Inflammation in aortic surgery: postoperative evolution of biomarkers according pathologies and segments of the aorta.

OBJECTIVES: Aortic pathologies often present with elevated inflammatory biomarkers due to the nature of the disease. Open aortic surgery causes significant trauma to the body due to often mandatory ischemic periods, long cardiopulmonary bypass times and polytransfusion. We aim to determine postoperative trends on inflammation biomarkers for different aortic pathologies and type of surgery in different segments of the aorta. METHODS: Retrospective review of prospectively collected data of 193 consecutive patients who underwent aortic surgery in our centre between 2017 and 2021, grouped according to the type of aortic intervention: (1) Type A aortic dissection (AD) repair with ascending aorta/hemiarch replacement, (2) Aortic root replacement (ARR), (3) Aortic arch + Frozen elephant trunk (FET), (4) Descending thoracic aorta (DTA)/Thoraco-Abdominal aortic repair (TAA). Primary outcomes were daily values of white blood cells (WBC) and C-Reactive Protein (CRP) during the first 15 postoperative days. RESULTS: All groups had a similar inflammatory peak in the first 2-4 days (WBC 12-15 × 109 c/L). AD and FET groups show similar trends with WBC and CRP peaks on days 2 and 10. The ARR group didn't experience the 2nd peak as most patients were already discharged. DTA/TAA patients experienced a more prolonged inflammatory response, reaching a plateau by day 5-10. AD group shows the highest WBC levels and the DTA/TAAA group the highest CRP levels. CRP levels remain elevated (100-200 mg/L) in all groups after 15 postoperative days. CONCLUSIONS: Inflammatory biomarkers show different postoperative trends depending on the clinical presentation and complexity of the aortic procedure performed. Further understanding of the inflammatory response to different aortic pathologies and surgical procedures will permit reduction on the liberal use of antibiotics that this cohort of patients are usually exposed to. An earlier version of the data included in this manuscript was presented as Oral Abstract in the UK Society of Cardiothoracic Surgery Annual meeting in 2021.

Managing the Root in Acute Type A Aortic Dissections: Are We Ready for a Standardized Approach?

OBJECTIVES: Surgical repair of Type A aortic dissection (TAAD) requires exclusion of the primary entry tear and reestablishment of flow into the distal true lumen. Provided that the majority of tears occur within the ascending aorta (AA), replacing only that segment seems a safe option; however, this strategy leaves the root susceptible to dilatation and need for reintervention. We aimed to review the outcomes of the two strategies: aortic root replacement (ARR) and isolated ascending aortic replacement. METHODS: Retrospective analysis of prospectively collected data for all consecutive patients who underwent repair of acute TAAD at our institution from 2015 to 2020 was conducted. Patients were divided into two groups: (1) ARR and (2) isolated AA replacement as index operation for TAAD repair. Primary outcomes were mortality and need for reintervention during the follow-up. RESULTS: A total of 194 patients were included in the study; 68 (35%) in the ARR group and 126 (65%) in the AA group. There were no significant differences in postoperative complications or in-hospital mortality (23%; p = 0.51) between groups. Seven patients (4.7%) died during follow-up and eight patients underwent aortic reinterventions, including proximal aortic segments (two patients) and distal procedures (six patients). CONCLUSION: Both aortic root and AA replacement are acceptable and safe techniques. The growth of an untouched root is slow, and reintervention in this aortic segment is infrequent compared with distal aortic segments, hence preserving the root could be an option for older patients provided that there is no primary tear within the root.

A multi-centre prospective cohort study of patients on the elective waiting list for cardiac surgery during the COVID-19 pandemic.

