Adult Cardiac Aorta
A1 Perfusion Strategies for Thoraco Abdominal Aortic Aneurysms—Our Institutional Experience
Selvaraj, Sam, Mr; PVS, Prakash, Mr; Rajamani, Selvakumar, Mr; C George, Thomson,
Mr; Santhosh, Gopika, Ms; Shetty, Varun, Dr; Shahansha, S, Mr
Narayana Health Hospitals, Bangalore, India
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A1
Background
Thoraco Abdominal Aortic Aneurysm (TAAA) is rare, occurring in approximately 6–10
per every 100,000 people. But surgical correction of this pathology possesses serious
complications like paraplegia and spinal cord problems. The overall 30-day mortality
and paraplegia results are 8.5% and 4.2% respectively.
Methods
Between Jan 2019 & Sept 2021 we have performed about 12 Thoraco Abdominal Aortic Aneurysm
cases and our perfusion techniques for this type of surgery provides good clinical
practice and prevents the neuro, spinal cord, gut and renal related complications.
All the 12 cases are retrospectively analysed in detail for perfusion techniques,
neurological outcome, renal function and the post-operative outcome.
Operative technique
CPB established with cannulation on PA, RA and Descending Aorta or Femoral venous
and Descending Aorta. The surgery was performed at 26 °C and
Systemic Potassium was administered into the venous reservoir to arrest the heart
. Retrograde cerebral perfusion was performed through the Long Femoral venous cannula.
Once the Proximal anastomosis is done under RCP, the upper body flow is established
by the sidearm of the anteflo graft. The abdominal vessels are perfused by Silicon
catheter. The abdominal vessels and renal arteries are anastomosed one after another
to the arms of coselli graft. We perfused the renal arteries with renoplegia every
10 min in each renal artery. Once the descending aorta is anastomosed the clamp is
removed and rewarmed to 36 °C. Hemostasis secured and came off CPB uneventfully.
Results
There was no incidence of any neurological deficit in the post-operative period for
all the 12 Patients. Two patients required tracheostomy in the post-operative phase.
The Sr. Creatinine was in the desirable range and there was no gut ischemia in the
post-operative period.
Conclusion
Our strategic planning of perfusion techniques for the Thoraco Abdominal Aortic Aneurysm
cases resulted in yielding favorable outcome.
A2 Acute type A Aortic Dissection—A Welsh National Audit
Smith, Harry
1, Dr; Chan, Jeremy1, Dr; Mehta, Dheeraj2, Mr; Kumar, Pankaj1, Mr; Field, Mark3, Prof
1Morriston Hospital, Swansea, UK; 2University Hospital of Wales, Cardiff, UK; 3Liverpool
Heart and Chest Hospital, Liverpool, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A2
Background
Acute type A Aortic Dissection (TAAD) is a time-critical, cardiac surgical emergency.
Mortality for TAAD increases 1% per hour. Research showed that TAAD was considered
in < 50% of patient presented to A&E and 33% were treated for an incorrect diagnosis.
We aimed to perform a national audit to evaluate our performance in Wales.
Methods
All Welsh patients underwent surgery for TAAD from 2007 to 2019 were identified. A&E
notes, CT report, cardiac surgical data base and survival status was evaluated in
individual hospital’s data base. The A&E assessment, time of diagnosis (CT) and mortality
rate were analysed.
Results
99 patients underwent TAAD in all 3 centres during the above period. The median time
from assessment to diagnosis was 222 min (Ranged 34–14,424). No statistically significant
differences were seen between time of assessment to diagnosis across the three sites
(p = 0.07) and to survival status (p = 0.66).
Conclusion
Further work is required to raise awareness of TAAD in Wales, delay in diagnosis correlates
with increased risk of mortality and this can be mitigated through increasing awareness
amongst clinicians throughout Wales.
A3 High Wall Shear Stress Can Predict Wall Degradation in Ascending Aortic Aneurysms:
a Biomechanics Approach to Risk Stratify Disease
Salmasi, M Yousuf, Dr; Pirola, Selene, Dr; Sasidharan, Sumesh, Dr; Fisichella, Serena
M, Ms; Jarral, Omar A, Dr; O'Regan, Declan, Prof; Moore Jr, James E, Prof; Xu, Xiao
Yun, Prof; Athanasiou, Thanos, Prof
Imperial College London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A3
Objective
Blood flow patterns can alter material properties of ascending thoracic aortic aneurysms
(ATAA) via vascular wall remodelling. This study examines the relationship between
wall shear stress (WSS) obtained from image-based computational modelling with tissue-derived
material properties of the ATAA wall using segmental analysis.
Methods
Ten patients undergoing surgery for root or ascending ATAA were recruited. Exclusions:
bicuspid aortopathy, connective tissue disease. All patients had pre-operative 4-dimensional
flow magnetic resonance imaging (4D-MRI), allowing for patient-specific computational
fluid dynamics (CFD) analysis and anatomically precise time-averaged WSS mapping of
ATAA regions (12 segments per patient). Aneurysmal aortic samples were obtained from
surgery and subjected to region specific tensile failure and peel testing (matched
to WSS segments). Computational pathology was used to characterise elastin/collagen
abundance and smooth muscle cell (SMC) count. Multilevel hierarchical regression modelling
was conducted to analyse the influence of aortic flow on material properties of the
aortic wall.
Results
Elevated values of time-averaged WSS (TAWSS) were predictive of: reduced wall thickness
(coef − 0.0489, 95% CI [− 0.0905, − 0.00727], p = 0.022) and dissection energy function
(longitudinal) (− 15,0, 95% CI [− 33.00, − 2.98], p = 0.048). High TAWSS values also
predicted higher ultimate tensile strength (coef 0.136, 95% CI, [0 0.001, 0.270],
p = 0.048) i.e. increased wall stiffness. Additionally, elevated TAWSS predicted a
reduction in elastin levels (coef − 0.276, 95% [CI − 0.531, − 0.020], p = 0.035) and
lower SMC count (coef − 6.19, 95% CI [− 11.41, − 0.98], p = 0.021). TAWSS was found
to have no effect on collagen abundance or circumferential mechanical properties.
Conclusions
Our study identifies a strong association between WSS and aortic wall degradation
in ATAA disease. Further studies will help identify its utility in predicting acute
aortic events.
A4 Endovascular Treatment of Ascending Aortic Pathology- A Meta-Analysis
Alwis, Shehani
1, Dr; Mozalbat, David2, Mr; Cyclewala, Shabnam
1, Dr; Metwalli, Amr3, Ms; Athansiou, Thanos3, Mr; Salmasi, M Yousuf3, Mr; Nienabar,
Christoph A.3, Prof
1Barts Health NHS Trust, London, UK; 2St George's Hospital, London, UK; 3Royal Brompton
and Harefield NHS Trust, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A4
Objectives
Open surgical repair is the established gold standard treatment for pathology of the
ascending aorta (AA). In recent years, endovascular stenting (TEVAR) of the AA has
been attempted, but only in expert centres with a limited understanding of outcomes.
This study aimed to systematically review the literature to determine the safety and
outcomes of stenting in the ascending aorta.
Methods
A systematic literature search was conducted in 5 online databases, incorporating
cohort studies and case series of patients undergoing TEVAR for pathology in the AA
region. Case reports were excluded Qualitative analysis of patient covariates and
outcomes were measured using pooled meta-analysis. Meta-regression was used to assess
the influence of covariates on complication rates.
Results
Overall, 25 full-text titles were included, encompassing a total of 572 endovascular
procedures, the majority of which were elective aneurysm repairs (89%), and 11% acute
aortic dissection. Pooled analysis revealed a procedural mortality as 4.19%. The incidence
of endoleaks was17.6% and at long-term follow-up 17.1% (98 cases) required reintervention.
Neurological complications occurred at a rate of 6.8% which was a combination of major
strokes, minor strokes and spinal cord ischaemia.
A meta-regression analysis revealed congestive heart failure as a predictor post-operative
endoleak (coef 27.47, 95% CI [6.53, 48.42], p = 0.017). No other variables (age, gender
diabetes, PVD, COPD) were shown to be predictive of endoleaks post-operatively. The
presence of diabetes as a covariate was found to be a predictor of lower rates of
re-intervention (coef − 17.66, 95% CI [− 28.2, − 7.14], p = 0.004).
