Video-Assisted-Thoracoscopic-Surgery Pleural Decorticator for Emergency Empyema Surgery.

BACKGROUND/NEED: Pleural empyemas carry a high morbidity and mortality. Some can be managed with medical treatment but most require some form of surgery with the goals to remove the infected material from the pleural space and to help re-expand the collapsed lung. Keyhole surgery by Video Assisted Thoracoscopy Surgery (VATS) is rapidly becoming a common approach to deal with early stage empyemas to avoid larger, more painful thoracotomies that hinder recovery. However, the ability to achieve those aforementioned goals is often hindered by VATS surgery due to the instruments available. METHODOLOGY AND DEVICE DESCRIPTION: We have developed a simple instrument called the "VATS Pleural Debrider" to achieve those goals in empyema surgery that can be used in keyhole surgery. PRELIMINARY RESULTS: We have used this device in over 90 patients with no peri-operative mortality and a low re-operation rate. CURRENT STATUS: Used in routine urgent/emergency pleural empyema surgery across 2 cardiothoracic surgery centres.

Outcomes following coronary artery bypass surgery in diabetic treatment sub-groups. A propensity matched analysis of >7000 patients over 18 years.

BACKGROUND: European System for Cardiac Operative Risk Evaluation II incorporates insulin-controlled diabetes whilst omitting tablet-controlled diabetes. Differences in adverse clinical outcomes following coronary artery bypass graft between these groups are poorly established. Therefore, a propensity matched comparison of short and longer term mortality and morbidity in insulin-controlled diabetes, tablet-controlled diabetes and non-diabetic patients was undertaken. METHODS: Isolated first-time coronary artery bypass graft surgeries between April 1999 and April 2017 were propensity score matched by pre- and intra-operative variables. RESULTS: 8241 patients; 23.5% diabetics and 76.5% non-diabetics. The groups' demographical and clinical characteristics were comparable after matching. Insulin-controlled diabetes patients had significantly higher in-hospital mortality (3.8% vs. 1.7%, p < 0.05), multisystem failure (2.6% vs. 1.8%, p < 0.05), sternal wound infections requiring debridement (3.6% vs. 1.3%, p < 0.05), respiratory complications (25.6% vs. 21.9%, p < 0.05), new dialysis (4.7% vs. 0.9%, p < 0.05) and longer hospital stays (13.5 ± 13.3 vs. 10.6 ± 8.0, p < 0.05) compared to non-diabetic patients.Tablet-controlled diabetes patients had significantly higher strokes (2.9% vs. 1.2, p < 0.05), superficial sternal wound infections (6.7% vs. 5.4%, p < 0.05), respiratory complications (25.7% vs. 22.7%, p < 0.05), new dialysis (1.7% vs. 0.6%, p < 0.05), post-operative atrial fibrillation (37.1% vs. 33.9%, p < 0.05) and readmission with myocardial infarction (22.4% vs. 19.6%, p < 0.05) compared to non-diabetic patients. CONCLUSION: Diabetic treatment sub-groups are an independent risk factor for sternal wound infection, new dialysis requirement, multisystem failure and readmission with myocardial infarction after isolated first coronary artery bypass graft surgery. The findings suggest the need for better risk stratification of diabetic groups prior to cardiac surgery and for improved cardiovascular risk management post-surgery in tablet-controlled diabetes patients.

Challenges and satisfaction in Cardiothoracic Surgery Residency Programmes: insights from a Europe-wide survey.

