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Background Acute Stanford type A aortic dissection (TAAD) is a life-threatening condition. Surgery is usually performed as a salvage procedure and is associated with significant postoperative early mortality and morbidity. Understanding the patient’s conditions and treatment strategies which are associated with these adverse events is essential for an appropriate management of acute TAAD. Methods Nineteen centers of cardiac surgery from seven European countries have collaborated to create a multicentre observational registry (ERTAAD), which will enroll consecutive patients who underwent surgery for acute TAAD from January 2005 to March 2021. Analysis of the impact of patient’s comorbidities, conditions at referral, surgical strategies and perioperative treatment on the early and late adverse events will be performed. The investigators have developed a classification of the urgency of the procedure based on the severity of preoperative hemodynamic conditions and malperfusion secondary to acute TAAD. The primary clinical outcomes will be in-hospital mortality, late mortality and reoperations on the aorta. Secondary outcomes will be stroke, acute kidney injury, surgical site infection, reoperation for bleeding, blood transfusion and length of stay in the intensive care unit. Discussion The analysis of this multicentre registry will allow conclusive results on the prognostic importance of critical preoperative conditions and the value of different treatment strategies to reduce the risk of early adverse events after surgery for acute TAAD. This registry is expected to provide insights into the long-term durability of different strategies of surgical repair for TAAD. Trial registration ClinicalTrials.gov Identifier: NCT04831073.

Objectives Management of infected prosthetic aortic grafts in the ascending and or root is complex and multifaceted. We report our diagnostic pathway, management and outcomes, identifying successful strategies. Methods This was a retrospective, single center, observational study. Consecutive patients who underwent management of infected aortic grafts in the ascending and/or root at our institution between October 1998 and December 2019 were included. The main outcome measures were: discharge from hospital alive with at least 1 year survival, operative mortality and success of primary treatment strategy. Results Twenty‐six patients presented with infection of proximal aortic grafts and were managed through a number of strategies with an overall hospital‐survival of 81% and 1 year survival of 69%. Twenty of them ultimately underwent redo surgery with 25% operative mortality (within 24 h of surgery). Five patients underwent washout and irrigation of which two were successfully treated and cured with adjunctive antibiotics and two went on to have staged explant and definitive surgery. Interval between surgery and infection was 42.5 ± 35.8 months. All patients had at least one major criterion and three minor criterions with no diagnostic uncertainty. The commonest primary strategy was 3a (definitive surgery), (13/26, 50%). Conclusions Adopting a systematic and flexible patient specific approach to the diagnosis and management of patients with proximal aortic graft infections results in reasonable overall 1 year survival. In the majority of patients surgery is ultimately required in an attempt to achieve a curative treatment; however this comes with high operative mortality risk.

The emergence of severe acute respiratory syndrome coronavirus 2 in December 2019, presumed from the city of Wuhan, Hubei province in China, and the subsequent declaration of the disease as a pandemic by the World Health Organization as coronavirus disease 2019 (COVID‐19) in March 2020, had a significant impact on health care systems globally. Each country responded to this disease in different ways, however this was done broadly by fortifying and prioritizing health care provision as well as introducing social lockdown aiming to contain the infection and minimizing the risk of transmission. In the United Kingdom, a lockdown was introduced by the government on March 23, 2020 and all health care services were focussed to challenge the impact of COVID‐19. To do so, the United Kingdom National Health Service had to undergo widespread service reconfigurations and the so‐called “Nightingale Hospitals” were created de novo to bolster bed provision, and industries were asked to direct efforts to the production of ventilators. A government‐led public health campaign was publicized under the slogan of: “Stay home, Protect the NHS (National Health Service), Save lives.” The approach had a significant impact on the delivery of all surgical services but particularly cardiac surgery with its inherent critical care bed capacity. This paper describes the impact on provision for elective and emergency cardiac surgery in the United Kingdom, with a focus on aortovascular disease. We describe our aortovascular activity and outcomes during the period of UK lockdown and present a patient survey of attitudes to aortic surgery during COVID‐19 pandemic.