Conclusions
Endovascular repair of ascending aortic aneurysms is a safe alternative to surgery
in high-risk patients, although the risks of endoleaks and re-intervention are not
negligible. This analysis indicates careful patient selection is needed, especially
to ensure a good short-term outcome.
A5 Impact of Perioperative Sarcopenia on In-hospital Mortality and Spinal Cord Ischaemia
Following Open Thoracoabdominal Aortic Aneurysm Repair (TAAA)
Simoniuk, Urszula
1, Ms; Christodoulidou, Michelle2, Miss; Ntouskou, Marousa3, Miss; Shaw, Mathew3,
Mr; Richards, Toby2, Mr; Muneer, Asif4, Mr; Kuduvalli, Manoj3, Mr; Field, Mark3, Prof;
Theologu, Thomas3, Mr; Y Oo, Aung1, Prof
1St Bartholomew's Hospital, London, UK; 2University College London, Division of Surgery
and Interventional Sciences, London, UK; 3Liverpool Heart and Chest Hospital, Liverpool,
UK; 4NIHR Biomedical Research Centre UCLH and Division of Surgery and Interventional
Science UCL, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A5
Table 1. Cohort Mortality
Total number of the patients (n-88)
Male (n-47) p value
Female (n-41) p value
Age
0.035 (U = 81.500)
0.054
Hypertension
0.81
0.026 OR = 0.590 CI 95% [0.45–0.766]
0.46
Sarcopenia
48(54.5%)
0.54
0.016 OR = 10.9 CI 95% [1.135–104.807]
TAAA Extent V
1 (6.7%)
0.02 OR = 1.14 CI 95% [0.88–1.48]
0.54
Stroke
4 (26.7%)
0.049 OR = 5.25 CI 95% [0.89–30.7]
0.34
Re-operation
4 (26.7%)
0.23
< 0.0001 OR = 33 CI 95% [3.59–303]
Haemofiltration
10(66.7%)
0.29
0.035 OR = 8.46 CI 95% [0.88–80.5]
Spinal Cord Ischaemia
5 (33%)
0.85
< 0.001 OR = 21.3 CI 95% [2.69–168.9]
Paraplegia
4 (26.7%)
0.51
< 0.0001 OR = 68 CI 95% [4.97–928.89]
Objective
Sarcopenia is defined as loss of skeletal mass making it a quantifiable marker for
frailty. We aim to evaluate whether sarcopenia may predict postoperative outcomes
like spinal cord ischaemia and mortality following open TAAA.
Methods
Between 2008–2017, we identified 88 out of 232 patients who underwent open TAAA repair
with available preoperative imaging for sarcopenia evaluation. Sarcopenia was defined
by the skeletal muscle index using specialised computer software and CT imaging. To
reduce reporting bias, we analysed male and female subgroups, as gender is known to
cause differences in body composition.
Results
Female
In-hospital mortality in sarcopenic patients was significantly higher compared to
non-sarcopenic group following the surgery (p = 0.013). Additionally, univariate analysis
revealed that sarcopenia (p = 0.016), spinal cord ischaemia (p < 0.001), paraplegia
(p < 0.0001), redo-surgery (p < 0.0001), and post-op haemofiltration (p = 0.035) influenced
hospital mortality. Following multivariate analysis, haemofiltration and sarcopenia
remained independently predictors of mortality (95%CI;p < 0.05).
Male
Univariate analysis identified age, hypertension, and postoperative stroke as statistically
significant with in-hospital mortality. In-hospital mortality in the sarcopenic vs
non-sarcopenic group was higher but not significant (p = 0.55).
Conclusions
Sarcopenia correlates with poor survival outcomes and higher in-hospital mortality
in female patients compared to non-sarcopenic group. It has the potential of becoming
a valuable tool in assessing preoperative frailty to assist in perioperative risk
stratification of aortic patients. This is the first study evaluating sarcopenia in
extensive TAAA repair, and further studies in a larger group are required to assess
the full impact of this frailty marker on patient outcomes.
A6 Identification of High-risk Cases Through Micromechanical Characterisation of Aneurysmal
Aortic Tissues
Hossack, Martin
1, Mr; Fisher, Robert1, Prof; Torella, Francesco1, Prof; Field, Mark2, Mr; Madine,
Jillian3, Dr; Akhtar, Riaz4, Dr
1Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK; 2Liverpool Heart
and Chest Hospital NHS Foundation Trust, Liverpool, UK; 3Institute of Systems, Molecular
and Integrative Biology, University of Liverpool, Liverpool, UK; 4Mechanical, Materials
and Aerospace Engineering, University of Liverpool, Liverpool, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A6
Objectives
Use of a maximum diameter threshold as the sole indicator for aneurysm repair risks
rupture during surveillance in higher-risk cases, and unnecessary repair in others.
Here, we utilise nanoindentation, a high-resolution technique capable of measuring
the material properties of vascular tissue non-destructively at an appropriate length-scale.
This study aims to characterise the micromechanical properties of aneurysmal aortic
tissue to personalise rupture risk and direct specific management.
Methods
Full thickness aortic wall tissue samples were harvested from 8 patients undergoing
repair of thoracoabdominal aneurysm (n = 1), aneurysmal dilatation of chronic aortic
dissection (n = 1), asymptomatic (n = 3) and symptomatic (n = 2) abdominal aortic
aneurysm, and stent explantation after failed endovascular repair (n = 1). We probed
the micromechanical properties using nanoindentation with a 100 mm flat punch tip,
determining the shear storage modulus (G′). We performed 4–5 indentations in axial
orientation on cross-sectional wall samples in 3 layers (inner, middle, outer) where
possible. 9–10 samples were tested from each patient. In total, there were 89 samples
(962 indentations).
Results
All tissues demonstrated a pattern of reducing stiffness from the luminal to abluminal
edge (median 30.6 kPa vs 12.9 kPa, P < 0.05), likely a consequence of atherosclerosis
affecting the intima. Symptomatic aneurysms were stiffer than asymptomatic (median
20.9 kPa vs 16.1 kPa, P < 0.05), whilst tissue from the explantation subgroup demonstrated
significantly higher stiffness (median 41.6 kPa) than all others, which were not significantly
different (Fig. 1).
Conclusions
This micromechanical approach may distinguish between higher risk (symptomatic) and
lower risk (asymptomatic) aneurysms. Aortic wall micro-stiffness may be an indicator
of high-risk aneurysm. Further studies are needed to confirm the findings and correlate
aortic stiffness with clinical and radiological presentation.
A7 The Elephant in the Room, Does Frozen Elephant Trunk Offer Better Outcomes in Type
A Aortic Dissection? A Comparative Study in a Single Centre
Moawad, Nader, Mr; Sinha, Shubhra, Miss; Harfield, Jack, Mr; Villaquiran, Jaime, Mr;
Villaquiran, Christopher, Mr; Wali, Anuj, Mr; Unsworth-White, Jonathan, Mr; Kuo, James,
Mr
Derriford Hospital, Plymouth, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A7
Objectives
To compare the outcomes of hybrid stented graft (Frozen elephant trunk) versus other
operative strategies in surgical repair of acute aortic dissection.
Methods
Single centre retrospective analysis of prospectively collected data for patients
undergoing repair of acute type A Aortic dissection repair between April 2012 and
October 2021 (N: 181). They were divided into two groups; Group A had isolated Ascending
Aorta replacement +/− extension to Aortic arch (N: 152), Group B had FET (N: 29).
Results
Pre-operative characteristics were comparable between the two groups. Cardiopulmonary
bypass times and cross-clamp times were shorter in Group A. However, when comparing
Arch replacement case cases from Group A with Group B, the times were comparable.
There was no marked difference in reoperation for bleeding, dialysis nor sepsis between
both groups. The incidence of temporary neurologic dysfunction was slightly higher
in group B (24% vs 17%). The 30-day mortality was lower in Group B (13.8% Vs 20.4%)
but this did not reach statistical significance due to the small sample size. At median
follow-up of 3 years there was a trend towards improved survival in Group B.