OBJECTIVES: The increasing complexity of surgical patients and working time constraints represent challenges for training. In this study, the European Association for Cardio-Thoracic Surgery Residents' Committee aimed to evaluate satisfaction with current training programmes across Europe. METHODS: We conducted an online survey between October 2018 and April 2019, completed by a total of 219 participants from 24 countries. RESULTS: The average respondent was in the fourth or fifth year of training, mostly on a cardiac surgery pathway. Most trainees follow a 5-6-year programme, with a compulsory final certification exam, but no regular skills evaluation. Only a minority are expected to take the examination by the European Board of Cardiothoracic Surgery. Participants work on average 61.0 ± 13.1 h per week, including 27.1 ± 20.2 on-call. In total, only 19.7% confirmed the implementation of the European Working Time Directive, with 42.0% being unaware that European regulations existed. Having designated time for research was reported by 13.0%, despite 47.0% having a postgraduate degree. On average, respondents rated their satisfaction 7.9 out of 10, although 56.2% of participants were not satisfied with their training opportunities. We found an association between trainee satisfaction and regular skills evaluation, first operator experience and protected research time. CONCLUSIONS: On average, residents are satisfied with their training, despite significant disparities in the quality and structure of cardiothoracic surgery training across Europe. Areas for potential improvement include increasing structured feedback, research time integration and better working hours compliance. The development of European guidelines on training standards may support this.

Validation of Cardiac Surgery Score (CASUS) in Postoperative Cardiac Patients.

Introduction. Cardiac Surgery Score (CASUS) was introduced in 2005 as the first postoperative scoring system specific for patients who had cardiac surgery. Prior to this, European System for Cardiac Operative Risk Evaluation (EuroSCORE) has been used preoperatively, while Intensive Care National Audit and Research Centre Score (ICNARC) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, which are widely used in general intensive care unit population, have been used to score cardiac patients postoperatively. The development of CASUS by Hekmat and colleagues for use in postoperative cardiac patients aims to change this. We wanted to validate CASUS against the well-established preoperative Logistic EuroSCORE, and postoperative APACHE II and ICNARC scores. Method. Institutional approval for this study was granted by the Audit and Clinical Governance Committee. We analyzed prospectively collected data of patients who had cardiac surgery in Castle Hill Hospital between January 2016 and September 2018. All patients who underwent surgery in the unit would have had Logistic EuroSCORE, APACHE, and ICNARC scores calculated as standard. CASUS was then calculated for these patients based on their day 1 postoperative variables. The scoring systems were compared and data presented as area under the receiver operating characteristic curve. Result. Our study shows that CASUS is the best predictor of mortality followed by ICNARC, Logistic EuroSCORE, and APACHE II. ICNARC score remains the most accurate predictor of renal and pulmonary complication followed by CASUS. Conclusion. CASUS is a useful scoring system in post-cardiac surgery patients. The accuracy of CASUS and ICNARC scores in predicting mortality, pulmonary, and renal complications are comparable.

Intermittent Cross-Clamp Fibrillation Versus Cardioplegic Arrest During Coronary Surgery in 6,680 Patients: A Contemporary Review of an Historical Technique.

OBJECTIVE: Myocardial management during on-pump coronary artery bypass grafting (CABG) surgery includes aortic cross-clamping followed by fibrillation (XCF) and aortic cross-clamping followed by diastolic cardioplegia (cardioplegia). The authors wished to compare in-hospital and survival outcomes between these procedures. DESIGN: A retrospective observational study utilizing propensity matching. SETTING: Tertiary Referral Centre for Heart Surgery. PARTICIPANTS: A total of 8,875 consecutive patients undergoing CABG surgery between August 1999 and February 2018. INTERVENTIONS: After 1:1 matching, the authors had 3,340 patients in the cardioplegia group and 3,340 in the XCF group. MEASUREMENTS AND MAIN RESULTS: Baseline characteristics were not significant between the matched cardioplegia and XCF groups. The XCF group had shorter pump times (61.8 minutes +/-26.8 v 74.7 minutes +/-29.5, p < 0.0001) and shorter cross-clamp times (27.80 minutes +/-10.5 v 44.44 minutes +/-18.0, p < 0.0001) compared with the cardioplegia group despite a similar median number of distal anastomoses (3 v 3, p = 0.08). After surgery, atrial arrhythmias (32% v 36%, p = 0.01) and inotropic requirement (25% v 28%, p = 0.006) were less in the XCF group compared with the cardioplegia group, respectively. Other postoperative outcomes (such as mortality and cerebrovascular events) were not statistically different. There was a mean survival advantage in using cardioplegia compared with XCF (15.4 years versus 14.7 years, log-rank, p = 0.014; 10-year survival 64% v 61% and 18-year survival 38% v 34%). CONCLUSION: This is the largest analysis of XCF. XCF does not adversely affect in-hospital outcomes. Long-term results demonstrate cardioplegic arrest may convey a survival advantage that would preclude routine XCF in the modern era.