OBJECTIVES: During the worldwide COVID-19 pandemic, elective cardiac surgery was suspended to provide ICU beds for COVID-19 patients and those requiring urgent cardiac surgery. The aim of this study is to assess the effect of the pandemic on outcomes of patients awaiting elective cardiac surgery. DESIGN: A multi-centre prospective cohort study. SETTING: The elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres. PARTICIPANTS: Patients on the elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres. MAIN OUTCOME MEASURES: Primary outcome was surgery, percutaneous therapy or death at one year. METHODS: Data were collected prospectively on patients on the elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres. Primary outcome was surgery, percutaneous therapy or death at one year. Demographic data and outcomes were obtained from local electronic records, anonymised and submitted securely to the lead centre for analysis. RESULTS: On 1 March 2020, there were 1099 patients on the elective waiting list for cardiac surgery. On 1 March 2021, 83% (n = 916) had met a primary outcome. Of these, 840 (92%) had surgery after a median of 195 (118-262) days on waiting list, 34 (3%) declined an offer of surgery, 23 (3%) had percutaneous intervention, 12 (1%) died, 7 (0.6%) were removed from the waiting list. The remainder of patients, 183 (17%) remained on the elective waiting list. CONCLUSIONS: This study has shown, for the first time, significant delays to treatment of patients awaiting elective cardiac surgery. Although there was a low risk of mortality or urgent intervention, important unmeasured adverse outcomes such as quality of life or increased perioperative risk may be associated with prolonged waiting times.

Concomitant Atrial Fibrillation Procedures During Cardiac Surgery in a UK Center: Reflection of Worldwide Practice?

Background: Guidelines recommend concomitant atrial fibrillation (AF) ablation during cardiac surgery to restore normal sinus rhythm (NSR). The study determines, to what extent patients with AF undergoing cardiac surgery at our institution received a concomitant AF procedure, what these procedures entailed, and short-term outcomes. Methods: A retrospective study of 2,984 patients undergoing cardiac surgery over 18 months. Patients who were in preoperative AF were identified and those who underwent a concomitant AF procedure (Group 1) were compared with those who did not (Group 2). Results: Three hundred and thirteen (10.5%) patients had pre-operative AF; paroxysmal (19.5%), persistent (11.8%), longstanding (63%), unknown (5.8%). 116/313 (37.1%) patients had a concomitant AF procedure: 7.7% patients had a concomitant AF ablation and 29.4% had only a Left Atrial Appendage Occlusion (LAAO). Fewer patients with paroxysmal and persistent AF underwent concomitant AF procedures compared with the ones who had no AF procedures (6.7 vs. 12.8% and 17.6 vs. 31%, respectively). Greater in-hospital survival (99.1 vs. 93.9%, p = 0.025) and survival at a mean follow up of 6 weeks (97.4 vs. 89.3%, p = 0.09) was probably determined by patient's preoperative comorbidities. There were no differences in readmission rates, permanent pacemaker insertion, cerebral events or NSR at discharge or follow-up, between groups. Conclusions: In our center, concomitant AF ablation is performed only in 7.7% of cases, 29.4% had only an LAAO performed at the time of surgery. There was no difference in restoring NSR, cerebral events, or readmission rates compared with patients who had nothing done for their preoperative AF.

Surgical excision of a rare cardiac tumor: Cardiac hibernoma.

BACKGROUND AND AIM: Cardiac hibernoma is a very rare benign cardiac tumour. We report a case of its surgical management. METHODS: A case study with retrospective review of prospective patient data. RESULTS: A 60 year old male who presented with acute shortness of breath was found to have SVC compression on cardiac imaging. At operation the tumour was in the right atrial wall invading the intra-atrial groove and extending over superior vena cava (SVC), causing significant symptoms of SVC obstruction and tamponade. This was resected and the right atrium was reconstructed with Bovine pericardial patch. He was discharged home well. CONCLUSIONS: Cardiac hibernoma is a rare tumour which can be successfully treated by surgical excision.

Alternative and Safe Technique to Tie Down a Biologic Aortic Valve in Small Aortic Roots.

Biologic aortic valves are constructed with 3 stents corresponding to the commissures, which sit in the aortic root. When implanted using interrupted sutures, these stents may make the valve difficult to tie down safely in patients with small, calcified aortic roots. We present an easily reproducible technique to make this valve tie down safer.

The EXCEL Trial: The Surgeons' Perspective.

There have been several investigations comparing the efficacy of percutaneous coronary intervention and coronary artery bypass grafting surgery for treatment of left main stem disease. This includes the Evaluation of XIENCE versus Coronary Artery Bypass Graft Surgery for Effectiveness of Left Main Revascularizaton (EXCEL) trial, which has garnered significant controversy surrounding its experimental design and reporting of its results. The authors review the methodology, results, caveats and statements on the EXCEL trial. They also review the other trials in the management of left main stem disease comparing percutaneous coronary intervention with coronary artery bypass grafting, as well as the SYNTAX score and its role in future guidelines for revascularisation. These findings have significant implications for current practice, influencing the growing role for multidisciplinary team meeting and allowing clinicians and patients to make the right choice.