OBJECTIVES Pre-emptive strategies to manage the aortic complications of Marfan syndrome have resulted in improved life expectancy yet, secondary to the variation of phenotypic expression, anticipating the risk and nature of future aortic events is challenging. We examine rates of new aortic events and reinterventions in a Marfan cohort following initial aortic presentation. METHODS Retrospective cohort study of Marfan patients with aortic pathology presenting to our institution 1998–2018. Patients were grouped according to index event: aortic dissection or root aneurysm. Patients with aortic dissection were classified according to Debakey criteria. Incidence of new aortic events and frequency of reintervention were analysed. RESULTS One hundred and twenty-six aortic procedures were performed in 74 Marfan patients with a median follow-up of 7 years. Forty-seven patients had an index event of root aneurysm and 27 had aortic dissection. Following operative intervention in the aneurysm group, 7 patients developed Debakey III dissections raising the overall number of patients who developed dissection within this cohort to 34. Reinterventions were more frequent in the dissection group with full replacement of the native aorta in 5 patients. CONCLUSIONS After operative intervention on the proximal aorta, a proportion will develop distal pathology. A greater focus on factors contributing to future events, such as mapping genotypes to clinical course, may lead the way for targeted operative techniques and surveillance.

Correction to:Journal of Cardiothoracic Surgery (2021) 16:171 - https://doi.org/10.1186/s13019-021-01536-5

Diseases of the thoracic aorta are increasing in prevalence worldwide. Recent data indicated wide regional variation in the volume and complexity of aortic cases undertaken in United Kingdom cardiac centers, especially in case of acute type A aortic dissection (ATAAD) conditions. Patients treated in high-volume centers with a specific multidisciplinary aortic program had a significant reduction in ATAAD mortality when compared with low-volume centers. Following the initial phase of a national aortic center reorganization, the current study reflects the initial experience of a national collective of cardiothoracic surgeons with expertise in complex aortic surgery, using frozen elephant trunk as standard technique for the surgical treatment of patients affected by ATAAD. Between June 2013 and October 2017, 66 ATAAD patients (45% women) underwent hybrid aortic arch and frozen elephant trunk repair with the Thoraflex hybrid graft at 8 UK high-volume aortic centers. The in-hospital mortality accounted for 8 patients (12%). Postoperative temporary or permanent neurologic events and temporary renal replacement therapy occurred in 17% and 20% of patients, respectively. No spinal cord injury events were documented. Our data were similar to those reported in literature in the 2 largest experiences with the use of frozen elephant technique in ATAAD condition (in-hospital/30-day mortality: 11-12%). This initial experience demonstrated that frozen elephant technique can potentially be adopted as standard approach in life-threatening aortic diseases, with acceptable complication and mortality rates.

Background: While short-term outcomes for patients undergoing transcatheter aortic valve implantation (TAVI) have long been studied, there is very little data on their predictors. We aimed to identify the predictors of outcomes, such as intensive care unit (ICU) and in-hospital length of stay (LOS), duration of postoperative intubation and in-hospital mortality, after TAVI procedures. Methods: We conducted a retrospective cohort study of 162 consecutive patients with aortic valve disease, who were admitted to a tertiary hospital of Liverpool for TAVI, during a five-year period. The data was collected using of the hospital’s structured database on November 2014. Results: By using a multivariate analysis we found that any postoperative bleeding [odds ratio (OR) 2.71; 95% confidence interval (CI): 1.41–5.24] was the independent predictor of prolonged ICU-LOS, while older age (OR 1.11; 95% CI: 1.05–1.17) and transapical TAVI (OR 4.11; 95% CI: 1.94–8.71) were the predictors of prolonged in-hospital LOS. Additionally, patients treated with oral inotropic agents, preoperatively (OR 5.77; 95% CI: 2.21–15.01), non-diabetics (OR 3.07; 95% CI: 1.12–8.42) and those with any postoperative bleeding (OR 3.53; 95% CI: 1.68–7.43) had a significantly greater probability in remaining intubated postoperatively. The multivariate analysis did not reveal any predictor of in-hospital mortality. Conclusions: The above predictors permit the early identification of TAVI patients at high risk for longer hospitalization and increased mechanical ventilation. This piece of information is crucial for clinicians and administrators contributing to more efficient patient care planning and better allocation of healthcare resources.