Prediction of Postoperative Outcomes and Long-Term Survival in Cardiac Surgical Patients Using the Intensive Care National Audit & Research Centre Score.

OBJECTIVES: Scoring systems used in cardiac surgery, such as the European System for Cardiac Operative Risk Evaluation and the Society of Thoracic Surgeons scoring systems, do not adjust for events that take place intraoperatively. The authors hypothesized that intensive care unit scoring systems such as the Intensive Care National Audit & Research Centre (ICNARC) could predict accurately not only in-hospital mortality, but also other significant complications, as well as long-term survival after cardiac surgery. DESIGN: Prospective cohort study using perioperative data from the ICNARC Audit and Dendrite database. SETTING: Single tertiary referral cardiac surgery center. PARTICIPANTS: A total of 4,446 consecutive cardiac surgical patients who had surgery between January 2011 and April 2018. INTERVENTIONS: Comparison of scoring systems to predict postoperative outcomes. MEASUREMENTS AND RESULTS: Receiver operating curves (ROCs) were used to evaluate how well the ICNARC scores predicted in-hospital mortality and postoperative complications (renal failure, pulmonary complications, gastrointestinal complications, and multiorgan failure). Cox regression analysis was used to determine factors affecting long-term survival. The C-indices for the ROC graphs for the ICNARC score were 0.840 for in-hospital mortality, 0.858 for renal failure, 0.665 for pulmonary complications, 0.764 for gastrointestinal complications, 0.702 for neurological complications in general and 0.654 for confusion, and 0.885 for multiorgan failure. From Cox regression analysis, the significant (p < 0.05) predictors of midterm mortality (5 years) were a higher ICNARC score, a higher age at surgery, chronic obstructive pulmonary disease, preoperative renal failure, preoperative neurological comorbidity, arteriopathy, and non-coronary artery bypass graft surgery. CONCLUSION: The ICNARC scoring system is simple and can be used as an early warning screening tool to predict which patients are at higher risk for postoperative organ failure.

Mini-extracorporeal circulation technology, conventional bypass and prime displacement in isolated coronary and aortic valve surgery: a propensity-matched in-hospital and survival analysis.

OBJECTIVES: Conventional cardiopulmonary bypass is the most commonly used means of artificial circulation in cardiac surgery. However, it suffers from the effects of haemodilution and activation of inflammatory/coagulation cascades. Prime displacement (PD) can offset haemodilution and mini-extracorporeal technology (MIECT) can offset both. So far, no study has compared all of these modalities together; hence, we compared the outcomes of these 3 modalities at our institution. METHODS: This was a retrospective analysis of our cardiac surgical database. A total of 9626 patients underwent conventional bypass (CB), 3125 patients underwent a modification of CB, called PD, and 904 underwent MIECT. A 1:1 propensity-matching algorithm was employed using IBM SPSS 24 to match (i) 813 MIECT patients with 813 CB patients and (ii) 717 MIECT patients with 717 PD patients. The patients included coronary artery bypass grafting and valve surgery. RESULTS: MIECT had significantly (P < 0.05) longer bypass and cross-clamp times compared to CB and PD. MIECT had significantly higher rates of postoperative atrial fibrillation associated with it compared to CB. The mean red cell blood transfusion was significantly lower in the MIECT group compared to the CB group as was the mean platelet transfusion and fresh frozen plasma transfusion. The overall 5-year survival was higher in the MIECT group compared to the CB group (log-rank, P = 0.018). Between the MIECT and the PD groups, we found the incidence of renal failure and gastrointestinal complications to be significantly higher in the PD group compared to the MIECT group. CONCLUSIONS: MIECT has short-term advantages over CB and PD. However, due to the retrospective limitations of the study, including calendar time bias, a multicentre randomized controlled trial comparing all 3 modalities will be beneficial for the larger cardiac community.