Conclusion
Frozen Elephant trunk offers good early results and comparable operative times to
other surgical techniques. We believe that it should be considered as first-line therapy
in experienced centres.
A8 Subacute Dissection—Saturday Night TEVAR
Muston, Benjamin
1, Mr; Guo, Allen1, Mr; Sahai, Prachi2, Ms; Wilson-Smith, Ashley3, Dr
1University of New South Wales, Sydney, Australia; 2University of Newcastle, New South
Wales, Australia; 3Chris O’Brien Lifehouse Center, Sydney, Australia
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A8
Objectives
While there has been discussion in the field for some time regarding the preference
of medical management, open surgery or minimally invasive intervention for the treatment
of aortic dissection, the subacute population is an upcoming and relatively unknown
cohort. This systematic review and meta-analysis provides a complete aggregation of
reported long-term survival and freedom from reintervention of subacute complicated
Type B aortic dissection patients based on the existing literature.
Methods
Three online databases (Embase, Medline, Scopus) were searched from date of inception
until June 2021, accruing a total of 2580 references which were reviewed by three
independent authors. The primary endpoints were survival and freedom from reintervention,
whilst secondary endpoints were post-operative outcomes, such as technical success
and endoleak. Kaplan–Meier curves were digitized and aggregated to graph estimated
survival data.
Results
Sixteen studies were selected according to our criteria, yielding 365 patients with
a mean age of 59.1 ± 6.0 years. The ‘subacute’ cohort had a mean time from symptom
onset to diagnosis of 21.0 ± 2.6 days, differentiating it from both acute and chronic
dissection definitions. Overall survival at 1, 3, and 5 years was 85.7%, 73.9% and
71.2%, respectively. Freedom from reintervention at 1, 3 and 5 years was 88.0%, 78.0%
and 73.1%, respectively.
Conclusions
This systematic review and meta-analysis described the first aggregated survival data
for a subacute dissection cohort receiving thoracic endovascular aortic repair to
date. TEVAR is associated with promising long-term outcomes to 5-years, with high
rates of technical success, though more data is needed to make true comparisons to
acute/chronic cohorts. Randomized controlled trials involving TEVAR for aortic dissection
with varying chronicity is required for progression in this field.
A9 Type-I Aortic Dissection: The Fate of Distal Aorta Following Limited to the Ascending
Aorta Repair
Verdichizzo, Danilo, Mr; Braithwaite, Simon, Dr; Kemp, Ben, Dr; Kearns, Daniel, Dr;
D'Alessio, Andrea, Mr; Ttofi, Iakovos, Mr; Power, Harvinder, Dr; Keiralla, Amar, Dr;
Uberoi, Raman, Dr; Krasopoulos, George, Mr
John Radcliffe Hospital, Oxford, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A9
Objectives
The aim of this study was to assess the remodelling of distal aorta after emergency
limited to ascending aorta repair of acute De Bakey type I aortic dissection.
Methods
55 surviving patients (2011–2019) were enrolled. All patients had pre-operative computed
tomography (CT) scan and at least one follow-up CT. Intramural haematomas and retrograde
dissections were excluded. The repair was limited to the ascending aorta (± aortic
root), with open distal anastomosis at Zone-0. Longitudinal study analysis was applied
for unbalanced data. Mixed effect linear regression model with random intercept and
random slopes was used.
Results
Median age 59 (IQR:52–66), 39 (71%) male; Log-EuroSCORE 21.10(12.35–21.90); cardiopulmonary
bypass 175 min (146–197), cross clamp 84 min (59–120), circulatory arrest 23 min (20–31),
length of stay 11 days(IQR 7–18), follow-up 39 months (29–73).
Presence of residual patent false lumen (pFL) has a significant adverse impact on
the remodelling to the aortic arch with fixed effect related growth of 4.42 mm/year
(inter-individual variance 3.87 mm/year, p = 0.05) and 4.64 mm/year for descending
thoracic aorta (individual variance 4.32 mm/year, p = 0.03).
The aortic dilatation adverse remodelling was not associated with increased mortality.
Conclusions
Limited to the ascending aorta surgical repair of a Type-I aortic dissection with
pFL is a life-saving procedure that leads into a time related negative remodelling
and possible need for further interventions.
A10 Is Rural Status Associated with Adverse Outcomes in Patients Undergoing Surgery
for an Acute Type A Aortic Dissection: A Western Australian Study
Eranki, Aditya, Dr
John Hunter Hospital, Newcastle, Australia
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A10
Introduction
Acute Type A Aortic Dissection (ATAAD) represents a cardiothoracic emergency and should
be managed without delay. Western Australia is an expansive state of 2.5 million square
kilometeres with a network of regional centres and cardiothoracic centres located
in the capital Perth. The aim of this study is to assess the differences in presentation
and outcomes between rural and urban patients undergoing emergent repair for an ATAAD.
Methods
We performed a retrospective analysis of all patients undergoing emergent repair of
an ATAAD at Fiona Stanley Hospital between 2015 to 2020. A number of variables associated
with the patient’s geography, physiology, and postoperative outcome were assessed.
Univariate and multivariate logistical regression analysis was performed to evaluate
significant differences between the cohorts.
Results
A total of 64 patients underwent emergent repair of an ATAAD between 2015–2020. The
overall 30-day mortality rate was 20%. The 30-day mortality rate in the rural cohort
was higher than the urban cohort (30% vs 16%) however this was not statistically significant.
The rural cohort faced a higher median time to surgery (12 vs 6 h, P = 0.002) and
are likely to require transfer between more than two centres (7 vs 1, P = 0.001).
Rural patients were also more likely to require resuscitation perioperatively (OR
4.33, P = 0.013) and more likely to require return to theatre postoperatively (OR
7.60, P = 0.002). Both return to theatre and multi-hospital transfer were associated
with rural status in multivariate analysis.
Conclusion
Rural patients wait twice as long for definitive surgery as their urban counterparts
and require multi-hospital transfer. Rural patients are more likely to present in
a critical peri-operative state requiring resuscitation, and have a significantly
higher risk of returning to theatre post operatively.
A11 Risk Factors for Haemofiltration Following Surgery on the Descending Thoracic
and Thoracoabdominal Aorta
Bennett, James, Mr; Field, Mark, Prof; Kuduvalli, Manoj, Mr; Doonan, Robert, Mr; Shaw,
Matthew, Mr
Liverpool Heart and Chest Hospital, Liverpool, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A11
Objectives
Open surgical repair of the thoracoabdominal aorta (TAA) and descending thoracic aorta
(DTA) carries significant morbidity risk. We sought to identify risk factors for haemofiltration
(HF) requirement after TAA and DTA surgery.
Methods
Retrospective analysis was conducted using characteristics of 491 patients undergoing
TAA or DTA repair from October 1998 to October 2021 at a single institution. HF by
perfusion modality was assessed in 346 patients. Univariate and multivariate analyses
were performed to identify predictors of post-operative HF.
Results
New post-operative HF was required in 66 (13.4%) patients. HF was associated with
increased age (median age = 63 vs 66; p = 0.03) and lower pre-operative estimated
glomerular filtration rate (eGFR) (median 76 vs 68; p = 0.01). Patients who required
TAA Extent II (p < 0.001) or III (p = 0.01) repair were more likely to require HF.
For TAA repair, HF was required in 35 (21.6%) patients when left heart bypass (LHB)
was used and 6 (16.2%) patients when deep hypothermic circulatory arrest (DHCA) was
used. For DTA repair, HF was required in 2 (4.8%) patients when LHB was used and 2
(4.2%) of patients when DHCA was used.
Need for HF was associated with in-hospital mortality (28.8% vs. 9.9%, p < 0.001),
stroke, paraplegia, and need for reoperation. HF was associated with longer ICU stay
(p < 0.001).
Multivariable analysis revealed increasing age (OR (95% CI) = 1.03 (1.01, 1.06); p = 0.005),
body mass index ≥ 25 (1.86 (1.03, 3.36); p = 0.039 and Extent II or Extent III surgery
(4.83 (2.71, 8.63); p < 0.001) were associated with post-operative HF.