OBJECTIVES Biological valves are the most commonly used prostheses for aortic valve replacement (AVR) surgery in the UK. The aim of this retrospective observational study was to compare 10-year outcomes of Perimount Magna and Mitroflow bioprosthesis implanted in a single center. METHODS The medical records of patients undergoing AVR in Liverpool Heart and Chest Hospital between 1999 and 2014 were examined. All data were collected retrospectively, and a propensity match analysis was performed with a ratio 3:1 to analyze 10-year outcomes. The primary outcomes were all-cause mortality rates and aortic valve reintervention rates. RESULTS A total of 2608 patients were included; Mitroflow bioprosthesis was used in 352 patients while Perimount Magna was used in 2256 patients. Median (interquartile range [IQR]) follow-up for the entire data set was 6.95 (4.99, 9.69) years. After 10 years, the all-cause mortality rate was higher in Mitroflow cohort 34.8% vs 14.7% (P

We introduced a new algorithm utilizing a patient's own platelet rich plasma and factor concentrates to better manage coagulopathy in aortic surgery under circulatory arrest. This study compares the outcomes of the patients treated with a new algorithm with those of patients managed with our traditional approach.The data of 247 consecutive patients who had aortic surgery were analyzed. The 158 patients (group 1) who were managed with our usual algorithm were compared with the 89 patients (group 2) who were treated with the novel algorithm consisting of utilization of the patient's own platelet rich plasma, fibrinogen, and prothrombin cell concentrates. Differences in transfusion and intensive care unit stay were analyzed. Univariate and multivariable robust regression analyses were performed.In comparison with group 1, patients in group 2 had significantly reduced need for transfusion of red cells (7.9 ± 8.6 vs 3.5 ± 3.8 units, P.001). Postoperative intubation time was reduced from a mean of 42 hours to a mean of 12 hours (P.001). The time to medical discharge from the intensive care unit was reduced from a mean of 7 days to a mean of 5 days (P.001), favoring the new algorithm. After adjustment for demographics and comorbidities, the novel algorithm remained significantly associated with a reduction in units of red blood cells transfused (robust parameter estimate, -1.14; P = .027) and blood products transfused (robust parameter estimate, -5.11; P.001).Using autologous plasma and factor concentrates to reverse coagulopathy in aortic surgery significantly reduces blood product transfusion.

Objective We seek to assess the safety of total arch replacement with frozen elephant trunk for acute type A aortic dissection in respect to the risks of operative mortality, stroke, and paraplegia using an international multicenter registry (ARCH). Methods The ARCH Registry database from 37 participating centers was analyzed between 2000 and 2015. Patients who underwent emergency surgery for acute type A aortic dissection treated by total arch replacement with or without frozen elephant trunk were included. Operative mortality, permanent neurologic deficits, and spinal cord injury were primary end points. These end points were analyzed using univariate and hierarchical multivariate regression analyses, as well as conditional logistic regression analysis and post hoc propensity-score stratification. Results A total of 11,928 patients were enrolled in the ARCH database, of which 6180 were managed with total arch replacement. A comprehensive analysis was performed for 978 patients who underwent total aortic arch replacement for acute type A aortic dissection with or without frozen elephant trunk placement. In propensity-score matching, there were no significant differences between total arch replacement and frozen elephant trunk in terms of permanent neurologic deficits (11.9% vs 10.1%, P = .59) and spinal cord injury (4.0% vs 6.3%, P = .52) For patients included in the post hoc propensity-score stratification, frozen elephant trunk was associated with a statistically significantly lower mortality risk (odds ratio, 0.47; P = .03). Conclusions The use of frozen elephant trunk for acute type A aortic dissection does not appear to increase the risk of paraplegia in appropriately selected patients at experienced centers. The exact risk factors for paraplegia remain to be determined.