Is preoperative hypercapnia a justified exclusion criterion for lung volume reduction surgery?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether potential surgical candidates for lung volume reduction surgery (LVRS), who have preoperative hypercapnia, should be excluded on this basis. Using the reported search, 45 papers were found, of which 14 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. Of these, seven papers showed a significant (P < 0.05) improvement in postoperative forced expiratory volume in 1 second (FEV1) at up to 6 months in hypercapnic patients. There were six papers which found significant decreases in postoperative arterial carbon dioxide partial pressures (PaCO2) levels following LVRS up to 6 months. There were three papers which showed significant (P < 0.05) improvements in the 6-min walk test in hypercapnic patients following LVRS. Only two papers showed an increased operative mortality in the hypercapnic group compared to the normocapnic group, while nine papers did not find a difference in perioperative mortality. The only randomized controlled study, the landmark NETT study, excluded patients with severe hypercapnia (PaCO2 >55 mmHg and >60 mmHg) and the mean PaCO2 in the surgical and medical group were 43.3 ± 5.9 and 43.0 ± 5.8, respectively. We conclude that the evidence is not strong enough to consider hypercapnia in isolation as high risk or unsuitable for LVRS.

Multicentre, propensity-matched study to evaluate long-term impact of implantation technique in isolated aortic valve replacement on mortality and incidence of redo surgery.

OBJECTIVES: Studies suggest that the use of semicontinuous suture (SC) technique increases the risk of redo valve surgery after aortic valve replacement (AVR). The objective of this study was to identify 30-day mortality, rate of redo operation and long-term outcomes after AVR using either a semicontinuous suture or interrupted suture (IS) technique. METHODS: A total of 1617 patients from 2 cardiothoracic centres, undergoing isolated AVR between April 2005 and August 2013 were included. AVR was performed using SC technique in 765 patients and IS technique in 852 patients. Data were collected prospectively and follow-up was obtained to date for all patients. We compared 30-day mortality, rate of redo operation and long-term mortality in SC and IS groups. One-to-one propensity-matching analysis was performed using IBM SPSS version 22 to evaluate outcomes. RESULTS: Four hundred and eleven patients in the SC group were matched to 411 patients in the IS group (total of 822 patients) using propensity-score matching. The baseline characteristics were similar between SC and IS groups after matching. There were no statistically significant differences in 30-day mortality (3.9 vs 2.7%; P = 0.328), long-term mortality at 9-year follow-up (14.4 vs 15.3%; log-rank = 0.524) or rate of redo surgery (2.9 vs 2.0%; P = 0.320) between SC and IS, respectively. However, shorter cross-clamp time (51.9 ± 15.2 vs 60.9 ± 17.6 min; P < 0.001), bypass time (71.3 ± 23.0 vs 81.3 ± 37.8 min; P < 0.001) and the use of larger valve sizes (23.4 ± 2.1 vs 21.9 ± 2.2 mm; P < 0.001) were observed in SC patients compared with IS patients. Multivariate analysis did not show the suture technique as a significant determinant of redo valve surgery. CONCLUSIONS: This multicentre study demonstrates that neither mortality nor the risk of redo surgery was influenced by the choice of implantation technique using semicontinuous vs interrupted suture techniques. The SC technique allowed shorter operations and larger size valves to be utilized.

Long-term prognosis and a prediction model for acute bowel ischaemia following cardiac surgery.

