Circumferent dissection of the ascending aorta resulting in the occlusion of supra-aortic vessels repaired using the frozen elephant trunk technique - a case report.

BACKGROUND: Our patient presented with acute back pain and dyspnea, without neurological symptoms. The computed tomography (CT) scan showed a circumferent rupture of the ascending aortic intima which was invaginated in the arch and descending aorta. CASE PRESENTATION: A 54-year-old male patient was diagnosed with a Type A aortic dissection. He was immediately transferred to our operation room (OR) from the emergency department of a peripheral hospital. He presented with a circumferential dissection of the ascending aorta originating just distal to the coronary ostia, with the invaginated intimal mass extending through the arch down the descending aorta. In mild hypothermia, the intimal mass was safely extracted and a frozen elephant trunk (FET) procedure was performed. CONCLUSIONS: Despite the extensive dissection affecting the ascending aorta and aortic arch, resulting in partially occluded supra-aortic vessels by an intimal mass, the patient remained without neurological symptoms in the pre- and post-operative period and remains well one year post surgery.

David V procedure and hemiarch replacement in a patient with Loeys-Dietz-Syndrome and beta thalassemia minor: a case report.

We report the case of a 36-year-old European female patient presenting with a sinus valsalva aneurysm of 47 mm with moderate aortic regurgitation. Additionally, an aneurysm of the brachiocephalic trunk and multiple aneurysms of the right internal mammary artery were identified. Previous medical history included Loeys-Dietz syndrome (LDS) Type RII due to a TGF-beta receptor mutation, and beta thalassemia minor with a baseline hemoglobin of 9,3 g/dL on admission.Reconstruction of the aortic root and hemiarch replacement was performed in circulatory arrest under moderate hypothermia. During surgery, hypothermia was required as part of the cerebral protection strategy. We aim to highlight special considerations and discuss the effects of cooling, rewarming and the use of cardiopulmonary bypass (CPB) during extensive surgery in a patient with LDS and beta thalassemia minor.

Do older surgeons have safer hands? A retrospective cohort study.

BACKGROUND: For complex surgical procedures a volume-outcome relationship can often be demonstrated implicating multiple factors at a unit and surgeon specific level. This study aims to investigate this phenomenon in lung transplantation over a 30-year period with particular reference to surgeon age and experience, cumulative unit activity and time/day of transplant. METHODS: Prospective databases identified adult patients undergoing isolated lung transplantation at a single UK centre between June 1987 and October 2017. Mortality data was acquired from NHS Spine. Individual surgeon demographics were obtained from the General Medical Council. Student t-test, Pearson's Chi-squared, Logistic Regression, and Kaplan-Meier Survival analyses were performed using Analyse-it package for MicrosoftExcel and STATA/IC. RESULTS: 954 transplants (55.9% male, age 44.4 ± 13.8 years, 67.9% bilateral lung) were performed, with a median survival to follow-up of 4.37 years. There was no difference in survival by recipient gender (p = 0.661), between individual surgeons (p = 0.224), or between weekday/weekend procedures (p = 0.327). Increasing centre experience with lung transplantation (OR1.001, 95%CI: 1.000-1.001, p = 0.03) and successive calendar years (OR1.028, 95%CI: 1.005-1.052, p = 0.017) was associated with improved 5-year survival. Advancing surgeon age at the time of transplant (mean, 48.8 ± 6.6 years) was associated with improved 30-day survival (OR1.062, 95%CI: 1.019 to1.106, p = 0.003), which persisted 5 years post-transplant (OR1.043, 95%CI: 1.014-1.073, p = 0.003). Individual surgeon experience, measured by the number of previous lung transplants performed, showed a trend towards improved outcomes at 30 days (p = 0.0413) with no difference in 5-year survival (p = 0.192). CONCLUSIONS: Our study demonstrates a relationship between unit volume, increasing surgeon age and survival after lung transplantation. A transplant volume: outcome relationship was not seen for individual surgeons.

Radical Surgery for Recurrent Pulmonary Artery Sarcoma With 4-Year Survival.

Primary pulmonary artery sarcoma is a rare disease with poor prognosis. Radical resection provides the best curative chances. Our 60-year old male patient underwent pulmonary artery sarcoma excision with pericardial patch repair of the main pulmonary artery in 2017, but required reoperation in 2019 due to recurrence. Total pulmonary artery bifurcation replacement was performed using a handmade 2-limbed bovine pericardial tube graft. This technique is safe and reproducible, and may offer a valuable alternative surgical strategy for this patient cohort. Our patient is still alive 4 years after initial presentation.

