients and 8938 off-pump patients) were included in the systematic review. In-hospital mortality (pooled OR = 0.64, 95% CI = 0.44 to 0.93; p = 0.02), stroke rate (pooled OR = 0.61, 95% CI = 0.48 to 0.76; p < 0.001) and length of hospital stay (pooled WMD = +0.29, 95% CI = +0.02 to +0.56; p = 0.04) were significantly lower in the off-pump patients. Atrial fibrillation (p = 0.36), acute renal failure (p = 0.47), reoperation for bleeding (p = 0.99), deep sternal wound infection (p = 0.59), myocardial infarction (p = 0.93), and length of ITU stay (p = 0.27) were comparable., Conclusion: Off-pump compared to on-pump CABG offers surgical myocardial revascularization to octogenarians with lower in-hospital mortality, stroke rate and length of hospital stay with similar incidence of other adverse outcomes. Preferentially offering off-pump CABG to octogenarians could translate into reduced economic burden on the healthcare providers., (Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: Additional arterial grafts such as the right internal mammary artery (RIMA) or the radial artery (RA) have been proposed to improve long term outcomes in coronary artery bypass grafting (CABG). RA is largely preferred over RIMA as it is less technically demanding and there is a perception that bilateral IMA usage increases the risk of sternal wound complications. However, there is a paucity of direct comparison of the two conduits to guide surgeons to choose the best second arterial conduit for CABG., Methods: A propensity score adjusted analysis of patients undergoing multiple arterial grafting with RIMA (n = 747) and RA (n = 779) during the study period (2001-2013) was conducted to investigate the impact of the two strategies on early and late outcomes., Results: RIMA did not increase the incidence of postoperative complications including deep sternal wound infection (P = 0.8). Compared to the RIMA, the RA was associated with an increased risk for late mortality (Hazard Ratio [HR] 1.9; 95% confidence interval (CI) 1.2-3.1; P = 0.008) and repeat revascularization (HR 1.5; 95% CI 1.0-2.2; P = 0.044). A trend towards an extra risk for late mortality from RA over RIMA was observed among diabetic (HR 3.3; 95% CI 1.1-9.7) and obese patients (HR 2.1; 95% CI 0.8-5.46)., Conclusions: RIMA as a second conduit did not increase the operative risk including sternal wound complications and improved long term outcomes including overall survival when compared to RA. This advantage was stronger among diabetic and obese patients. These findings strongly support RIMA as the first choice second arterial conduit in CABG. Further randomized studies with angiographic control and long-term follow-up are needed to address this issue., (Copyright © 2014 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Coronary artery disease (CAD) is a leading cause of mortality and morbidity in diabetics. Diabetics make up to 20%-35% of all patients undergoing coronary revascularization. Patients with diabetes represent a particularly difficult subset for revascularization due to increased short- and long-term mortality as well as a higher risk of repeat revascularization procedures. Potential factors contributing to the increased risk include co-morbid illnesses, small, diffusely diseased target vessels, progression of native CAD, hyperglycaemic endothelial dysfunction, and systemic inflammation. For diabetic patients with multi-vessel disease, revascularization by coronary artery bypass grafting (CABG) is regarded as the preferred option. There is increasing recognition that the use of arterial conduits for CABG is associated with improved outcomes compared to use of venous conduits. Amongst arterial conduits bilateral internal mammary arteries (BIMA) have emerged as the superior conduits due to better cardiac event-free survival. Consistent with its benefits in non-diabetic patients, BIMA grafting is presumed to offer similar benefits in diabetic patients. However, BIMA grafting remains underutilised in diabetics due to perceived increased risk of sternal wound infection. This review article provides an overview of BIMA grafting in diabetic patients focussing on outcomes, concerns, and controversies associated with BIMA usage in this high-risk group of patients., (Copyright © 2014 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

The internal mammary artery is universally recognised as the preferred conduit for coronary artery bypass grafting. Accumulating evidence in recent years has demonstrated the superiority of bilateral internal mammary artery (BIMA) grafting over single internal mammary artery grafting in terms of survival, event-free survival, and freedom from re-intervention. The survival benefit seen with BIMA grafting has been associated particularly to grafting the myocardium supplied by the left coronary artery system. Several surgical strategies have been used to achieve left-sided myocardial revascularisation with BIMA grafting. These include in-situ right internal mammary artery (RIMA) to the left anterior descending and the left internal mammary artery (LIMA) to circumflex marginal branches, directing the RIMA through the transverse sinus in a retroaortic course, and free RIMA graft connected proximally either to the LIMA (composite grafting) or to the ascending aorta. Each one of these surgical strategies for BIMA grafting has its merits and