OBJECTIVES: Bowel ischaemia following cardiac surgery is associated with a high postoperative mortality. No scoring system exists as yet to predict this complication following surgery. In addition, the long-term survival is not known. We sought to evaluate in-hospital outcomes and long-term outcomes in bowel ischaemia following cardiac surgery. We also sought to devise a simple risk prediction model for this catastrophic entity. METHODS: This was a retrospective study of data entered prospectively into our cardiac surgical database between July 1999 and May 2014. We compared the short- and long-term outcomes of patients who developed bowel ischaemia following cardiac surgery with those who did not develop bowel ischaemia using propensity-matched analysis. We developed a prediction model for bowel ischaemia from logistic regression. RESULTS: In total, 13 853 patients underwent cardiac surgery. Of these, 85 had confirmed bowel ischaemia following surgery. The in-hospital mortality rate for those with bowel ischaemia was 60%, while in those without bowel ischaemia, the mortality rate was 3% (P < 0.0001). In those bowel ischaemia patients who had a laparotomy for corrective surgery, the in-hospital mortality was significantly less compared with those who did not have a laparotomy (39.2 vs 91.2%, P < 0.0001). The long-term survival for bowel ischaemia at 2, 6 and 10 years was 35% (±5), 31% (±5) and 26% (+/6), respectively. Multivariable analysis revealed that advanced age at surgery, peripheral vascular disease, intra-aortic balloon pump usage, NYHA IV and postoperative atrial fibrillation were the significant (P < 0.005) determinants of developing postoperative bowel ischaemia. We developed a model to predict bowel ischaemia and validated it within our population (c-index = 0.781). CONCLUSIONS: We have shown that whilst bowel ischaemia carries a higher short-term mortality, the long-term mortality is not significantly greater for those few who survive to discharge. We have developed a simple prediction model to identify those at high risk of developing bowel ischaemia following cardiac surgery in order to optimize perioperative strategies in future.

Minimally invasive aortic valve replacement: Comparison of long-term outcomes.

BACKGROUND: Minimally invasive aortic valve replacement tends to be performed in specialist centers. Little data exists with regard to long-term outcomes of the upper hemi-sternotomy technique. We sought to evaluate the short- and long-term outcomes of this procedure in our institution. METHODS: Data were collected from our cardiac surgical database. We compared the outcomes of all patients who underwent minimally invasive aortic valve replacement with all who underwent conventional aortic valve replacement between July 1999 and December 2013. Propensity-matching analysis was performed to evaluate hospital outcomes. RESULTS: There were 125 patients who underwent minimally invasive aortic valve replacement and 1446 who had conventional surgery. After propensity score matching, there were no differences in postoperative mortality or complications between the 2 groups. The only significant differences were longer bypass (62.69 ± 10.12 vs. 68.94 ± 14.79 min, p = 0.002) and crossclamp times (45.48 ± 8.08 vs. 52.30 ± 16.29 min, p < 0.001) in conventional surgery. Long-term survival after minimally invasive aortic valve replacement at 2, 6, and 10 years was 88% ± 3.0%, 79% ± 4.0%, and 66% ± 6.0%, respectively. Predictors of long-term survival were age, peripheral vascular disease, and low ejection fraction (p < 0.005). CONCLUSION: Minimally invasive aortic valve replacement has similar hospital outcomes compared to conventional aortic valve replacement. The operation is quicker and does not confer any significant increase in complications or length of hospital stay. The long-term outcomes are favorable and justify its continued use by specialist surgeons in the United Kingdom.

Validation of the Intensive Care National Audit and Research Centre Scoring System in a UK Adult Cardiac Surgery Population.