Outcomes of patients diagnosed with COVID-19 in the early postoperative period following cardiac surgery.

The coronavirus 2019 (COVID-19) pandemic has disrupted patient care across the NHS. Following the suspension of elective surgery, priority was placed in providing urgent and emergency surgery for patients with no alternative treatment. We aim to assess the outcomes of patients undergoing cardiac surgery who have COVID-19 infection diagnosed in the early postoperative period. We identified 9 patients who developed COVID-19 infection following cardiac surgery. These patients had a significant length of hospital stay and extremely poor outcomes with mortality of 44%. In conclusion, the outcome of cardiac surgical patients who contracted COVID-19 infection perioperatively is extremely poor. In order to offer cardiac surgery, units must implement rigorous protocols aimed at maintaining a COVID-19 protective environment to minimize additional life-threatening complications related to this virus infection.

Cardiothoracic surgery in the midst of a pandemic: Operative outcomes and maintaining a coronavirus disease 2019 (COVID-19)-free environment.

OBJECTIVE: In the United Kingdom, the coronavirus disease 2019 (COVID-19) pandemic has led to the cessation of elective surgery. However, there remains a need to provide urgent and emergency cardiac and thoracic surgery as well as to continue time-critical thoracic cancer surgery. This study describes our early experience of implementing a protocol to safely deliver major cardiac and thoracic surgery in the midst of the pandemic. METHODS: Data on all patients undergoing cardiothoracic surgery at a single tertiary referral center in London were prospectively collated during the first 7 weeks of lockdown in the United Kingdom. A comprehensive protocol was implemented to maintain a COVID-19-free environment including the preoperative screening of all patients, the use of full personal protective equipment in areas with aerosol-generating procedures, and separate treatment pathways for patients with and without the virus. RESULTS: A total of 156 patients underwent major cardiac and thoracic surgery over the study period. Operative mortality was 9% in the cardiac patients and 1.4% in thoracic patients. The preoperative COVID-19 protocol implemented resulted in 18 patients testing positive for COVID-19 infection and 13 patients having their surgery delayed. No patients who were negative for COVID-19 infection on preoperative screening tested positive postoperatively. However, 1 thoracic patient tested positive on intraoperative bronchoalveolar lavage. CONCLUSIONS: Our early experience demonstrates that it is possible to perform major cardiac and thoracic surgery with low operative mortality and zero development of postoperative COVID-19 infection.

Safe Surgical Retrieval of Embolized Atrial Septal Defect Closure Device.

Surgical retrieval of atrial septal closure device is associated with significant morbidity. We present a technique for safer removal of such devices from the heart.

Perioperative management and outcomes of aortic surgery during pregnancy.

OBJECTIVE: Pathology of the aortic valve and ascending thoracic aorta is an uncommon but life-threatening complication of pregnancy. Cardiac surgery during pregnancy is known to carry a high risk of mortality to both the mother and fetus. We present our experience of performing aortic surgery during the patients' pregnancy. METHODS: All patients undergoing aortic surgery during pregnancy at St George's Hospital, from January 2004 until October 2013, were identified. Surgery was performed using cardiopulmonary bypass at 36°C, with pulsatile perfusion at 70 mm Hg. Fetal blood flow parameters were serially monitored during surgery, via transabdominal and/or transvaginal Doppler ultrasonography. Surgery was performed in the second trimester when possible to allow completion of organogenesis and minimize hemodynamic compromise. RESULTS: Eleven patients underwent aortic surgery. The median age was 28 years (range, 26-31 years), with gestational age 19 weeks (range, 16-21 weeks). Six patients had aortic root dilatation with aortic regurgitation, and 5 had aortic stenosis, one of whom presented with acute type A dissection. Four patients had Marfan syndrome, and 2 had undergone previous cardiac surgery. The operative procedures were aortic root replacement (tissue valve, n = 5; homograft, n = 1), aortic valve replacement (n = 3), valve-sparing root replacement (n = 1), and aortic and mitral valve replacements (n = 1). Mean cardiopulmonary bypass and cross-clamp times were 105 and 89 minutes, respectively. There were no maternal deaths; 8 healthy babies were born at term, and 3 pregnancies resulted in intrauterine demise within 1 week of surgery. CONCLUSIONS: Major aortic surgery during pregnancy carries a high risk to both mother and baby. With appropriate maternal and fetal monitoring, attention to cardiopulmonary bypass, pulsatile perfusion, near-normothermia, and avoidance of vasoconstrictors, these risks may be minimized.