Paraplegia is a complication that may occur following surgery or endovascular stenting of thoracic and thoracoabdominal aortic pathology. Measuring transcranial motor evoked potentials (tcMEPs) has been shown to provide a reliable measure of spinal cord function during such procedures allowing interventions to protect cord function. In the spirit of sharing experience and eliminating the learning curve for others, this manuscript describes our experience of setting up a service for tcMEP monitoring as well as the documents and algorithms for measuring, recording and acting on the patient data, the so-called 'MEP Pathway'.Recording and interpretation of tcMEP during thoracoabdominal aortic intervention requires training of staff and close team working in the operating theatre and postoperative intensive care unit. Providing consistent, reliable, specific and sensitive information on spinal cord function and its safe and effective use to alter patient outcomes requires a protocol. The MEP pathway was developed by medical and paramedical staff at our institution based on clinical experience and literature reviews over a 1-year period (2012-2013).The tcMEP pathway comprises six documents that guide staff in: (a) assessing suitability of patients, (b) setting up hardware, (c) preparing algorithms for management, (d) documenting intervention (left heart bypass, cardiopulmonary bypass or endovascular stenting) as well as (e) documenting postoperative intensive care processes.The tcMEP pathway acts as a guide for safe introduction and use of tcMEPs in thoracoabdominal aortic interventions. tcMEP-led guidance of intraoperative and postoperative management in thoracic aortic surgery is an important adjunct in caring for this patient group.

Introduction: Readmission in the intensive care unit (ICU) is a significant morbidity index, which has been related to poor patient outcomes Aim: To identify the preoperative and intraoperative risk factors for readmission in the cardiac surgery ICU. Methods: We conducted a retrospective cohort study of 595 consecutive patients who were admitted to the cardiac surgery ICU of a tertiary hospital of Athens - Greece during the one-year period (September 2011-September 2012). Data collection was carried out, retrospectively, by the use of a short questionnaire and based on the review of medical and nursing patient records at December 2012. Results: The incidence of ICU readmission was 3.7% (22/595). Respiratory disorders were the main reason for readmission (45.4%). Readmitted patients had a significantly higher in-hospital mortality compared to those requiring no readmission (P < 0.001). Multivariate analysis revealed that female gender [for males odds ratio (OR) 0.37, 95% confidence interval (CI) 0.15-0.89], high logistic EuroSCORE (OR 1.02, 95% CI 1.00-1.04), prolonged cardiopulmonary (CPB) duration (OR 1.01, 95% CI 1.00-1.02) and preoperative renal failure (OR 1.02, 95% CI 1.00-1.05) were the independent risk factors for readmission to the cardiac surgery ICU. Conclusions: One intraoperative and three preoperative variables are associated strongly with higher probability for ICU readmission. Shorter CPB duration could contribute to lower ICU readmission incidence. In addition, the early identification of high risk patients for readmission in the cardiac surgery ICU could encourage both the more efficient healthcare planning and resources allocation.

