An alternative surgical approach to subclavian and innominate stenosis: a case series

We report three cases of symptomatic stenosis of the great vessels or supra-aortic trunks successfully treated surgically with aorto-subclavian and aorto-innominate bypass. Two were performed via manubriotomy and a third case via standard median sternotomy because of concomitant coronary revascularisation. There was complete symptomatic relief on follow-up, and radiological imaging confirmed good flow in the grafts and post-stenotic arteries

Formal consensus study on surgery to replace the aortic valve in adults aged 18-60 years

Objective: There is uncertainty about surgical procedures for adult patients aged 18-60 years undergoing aortic valve replacement (AVR). Options include conventional AVR (mechanical, mAVR; tissue, tAVR), the pulmonary autograft (Ross) and aortic valve neocuspidisation (Ozaki). Transcatheter treatment may be an option for selected patients. We used formal consensus methodology to make recommendations about the suitability of each procedure. Methods: A working group, supported by a patient advisory group, developed a list of clinical scenarios across seven domains (anatomy, presentation, cardiac/non-cardiac comorbidities, concurrent treatments, lifestyle, preferences). A consensus group of 12 clinicians rated the appropriateness of each surgical procedure for each scenario on a 9-point Likert scale on two separate occasions (before and after a 1-day meeting). Results: There was a consensus that each procedure was appropriate (A) or inappropriate (I) for all clinical scenarios as follows: mAVR: total 76% (57% A, 19% I); tAVR: total 68% (68% A, 0% I); Ross: total 66% (39% A, 27% I); Ozaki: total 31% (3% A, 28% I). The remainder of percentages to 100% reflects the degree of uncertainty. There was a consensus that transcatheter aortic valve implantation is appropriate for 5 of 68 (7%) of all clinical scenarios (including frailty, prohibitive surgical risk and very limited life span). Conclusions: Evidence-based expert opinion emerging from a formal consensus process indicates that besides conventional AVR options, there is a high degree of certainty about the suitability of the Ross procedure in patients aged 18-60 years. Future clinical guidelines should include the option of the Ross procedure in aortic prosthetic valve selection

Amaze: a randomized controlled trial of adjunct surgery for atrial fibrillation

OBJECTIVES: Atrial fibrillation (AF) reduces survival and quality of life (QoL). It can be treated at the time of major cardiac surgery using ablation procedures ranging from simple pulmonary vein isolation to a full maze procedure. The aim of this study is to evaluate the impact of adjunct AF surgery as currently performed on sinus rhythm (SR) restoration, survival, QoL and costeffectiveness. METHODS: In a multicentre, Phase III, pragmatic, double-blinded, parallel-armed randomized controlled trial, 352 cardiac surgery patients with >3 months of documented AF were randomized to surgery with or without adjunct maze or similar AF ablation between 2009 and 2014. Primary outcomes were SR restoration at 1 year and quality-adjusted life years at 2 years. Secondary outcomes included SR at 2 years, overall and stroke-free survival, medication, QoL, cost-effectiveness and safety. RESULTS: More ablation patients were in SR at 1 year [odds ratio (OR) 2.06, 95% confidence interval (CI) 1.20–3.54; P = 0.009]. At 2 years, the OR increased to 3.24 (95% CI 1.76–5.96). Quality-adjusted life years were similar at 2 years (ablation - control -0.025, P = 0.6319). Significantly fewer ablation patients were anticoagulated from 6 months postoperatively. Stroke rates were 5.7% (ablation) and 9.1% (control) (P = 0.3083). There was no significant difference in stroke-free survival [hazard ratio (HR) = 0.99, 95% CI 0.64–1.53; P = 0.949] nor in serious adverse events, operative or overall survival, cardioversion, pacemaker implantation, New York Heart Association, EQ-5D-3L and SF-36. The mean additional ablation cost per patient was £3533 (95% CI £1321–£5746). Cost-effectiveness was not demonstrated at 2 years. CONCLUSIONS: Adjunct AF surgery is safe and increases SR restoration and costs but not survival or QoL up to 2 years. A continued follow-up will provide information on these outcomes in the longer term

The influence of seasonal variation on cardiac surgery: A time-related clinical outcome predictor

