Surgical aortic valve replacement in the era of transcatheter aortic valve implantation: a review of the UK national database.

OBJECTIVES: To date the reported outcomes of surgical aortic valve replacement (SAVR) are mainly in the settings of trials comparing it with evolving transcatheter aortic valve implantation. We set out to examine characteristics and outcomes in people who underwent SAVR reflecting a national cohort and therefore 'real-world' practice. DESIGN: Retrospective analysis of prospectively collected data of consecutive people who underwent SAVR with or without coronary artery bypass graft (CABG) surgery between April 2013 and March 2018 in the UK. This included elective, urgent and emergency operations. Participants' demographics, preoperative risk factors, operative data, in-hospital mortality, postoperative complications and effect of the addition of CABG to SAVR were analysed. SETTING: 27 (90%) tertiary cardiac surgical centres in the UK submitted their data for analysis. PARTICIPANTS: 31 277 people with AVR were identified. 19 670 (62.9%) had only SAVR and 11 607 (37.1%) had AVR+CABG. RESULTS: In-hospital mortality for isolated SAVR was 1.9% (95% CI 1.6% to 2.1%) and was 2.4% for AVR+CABG. Mortality by age category for SAVR only were: <60 years=2.0%, 60-75 years=1.5%, >75 years=2.2%. For SAVR+CABG these were; 2.2%, 1.8% and 3.1%. For different categories of EuroSCORE, mortality for SAVR in low risk people was 1.3%, in intermediate risk 1% and for high risk 3.9%. 74.3% of the operations were elective, 24% urgent and 1.7% emergency/salvage. The incidences of resternotomy for bleeding and stroke were 3.9% and 1.1%, respectively. Multivariable analyses provided no evidence that concomitant CABG influenced outcome. However, urgency of the operation, poor ventricular function, higher EuroSCORE and longer cross clamp and cardiopulmonary bypass times adversely affected outcomes. CONCLUSIONS: Surgical SAVR±CABG has low mortality risk and a low level of complications in the UK in people of all ages and risk factors. These results should inform consideration of treatment options in people with aortic valve disease.

The risk and outcomes of reoperative tricuspid valve surgery.

BACKGROUND: Outcomes after tricuspid valve reoperation have not been published before. This study examines our 32-year experience in this cohort of patients. METHODS: Between May 1979 and January 2011, a total of 68 patients who had previous tricuspid valve surgery (49 repairs and 19 replacements) had reoperations on their tricuspid valves. The median age was 60 years (19 to 75). Redo tricuspid valve pathologies included 18 functional and 50 organic. Follow-up was 100% complete, with a mean follow-up of 87 months (5 to 248). RESULTS: Re-repair of the tricuspid valve was feasible in 26 patients (16 of 18 [89%] functional and 10 of 31 [32%] organic, p < 0.001). In-hospital mortality was 13.2%. Factors related to early mortality were nonelective surgery, New York Heart Association (NYHA) functional class III/IV, left ventricle ejection fraction less than 0.40, cardiopulmonary bypass time greater than 136 minutes, and postoperative low cardiac output syndrome (p < 0.05). Postoperative complications included 9 reoperations for bleeding, 11 postoperative low cardiac output syndrome, 5 renal failure requiring dialysis, 3 strokes, and 13 pacemaker implantation. Factors related to late mortality were age greater than 60 years, male sex, ventilation time greater than 24 hours, cardiopulmonary bypass time greater than 136 minutes, and postoperative low cardiac output syndrome (p < 0.05). Survivors had 5-, 10-, and 15-year survival rates of 86%, 64%, and 33%, respectively. Functional class improved in hospital survivors; NYHA class I/II 80.6% compared with preoperative NYHA class III/IV of 90% (p = 0.001). CONCLUSIONS: Redo tricuspid valve surgery is associated with high operative mortality and morbidity; however, survivors benefited from reasonable survival rates. Re-repair of the tricuspid valve is feasible in the majority of patients with functional tricuspid valve pathology, while the majority of patients with underlying organic pathology required a valve replacement.

Concomitant mitral valve surgery in patients undergoing surgical ventricular reconstruction for ischaemic cardiomyopathy.