OBJECTIVES: Paraplegia is a rare but devastating complication, which may follow thoracoabdominal aortic surgery. Many adjuncts have been developed to reduce this risk including cerebrospinal fluid (CSF) drainage. Acetazolamide (carbonic anhydrase inhibitor) is a drug used to counteract mountain sickness and one of its effects is to reduce CSF production. Here, we report its first postoperative application in thoracoabdominal surgery with the aim of reducing cerebrospinal cord perfusion pressure and reducing risk of paraplegia. METHODS: We retrospectively reviewed 6 patients who have been treated with this drug between 2011 and 2012 who were undergoing thoracoabdominal aortic surgery. Our indications were decided to include: (i) patients in whom a spinal drain could not be positioned; (ii) patients with blood-stained CSF; (iii) patients in whom the volume of CSF drained was outside guidelines; (iv) patients in whom CSF pressure was elevated; (v) patients with excessive vasopressor usage and (vi) patients with postoperative neurological dysfunction as measured by motor-evoked potentials or clinical examination. All were given 500 mg intravenous acetazolamide, not more than eight hourly, for a duration dependent on response. RESULTS: In the 6 patients, 2 received a single dose of the drug and responded by an immediate drop in intracranial pressure (ICP) pressure. Of the 4 who received multiple doses of the drug, 1 had an immediate decline in ICP after each of the first six doses, while 3 had no discernable response. CONCLUSIONS: This is the first report of the efficacy of acetazolamide in reducing CSF production and lowering ICP during thoracoabdominal aortic surgery. We believe that its use will be beneficial in the 6 patient groups described. Our experience suggests there are ‘responders’ and ‘non-responders’, the characteristics of whom are yet to be defined. Its efficacy in reducing not just CSF volume and ICP but also clinically relevant morbidity such as paraplegia, is the subject of a planned randomized controlled trial. This report serves to raise awareness of the possible efficacy of this drug when normal management strategies are limited or exhausted.

We present a case of blunt traumatic aortic laceration following a motor vehicle crash. The aortic laceration was 4.5 cm above the coeliac axis and occurred because of an unstable tenth thoracic vertebral body. Open surgery was considered high risk, whereas an endovascular approach with an endoprosthesis placed at the exact anatomic location of the laceration was advocated.

Background The follow-up data for the Alfieri edge-to-edge technique of mitral valve repair is still a matter of interest. We describe the medium-term results of a single surgeon's practice with clinical and echocardiographic follow-up. Methods Between October 1998 and July 2003, 41 patients underwent the Alfieri repair. Mean age of the patients was 68 years, 34.2% were female, 26 (63.41%) had New York Heart Association (NHYA) class III symptoms, and 19 (46.3%) had concomitant coronary disease. Preoperatively, 26 patients had grade 4+, 12 patients had grade 3+, and 3 patients had grade 2+ mitral regurgitation. The pathologies included myxomatous degeneration (73.2%), ischemic cardiomyopathy (12.2%), rheumatic (4.9%), dilated cardiomyopathy (2.4%), previous infection (2.4%), and indeterminate pathology (4.9%). Thirty-three patients (80.4%) had a ring annuloplasty, and 17 (41.4%) had concomitant coronary surgery. Median duration of echocardiographic follow-up was 22.1 months (range, 0.2 to 60.1). Results Hospital mortality was 4.8% (2 of 41). Four patients underwent reintervention on the mitral valve. At follow-up, 26 patients (66.6%) were in NYHA class I. The actuarial freedom from death or reoperation at 5 years was 80.4%. Transthoracic echocardiography was performed in 94.3% of the 35 hospital survivors who did not undergo reoperation. Twenty-nine patients (87.8%) had grade 0–1+ mitral regurgitation, and the remainder had grade 2+ mitral regurgitation. All patients discharged from hospital were alive in December 2005. Conclusions The Alfieri edge-to-edge repair for mitral regurgitation is a safe and useful technique and should be included in the armamentarium of the mitral valve surgeon.