Conclusions
Age, baseline renal function, BMI, and extent II/III operations were associated with
post-operative HF in TAA and DTA surgery. Need for post-operative HF was also associated
with complications such as death, stroke, paraplegia, need for reoperation and extended
length of stay.
Aortic Presentation
No Post-op HF (n = 425)
Post-op HF (n = 66)
P value
DTA Type A
41 (9.7)
2 (3.0)
0.08
DTA Type B
16 (3.8)
2 (3.0)
> 0.99
DTA Type C
91 (21.4)
4 (6.1)
0.003
TAA Extent I
62 (14.6)
7 (10.6)
0.39
TAA Extent II
122 (28.7)
35 (53.0)
< 0.001
TAA Extent III
31 (7.3)
11 (16.7)
0.01
TAA Extent IV
23 (5.4)
3 (4.6)
> 0.99
TAA Extent V
12 (2.8)
2 (3.0)
> 0.99
Data N/A
27 (6.4)
0 (0)
0.04
A12 Patient Reported Outcome Measures in Patients Undergoing Proximal Aortic Surgery
for Aneurysmal Disease – A Pilot Study
Shaw, Matthew1, Dr; Salem, Agni
2, Miss; Day, Jennie3, Dr; Oo, Aung4, Prof; Field, Mark2, Prof; Haycox, Alan3, Dr;
Rowe, Michael3, Dr
1No affiliation; 2Liverpool Heart and Chest Hospital, Liverpool, UK; 3University of
Liverpool, Liverpool, UK; 4Barts Health NHS Trust, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A12
Objectives
Surgical interventions to treat aortic aneurysms are relatively invasive and can impact
greatly on well-being, particularly as patients are often asymptomatic. Tracking post-operative
health-related quality of life (HRQOL) is problematic as patient reported outcome
measures (PROMs) have not yet been specifically designed for this disease. This study
aims to assess the feasibility of PROM delivery and HRQOL reporting in this patient
cohort.
Methods
Suitable patients scheduled for elective aortic surgery at Liverpool Heart and Chest
Hospital between October 2017 and March 2019 were identified and invited to participate
in the pilot study. Patients were asked to complete the PROM prior to surgery and
then at 6 weeks and 3 months after their operation. The PROM items were arranged into
four domains: symptoms, physical, psychosocial and cognitive. The newly developed
instrument underwent preliminary testing for its appropriateness, acceptability, feasibility,
interpretability, precision, reliability and responsiveness.
Results
In total, 30 patients completed all 3 questionnaires. Initial testing showed that
the newly developed instrument performed to acceptable standards. It showed good internal
consistency (Cronbach’s alpha results for all domains > 0.85), and test retest reliability
(intraclass correlation coefficient for all domains > 0.85). In paired sample tests,
the values in each domain led to statistically significant differences from baseline
at either 6 weeks or 3 months (p < 0.05), supporting the construct validity and responsiveness
of the instrument.
Conclusions
The PROM pilot questionnaire demonstrated satisfactory validity as well as good internal
reliability and test–retest reliability for each item across all four domains. The
PROM identified a negative impact of a diagnosis of aneurysm on all domains and a
positive influence of surgery.
A13 The Risk of Right Ventricular Outflow Tract Breach or Rupture in Patients Undergoing
Aortic Valve Sparing Procedures
Abdul Hakeem, Muhammad, Mr; Shaw, Matthew, Mr; Kenawy, Ayman, Mr; Othman, Ahmed, Mr;
Harrington, Deborah, Ms; Kuduvalli, Manoj, Mr; Field, Mark, Prof; Nawaytou, Omar,
Mr
Liverpool Heart and Chest Hospital, Liverpool, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A13
Objective
Deep anterior dissection (DAD) separating the RVOT from the interventricular septum
may be necessary in some cases of aortic valve and root repair to reach below the
level of the basal ring anteriorly.
This may help support the aortic annulus, and prevent late incompetence. However,
this technique may breach the RVOT. This study aims to identify patients at higher
risk of having this complication.
Methods
We included all patients having valve preserving aortic root surgery with either David's
procedure, or complete external ring annuloplasty, from November 2017 to September
2021, in our centre.
We identified patients in which DAD was needed to reach below the basal ring. We also
identified patients in which the RVOT was breached. We used logistic regression to
identify predictors for these outcomes.
Results
147 patients were included. Mean age was 51 years. DAD was required in 93 patients
(63%).
Mean pre-operative annular diameter was 26.5 mm, mean diameter at the sinuses of Valsalva
was 48 mm. 41 patients (28%) had bicuspid aortic valves (BAV). 11 patients were re-explored
for bleeding, 8 of which had had DAD, one patient was to repair an RVOT breach. Predictors
for DAD were age (OR 0.94), connective tissue disorders (OR 15.9), BAV (OR 8.9) and
preoperative annulus diameter (OR 1.2), on multivariable logistic regression. Anterior
leaflet prolapse was the only predictor of RVOT breach (OR 3). All patients left the
operating theatre with aortic incompetence of 1/4 or less.
Conclusion
DAD is safe when used to augment annular support. Younger age, connective tissue disorders,
wider annuli and BAV required DAD to reach below the basal anterior ring, as these
patients have a more extensive anterior annular dilation into the septum. Caution
is needed in patients with anterior leaflet prolapse, as they show extreme anterior
annular degeneration, and are prone to RVOT breach. Further follow-up is needed to
assess the role of DAD in maintaining aortic valve competence.
A14 Predictors of Permanent Pacemaker Implantation Following Valve Preserving Aortic
Root Procedures
Abdul Hakeem, Muhammad, Mr; Rao, Archana, Dr; Kenawy, Ayman, Mr; Othman, Ahmed, Mr;
Harrington, Deborah, Ms; Kuduvalli, Manoj, Mr; Field, Mark, Prof; Nawaytou, Omar,
Mr
Liverpool Heart and Chest Hospital, Liverpool, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A14
Objective
Unlike valve replacements, data regarding the need for permanent pacemaker (PPM) following
valve preserving root surgery has not been adequately investigated. This study aims
at detecting predictors of PPM implantation following these procedures.
Methods
We included patients who had valve preserving root surgery, with either David's Procedure,
or a complete external annuloplasty, at our centre, between November 2017 and April
2021. We excluded intraoperative conversions to valve replacement, and those who had
only subcommisural annuloplasty or lone leaflet repair.
Decision for PPM was based on significant conduction abnormality lasting at least
4 days postoperatively, after consulting electrophysiology team.
Results
120 patients were included. Mean age was 52 years.
David's procedure was done in 114 patients (95%), 6 patients had external annuloplasty.
9 patients (7.5%) had a PPM, of which 3 had preoperative first-degree AV block.
33 patients had bicuspid aortic valves (28%).
65% of patients had significant preoperative aortic incompetence, and 46% had preoperative
annular dilatation (> 26 mm).
Significant predictors of PPM implantation were mild or moderate LV systolic dysfunction
(OR 7.2 and 8.6, p-value 0.04 and 0.02, respectively), preoperative aortic annular
diameter (OR 1.19, p-value 0.04) and preoperative LVESD (OR 1.09%, p-value 0.02).
PPM was inserted between post-operative day 4 and 14 (median day 9). At 3 months after
insertion, 7 out of 9 patients had > 90% pacing. One patient had significant LV dysfunction
with RV pacing.
Conclusion
PPMs remain a problem in valve preserving aortic root surgery.
We employ deep anterior dissection, separating RVOT from the muscular interventricular
septum, this may explain our higher rate of PPMs, in addition to the fact that 18%
of our patients had preoperative conduction abnormalities.
Caution has to be employed in patients with a dilated annulus, as they are at risk
for conduction disorders.
A15 Organ Protection Strategies in Thoracoabdominal Aortic Aneurysm (TAAA) Repair
– A Single Centre Experience
Simoniuk, Urszula, Ms; Naruka, Vinci, Mr; Mangel, Tobin, Miss; Lopez-Marco, Ana, Miss;
Adams, Benjamin, Mr; Mastracci, Tara, Miss; Oo, Aung, Prof
St Bartholomew's Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A15
Objective
Organ ischaemia following TAAA repair is associated with significant comorbidities.