OBJECTIVES: Ischaemic mitral valve regurgitation is associated with a significant reduction in survival and its treatment in patients undergoing surgical ventricular reconstruction is usually associated with higher perioperative morbidity and mortality. We evaluated our 11-year experience in this cohort of patients. METHODS: Between January 2000 and December 2010, a total of 282 patients underwent surgical ventricular reconstruction, of which 45 (16%) had concomitant mitral valve surgery. The data was retrospectively analyzed to identify variables that could predict early mortality. RESULTS: Overall in-hospital mortality was 6.4% (n = 18), of which 5.1% (n = 12) occurred in patients undergoing surgical ventricular reconstruction and 13.3% (n = 6) in patients undergoing surgical ventricular reconstruction + mitral valve surgery (P = 0.05). Patients undergoing surgical ventricular reconstruction + mitral valve surgery had poorer LV function (P < 0.01) and advanced NYHA class IV symptoms (P = 0.02) compared with patients undergoing surgical ventricular reconstruction. These patients had a higher requirement for postoperative inotropic (P < 0.01) and IABP support (P < 0.01) and were more likely to suffer from low cardiac output syndrome (P < 0.01). In patients undergoing surgical ventricular reconstruction + mitral valve surgery, 34 patients had mitral valve repair and 11 patients had mitral valve replacement. The mortality was 17.6% (n = 6) vs 0% (P = 0.31) in the mitral valve repair vs mitral valve replacement groups, respectively. The cohort of patients undergoing surgical ventricular reconstruction + mitral valve repair had poorer LV function and more advanced symptoms. CONCLUSIONS: Patients undergoing surgical ventricular reconstruction have excellent early outcomes. However, there are patients that are at an increased operative risk, such as those with concomitant ischaemic mitral regurgitation that might be better served with other surgical modalities, such as ventricular assist device or heart transplantation. The suggested algorithm based on current evidence provides a stepwise approach when dealing with patients with ischaemic mitral regurgitation ± left ventricular remodelling.

Systolic anterior motion of mitral valve with calcified annulus in octogenarians.

Systolic anterior motion of the mitral leaflet causing left ventricular outflow tract obstruction is commonly seen in hypertrophic cardiomyopathy and also in patients with advanced mitral valve disease with excessive anterior leaflet tissue or a reduced aortic-mitral angle. We describe 2 octogenarians who presented with systolic mitral leaflet anterior motion in advanced mitral valve disease with severe mitral annular calcification and associated asymmetrical septal hypertrophy.

Left apical pedunculated thrombus with normal ventricular function mimicking an intracardiac tumor.

Left ventricular thrombus formation in the presence of normal ventricular function is a rare phenomenon, with only seven cases described in the literature. Their morbidity arises from the embolic sequelae that ensues. The management of these patients is complex, and requires the decision-making process of both the medical and surgical teams.

Does pre-operative estimation of oesophageal tumour metabolic length using 18F-fluorodeoxyglucose PET/CT images compare with surgical pathology length?

PURPOSE: The aim of the study was to compare the pre-operative metabolic tumour length on FDG PET/CT with the resected pathological specimen in patients with oesophageal cancer. METHODS: All patients diagnosed with oesophageal carcinoma who had undergone staging PET/CT imaging between the period of June 2002 and May 2008 who were then suitable for curative surgery, either with or without neo-adjuvant chemotherapy, were included in this study. Metabolic tumour length was assessed using both visual analysis and a maximum standardised uptake value (SUV(max)) cutoff of 2.5. RESULTS: Thirty-nine patients proceeded directly to curative surgical resection, whereas 48 patients received neo-adjuvant chemotherapy, followed by curative surgery. The 95% limits of agreement in the surgical arm were more accurate when the metabolic tumour length was visually assessed with a mean difference of -0.05 cm (SD 2.16 cm) compared to a mean difference of +2.42 cm (SD 3.46 cm) when assessed with an SUV(max) cutoff of 2.5. In the neo-adjuvant group, the 95% limits of agreement were once again more accurate when assessed visually with a mean difference of -0.6 cm (SD 1.84 cm) compared to a mean difference of +1.58 cm (SD 3.1 cm) when assessed with an SUV(max) cutoff of 2.5. CONCLUSION: This study confirms the high accuracy of PET/CT in measuring gross target volume (GTV) length. A visual method for GTV length measurement was demonstrated to be superior and more accurate than when using an SUV(max) cutoff of 2.5. This has the potential of reducing the planning target volume with dose escalation to the tumour with a corresponding reduction in normal tissue complication probability.

Transcaval migration of an acupuncture needle from the abdominal cavity to the heart.

We report the case of a patient who was noted to have inserted an acupuncture needle into his abdomen. The needle migrated to the heart and was removed from the right ventricle using cardiopulmonary bypass.

Have improvements in myocardial protection influenced a surgeon's choice of coronary artery bypass surgery?

The aim of this study is to determine whether improvements in myocardial protection strategy have influenced the surgeon's choice of coronary artery bypass surgery. Between February 2002 and April 2009, a total of 662 patients underwent coronary artery bypass surgery under the provision of a single consultant surgeon. Operative mortality was defined as in-hospital death and comparison was made based on both the observed and expected mortalities as derived from the logistic EuroSCORE. Of the 662 patients who underwent cardiac surgery, 155 had off-pump whilst 507 had conventional coronary artery bypass surgery. The observed mortalities improved over the years in line with the improvements in myocardial protection strategy despite the increasing risk as predicted by the logistic EuroSCORE, with a reduction in the ratio of observed to expected mortalities of 1.2 in the off-pump group to 0.4 in the conventional group who had better myocardial protection. This has lead to a change in practice being predominantly off-pump at the beginning to that of conventional surgery in the later part of the study. As the case mix of patients gets worse with the increasing severity of multi-vessel disease and poor ventricular function, myocardial protection becomes crucial to the surgeon's preoperative assessment.