Objective: Several studies have shown no significantly increased risk of in-hospital mortality for obese patients after coronary artery bypass grafting (CABG). However, the effect of obesity on mid-term survival has not been adequately studied. We set out to examine whether mid-term survival following CABG is affected by obesity. Methods: We performed a retrospective study of 4713 consecutive patients undergoing isolated CABG between April 1997 and September 2001. Body mass index (BMI) was used as the measure of obesity, with 3429 patients categorised as non-obese (BMI < 30 kg/m 2 ), and 1284 patients as obese (EMI ≥ 30 kg/m 2 ). Patient records were linked to the National Strategic Tracing Service, which records all deaths in the community, to establish current vital status. Deaths occurring over time were described using Kaplan-Meier techniques. To control for differences in patient characteristics, we used Cox proportional hazards analysis to calculate adjusted hazard ratios (HR) and 95% confidence intervals (CI). Results: Three hundred and thirty (7.0%) deaths occurred during the study period, with a mean follow-up of 2.4 ± 1.4 years. The crude HR of mid-term mortality for obese patients was 1.09 (95% Cl 0.86-1.39; P = 0.457). After adjustment for core pre-operative factors, the adjusted HR of mid-term mortality for obese patients was 1.28 (95% Cl 1.01-1.64; P = 0.048). The adjusted freedom from death in the obese patients at 30 days, 1, 2, 3, and 4 years was 97.9, 95.9, 94.2, 92.4 and 90.5%, respectively, compared with 98.4, 96.8, 95.5, 94.0 and 92.5% for the non-obese patients. Conclusions: Although in-hospital mortality after CABG does not seem to be adversely affected by obesity there appears to be a significant increase in mortality in obese patients during a 4-year follow-up period.

Objectives: Obesity is often perceived to be a risk factor for adverse outcomes following coronary artery bypass graft (CABG) surgery. Several studies have been unclear about the relationship between obesity and the risk of adverse outcomes. The aim of this study was to examine the relationship between obesity and in-hospital outcomes following CABG, while adjusting for confounding factors. Methods :A total of 4713 consecutive patients undergoing isolated CABG between April 1997 and September 2001 were retrospectively analyzed. Body mass index (BMI) was used as the measure of obesity and was grouped as non-obese (BMI ,30), obese (BMI 30–35), and severely obese (BMI $35). Associations between obesity and in-hospital outcomes were assessed by use of logistic regression to adjust for differences in patient characteristics. Results: A total of 3429 patients were defined as non-obese, compared to 1041 obese and 243 severely obese. There was no association between obesity and in-hospital mortality, stroke, myocardial infarction, re-exploration for bleeding and renal failure. Obesity was significantly associated with atrial arrhythmia (adjusted odds ratio (OR) 1.19, P ¼ 0:037 for the obese; adjusted OR 1.52, P ¼ 0:008 for the severely obese) and sternal wound infections (adjusted OR 1.82, P ¼ 0:002 for the obese; adjusted OR 2.10, P ¼ 0:038 for the severely obese). The severely obese patients were 4.17 (P , 0:001) times more likely to develop harvest site infections. Severely obese patients were also more likely to have prolonged mechanical ventilation and post-operative stays, compared to non-obese patients. Conclusions: Obese patients are not associated with an increased risk of in-hospital mortality following coronary artery bypass surgery. In contrast, there is a significant increased risk of morbidities and post-operative length of stay in obese patients compared to non-obese patients. q 2002 Elsevier Science B.V. All rights reserved.

We report a case in which a thoracoabdominal aneurysm was present in association with previously unknown critical spinal canal stenosis. In spite of using left heart bypass, systemic hypothermia, and controlled cerebrospinal fluid drainage for spinal cord protection, the patient developed paraplegia following aortic aneurysm repair. Computed tomography scan revealed critical stenosis of the spinal canal that was thought to be sufficient to produce spinal cord compression syndromes including paraplegia.

Structural valve degeneration in a mechanical ball and cage prosthesis is a well-described entity. Here we describe an unusual case of structural valve degeneration of a cloth-covered composite-seat Starr-Edwards ball and cage valve prosthesis in the mitral position, where degeneration of the cloth covering of the seat of the valve led to significant intravalvular mitral regurgitation.