What is the optimal revascularization technique for isolated disease of the left anterior descending artery: minimally invasive direct coronary artery bypass or percutaneous coronary intervention?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, 'What is the optimal revascularization technique for isolated disease of the left anterior descending artery (LAD) in terms of patient survival, morbidity such as myocardial infarction (MI) and need for repeat target vessel revascularization: minimally invasive direct coronary artery bypass graft (MIDCAB) or percutaneous coronary intervention (PCI)?' Altogether 504 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. Outcome parameters that were used in the assessment include the incidence of major adverse cardiovascular or cerebral events (MACCEs), mortality and the rate of repeat target vessel revascularization. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the papers are tabulated. One meta-analysis showed no significant difference in terms of individual incidences of MI, stroke or mortality, but when considered as a composite MACCE outcome, this was found to be significantly lower in the MIDCAB group. Moreover, further meta-analytical data have revealed a 5-fold increase in the need for repeat revascularization with PCI, with some centres reporting rates of up to 34%. However, retrospective data have shown that average length of hospital stay was longer in the MIDCAB group (7.4 ± 3.2 vs 3.4 ± 3.5 days; P < 0.001). We conclude that there are obvious proven benefits with MIDCAB, namely in terms of a reduced need for repeat target vessel revascularization and incidence of MACCE, and one study has even shown that there is a long-term survival benefit in 'real-world' clinical practice. However, given that there is a lack of well-powered randomized controlled trial and long-term follow-up data to prove a mortality benefit in support of MIDCAB, patients requiring revascularization of isolated proximal LAD stenosis and being considered for percutaneous coronary intervention should be discussed in a multidisciplinary team setting prior to intervention.

Impact of European Society of Cardiology and European Association for Cardiothoracic Surgery Guidelines on Myocardial Revascularization on the activity of percutaneous coronary intervention and coronary artery bypass graft surgery for stable coronary artery disease.

OBJECTIVE: Joint guidelines on myocardial revascularization were published by the European Society of Cardiology and European Association for Cardiothoracic Surgery: Patients with left main stem, proximal left anterior descending, or 3-vessel disease should be discussed with a surgeon before revascularization, and ad hoc percutaneous coronary intervention has no elective indication in these categories. We assess the impact of the guidelines on referral patterns to a cardiac surgery service at a large-volume cardiac center in the United Kingdom. METHODS: Joint guidelines were published in August 2010. All patients with severe disease undergoing percutaneous coronary intervention at one institution were identified 6 months before (January to June 2010) and 6 months after (January to June 2011) their introduction. Decision-making and surgical referral were determined from minutes of multidisciplinary meeting. RESULTS: A total of 197 patients underwent elective percutaneous coronary intervention pre-guidelines, of whom 62 had severe disease. Only 6 patients (9%) were discussed at a multidisciplinary meeting before intervention. After introduction of the guidelines, elective percutaneous coronary interventions were performed in 164 patients, of whom 42 had surgical disease. Only 8 patients (17%) were discussed at a multidisciplinary meeting before intervention (P = not significant). Follow-up was a median of 480 (380-514) days for the pre-guideline group and 104 (31-183) days for the post-guideline group. Ad hoc percutaneous coronary intervention in surgical disease occurred in 8 patients (14%) pre-guidelines and was unchanged for 9 patients (26%) post-guidelines (P = not significant). CONCLUSIONS: Despite recommendation by both cardiology and cardiac surgical bodies and widespread publicity, a significant number of patients in this single-center study are not receiving optimal treatment recommended by these guidelines.