ObjectiveThe effect of seasonal variation on cardiac surgery outcomes is unknown. We investigated the effect of season on risk-adjusted hospital mortality and length of stay.MethodsProspectively collected data from cardiac operations at one center between April 1996 and March 2006 were analyzed. Seasonal variation in outcomes was studied by using multiple regression models that included EuroSCORE and year of operation to adjust for risk profile and changes over time. Analysis was performed for 2 separate surgical groups: patients having coronary artery bypass grafting only and patients having other cardiac procedures with or without coronary artery bypass grafting.ResultsThere were 16,290 patients who had a first record of cardiac surgery in the study period between April 1, 1996, and March 31, 2006, with 10,263 patients having coronary artery bypass grafting only and 6027 patients having another procedure with or without coronary artery bypass grafting. There were increased odds of hospital mortality in patients having operations in winter compared with the average across all seasons for both surgical groups, although this was only significant in the coronary artery bypass grafting–only group (odds ratio, 1.29; 95% confidence interval, 1.01–1.63; P = .04). There were decreased odds of death in the coronary artery bypass grafting–only group in summer (odds ratio, 0.76; 95% confidence interval, 0.60–0.96; P = .02). Intensive care unit stay was 4% (95% confidence interval, 1%–6%) longer in the coronary artery bypass grafting–only group in winter and 3% (95% confidence interval, 1%–5%) shorter in summer than the average stay (P = .003 and .006, respectively). There were no differences in intensive care unit stay in the combined surgery group by season and no differences in total length of stay for either group (coronary artery bypass grafting only and coronary artery bypass grafting with other cardiac procedures).ConclusionsCardiac surgery outcomes are influenced by the time of year. Hospital mortality and intensive care unit stay after coronary artery bypass grafting were increased during the winter season compared with the rest of the year

Impact of cardiothoracic resident turnover on mortality after cardiac surgery: A dynamic human factor

Background. The study was designed to determine whether cardiac surgical outcomes are affected during times of major turnover of cardiothoracic resident surgical staff and at the beginning versus the end of their training periods.Methods. This observational cohort study analyzed data from cardiac operations between April 1996 and March 2006 at a single institution. In- hospital mortality and other outcomes were compared between operations done during months of major change in resident staff rotation (July, August, January, February, n = 5,517) and the rest of the year (n = 10,773). We also compared outcomes at the beginning and end of surgical rotation for cardiothoracic residents. Adjustment was made for EuroSCORE (European System for Cardiac Operative Risk Evaluation), year of operation, and surgeon resident status. Analyses were done within surgery procedure subgroups of isolated coronary artery bypass graft surgery (CABG) and complex operations (CABG combined with other procedures).Results. Patient populations in the groups were similar. After risk adjustment, there was a significant increase in hospital mortality for the complex cases during months of resident staff change compared with rest of the year (odds ratio 1.3, 95% confidence interval: 1.3, 1.4; p = 0.02). There was, however, no significant difference in mortality for the CABG only cases (odds ratio 1.1, 95% confidence interval: 0.8, 1.4; p = 0.61). Risk-adjusted mortality after operations done by residents was the same at the start and finish of their surgical rotation. During the change months, the surgery time was 2.2 minutes longer on average in CABG operations (95% confidence interval: 0.3, 4.0; p = 0.02), and no different in combined cases.Conclusions. Periods of major change in resident surgical staff are associated with increased risk-adjusted in-hospital mortality after complex cardiac operations but not after CABG alone.</p

Should surgeons take a break after an intraoperative death? Attitude survey and outcome evaluation

