The optimal treatment of multivessel coronary artery disease

The practice of percutaneous coronary intervention has overtaken coronary bypass surgery in the treatment of ischaemic heart disease. Several randomized controlled as well as registry and observational trials have addressed the issue of patient selection and outcomes in order to provide the cardiologist with data enabling optimal treatment selection. This article reviews the major trials performed over the past 25 years, underscoring their strengths and limitations and draws on lessons and guidelines that are relevant to our local practice.peer-reviewe

Cardiac transplantation : an evolving practice

When Barnard performed the first orthotopic transplant he became an instant celebrity. By today’s standards the method of retrieval was daring and fraught with risk. In this article the author starts by explaining the first attempted heart transplant being performed in 1968. Heart transplantation still provides the best outcome and 5 year survival in established centres now approximates 65%. The immediate success of surgery is directly related to the correct choice of the ideal donors and recipients.peer-reviewe

Early and late outcomes after heart transplantation in a low-volume transplant centre

Early (one year) and late (15 year) outcomes after heart transplantation in Malta were evaluated by means of a retrospective analysis of mortality and morbidity, derived from the transplant database. Fifteen transplants were performed with an 87% operative and one-year survival and an 80% 15-year survival. Four patients experienced complications necessitating major surgical interventions and 5 further patients required hospital admission for other complications. Four patients never required hospital admission after their transplant. Twelve long- term survivors enjoy an unrestricted life, whereas one patient is troubled with recurrent gout. Results of heart transplantation can be gratifying, even when performed in a low-volume centre.peer-reviewe

Sir Charles Ballance : A pioneer surgeon in Malta

Charles Ballance was arguably the most eminent surgeon stationed in Malta during the Great War. On the 16th February 1918 he removed a bullet from the heart of trooper Robert Martin who was shot in the chest in Salonika three months previously. Sadly the patient died of sepsis one month later, a fact that obscured the importance of this landmark operation, the third of its kind worldwide. This paper sets the background to this achievement and celebrates the impact that this surgical pioneer left on our shores.peer-reviewe

Leadership, clinical freedom and costcontainment: lessons from recent history

Public Health provision, free at the point of contact, is espoused in many countries within the European Union. The method of funding, whether by direct taxation, or via insurance companies, is not so much a problem as the ever increasing cost of medical advances and are. Clearly structures need to be in place to manage this service, and the modern doctor is called upon to play an ever- increasing role. The British National Health Service has served as a template for our local health service, albeit with various divergences along the way. This article highlights the central role of the doctor, as leader and manager, in effecting constant change within the service.peer-reviewe

Why audit?

Decision making in surgery is based on contemporary hard data describing outcomes in a particular patient population. As a professional body, with powers of self regulation and peer review, we need to be cognisant of the expected norm of practice. This can only be derived from information that is shared amongst our colleagues both locally and abroad. We have the responsibility to contribute to this database by way of audit in a rigourous and honest fashion and to utilise it routinely in the management of our patients.peer-reviewe

Coronary artery bypass surgery in the elderly : is it worthwhile?

Objectives: To evaluate the early outcomes after coronary surgery in the elderly. Methods: A retrospective analysis (April 1995- January 2012) of mortality, morbidity and hospital stay, derived from a single surgeon’s practice. Outcomes of patients over 70 (group A, n=785) were compared with those of controls under 70 (group B, n=2772). Results: Intervention rate was significantly higher (1502/106 vs 467/106, p<0.0001). There were significantly fewer single and quintuple grafts, and significantly more double grafts in group A. The use of an internal thoracic artery (ITA) was lower in group A (748/785, 95.3% vs 2695/2772, 97.2%, p=0.006). Mortality for the entire coronary surgical practice was 1.2%. The overall mortality was 2.7% in group A and 0.8% in group B (p<0.0001). Freedom from any post- operative complication occurred in 57.7% in group A and in 75.6% in group B (p<0.0001). Cardiac complications (except for perioperative MI and atrial flutter) were significantly higher in group A, as were major neurological, renal and respiratory complications, as well as minor wound complications. All complications resulted in patient morbidity but cerebrovascular accident had the worst impact, contributing to perioperative death in 8 of the 18 cases ingroupAandin4ofthe24casesingroupB (p=0.049). Average length of stay on intensive care was similar (1.19±1.84 days for group A and 1.13±1.48 days for group B, p=0.38). The average HDU stay was longer in group A (1.43±2.70 vs 0.95±3.68 days, p=0.006) as was the average ward stay (4.00±3.33 vs 3.25±2.23 days, p<0.0001). Conclusions: Although mortality and morbidity remain significantly higher, taken in the context of the overall clinical problem, cardiac surgery has much to offer in this select group of patients.peer-reviewe

Is transfusion in coronary artery surgery a predictor or a cause of reduced long-term survival?