Paraplegia is a devastating complication which may occur following surgery on the thoracic aorta. The use of a cerebrospinal fluid drain (CSFD) has helped reduce the incidence of neurological deficit; however, the management of patients with a CSFD postsurgery requires nurses and doctors to have expertise and awareness of the associated complications. The National Patient Safety Agency (UK) has highlighted a number of cases involving inadvertent spinal injections throughout the UK National Health Service (NHS). To this end we have introduced a protocol or 'care bundle' for safe CSFD care as well as drain management. The protocol was developed by medical and nursing staff at our institution based on clinical experience and literature reviews over a two-year period (2008-2010). Interventions undertaken during the development of the protocol included discussion with the UK National Patient Safety Agency (NPSA). Content of the protocol was reviewed by internal regulatory bodies within the hospital prior to ratification and general dissemination. Clear guidance is given within the policy on the standards expected when caring for the line and managing drainage according to agreed parameters of spinal cord perfusion pressure. The protocol constitutes five documents which guide staff in the care of CSFD, its routine management, documentation and interventions necessary once neurological deficit is detected. Document 1 which is a checklist, communication tool and aide-memoire was developed to ensure effective management, when the patient arrives in intensive care unit (ICU) from theatre. Document 2 ensures that early detection of a neurological deficit is noted and with Document 3 is acted upon immediately to reverse the injury. Document 4 provides information on the safe administration of analgesia via the spinal drain and has reference to the Glasgow Coma Scale. Document 5 is a bespoke observation chart for documenting CSFD pressure and cerebrospinal fluid drainage. In conclusion, the protocol acts as a guide for safe management of the CSFD and directs staff in reacting to detection of neurological deficit.

We report a 58-year-old man who had a multi-lobulated pseudomyxomatous lesion in his ascending aorta 6 months after his root and ascending aorta was replaced by a Dacron graft.

Spinal cord ischaemia remains a major problem after surgery of the thoracic aorta. Early detection and avoidance of systemic hypotension can prevent permanent neurological damage. We report a rare case that developed a temporary paraplegia postoperatively, associated with the use of helmet continuous positive airway pressure.

From the Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Feb 8, 2010; revisions received June 23, 2010; accepted for publication July 12, 2010; available ahead of print Aug 30, 2010. Address for reprints: Saina Attaran, MRCS, Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Dr, Liverpool, L14 3PE, United Kingdom (E-mail: saina.attaran@kcl.ac.uk). J Thorac Cardiovasc Surg 2011;141:1078-9 0022-5223/$36.00 Copyright 2011 by The American Association for Thoracic Surgery doi:10.1016/j.jtcvs.2010.07.022

OBJECTIVE: To develop a multivariate prediction model for in-hospital mortality following aortic valve replacement. METHODS: Retrospective analysis of prospectively collected data on 4550 consecutive patients undergoing aortic valve replacement between 1 April 1997 and 31 March 2004 at four hospitals. A multivariate logistic regression analysis was undertaken, using the forward stepwise technique, to identify independent risk factors for in-hospital mortality. The area under the receiver operating characteristic (ROC) curve was calculated to assess the performance of the model. The statistical model was internally validated using the technique of bootstrap resampling, which involved creating 100 random samples, with replacement, of 70% of the entire dataset. The model was also validated on 816 consecutive patients undergoing aortic valve replacement between 1 April 2004 and 31 March 2005 from the same four hospitals. RESULTS: Two hundred and seven (4.6%) in-hospital deaths occurred. Independent variables identified with in-hospital mortality are shown with relevant co-efficient values and p-values as follows: (1) age 70-75 years: 0.7046, p 85 years: 2.0339, p

The use of apical suction devices has been well described for maintaining satisfactory haemodynamics during off-pump surgical coronary revascularization. Its expanded use has been described in a few other situations. We describe here a case of recurrent coarctation where an extra-anatomic ascending to descending thoracic aorta bypass graft was constructed using cardiopulmonary bypass without arresting the heart, and access and exposure were facilitated by the use of an apical suction device.