OBJECTIVE: The Intensive Care National Audit and Research Centre (ICNARC) scoring system was conceived in 2007, utilizing 12 physiologic variables taken from the first 24 hours of adult admissions to the general intensive care unit (ICU) to predict in-hospital mortality. The authors aimed to evaluate the ICNARC score in predicting mortality in cardiac surgical patients compared to established cardiac risk models such as logistic EuroSCORE as well as to the Acute Physiology and Chronic Health Evaluation (APACHE) II. DESIGN: Retrospective analysis of data collected prospectively. SETTING: Single-center study in a cardiac intensive care in a regional cardiothoracic center. PARTICIPANTS: Patients undergoing cardiac surgery between January 2010 and June 2012. METHODS: A total of 1,646 patients were scored preoperatively using the logistic EuroSCORE and postoperatively using ICNARC and APACHE II. Data for comparison of scoring systems are presented as area under the receiver operating characteristic curve. MEASUREMENTS AND MAIN RESULTS: The mean age at surgery was 67 years±10.1. The mortality from all cardiac surgery was 3.2%. The mean logistic EuroSCORE was 7.31±10.13, the mean ICNARC score was 13.42±5.055, while the mean APACHE II score was 6.32±7.731. The c-indices for logistic EuroSCORE, ICNARC, and APACHE II were 0.801, 0.847 and 0.648, respectively. CONCLUSION: The authors have, for the first time, validated the ICNARC score as a useful predictor of postoperative mortality in adult cardiac surgical patients. This could have implications for postoperative management, focusing the utilization of resources as well as a method to measure and compare performance in the cardiothoracic ICU.

Thoracoscore and European Society Objective Score Fail to Predict Mortality in the UK.

BACKGROUND: Thoracoscore and the European Society Objective Score (ESOS.01) are two scoring systems used in thoracic surgery to estimate operative mortality risk. We aimed to evaluate if these are valid tools for use in the UK population. METHODS: A multi-center, prospective study was carried out on patients undergoing lung resection at six UK centers. Data were submitted electronically using our online data collection tool. Data were analyzed to determine the factors affecting mortality. A receiver operating characteristic analysis determined the ability of the thoracoscore and ESOS.01 to predict in-hospital mortality. RESULTS: Data were complete for 2,245 patients. The observed in-hospital mortality was 31 patients (1.38%). Mean thoracoscore was 2.66 (SD ± 3.21). Gender (P = 0.004, hazard ratio 4.786) and co-morbidity score (P = 0.005, hazard ratio 3.289) were identified as risk factors for mortality. A sub-analysis was performed using data from 1,912 patients with complete data for ESOS.01. In this group, mean thoracoscore was 2.55 (SD ± 2.94), mean ESOS.01 was 2.11(SD ± 1.41), and these were statistically significantly different (P < 0.0001). The observed in-hospital mortality was 28 patients (1.46%). The c-index for thoracoscore was 0.705, and for ESOS.01 was 0.739. CONCLUSIONS: Both thoracoscore and ESOS.01 overestimated mortality in the UK population. There is a continued need to develop an appropriate risk prediction system for the UK.

Test performance of PET-CT for mediastinal lymph node staging of pulmonary carcinoid tumours.

Positron emission tomography-CT (PET-CT) is one of the initial mediastinal staging modality for non-small cell lung cancer; however, the clinical utility in carcinoid tumours is uncertain. We sought to determine the test performance of PET-CT for mediastinal lymph node staging of pulmonary carcinoid tumours. We collated data from seven institutions, performing a retrospective search on pathological databases for a consecutive series of patients who underwent thoracic surgery (with lymph nodal dissection) for carcinoid tumours with preoperative PET-CT staging. PET-CT results were compared with the reference standard of pathologic results obtained from lymph node dissection and test performance reported using sensitivity and specificity. From November 1999 to January 2013, 247 patients from seven institutions underwent surgery for carcinoid tumours with a corresponding preoperative PET-CT scan. The mean age of the patients was 61 (SD 15, range 73) and 84 were male patients (34%). The pathologic subtype was typical carcinoid in 217 patients (88%) and atypical carcinoid in 30 patients (12%). Results from lymph node dissection were obtained in 207 patients. The calculated sensitivity and specificity of PET-CT to identify mediastinal lymph node disease was 33% (95% CI 4% to 78%) and 94% (95% CI 89% to 97%), respectively. Our results indicate that PET-CT has a poor sensitivity but good specificity to detect the presence of mediastinal lymph node metastases in pulmonary carcinoid tumours. Mediastinal lymph node metastases cannot be ruled out with negative PET-CT uptake, and if the absence of mediastinal lymph node disease is a prerequisite for directing management, tissue sampling should be undertaken.