Emergency biventricular assist device implantation in a patient with suspected COVID-19 disease.

Severe coronavirus disease 2019 (COVID-19) is a multisystem inflammatory disorder and knowledge and experience with severe acute respiratory failure in infected patients has grown considerably since reports of the first few cases. Little is known about the effect of the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus on the heart, and it has been suggested that fulminant cardiac failure, with or without respiratory failure, may occur several weeks following infection. A young man presented after a recent viral illness. He was in severe cardiogenic shock and was implanted with an emergency biventricular assist device, which also incorporated an extracorporeal membrane oxygenator. He stabilised soon after and, despite an intracerebral haemorrhage which resolved and bleeding into the trachea following percutaneous tracheostomy, he survived to explant and was successfully stepped down to a rehabilitation unit on postoperative day 50. He tested positive for SARS-CoV-2 antibodies when the test became available on postoperative day 33. We envisage there will be many more such presentations of acute COVID-19-associated cardiogenic shock and we recommend clinicians consider this diagnosis when presented with an acutely unwell patient with an unclear diagnosis following a viral illness. These patients should be discussed as early as possible with a transplant/mechanical circulatory support team.

Surgical repair of pulmonary vein injury from blunt trauma.

Pulmonary vein deceleration injury is rare and patients can be deceptively stable for a period after injury. Quick diagnosis and transfer to the operating theatre is the only way to treat this potentially lethal injury successfully. Techniques of repair are a useful addition to the cardiovascular surgeon's repertoire.

The competent isolated double orifice mitral valve: an incidental finding during excision of a papillary fibroelastoma.

The double orifice mitral valve is associated with a number of congenital abnormalities and comprises two mitral orifices separated by an accessory bridge of fibrous tissue and surrounded by a single fibrous annulus. We present our management of a case of a double orifice mitral valve associated with a papillary fibroelastoma.

Manubriosternal subluxation/dislocation can lead to manubriosternal septic arthritis in patients with kyphoscoliosis.

Locally deranged joint anatomy can predispose to septic arthritis which can be managed by surgical debridement. We present a case of manubriosternal subluxation/dislocation caused by kyphoscoliosis leading to manubriosternal septic arthritis.

Use of an image intensifier to remove a challenging foreign body in a segmental bronchiole.

Aspiration of foreign bodies into the tracheobronchial tree is a common presentation in children, but less so in adults. Successful extraction depends on the type of foreign body aspirated, location of the foreign body in the tracheobronchial tree, the experience of the operator and the instrumentation available. We report on our management of a patient who presented with an aspirated foreign body.

Endovenous laser ablation for the treatment of recurrent varicose vein disease--a single centre experience.

INTRODUCTION: Varicose vein surgery for recurrent disease can result from inadequate primary surgery. Redo open surgery is more difficult to perform than primary surgery and can be associated with a higher incidence of neurovascular injury and infection. In this study we evaluate EVLA, a percutaneous technique that uses intra-operative duplex ultrasound as an option for the treatment of recurrent varicose veins. MATERIALS AND METHODS: Data prospectively collected on patients who had EVLA for varicose veins were obtained from our dedicated vascular registry. From November 2004 to December 2008 we performed 586 EVLA procedures, 77 procedures were for recurrent varicose veins. RESULTS: The mean age was 52 +/- 12.77 years, range 28-80; and 48 (62%) were female. 64 (83%) cases were for recurrent LSV disease, 13 (17%) cases for recurrent SSV disease and all patients had LSV or SSV incompetence confirmed on preoperative duplex assessment. Median duration since primary surgery was 60 months (range 2-360). Mean length of vein treated was LSV--36 cm +/- 14.5 (6-73) and SSV--14.5 cm +/- 7.35 (5-24); mean energy delivered was LSV 3102J +/- 1053 (150-4656) and SSV--693J +/- 396 (135-1216). 17 patients had bilateral EVLA for recurrent disease at the same setting with one patient having bilateral procedures under local anaesthetic. There was an incidence of pulmonary embolism 10 days post EVLA and two patients required further phlebectomies post EVLA for residual varices that were present pre-operatively. Median follow-up was 18 months (range 1-38), with no clinical recurrence and no recannalisation of the treated LSV or SSV on duplex ultrasound. CONCLUSIONS: In our experience EVLA can be safely performed for recurrent varicose vein disease. In our experience Redo EVLA is not more difficult than primary EVLA to perform.

5-years of endovenous laser ablation (EVLA) for the treatment of varicose veins--a prospective study.