The incidence varies depending on the aortic centre practice: spinal cord ischaemia
(15–20%), stroke (8.1–10%) or renal impairment (20%). We aim to determine the outcomes
and effectiveness of organ protection techniques during TAAA repair.
Methods
Retrospective analysis of 88 patients who underwent open (75) and endovascular (13)
TAAA repair between 2017–2021. The cohort contained: Crawford extent I (9), II (55),
III (12), IV (12) TAAA repair, of which 23.9% of procedures were non-elective. We
evaluated intraoperative methods of spinal cord protection based on local protocol.
The renal protection strategies included blood or cold crystalloid perfusion, and
cerebral protection was monitored using cerebral near-infrared spectroscopy (NIRS).
Results
Overall mortality in the analysed cohort was 21.6%, including 17% in the Crawford
extent II subgroup.12.5% of patients developed spinal cord ischaemia post-operation.
14,8% of patients sustained renal impairment. Spinal cord ischaemia (p = 0.039) and
haemofiltration (p = 0.0062) significantly influenced cohort mortality. 8% of patients
developed stroke. The spinal cord protection protocol incorporated: cerebrospinal
fluid drainage 81(92%), left heart bypass 66 (75%), intercostal arteries reimplantation
49 (55.7%), motor evoked potential monitoring 61 (69.3%), controlled hypertension,
Hb > 100 and paraspinal NIRS. The renal perfusion was protected using cold crystalloid
34(38.6%) or blood 6(29.5%). Cerebral perfusion was monitored in all patients.
Conclusion
The organ protection programme's introduction helps decrease significant comorbidities
like spinal cord ischaemia, renal impairment or stroke associated with TAAA repair.
It is an essential component of the strategy for preventing ischaemia complications
and improving postoperative complications.
A16 The Acute Aortic Dissection Pathway—Reviewing the Referral Process to a Tertiary
Centre and Impact on Operative Mortality and Complications
Ashraf, Muhammad Arsalan
1, Mr; Mcgurk, Catherine
2, Miss; Salmasi, Mohammad Yousuf3, Mr; Zargaran, David1, Mr; El-Hilly, Abdulrahman1,
Mr; Jarral, Omar1, Mr; Baig, Kamran1, Mr; Sabetai, Michael1, Mr
1Guy's and St Thomas' NHS Foundation Trust, London, UK; 2King's College London, London,
UK; 3Department of Surgery, Imperial College London, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A16
Objectives
Acute Type A Aortic Dissections (AAD) often require transfer to a tertiary centre
for surgical management. There are no universal transfer guidelines for these patients
and little is known regarding impact on patient outcome. We aim to determine transfer
timings from onset of symptoms to knife to skin, the extent of medical optimisation
during transfer, and the impact on operative mortality.
Methods
A retrospective analysis of 118 patients referred to St. Thomas’ Hospital from Southeast
England for emergency surgical repair of AAD between 2014–2020. Notes were evaluated
to identify timings of each step of the referral process and optimisation of patients.
Regression analysis was performed to determine impact of these on outcome.
Results
Mean time from onset of symptoms to incision was 22.1 h. Mean time to diagnosis following
admission was 8.65 h, from referral to incision 7.6 h and in transit was 1.02 h. During
transit, 49% had blood pressure control with an infusion, 45% had an arterial line,
31% catheterized and 35% were accompanied by a medical escort. 51% were misdiagnosed
on initial presentation. Linear regression analysis found misdiagnosis to be a strong
predictor of patient delay to the operating theatre (coef 841, 95% CI [36—1646], p-0.041).
However, neither misdiagnosis nor patient delay were related to operative mortality,
stroke or renal failure (p > 0.05). Logistic regression found malperfusion pre-op
to be a strong predictor of patient death (OR 6.7, 95% CI [1.7—26.0, p = 0.006).
Conclusion
This cohort is the first evaluation of the timings and variability in medical optimisation
during transfer of patients with AAD. Our results show that misdiagnosis is a significant
cause for delay in in overall transfer time. Malperfusion was the only statistically
significant predictor of mortality immediately post-op. Future work will evaluate
survival outcomes related to the transfer timings and formulate a transfer optimisation
guideline.
A17 In-hospital and Long-term Outcomes of Surgery in Patients with Acute Type A Aortic
Dissection: A 15-year Experience
Jos, Helena, Ms; Wicks, William, Mr; Hamid, Umar, Mr; Awad, Wael IMr
Barts Health NHS Trust, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A17
Objectives
To evaluate long-term outcomes of patients with acute type A aortic dissection (ATAAD)
undergoing surgical repair at our centre over a 15-year period.
Methods
Patient demographics, operative details and post-operative outcomes were analysed
for the period of January 2005 to September 2020. This period was divided into First
Half (2005–2012) and Second Half (2012–2020) to assess trends. Kaplan–Meier curves
were constructed to establish long-term survival.
Results
A total of 323 patients underwent ATAAD repair during this period. The mean age of
the cohort was 59.2 ± 15.3 years, 222 patients out of 323 (68.7%) were male; 24 out
of 323 (7.4%) had previous cardiac surgery. There were significant changes between
First Half and Second Half periods including number of cases performed (88/323 versus
235/323, a 167% increase); number of patients undergoing surgery within 24 h of presentation
(22/70 (31.4%) versus 126/227 (55.5%), P = 0.0004); in-hospital mortality (16/88 (18.2%)
versus 60/235 (25.5%), P = 0.1656); ICU stay > 30 days (1/60 (1.7%) versus 23/212
(10.8%), P = 0.0268); post-operative haemofiltration requirement (2/72 (2.8%) versus
25/222 (11.3%), P = 0.0303) and any post-operative cerebrovascular event (15/72 (20.8%)
versus 85/222 (38.3%, P = 0.0066). The overall 5-year survival was 67%, 10-year survival
was 55% and 15-year survival was 38% (Fig. 1), with no significant difference in survival
between the two groups.
Conclusions
The number of ATAAD repair procedures performed increased significantly throughout
our study period. Patients have a more complicated post-operative recovery and both
early and late outcomes remain high.
Figure 1. Kaplan–Meier curve illustrating long-term survival of patients.
Adult Cardiac Aortic Valve
A18 Infected TEVAR Explantation, Descending Thoracic Aorta Repair & Repair of Aorto-Oesophageal
Fistula
Shehata, Monicka, Dr; Rizzo, Victoria, Miss; Price, Nicholas, Dr; Chawla, Amit, Dr;
Sallam, Morad, Mr; Sabetai, Michael, Mr
Guy's & St Thomas' NHS Foundation Trust, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A18
Large
Objectives
This study sought to compare the morbidity and mortality of redo Aortic Valve Replacement
(redo-AVR) versus valve-in-valve Transcatheter Aortic Valve Implantation (valve-in-valve
TAVI) for patients with a failing bioprosthetic valve.
Methods
A multicentre UK retrospective study of redo-AVR or valve-in-valve TAVI for patients
referred for redo aortic valve intervention due to a degenerated aortic bioprosthesis.
Logistic regression coefficients were used for propensity score matching with a tolerance
of 0.01.
Results
From July 2005 to April 2021, 911 patients underwent redo-AVR and 411 patients valve-in-valve
TAVI. There were 125 pairs for analysis after propensity score matching. In-hospital
mortality was 7.2% (n = 9) for redo-AVR vs 0 for valve-in-valve TAVI, p = 0.002. Long-term
mortality was 30.4% (n = 38) vs 15.2% (n = 19), p = 0.004, at 3.30 ± 3.29 years follow-up.
Redo-AVR had worse survival at every moment in time (Kaplan–Meier, p = 0.02). Surgical
patients suffered more post-operative complications, including IABP support (p = 0.02),
early re-operation (p < 0.001), arrhythmias (p < 0.001), respiratory and neurological
complications (p = 0.02 and p = 0.03) and multiple organ failure (p = 0.01). The valve-in-valve
TAVI group reported a shorter intensive care unit and hospital stay (p < 0.001 for
both). Finally, the degree of aortic regurgitation at discharge was significantly
higher in the percutaneous approach (p < 0.001).
Conclusion
Valve-in-valve transcatheter aortic valve implantation, as opposed to redo surgical
aortic valve replacement with a biological prosthesis, appears to be the best treatment
option for elderly patients with a degenerated bioprosthetic valve.