This study examines the association between avoiding the use of cardiopulmonary bypass (CPB) for coronary surgery and postoperative cardiac enzyme (CE) release, and its subsequent impact on survival.Between January 1999 and September 2002, 3734 consecutive patients underwent either off-pump or on-pump coronary surgery. Patient characteristics and postoperative cardiac enzyme release were collected prospectively. Logistic regression was used to assess the effect of off-pump coronary surgery on cardiac enzyme release. All analyses were adjusted for preoperative characteristics and number of grafts. All patients were followed up at 1 year to assess survival.Nine hundred and sixty (25.7%) patients had off-pump coronary surgery. Seven hundred and twenty-six (19.4%) patients had cardiac enzyme release three to six times the upper limit of the reference range, while 266 (7.1%) patients had cardiac enzyme release more than six times the upper limit of the reference range. After adjusting for patient characteristics, off-pump surgery was associated with less release (cardiac enzyme release three to six times, adjusted odds ratio 0.43, p0.001; cardiac enzyme release more than six times, adjusted odds ratio 0.59, p=0.005). Risk adjusted survival at 1 year was 97.5% for the on-pump group and 97.0% for the off-pump group (p=0.33).Avoiding cardiopulmonary bypass significantly reduces early cardiac enzyme release following coronary artery bypass grafting (CABG). However, it does not result in improved survival compared to coronary surgery using cardiopulmonary bypass. This absence of survival benefit may be due to higher mortality rates experienced by the fewer patients with high (6 times the upper limit of range) cardiac enzyme release following coronary artery bypass surgery without cardiopulmonary bypass.

Objective: The purpose of this study was to examine the effect of peri-operative red blood cell (RBC) transfusion on 30-day and 1-year mortality following coronary artery bypass grafting (CABG). Methods: We retrospectively analysed 3024 consecutive patients who underwent isolated CABG between January 1999 and December 2001. Patient records were linked to the National Strategic Tracing Service, which records all mortality in the UK. Thirty-day and 1-year mortality were derived from Kaplan-Meier curves. Confounding variables were controlled for by constructing a propensity score for the probability of receiving a transfusion from core patient characteristics including the lowest recorded laboratory haemoglobin (LL Hb) from a clinical chemistry database (C statistic 0.81). The propensity score and the comparison variable (transfusion versus no transfusion) were included in a Cox proportional hazards analysis, allowing calculation of adjusted hazard ratios (HR) and Kaplan-Meier survival curves. Results: Nine hundred and forty (31.1%) patients received RBC transfusion during or within 72 h of surgery. Predictors of the need for transfusion were LL Hb and lower body mass index, use of cardiopulmonary bypass, female sex, number of grafts, renal dysfunction, increased age, extent of disease, and prior CABG; these factors were all included in the propensity score. After 1-year of follow-up, 122 (4.03%) deaths occurred. The crude HR for 1-year mortality in patients transfused was 3.0 (P

We report a 31-year old woman who presented with acute onset of shortness of breath 19 years after multiple repairs of a preductal coarctation of the aorta using a Dacron tube graft. Imaging studies showed an aneurysm had developed in the tube graft. The aneurysmal tube graft was replaced during an open repair.

The postoperative course of a patient with hypoplastic left heart syndrome after a first-stage Norwood operation is governed to a large extent by the balance between the systemic and pulmonary circulations. Here we describe a simple and convenient technique for establishing an optimally sized systemic-pulmonary shunt by the application of a hemostatic clip. The method has been used in 6 patients.

Background Atrial fibrillation can occur in up to 40% of patients undergoing coronary surgery. Methods We retrospectively analysed 103 consecutive coronary surgery patients under the care of one surgeon between April 2003 and September 2003. These patients received 40 mg of sotalol orally twice daily from the first post-operative day for 6 weeks and 2 g of magnesium intravenously immediately post surgery and on the first post-operative day. We developed a propensity score for the probability of receiving sotalol and magnesium after coronary surgery. 89 patients from the sotalol and magnesium group were successfully matched with 89 unique coronary surgery patients who did not receive either sotalol or magnesium with an identical propensity score. Results Preoperative characteristics were well matched between groups. There was no significant difference with respect to in-hospital mortality between groups (sotalol and magnesium 1.1% versus control 4.5%; p = 0.17). The incidence of atrial fibrillation in the sotalol and magnesium group was 13.5% compared to 27.0% in the controls (p = 0.025). Conclusion The combination of sotalol and magnesium can significantly reduce the incidence of post-operative atrial fibrillation following coronary surgery.