The Importance of Culture Change Associated With Novel Surgical Approaches and Innovation: Does Perioperative Care Transcend Technical Considerations for Pulmonary Lobectomy?

Robotic thoracic surgery for pulmonary lobectomy was introduced at our unit in 2015, along with enhanced perioperative patient care pathways. We evaluated the effect of this practice change on short-term outcomes. Data on all adult patients who underwent a lobectomy in our unit between 2015 and 2019 were obtained retrospectively from our surgical database. Patients fell into three groups: conventional open surgery via thoracotomy, video-assisted thoracoscopic surgery (VATS), and robot-assisted thoracoscopic surgery (RATS). Survival was defined as survival to discharge. Our cohort included 722 patients. Three hundred and ninety-two patients (54.3%) underwent an open operation, 259 patients (35.9%) underwent VATS surgery, and 71 patients (9.8%) underwent a robotic procedure. Comparing these surgical approaches, there was no statistically significant difference in the overall incidence of post-operative complications (p = 0.15) as well as the incidence of wound infections, arrhythmias, prolonged air leaks, respiratory failure, or ICU readmissions. Additionally, there was no statistically significant difference in survival to discharge (p = 0.66). However, patients who had a VATS procedure were less likely to develop a post-operative chest infection (p = 0.01). Evaluating our practice over time, we found a decrease in the overall incidence of post-operative complications (p = 0.01) with an improvement in survival to discharge (p = 0.02). In our experience, VATS lobectomy was associated with a lower incidence of post-operative chest infections. However, the limitations of our study must be considered; factors such as patient selection that may have had a substantial impact. The culture change associated with adoption of a VATS and robotic surgical programme appears to have corresponded with an improved survival to discharge for all lobectomy patients, irrespective of surgical approach. Perioperative care may therefore have a more significant impact on outcomes than technical considerations.

Dissecting the Management and Outcomes of Thoracic Aortovascular Disease During the COVID-19 Pandemic.

OBJECTIVE: The COVID-19 pandemic has forced the cancellation of planned surgery and led to significant surgical service reductions. Early intervention in aortovascular disease is often critical and cannot be deferred despite these reductions. There is urgent need to evaluate the provision and outcomes of thoracic aortovascular intervention during the peak of the pandemic. METHODS: Prospective data was collected for patients receiving open and endovascular thoracic aortovascular intervention over two-time points; January-May 2020 and January-May 2019 at three tertiary cardiovascular centres. Baseline demographics, cardiovascular risk and COVID-19 screening results were noted. Primary outcomes were median length of intensive care unit and hospital stay, intra-operative mortality, 30-day mortality, post-operative stroke, and spinal cord injury. RESULTS: Patients operated in 2020 (41) had significantly higher median EuroSCORE II than 2019 (53) (7.44 vs. 5.86, P = 0.032) and rates of previous cardiac (19.5% vs. 3.8%, P = 0.019), aortic (14.6% vs. 1.9%, P = 0.041), and endovascular (22.0% vs. 3.8%, P = 0.009) intervention. There was an increase in proportion of urgent cases in 2020 (31.7% vs. 18.9%). There were no intra-operative deaths in 2020 and 1 in 2019 (P = 1.00). There were no significant differences (P ≥ 0.05) in 30-day mortality (4.9% vs. 13.2%), median intensive care unit length of stay (72 vs. 70 hr), median hospital length of stay (8 vs. 9 days), post-operative stroke (3 vs. 6), or spinal cord injury (2 vs. 1) between 2020 and 2019 respectively. CONCLUSIONS: Despite the increased mortality risk of patients and urgency of cases during COVID-19, complicated by the introduction of cohorting and screening regimens, thoracic aortovascular intervention remained safe with comparable in outcomes to pre-COVID-19.

Surgeon-Powered Robotics in Thoracic Surgery; An Era of Surgical Innovation and Its Benefits for the Patient and Beyond.

Following its introduction in 1992, the growth of minimally invasive thoracic surgery was initially hampered by the lack of specialized instruments, impeded visualization and stapling. However, in subsequent years these challenges were somewhat overcome and video-assisted thoracoscopic surgery (VATS) became the preferred modality of many centers. More recently, robotic surgery has come to the fore. Whilst it offers outstanding precision via robotic wristed instruments, robotic surgery is expensive and has safety implications as the surgeon is away from the patient's side. Wristed VATS instruments offer a new, exciting alternative. By placing the robotic-like wristed instruments in the hands of the surgeon, a concept we call surgeon-powered robotics, the benefits of robotic surgery can be achieved by the patient's side. We describe our experience of the ArtiSential® wristed instruments and discuss the benefits and challenges of this technology. By combining wristed instruments with the latest surgeon-controlled 3D camera technology, surgeon-powered robotics is an affordable reality.