A19 Perioperative Outcomes and Long Term Survival of Octogenarian Patients Undergoing
Re-sternotomy for Aortic Valve Replacement
Masraf, Hannah
1, Miss; G Malvindi, Pietro2, Mr; Luthra, Suvitesh2, Mr; Ohri, Sunil K2, Prof
1University of Southampton, Southampton, UK; 2University Hospital Southampton, Southampton,
UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A19
Objectives
Little data on the safety of re-sternotomy for surgical aortic valve replacement (SAVR)
in octogenarians with prior surgery exists. Our study aims to analyse the perioperative
results and long-term survival outcomes of re-sternotomy for SAVR in octogenarians.
Methods
This is a retrospective, single-centre study (Apr 2000–Dec 2019). Perioperative data
were compared for re-sternotomy with isolated SAVR and re-sternotomy with SAVR and
associated cardiac procedure(s). Uni- and multivariable logistic regression analyses
were performed to identify predictors of inpatient mortality. Cox regression was used
to calculate hazard ratios (HRs) for covariates of long-term survival and Kaplan Meier
survival curves were compared for groups.
Results
There were 163 patients (Isolated redoSAVR; 69, Associated redoSAVR; 94). The median
age was 83 (81–85) years and the median logistic EuroSCORE was 19.2% (13.0–26.7%).
The mean follow-up period was 4.2 ± 3.5 years. Inpatient mortality was 4.9% (1.4%
versus 7.4% for Isolated redoSAVR and Associated redoSAVR respectively, p = 0.08).
Demographics, operative data and postoperative results were broadly comparable between
both groups. Multivariable logistic regression identified COPD as a significant predictor
of inpatient mortality (OR 8.86 95%CI: 1.19, 66.11, p = 0.03). Overall survival was
88.7% at 1 year, 86.4% at 2 years, 70.1% at 5 years, 49.5% at 7 years and 26.3% at
10 years. There was no survival difference between Isolated redoSAVR and Associated
redoSAVR (logrank p = 0.36, Wilcoxon p = 0.84). Significant predictors of adverse
long-term survival were COPD, postoperative TIA/stroke and length of stay. Survival
is comparable but lower than age- and sex-matched first-time SAVR and England's general
population.
Conclusions
RedoSAVR in octogenarians is associated with significant morbidity and mortality although
results are acceptable in carefully selected patients.
A20 Aortic Valve Replacement and Coronary Artery Bypass Grafts. Do Numbers Matter?
Layton, Georgia R., Miss; Marsico, Roberto, Mr; Hadjinikolaou, Leon, Mr; Mariscalco,
Giovanni, Mr; Murphy, Gavin, Prof; Zakkar, Mustafa, Mr
Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester
NHS Trust, Leicester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A20
Objectives
Concomitant aortic valve replacement (AVR) and coronary artery bypass grafting (CABG)
is associated with a mean mortality of 5.4% in the UK. It has been debated whether
number of grafts adversely impacts patient outcomes. We aim to investigate the influence
of number of bypass grafts on in-hospital and long-term survival.
Methods
Retrospective analysis of prospectively collected data of consecutive patients undergoing
AVR + CABG in a single unit between January 2016 and January 2021.
Results
406 patients (mean age 72.5 ± 7.5 years, mean EuroSCORE II 4.7% ± 6.4) were included:
65 had more than 2 grafts in addition to AVR.
There were no significant differences in mean age or surgical risk between groups.
There was a preponderance of male patients with increasing graft number (p = 0.0027).
Overall, in-hospital mortality was 5.7% but this increased significantly with graft
number (p = 0.01). Similarly, there was increased use of IABP by graft number (p = 0.002).
Overall, 0.5% of patient had CVA and 2.2% had TIA which did not differ between groups
(p = 0.7, 0.9 respectively). 22 patients (5.4%) required CVVHF with no difference
between groups (p = 0.06). Logistic regression identified the performance of more
than 2 grafts (OR 3.1, CI 1.2–7.5, P = 0.02), bypass time (OR 1.02, CI 1.02–1.04,
p = 0.001) and BMI (OR 1.01, CI 0.38–8.8, p = 0.04) as independent predictors of in
hospital mortality. Multivariate Cox model identified bypass time but not the number
of grafts as independent predictor of long-term survival. Similarly, 5 years survival
was not impacted by the number of grafts (log rank p = 0.099).
Conclusions
More than 2 bypass grafts in addition to AVR is associated with increased in-hospital
mortality and use of IABP. This highlights the need for consideration of alternative
intervention or hybrid approach for such high-risk patients.
A21 Redo Intervention on the Aortic Valve: Indications, Outcomes and Factors Predicting
Mortality
Oyebanji, Tunde, Dr; Aljanadi, Firas, Mr; Jones, Mark, Mr
Royal Victoria Hospital, Belfast, Northern Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A21
Objectives
To evaluate the indications and early and long-term outcomes of redo surgical aortic
valve replacement (rSAVR).
Methods
The study was carried out retrospectively over ten years (2010–2020). We included
patients requiring isolated redo-AVR, redo-AVR plus CABG, complex aortic surgery involving
AVR, and concurrent mitral valve procedures. Primary outcome was mortality at 30-days,
1, 5 and 10 years. Secondary outcomes were 30-day incidences of stroke, AKI, myocardial
infarction (MI), permanent pacemaker (PPM) requirement, and hospital stay (LOHS).
Results
83 patients had rSAVR during the period. 30 (36.6%) patients required rSAVR because
of endocarditis (mechanical – 11 [13.2%], biological – 19 [23.4%]; p = 0.92) and 31
(37.8%) for bioprosthetic valve degeneration. 30 (36.6%) patients required concomitant
procedures including CABG, aortic root enlargement, aortic root replacement and mitral
valve surgeries. Mortality at 30-days, 1, 5 and 10 years was 14 (16.87%), 16 (19.28%),
19 (22.89%) and 22 (26.51%) respectively. Cox regression showed the following predictors
of mortality: increasing age (HR 1.08, 95% CI 1.03 to 1.14, p = 0.001), long cardiopulmonary
bypass time (HR 1.02, 95% CI 1.01 to 1.02, p < 0.001), endocarditis (HR 8.93, 95%
CI 2.56 to 31.2, p < 0.001), peripheral vascular disease (HR 4.44, 95% CI 1.35 to
14.61, p = 0.01), valve and CABG (HR 21.34, 95% CI 1.55 to 294.62, p = 0.02), and
moderate ejection fraction (HR 9.73, 95% CI 2.87 to 32.98, p < 0.001). Of patients
that died within 30-days of surgery, 9 (64.2%) had endocarditis. The incidence of
stroke, MI, AKI, and PPM were 2.44%, 3.87%, 15.86% and 15.86%, respectively. The mean
LOHS was 26.9 ± 22.3 days. Mean survival time was 99.8 months. 1, 5, and 10-year survival
were 80%, 74% and 64%, respectively.
ConclusionrSAVR achieves good mid and long-term outcomes, but there is significant
postoperative morbidity and mortality. Endocarditis is a common indication and strongly
affects outcomes.