A surgeon's case volume of oesophagectomy for cancer does not influence patient outcome in a high volume hospital.

The aim of this study is to assess if individual case volume of oesophageal resections influences the operative mortality rate in a high volume hospital. Between June 1994 and June 2006, 252 total thoracic oesophageal resections (75% male, mean age 63 years) were performed by five surgeons in tertiary referral centre. Operative approach was standardised in all cases and consisted of left thoracolaparotomy, resection of all intrathoracic and abdominal oesophagus and left cervical incision for anastomosis. Operative mortality, defined as in-hospital death irrespective of length of stay, was compared among consultants and also trainees. A total of 207 operations were performed by five consultants with nine deaths (4.3%) compared to two deaths after 45 operations by 17 trainees (4.4%) [Fisher's exact test, P=0.61 (CI=0.84-1.26)]. Individual case volume for consultants ranged from 5 to 10.5 cases/years [chi2-test, P=0.34 (CI=0.89-1.29)] with 0-5.4% mortality rate [chi2-test, P=0.24 (CI=0.96-1.19)]. Overall hospital volume ranged from 17 to 57 cases/years. This study confirms that surgeons with appropriate training in oesophageal resection may get good results despite lower individual case volumes when a standardised approach is taken in an institution with a high case volume.

Bilateral thoracoscopic sympathectomy: results and long-term follow-up.

The aim of this study is to evaluate the efficacy of bilateral thoracoscopic sympathectomy in alleviating symptoms and improving quality of life in patients with hyperhidrosis or facial blushing and to investigate the occurrence, severity and possible underlying factors to compensatory sweating after surgery. One hundred and sixty-three patients in a single institution underwent bilateral thoracoscopic sympathectomy with a mean follow-up period of 51 (5-140) months. Indications were for palmar hyperhidrosis (41%), axillary hyperhidrosis (17%), combined palmar and axillary hyperhidrosis (27%) and facial blushing+/-facial hyperhidrosis (15%). Success rates were palmar 98.5%, axillary 96.4%, palmar and axillary 97.7% and facial blushing+/-facial hyperhidrosis 84%. Compensatory sweating occurred in 77% of patients and its severity was related to the severity of the primary complaint. Recurrence rates were palmar 4.6%, axillary 7.4%, palmar and axillary 9.3% and facial blushing+/-facial hyperhidrosis 4.7% at a mean of 22 (3-72) months. An improvement in quality of life was seen in 85% and a diminution of quality of life was noted in 5% due to compensatory sweating. This large mature series demonstrates that bilateral thoracoscopic division of the sympathetic chain as opposed to resection can be performed effectively in patients with success rates higher than 90% and low recurrence rates.

Traumatic left anterior descending artery-to-pulmonary artery fistula with delayed pericardial tamponade.

Traumatic coronary artery fistulas are rare, but 80% are secondary to penetrating injuries. Although the left coronary artery is involved in 46% of cases, these are usually associated with fistulas to the right ventricle. We describe a successful repair of a traumatic fistula from the proximal left anterior descending artery to the pulmonary artery after delayed presentation.

Primary mediastinal synovial sarcoma.

Synovial sarcoma occurs predominantly in the soft tissues of the extremities, but is exceedingly rare in the mediastinum. It has overlapping histological and immunophenotypic features with other tumours in the differential diagnosis. We report a case of a patient who had an incidental finding of such a tumour. Because of the rarity of this tumour in the mediastinum, optimal therapy is unknown and the prognosis remains guarded.

Treatment of a persistent false lumen with aneurysm formation following surgical repair of type a dissection.

We describe the case of a 68-year-old man who developed aneurysmal dilatation of the proximal descending thoracic aorta 8 years after repair of a type A dissection. The aneurysm was due to an anastomotic leak at the distal end of the previous repair in the ascending aorta with antegrade perfusion of the false lumen. Surgical repair of the anastomotic leak partially obliterated the false lumen and computed tomography scan demonstrated thrombosis in a large proportion of the false lumen aneurysm. Follow-up with surveillance scans showed persistent filling of this aneurysm due to retrograde flow of blood within the false lumen. Coil embolization of the false lumen within the thoracic aorta was performed which successfully thrombosed the aneurysm with a reduction in diameter. Late aneurysm formation may complicate type A dissection repairs during follow-up due to a persistent false lumen, especially if there is an anastomotic leak. This case report describes a strategy to deal with this difficult clinical problem.

Spontaneous aortic dissection in a 14-year-old adolescent.

We describe a case of a 14-year-old boy with a spontaneous aortic dissection. The diagnosis was suspected and confirmed with an urgent transthoracic echocardiogram and computer tomography (CT). He underwent an immediate surgery with tube graft replacement of the ascending aorta using a biological glue to reinforce the distal false lumen. Although the immediate postoperative course was uneventful, he continued to have a persistent distal false lumen, which was observed to be enlarging in size on close follow-up. Potential causes of this complication are discussed along with the various different etiologies for aortic dissection in this rare age group.