Training cardiothoracic surgeons of the future: The UK experience.

OBJECTIVE: The study aimed to assess targeted simulation courses, including live animal operating, as complementary training tools with regard to 2 key surgical skills in early cardiothoracic surgeon training. METHODS: Twenty UK surgical trainees (equivalent to cardiothoracic surgery resident physicians in the United States) in their first year of residency training were evaluated. Assessment of skills in pulmonary wedge resection and cardiopulmonary bypass were undertaken before and after 2 boot camp-style courses, including live animal operating (boot camp 1 and boot camp 2). Resident performance was evaluated by surgical trainers using objective structured assessment of technical skills matrices. Trainers completed a survey on skill development and trainer confidence in the trainee precourse and postcourse. RESULTS: Trainee assessment scores pre- and postcourses were analyzed using a 2-tailed Wilcoxon signed-rank test demonstrating a significant improvement in trainee performance in boot camp 1 in performing cardiopulmonary bypass (median score, 21 precourse and 28 postcourse; P = .001) and pulmonary wedge resection (median score, 25 precourse and 32 postcourse; P = .012), and in boot camp 2, in performing cardiopulmonary bypass (median score, 28 precourse and 30.5 postcourse; P = .018) and pulmonary wedge resection (median score, 31.5 precourse and 37 postcourse; P = .018). Trainers reported increased confidence and decision-making competency of residents and increased confidence of trainers to allow more participation in management. It was found that 83.3% of trainers would support trainee attendance in subsequent years. CONCLUSIONS: Live animal operating as a component of targeted cardiothoracic surgery skill training courses significantly improves technical skills, builds confidence of surgical trainers in resident physicians' practice, and should be supported by the surgery community.

Accelerated acute severe antibody-mediated graft failure related to a Ross procedure 17 years earlier.

A 31-year-old male patient underwent a heart transplantation due to dilated cardiomyopathy. He experienced accelerated acute antibody-mediated rejection despite being negative for human leukocyte antigen antibodies (0% panel-reactive antibodies prior to surgery). Further assessment revealed a common antigen between a homograft implanted 17 years earlier during the Ross procedure and the heart donor. The homograft likely induced specific antibody formation. Interestingly, panel-reactive antibody levels measured 7 years prior to transplantation were 7%. Because of the long time span between the Ross procedure and heart transplantation, no circulating antibodies could be detected in 2015, but reactivation of memory cells might potentially have led to this fulminant rejection episode. For future cases, particular attention should be given to patients with homografts.

Replacement of a Stenotic Quadricuspid Aortic Valve With a Sutureless Prosthesis.

Quadricuspid aortic valve is a rare occurrence, usually presenting with insufficiency rather than stenosis. We report an aortic valve replacement in a septuagenarian with a stenotic quadricuspid aortic valve, achieving a good result with a Perceval (Sorin Biomedica Cardio Srl, Sallugia, Italy) sutureless bioprosthesis. We emphasize the particular technique of implantation and possible pitfalls. Sutureless bioprosthetic valves present a feasible option for aortic valve replacement in patients with uncommon valve morphologies, aiming to reduce operative time.

The recipient's heme oxygenase-1 promoter region polymorphism is associated with cardiac allograft vasculopathy.

Heme oxygenase-1 (HO-1) catalyses the degradation of heme to biliverdin, free iron, and carbon monoxide. The promoter region contains a highly polymorphic (GT)n repeat, where shorter (GT)n repeat sequences are linked to higher transcriptional activity, which was shown to correlate with a cytoprotective effect. Higher HO-1 levels may protect from cardiac allograft vasculopathy. Cardiac allograft recipients transplanted between 1988 and 2012 were analyzed for the HO-1 (GT)n repeat polymorphism using PCR and DNA fragment analysis with capillary electrophoresis. A relation to cardiac allograft vasculopathy (CAV) was analyzed using Cox regression including common risk factors for CAV and the occurrence of rejection episodes as explanatory variables. A total of 344 patients were analyzed, of which 127 patients were positive for CAV (36.9%). In our multivariable Cox regression analysis, the short homozygous HO-1 (GT)n genotype with <27 repeats (S/S) revealed a higher risk for CAV (P = 0.032). Donor age (P = 0.001) and donor weight (P = 0.005) were significant predictors for CAV. A potential risk for CAV was associated with rejection episodes (P = 0.058) and history of smoking (P = 0.06). The recipient HO-1 (GT)n genotype may contribute to CAV development. This finding has to be evaluated in larger series including studies targeting the underlying disease mechanism.