OUTCOME
TOTAL
MECHANICAL
BIOLOGICAL
P-VALUE
AGE (YEARS)
62.14 ± 15.82
56.5 ± 15.44
70 ± 13.11
< 0.05*
GENDER MALE FEMALE
83 50(60.24%) 33(39.76%)
48(57.83) 29(34.94%) 19(22.89%)
35 (42.17%) 21(25.3%) 14(16.87%)
0.97
LOGISTIC EUROSCORE
26.22 ± 21.9
21.77 ± 19.7
32.33 ± 23.55
0.03
MORTALITY 30-DAY 1-YEAR 5-YEARS
14(16.87%) 16(19.28%) 19(22.89%) 22(26.51%)
8(9.64%) 9(10.84%) 11(13.25%) 13(15.66%)
6(7.23%) 7(8.43%) 8(9.64%) 9(10.84%)
0.95
MEAN SURVIVAL (MONTHS)
99.8
98.6
93.4
0.79
SURGERY TYPE VALVE ONLY VALVE + CABG COMPLEX AORTIC
62(74.7%) 9(10.84%) 12(14.46%)
36(43.37%) 4(4.82%) 8(9.64%)
26(31.33%) 5(6.02%) 4(4.82%)
0.59
MYOCARDIAL INFARCTION
3 (3.85%)
0
3 (3.85%)
0.04
STROKE
2 (2.44%)
0
2 (2.44%)
0.097
ACUTE KIDNEY INJURY
13 (15.86%)
6 (7.32%)
7 (8.54%)
0.37
A22 Analysis of Target INRs in Patients with On-X Mechanical Aortic Valve Replacement
– The Gap Between Evidence and Real World Practice
Mangel, Tobin, Dr; Rai, Karan, Dr; Yates, Martin, Mr; Balmforth, Damian, Mr; Lopez-Marco,
Ana, Ms; Shipolini, Alex, Mr; Uppal, Rakesh, Prof; Oo, Aung, Prof
St Bartholomew's Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A22
Objective
The PROACT trial showed the safety of a lower target INR (1.5–2) + Asprin in patients
with an On-X mechanical valve in the aortic position. This is thought to reduce the
risk of anticoagulation-associated bleeding however some surgeons may be reluctant
to reduce target INR. We aim to determine if clinical practice reflects the evidence
for On-X valve INR target values.
Methods
All patients undergoing On-X mechanical aortic valve replacement from June 2017 to
March 2021 were included. Those being anticoagulated for other reasons were excluded.
Electronic patient records were reviewed. Primary outcome was anticoagulation regime
three months following surgery. Secondary outcomes were presence or absence of discussion
of valve choice and anticoagulation plans in the pre or post-operative period.
Results
On-X valves were implanted in 156 patients. Mean age 48 years, 119(76%) were male,
121(78%) elective and 35(22%) urgent. Seventy-five (48%) of patients had a documented
discussion regarding valve choice preoperatively however only eleven (7%) mentioned
specific type of mechanical valve. Seventy-nine (51%) discharge letters had a post-operative
anticoagulation plan for low INR + Aspirin. Of these, 8(10%) were from doctors and
71(90%) were from pharmacy. Follow up clinic letters mentioned low INR + aspirin 28
(18%) patients. Only 34(22%) patients met primary outcome of low INR + Aspirin at
three months.
Conclusion
Despite evidence to run a lower INR, the majority of patients are not advised of this.
This may be due to lack of communication with patients or surgeons/anticoagulation
clinic staffs reluctance to lower INR targets.
A23 Trifecta Aortic Valve Bioprosthesis—Excellent Early and Long Term Outcomes
Karuppannan, Mukesh, Mr; Rose, David, Mr; Walker, Antony, Mr; Bose, Amal, Mr
Blackpool Victoria Hospital, Blackpool, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A23
Objectives
The Trifecta bio-prosthesis is a bovine pericardial valve externally mounted on a
titanium stent. Reports of early valve degeneration led to an evaluation of our experience
with this valve and its long-term outcomes.
Methods
Patients undergoing aortic valve replacement (AVR) with the Trifecta valve between
May 2011 and December 2019 at a single centre were included. The primary outcome was
overall survival. Secondary outcomes included operative mortality and morbidity, aortic
valve re-operations, and re-operation for structural valve deterioration. Echocardiographic
outcomes were evaluated.
Results
The study included 419 Trifecta valve implants (2 03—first generation, 216—GT series).
Operations included isolated AVR in 211 (50.35%), AVR plus coronary artery bypass
grafting in 165 (39.37%), and AVR plus mitral valve operation in 43 (10.26%). AVR
by minimal access technique was used in 53 patients (12.64%). Early mortality rate
was 3.81% (n = 16). Overall survival at 1 year, 5 years and 10 years were 89.03%,
77.08% and 73.51% respectively (Fig. 1). Overall freedom from aortic valve re-operation
was 98.33% and 98.1% at 5 years and 10 years respectively. There were a total of 8 re-operations
(median 3.4 years, IQR 3.46) with 2 re-operations in < 1 year and 4 late re-operations,
giving a total 10-year re-operation rate of 1.90%. Of these, 4 were for infective
endocarditis, 1 was for paravavular leak and 3 were for structural valve degeneration
(mean 4.52 years). Overall mean gradients were 6.9 ± 5.2 mm Hg postoperatively and
remained low at 10.5 ± 6.4 mm Hg at 1 year.
Conclusions
Our results demonstrate that this valve can be safely implanted in the aortic position
with excellent long-term durability and haemodynamics.
A24 Surgical Aortic Valve Replacement Outcomes in Young Patients Under the Age of
60
Meuris, Bart
1, Professor; Senage, Thomas2, Prof; Borger, Michael3, Prof; Siepe, Matthias4, Prof;
Stefano, Pierluigi5, Prof; Laufer, Guenther6, Prof; Langanay, Thierry7, Prof; De Paulis,
Ruggero8, Prof
1University Hospitals Leuven, Leuven, Belgium; 2Centre Hospitalier Universitaire de
Nantes, Nantes, France; 3Leipzig Heart Center, Leipzig, Germany; 4Freiburg Heart Center,
Baden-Wurttemberg, Germany; 5Careggi University Hospital, Firenze, Italy; 6Heart Center
Wien, Wien, Austria; 7CHU Rennes, Rennes, France; 8European Hospital Rome, Rome, Italy
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A24
Background
Prospective outcomes of bioprosthetic surgical aortic valve replacement (SAVR) in
young patients are scarce, but critical for decision-making. We assessed VARC-2 time-related
events and freedom from stage-3 SVD in patients below 60y.
Methods
INDURE is a prospective, multicenter registry with a 5-year core-lab adjudicated follow-up,
to assess the clinical outcomes of sAVR in patients younger than 60 years who received
a novel bioprosthetic valve (NCT03666741).
Results
435 patients ≤ 60y were enrolled at 21 sites in Europe and Canada: mean age 53 years,
female gender 22.5%, EuroSCORE II 1.6 ± 1.9% and 73.9% of bicuspid valve morphology
(BAV). Comparison of 103 patients ≤ 50y versus 332 patients 51-60y showed significant
differences: BAV 82.5% vs. 70.5% (p = 0.016), AR dominance 33.3% vs. 20.8% (p = 0.009),
severe AR w/o significant valve stenosis 19.6% vs. 11.4% (p = 0.034), diabetes 6.8%
vs. 15.4% (p = 0.025), hypertension 31.1 vs. 55.7% (p < 0.001). Isolated AVR was performed
in 59% of cases. Valve size 23-25 mm were implanted in 59% of the patients. Median
(IQR) hospital stay was 7d (6–10), ICU stay 29.5 h (22–56) with a 30-day mortality
of 0.7% for the entire cohort. At 1 year follow-up (195/435), preliminary safety outcomes
resulted in 3.6% (7/195) of all-cause mortality (42.9% not valve-related), 1.1% (2/189)
endocarditis, and no stage-3 SVD; valve hemodynamics were stable with MPG 12.7 ± 5.6,
EOA 1.8 ± 0.5 cm2.
Conclusions
Patients ≤ 50 years old undergoing SAVR were more likely to have a bicuspid aortic
valve or aortic valve regurgitation at baseline, and less likely to have aortic stenosis,
hypertension, or diabetes. INDURE registry data indicate excellent 30-day outcomes
of SAVR with a new tissue valve in young patients, including valve performance being
comparable across age subgroups. Preliminary 1 year follow-up outcomes confirm satisfactory
safety and valve performance with no stage-3 SVD. Further follow-up is ongoing with
echo corelab reviewed data.
A25 Avoiding Prosthesis-Patient Mismatch: The Role of Valve MDT and Root Enlargement
Sherif, Mohamed
1, Mr; Khan, Tanveer1, Mr; Capoccia, Massimo2, Mr; Elmahdy, Walid1, Mr
1Leeds General Infirmary, Leeds, UK; 2Bristol Heart Institute, Bristol, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A25
Objective
To report early results of a case series of patients with high preoperative risk of
PPM based on aortic root assessment. These patients were discussed pre-operatively
in valve MDT and had a planned aortic root enlargement (ARE).