Objectives To investigate attitudes of cardiac surgeons and anaesthetists towards working immediately after an intraoperative death and to establish whether an intraoperative death affects the outcome of subsequent surgery. Design Questionnaire on attitudes to working after an intraoperative death and matched cohort study. Setting UK adult cardiac surgery centres and regional cardiothoracic surgical centre. Participants 371 consultant cardiac surgeons and anaesthetists in the United Kingdom were asked to complete a questionnaire, and seven surgeons from one centre who continued to operate after intraoperative death. Main outcome measures Outcome for 233 patients operated on by a surgeon who had experienced an intraoperative death within the preceding 48 hours compared with outcome of 932 matched controls. Hospital mortality and length of stay as a surrogate for hospital morbidity. Results The questionnaire response rate was 76%. Around a quarter of surgeons and anaesthetists thought they should stop work after an intraoperative death and most wanted guidelines on this subject. Overall, there was no increased mortality in patients operated on in the 48 hours after an intraoperative death. However, mortality was higher if the preceding intraoperative death was in an emergency or high risk case. Survivors operated on within 48 hours after an intraoperative death had longer stay in intensive care (odds ratio 1.64, 95% confidence interval 1.08 to 2.52, P = 0.02) and longer stay in hospital (relative change 1.15, 1.03 to 1.24, P = 0.02). Conclusion Mortality is not increased in operations performed in the immediate aftermath of an intraoperative death, but survivors have longer stays in intensive care and on the hospital ward

Risk factor identification and mortality prediction in cardiac surgery using artificial neural networks.

ObjectiveThe artificial neural network model is a nonlinear technology useful for complex pattern recognition problems. This study aimed to develop a method to select risk variables and predict mortality after cardiac surgery by using artificial neural networks.MethodsProspectively collected data from 18,362 patients undergoing cardiac surgery at 128 European institutions in 1995 (the European System for Cardiac Operative Risk Evaluation database) were used. Models to predict the operative mortality were constructed using artificial neural networks. For calibration a sixfold cross-validation technique was used, and for testing a fourfold cross-testing was performed. Risk variables were ranked and minimized in number by calibrated artificial neural networks. Mortality prediction with 95% confidence limits for each patient was obtained by the bootstrap technique. The area under the receiver operating characteristics curve was used as a quantitative measure of the ability to distinguish between survivors and nonsurvivors. Subgroup analysis of surgical operation categories was performed. The results were compared with those from logistic European System for Cardiac Operative Risk Evaluation analysis.ResultsThe operative mortality was 4.9%. Artificial neural networks selected 34 of the total 72 risk variables as relevant for mortality prediction. The receiver operating characteristics area for artificial neural networks (0.81) was larger than the logistic European System for Cardiac Operative Risk Evaluation model (0.79; P = .0001). For different surgical operation categories, there were no differences in the discriminatory power for the artificial neural networks (P = .15) but significant differences were found for the logistic European System for Cardiac Operative Risk Evaluation (P = .0072).ConclusionsRisk factors in a ranked order contributing to the mortality prediction were identified. A minimal set of risk variables achieving a superior mortality prediction was defined. The artificial neural network model is applicable independent of the cardiac surgical procedure

EuroSCORE II dagger

To update the European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk model. A dedicated website collected prospective risk and outcome data on 22 381 consecutive patients undergoing major cardiac surgery in 154 hospitals in 43 countries over a 12-week period (May-July 2010). Completeness and accuracy were validated during data collection using mandatory field entry, error and range checks and after data collection using summary feedback confirmation by responsible officers and multiple logic checks. Information was obtained on existing EuroSCORE risk factors and additional factors proven to influence risk from research conducted since the original model. The primary outcome was mortality at the base hospital. Secondary outcomes were mortality at 30 and 90 days. The data set was divided into a developmental subset for logistic regression modelling and a validation subset for model testing. A logistic risk model (EuroSCORE II) was then constructed and tested. Compared with the original 1995 EuroSCORE database (in brackets), the mean age was up at 64.7 (62.5) with 31% females (28%). More patients had New York Heart Association class IV, extracardiac arteriopathy, renal and pulmonary dysfunction. Overall mortality was 3.9% (4.6%). When applied to the current data, the old risk models overpredicted mortality (actual: 3.9%; additive predicted: 5.8%; logistic predicted: 7.57%). EuroSCORE II was well calibrated on testing in the validation data subset of 5553 patients (actual mortality: 4.18%; predicted: 3.95%). Very good discrimination was maintained with an area under the receiver operating characteristic curve of 0.8095. Cardiac surgical mortality has significantly reduced in the last 15 years despite older and sicker patients. EuroSCORE II is better calibrated than the original model yet preserves powerful discrimination. It is proposed for the future assessment of cardiac surgical risk