Extracorporeal life support for severe drug-induced cardiotoxicity: a promising therapeutic choice

Drug-induced cardiovascular failure is an acute condition that is associated with significant healthcare consequences. Antidotes and supportive treatments are the initial measures to manage cardiotoxicity, but if severe drug-induced cardiotoxicity develops, usually as cardiovascular shock or cardiac arrest, then circulatory assistance may have an important role in the therapeutic algorithm. A number of circulatory assistance techniques have been increasingly employed to treat severe drug-induced cardiotoxicity. These include extracorporeal membrane oxygenation, intra-aortic balloon pumping and standard cardiopulmonary bypass. Recently, extracorporeal life support (ECLS) has been developed to provide percutaneous cardiopulmonary support peripherally without the need for sternotomy. ECLS can provide successful treatment of severe drug-induced cardiotoxicity in selected cases. This technique may be associated with complications of limb ischaemia, haemorrhage and embolism. An increased consideration of ECLS within the context of rigorous clinical studies and strong evidence can add to its future use for severe drug-induced cardiotoxicity

Emergency Prehospital On-scene Thoracotomy: A Novel Method

The necessity for prehospital thoracotomy is rare, but can be lifesaving. Occasionally an emergency practitioner or surgeon coincidentally arrives at a trauma scene before the arrival of emergency medical teams. In such a circumstance, even when thoracotomy may be indicated, it is not usually performed in view of the lack of equipment (e.g. dissecting tools or rib retractor). We present a novel technique of »L« shape thoracotomy, or Thoraco-sterno-costochondrotomy, whereby in a prehospital setting, and with minimal equipment (such as a penknife) a thoracotomy can be performed with adequate exposure of the heart and great vessels. The similarities of this pragmatic procedure are considered within the context of ancient Aztec and Mesoamerican thoracotomies

Meta-analysis: A practical decision making tool for surgeons

AbstractBackgroundThe exponential rise in published medical research on a yearly basis demands a method to summarise best evidence towards its application to patient care in clinical practice. A robust meta-analysis is a valid tool. It is often considered to be a simple process of pooling results from different studies. This is not true. It appears that surgeons lack a reference guide to help them conduct and appraise a meta-analysis.MethodsThis paper provides a structural framework to perform a meta-analysis. It guides the surgeon on a journey from identification of the correct clinical question to data analysis and through to producing a structured report. Statistical methods are discussed briefly as most commercial software calculates most results in the background. An example of a recent meta-analysis is given. However, important caveats are mentioned as there are limitations of the meta-analytical technique.ConclusionWhereas meta-analyses of homogeneous studies are the highest form of evidence, poorly conducted meta-analyses create confusion and serve to harm the patient. Surgeons practising their art in an era of evidence-based surgery need to understand the principles of meta-analyses

Strategies in the Surgical Management of Atrial Fibrillation

Atrial fibrillation (AF) is associated with substantial morbidity, mortality, and economic burden and confers a lifetime risk of up to 25%. Current medical management involves thromboembolism prevention, rate, and rhythm control. An increased understanding of AF pathophysiology has led to enhanced pharmacological and medical therapies; however this is often limited by toxicity, variable symptom control, and inability to modulate the atrial substrate. Surgical AF ablation has been available since the original description of the Cox Maze procedure, either as a standalone or concomitant intervention. Advances in novel energy delivery systems have allowed the development of less technically demanding procedures potentially eliminating the need for median sternotomy and cardiopulmonary bypass. Variations in the definition, duration, and reporting of AF have produced methodological limitations impacting on the validity of interstudy comparisons. Standardization of these parameters may, in future, allow us to further evaluate clinical endpoints and establish the efficacy of these techniques

A proposed role for sepsis in the pathogenesis of myocardial calcification

Myocardial calcification is a rare and life-threatening condition that is a recognised complication of ischaemic heart disease, cardiac surgery, rheumatic fever and myocarditis. It is distinct from coronary artery or valvular calcification, and can be seen in patients with abnormal calcium metabolism1 . Its presence in the context of sepsis is less well recognised and the mechanisms responsible are poorly understood. We review the relevant literature and propose a mechanistic theory for its pathogenesi