demerits. This review article provides an overview of the various surgical strategies for BIMA grafting focussing on their technical aspects, pros and cons as well as outcomes., (Copyright © 2014 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Objective: Surgical site infection (SSI) following coronary artery bypass grafting (CABG) is a serious complication associated with significant morbidity and mortality. Despite the substantial impact of SSI there is lack of a specific risk stratification tool to predict this complication after CABG. This study was undertaken to develop a specific prognostic scoring system for the development of SSI that could risk-stratify patients undergoing CABG., Methods: Between January 2009 and June 2012, continuous prospective surveillance data on SSI and a set of 41 variables were collected. Using binary logistic regression analysis we identified independent predictors of SSI. Initially we developed a predictive model in a subset of 769 patients. Dataset was expanded to 4087 cases and a final model and risk score were derived. Calibration of the scores was performed using the Hosmer-Lemeshow test., Results: The model had area under Receiver Operating Characteristic curve of 0.727 (0.827 for preliminary dataset). Baseline risk score incorporated independent predictors of SSI: female gender = 2 (p < 0.0001; RR 2.1), diabetes = 1 (p = 0.0098, RR 1.4) or HbA1c >7.5% = 3 (p < 0.0001; RR 3.4), body mass index ≥35 = 2 (p < 0.0001; RR 2.4), left ventricular ejection fraction < 45% = 1 (p = 0.0255; RR 1.4), and emergency surgery = 2 (p = 0.012; RR 2.4). A risk stratification system, the Brompton & Harefield Infection Score (BHIS) was developed., Conclusion: BHIS effectively predicts SSI risk and may help with risk stratification in relation to public reporting and reimbursement as well as targeted prevention strategies in patients undergoing CABG., (Copyright © 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Controversies exist whether off-pump coronary artery bypass (OPCAB) is superior to miniaturized extracorporeal circulation (MECC) in reducing deleterious effects of cardiopulmonary bypass as only a number of smaller randomized controlled trials (RCT) currently provide a limited evidence base. The main purpose of conducting the present meta-analysis was to overcome the expected low power in RCTs in an attempt to establish whether MECC is comparable to OPCAB., Methods: A MEDLINE/PubMed search was conducted to identify eligible RCTs. A pooled summary effect estimate was calculated by means of Mantel-Haenszel method., Results: The search yielded 7 RCTs included in this meta-analysis enrolling 271 patients in the OPCAB group and 279 in the MECC group. The OPCAB and MECC groups were comparable in terms of incidence of in-hospital mortality (Risk Difference [RD] 0.01; 95%CI -0.02, 0.03; P = 0.55; I(2) = 0%), stroke (RD -0.01; 95%CI -0.05, 0.04; P = 0.69; I(2) = 0%), need for renal replacement therapy (RD 0.00; -0.06, 0.06; P = 1; I(2) = 0%), postoperative atrial fibrillation (RD -0.03; -0.17, 0.10; P = 0.64; I(2) = 0%), re-exploration for bleeding (RD -0.01; 95%CI -0.03, 0.02; P = 0.65; I(2) = 0%), transfusion rate (RD -0.01; 95%CI -0.03, 0.02; P = 0.65; I(2) = 0%) and the amount of blood loss (weighted mean difference -25 mL; 95%CI -71, 21; P = 0.28; I(2) = 0%)., Conclusions: Using a meta-analytic approach, MECC achieves clinical results comparable to OPCAB including postoperative blood loss and blood transfusion requirement. On the basis of our findings, MECC should be considered as a valid alternative to OPCAB in order to reduce surgical morbidity of conventional cardiopulmonary bypass., (Copyright © 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: For the cardiac surgeon and patient the development of sternal wound infection is a serious post-operative complication associated with increased risk of death and also considerable morbidity., Methods: Nine publications were identified using the PubMed online database and search terms 'gentamicin-containing collagen implant' plus 'surgical site infection', 'wound infection' and 'cardiac surgery'., Results: Six out of eight studies demonstrated that prophylactic use of gentamicin-containing collagen implants (GCCI) significantly reduce the wound infection rate following cardiac surgery (via sternotomy) compared to standard treatment alone. The adjunctive use of GCCI is particularly beneficial in high-risk subjects e.g. diabetes and obese patients. GCCI significantly improve the morbidity associated with SSI following cardiac surgery by shortening the recovery phase and length of hospital stay; reducing the need for surgical revision and use of antibiotics. GCCI have been shown to be cost saving across a wide spectrum of patients. A further study has shown that GCCI may also have a therapeutic role to play in patients with deep sternal wounds., Conclusion: This review demonstrates that when used dry prior to insertion GCCI can be effective in reducing the rate of SSI following cardiac surgery. GCCI have also been shown to be cost saving as they reduce the substantial morbidity associated with deep SSI. The adjunctive use of GCCI is particularly beneficial in high-risk patients. GCCI may also have a role to play in the treatment of deep sternal wound infection., (Copyright © 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)