Background Transfusion is common after coronary bypass surgery. Transfused patients present with higher operative risk and an increased hazard ratio for curtailed long-term survival. There is debate as to whether transfusion itself may further exacerbate late mortality. Methods Long-term survival was studied in 2550 survivors following coronary revascularization in this retrospective, observational study. Kaplan-Meier survival curves were constructed to compare all transfused and non-transfused patients, as well as survival in propensity-matched transfused and non-transfused patients. Results Operative mortality was 1.05% (original cohort 2577). Maximum follow-up was 23 years (mean 11.8, median 12.4 years). 34.7% of patients received a transfusion (mean 2 units packed red blood cells). Baseline risk characteristics (age, female gender, small body habitus, risk stratification scoring, diabetes, hypertension and reduced stroke volume) operative parameters (urgency and no internal thoracic graft) as well as post-operative parameters (intensive care, hospital stay and ventilation time) and complications (haemorrhage, intra-aortic balloon, ventricular arrhythmias, prolonged inotropic support, atrial fibrillation, dialysis, doubling of creatinine and resternotomy) were higher in the transfused patients. The long-term survival of these patients was significantly reduced when compared with that of non-transfused patients (log rank test p<0.001). When analyzed as a sole risk factor, transfusion was associated with reduced long-term survival (log rank test p<0.001) but when analyzed collectively with other risk factors, transfusion failed to demonstrate a causative effect (p=0.953). When propensity matched groups were compared (612 transfused versus 1222 non-transfused patients) long-term survival was similar (log rank test p=0.554). Conclusions Transfusion was required in higher risk patients undergoing coronary revascularization. Long-term survival was curtailed in this group but this was due to preoperative risk and not directly to transfusion. Transfusion was a predictor but not a cause of reduced long-term survival.peer-reviewe

Evaluating a trainee’s progress in surgical dexterity

The local cardiac surgical training program is modelled on a one-to-one apprenticeship encompassing a number of years. Trainee progress is regularly audited and work of increasing complexity is provided, commensurate with the trainee's ability. Speed and accuracy are desirable surgical goals and reflect a high level of decision-making and dexterity. The trainee's surgical speed over a period of time was monitored as one measure of progress. The mean time required to complete a coronary anastomosis (graft time) decreased from 12.8±1.9minutes in the first year of training to 9.0±1.9minutes in year four, inter-group variance (ANOVA) was highly significant from year two to year three and from year three to year four (p<0.001). Risk stratification was utilised in the selection of patients for the trainee. Parsonnet score increased from 5.1±3.5 in year one to 6.0±5.0 in year four. Similarly, EuroSCORE increased from 2.1±1.8 to 2.4±2.1. Additionally, variable life-adjusted display (VLAD) plots were constructed in order to provide a visual representation of performance against predicted outcome by EuroSCORE. Successive VLAD plots demonstrate the changing practice of the trainee as it came to resemble more closely that of his instructor and this was achieved without jeopardising patient outcome.peer-reviewe

Are percutaneous coronary interventions changing our coronary surgery practice?

Aim: The aim of this retrospective study was to assess the impact of a growing percutaneous coronary intervention (PCI) program on our coronary artery bypass graft (CABG) practice. Method: The data were collected from 300 consecutive surgical patients from January 2000 (early series) and from a similar number from July 2008 (recent series). Results: Our recent series presented an increased risk (mean Parsonnet scores rose from 5.5 to 7.3, mean euroSCORE rose from 2.4 to 3.1). The mean age increased from 60.3 to 63.8 years, with the percentage of patients over 70 rising from 14.3 to 29.1%. The proportion of females increased from 15.1 to 18.6%. Mean number of vessels grafted diminished from 3.24 to 3.02 per case. Fewer coronary arteries over 3mm diameter were grafted and more advanced atheroma was encountered at the site of grafting in the recent series. Conclusion: The rise in PCI was associated with a smaller surgical population presenting an increased risk and challenge to the cardiac surgical team.peer-reviewe