PURPOSE: This prospective study evaluates the results of Endovenous laser ablation (EVLA) for the treatment of varicose veins. METHODS: Data were prospectively collected for all patients undergoing EVLA for varicose veins in our unit including clinical outcomes (CEAP classification) and post-operative duplex. RESULTS: 624 EVLA procedures were performed from April 2004 to February 2009. There were 527 LSV EVLA cases, 449 of which were for the above-knee segment only. There were 94 SSV EVLA cases and 3 patients needed LSV EVLA on the same leg at the same time. 84% were done under general anesthetic including 126 patients who underwent bilateral procedures at the same session. There were no intra-operative complications, and a 1% incidence of thrombophlebitis, and <1% incidence of neuropraxia. During a median follow-up of 20 months (Range 2-51) there was no clinical or duplex evidence of recurrence and no recannalisation of the treated vein. CONCLUSIONS: Our 5-year experience suggests that EVLA is a safe and effective alternative to conventional surgery for the treatment of varicose veins. Bilateral procedures were well tolerated by patients even under local anaesthesia.

Endovenous laser ablation for short saphenous vein incompetence.

Conventional surgery for short saphenous vein (SSV) incompetence has a high incidence of recurrence and is associated with neurovascular injury. The aim of this study was to evaluate the safety and efficacy of endovenous laser ablation (EVLA) as an alternative to open surgery for SSV incompetence. Data were prospectively collected for all patients undergoing EVLA for SSV disease in our unit, including clinical outcomes and postoperative duplex. There were 368 EVLA procedures performed from April 2004 through December 2007, of which 66 (18%) were for SSV incompetence. Six (9%) SSV procedures were for recurrent disease after conventional surgery. Forty (61%) procedures were performed under local anesthesia, including four patients who underwent bilateral procedures at the same session. There were no intraoperative complications, and there was no evidence of neurovascular injury. During a median follow-up of 14 months (interquartile range 6-24) there was no clinical or duplex evidence of recurrence and no recanalization of the SSV. Our early results suggest that EVLA is a safe alternative to conventional surgery for the treatment of SSV incompetence in patients with C2-C4 disease. Bilateral procedures have been performed under local anesthesia.

Surgery for fistula-in-ano: an audit of practise of colorectal and general surgeons.

OBJECTIVE: Some conditions, previously managed by general surgeons, may be treated more successfully by colorectal specialists. This argument is well established for rectal cancer but does it also apply to benign conditions? This study compares the treatment strategies and outcomes for fistulae-in-ano by general and colorectal surgeons in a district general hospital. METHOD: Patients who had surgery for fistula-in-ano from January 1992-October 2003 were identified from theatre records. Case notes were reviewed for data on type of fistula, aetiology, surgery performed and recurrence. All patients were sent a questionnaire requesting details of recurrence and incontinence. The severity of incontinence was assessed using the Faecal Incontinence Quality of Life Scale (FIQOLS) and the Faecal Incontinence Severity Index (FISI). RESULTS: Eighty four patients (male = 53) were identified. Colorectal surgeons performed surgery in 34 and general surgeons in 50 patients. These groups were comparable with terms of age, gender, aetiology (colorectal: IBD = 5, cryptoglandular = 21: general IBD = 14, cryptoglandular = 24; P = 0.28; Chi-squared test), and type of fistulae (colorectal: inter-sphincteric = 20, trans-sphincteric = 13: general inter-sphincteric = 30, trans-sphincteric = 18: P = 1.0; Fisher's exact test). Colorectal surgeons carried out fewer fistulotomies (47.1%vs 84.0%; P < 0.001; Fisher's exact test), more staged fistulotomies with Setons (44.1%vs 10.0%: P < 0.001; Fisher's exact test), and had fewer recurrences (9.7%vs 30.0%: P < 0.05; Fisher's exact test) when compared with general surgeons. Five patients with recurrence from the general surgery group were subsequently referred to the colorectal surgeons; four patients had further surgery (fistulotomy = 2; staged fistulotomy = 2) with no recurrence to date; one patient required proctectomy. Forty seven (64.4%) patients answered the questionnaire. There was no difference between patients operated on by colorectal or general surgeons with regards the frequency (43.5%vs 62.5%: P = 0.25; Fisher's exact test) or severity [FISI 26 (21-38); median (inter-quartile range) vs 26 (17-38); median (inter-quartile range: P = 0.85; Mann-Whitney test) of faecal incontinence. There was no difference between the groups with regards any of the four scales that comprised the FIQOLS. CONCLUSIONS: The number of included patients is far too low to draw any conclusions but there were some interesting trends. For similar patient samples, colorectal surgeons seem to adopt a more conservative approach and have fewer recurrences than general surgeons. These differences are not reflected in the frequency or severity of postoperative incontinence.