Current Trends and Future Developments in Robotic Cardiac Surgery

Robotic Cardiac Surgery has revolutionised operating for surgeons to provide less operative pain, shorter hospital stays and improved quality of life. As surgeons are constantly trying new techniques, Robotic Cardiac Surgery now encompasses mitral valve surgery, coronary revascularisation, atrial fibrillation surgery, pacing lead implantation, congenital cardiac operations, cardiac tumours resection and diaphragmatic pacing. Robotic technology is gradually becoming more affordable and so more centres are investing in training surgeons in these techniques. As a result, robotic cardiac surgery has developed into a rapidly evolving speciality with exciting new possibilities... (excerpt

Evolution of Outcomes in Cardiothoracic Surgery

The measurement of outcomes is a fundamental component of modern surgery to provide the foundations of surgical improvement. The conventional emphasis of clinical outcomes such as morbidity and mortality has been augmented with a growing focus on quality of life, quality of care and patient satisfaction. Outcome measures can provide cardiothoracic surgeons the opportunity to assess their results in increased precision and transparency.  An initiative to increase patient awareness and education regarding their hospitals and their surgeons has meant a necessary move towards greater clarity and accountability of all surgical centres.  This has seen an adaptation towards a more patient-centered approach. Comprehensive quality measures and a framework for analyzing and interpreting these results is pivotal as is knowing what to measure and how to measure it. Innovative approaches whereby the patient measures and reports their own ‘outcome’ and experience are being piloted in all surgical specialties, including cardiothoracic surgery. Adopting the Donabedian model for quality measurement in three domains structure, process, and outcomes is a valid and reliable instrument for assessing patient’s satisfaction and quality of care as are the wide range of validated surveys of health related quality of life, which should be routinely implemented

Thoracoabdominal aneurysm repair using a four-branched thoracoabdominal graft: a case series

Revascularization of the visceral arteries during thoracoabdominal aneurysm repair is usually performed sequentially by an anastomosis between a prosthetic graft and an aortic patch. There are immediate operative risks such as bleeding and distortion. In the longer term, aneurysm, pseudo-aneurysm and rupture may occur. These require reoperation and are associated with significant morbidity and mortality

Trends in immediate postmastectomy breast reconstruction in the United Kingdom

The study aimed to evaluate local and national trends in immediate breast reconstruction (IBR) using the national English administrative records, Hospital Episode Statistics. Our prediction was an increase in implant-only and free flap procedures and a decline in latissimus flap reconstructions.Data from an oncoplastic center were interrogated to derive numbers of implant-only, autologous latissimus dorsi (LD), LD-assisted, and autologous pedicled or free flap IBR procedures performed between 2004 and 2013. Similarly, Hospital Episode Statistics data were used to quantify national trends in these procedures from 1996 to 2012 using a curve fitting analysis.National data suggest an increase in LD procedures between 1996 (n = 250) and 2002 (n = 958), a gradual rise until 2008 (n = 1398) followed by a decline until 2012 (n = 1090). As a percentage of total IBR, trends in LD flap reconstruction better fit a quadratic (R(2) = 0.97) than a linear function (R(2) = 0.63), confirming a proportional recent decline in LD flap procedures. Conversely, autologous (non-LD) flap reconstructions have increased (1996 = 0.44%; 2012 = 2.76%), whereas implant-only reconstructions have declined (1996 = 95.42%; 2012 = 84.92%). Locally, 70 implant-assisted LD procedures were performed in 2003 -2004, but only 2 were performed in 2012 to 2013.Implants are the most common IBR technique; autologous free flap procedures have increased, and pedicled LD flap procedures are in decline

The volume-mortality relation for radical cystectomy in England: retrospective analysis of hospital episode statistics

Objectives To investigate the relation between volume and mortality after adjustment for case mix for radical cystectomy in the English healthcare setting using improved statistical methodology, taking into account the institutional and surgeon volume effects and institutional structural and process of care factors