Patients and Methods
We present the outcomes of 13 patients who had a preoperative predicated PPM and underwent
planned root enlargement post Valve MDT discussion. PPM risk was evaluated and predicated
by an effective orifice area index EOAI less than 0.85 cm2 m−2.
Pre and post-operative patients’ data collected from our local patients’ data software. There
were 2 (15.4%) male patients and 11 (84.6%) female patients who underwent electively
planned ARE and AVR ( ±) CABG. The mean age was 68.7 ± 5.3 years (61-77 years), body
mass index (BMI) 30.2 ± 5.7 kg m−2 and body surface area (BSA) 1.77 ± 0.30 m2. Patients
had mean Euroscore II of 11.2 ± 9.3.
Preoperative mean aortic valve area of 0.59 ± 0.20 cm2, mean gradient of 59 ± 21 mmHg
and peak gradient of 97 ± 32 mmHg. The mean aortic annulus size was 17 ± 1.5 mm.
Results
The mean implanted valve size was 22.4 ± 1.2 (19–23). The mean increase in valve size
post enlargement was 5.3 mm (SD 1.9 mm), and that was statically significant (p < 0.001).
The mean bypass time and aortic clamping times were 144 ± 30.9 min and 99 ± 18 min,
respectively. All patients had significant reduction in peak and mean pressure gradients,
with improvement in LV function.
There was no in-hospital mortality and all patients still alive during follow-up.
There is 0% paravalvular leak. Only one patient had permanent pacemaker for complete
heart block and one patient required surgical drainage of pericardial effusion. None
of the patients had TIA / stroke, renal or respiratory failure.
Conclusion
PPM can be predicated per-operatively and should be discussed in valve MDT for individualised
planning. Elective root enlargement in trained hands is a safe solution for preven
PPM.
A26 New Innovations, New Operations & Difficult Decisions—Movie
Deglurkar, Indu, Miss; Syed Nong Chek, Syed Aidil Hizman, Mr; John, Anish, Mr; Karthikeyan,
Sivagnanam, Dr
University Hospital of Wales, Cardiff, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A26
https://www.youtube.com/embed/tFF8xQRSZe8
A27 Patient Prosthesis Mismatch in Aortic Valve Replacement: Are all Bioprosthetic
Valves the Same?
Haqzad, Yama, Mr; Chrysikopoulou, Megan, Dr; Ripoll, Brenda, Ms; Jarvis, Martin, Mr;
Chaudhry, Mubarak, Mr; Loubani, Mahmoud, Prof
Castle Hill Hospital, Hull, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A27
Introduction
Patient Prosthesis Mismatch (PPM) is associated with increased morbidity and mortality.
Standard cut-offs for adjudicating PPM in a patient are effective orifice area index
(EOAI) 0.85 to 0.65 cm2/m2 for moderate PPM and < 0.65 cm2/m2 for severe PPM.
Objectives
Retrospective analysis of data from cardiothoracic database for patients undergoing
isolated aortic valve replacement (AVR) between 2010–2014. EOA of different valve
types were obtained from the respective manufacturers. EOAI was determined using EOA
divided by body surface area of the patient. Data was analysed using SPSS 24.
Results
240 patients were identified (149 (62%) males and 91 (38%) females). Mean age 74 ± 8.7.
Over 11% (27/240) of patients have severe PPM. Moderate to severe PPM was significantly
higher in patients with BMI > 25 (64.6%) compared to BMI < 25 (37.1%) p < 0.001. Severe
PPM was present in over 28% of Hancock II valves. Moderate PPM was present in 88%
of Mitroflow, 68% of Hancock II, 51% of St Jude Epic, 27% of St Jude Trifecta, 7%
of Sorin Soprano, 3% of Perimount Magna Ease with p < 0.001. Mortality at 7 years
was 56% in moderate to severe PPM versus 54% in mild/non-significant PPM. Average
valve sizes used were Hancock II 22.7 ± 2, Mitroflow 22.7 ± 2.1, St Jude Epic 22.8 ± 2,
St Jude Trifecta 22.9 ± 2.1, Sorin Soprano 22.8 ± 2.1 and Perimount Magna Ease 22.8 ± 2.1.
Conclusion
In our study, the incidence of moderate to severe PPM varied significantly depending
on the type of bioprosthesis. Additionally, overweight and obese patients had significantly
higher risk of moderate to severe PPM. We suggest that in this group of patients,
the EOA of valve type should be carefully considered. This is particularly important
as the Valve Academic Research Consortium recommends lower cut-offs for moderate/severe
PPM in patients with BMI > 30.
A28 Are There any Predominant Clusters of Pathology in Patients with Aortic Aneurysms
Presenting for Aortic valve and Root Repair?
Sriskandarajah, Sanjeevan, Mr; Abdul Hakeem, Muhammad, Mr; Popescu, Florentina, Miss;
Kenawy, Ayman, Mr; Harrington, Deborah, Miss; Othman, Ahmed, Mr; Kuduvalli, Manoj,
Mr; Field, Mark, Mr; Nawaytou, Omar, Mr
Liverpool Heart and Chest Hospital, Liverpool, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A28
Objective
Patients with underlying aortic aneurysms rarely present with singular pathology leading
to their aortic regurgitation. The aim of our study was to identify any common clusters
of pathology in a modern sample of patients presenting for aortic valve and root reconstruction
and to compare the techniques currently used against the proposed El Khoury classification.
Methods
Patients from a single centre who were listed for aortic valve sparing root and valve
repair from August 2017 to September 2021 were included in the study. Patients with
sole leaflet pathology, annular dilatation or dissection without an aortic aneurysm
were excluded from the study.
Results
A total of 178 patients were identified during this period and 159 of those patients
underwent a root and valve repair. Following application of the exclusion criteria
a total of 144 patients were identified. Five main clusters were noted in these patients.
Cluster 1 (El Khoury Ia) 9.7% of them 57% needed a David procedure and 43% had an
ascending aortic replacement and annuloplasty. Cluster 2 (El Khoury Ib) 30.5%, 93%
of them were treated with a David procedure. Cluster 3—(El Khoury Ib/Ic) 25%, 97%
of them had a David procedure and 17% of them needed concomitant leaflet repair. Cluster
4 (El Khoury Ib/IC/II & Ib /II) – 18.8%, 96% of these patients had a David procedure
and 89% of them also needed concomitant leaflet repair. Cluster 5 (El Khoury Ib/Ic/
III & Ib /III)—9%, 77% underwent a David Procedure with leaflet repair, with 8% undergoing
a David procedure alone and the remainder 15% had an ascending aorta replacement with
an annuloplasty.
Conclusion
The described five clusters accounted for 89.5% of patients undergoing root and valve
repair with underlying aneurysms. Isolated aneurysms commonly need an annuloplasty
to augment repair and isolated SOV aneurysm may require concomitant leaflet repair.
David procedure alone can sometimes be sufficient in some cases of valve prolapse
or restriction.
A29 Short and Medium-term Outcomes of Different Surgical Approaches for Transcatheter
Aortic Valve Implantation
Metwalli, AMr, Mr; Salmasi, M Yousuf, Mr; Zientara, Alicija, Ms; Duncan, Alison, Ms;
Shannon, Joanne, Ms; Quarto, Cesare, Mr
Royal Brompton and Harefield NHS Foundation Trust, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A29
Objectives
To review the early to medium-term outcomes after different surgical approaches for
transcatheter aortic valve implantation (TAVI).
Methods
We retrospectively reviewed the survival data and patient demographics of consecutive
cases who underwent TAVI using different surgical approaches; transapical, subclavian,
axillary and carotid, over an 8-year period (March 2013 to September 2021).
Results
We performed a total of 82 TAVI procedures with different surgical approaches. The
mean age was 80 ± 7 years and the age-range was 57–94 years. 80% of cases were aged
75 or older and 52.4% were 80 or older at the time of intervention. 46/82 (56%) had
a Katz Index of Independence score of 5 or above, while 34/82 (41.4%) had a score
of 3 or 4. The surgical approaches were either trans-subclavian/axillary 48/82 (58.5%),
trans-apical 22/82 (26.8%) and trans-carotid 11/82 (13%), with 7 cases (8.5%) performed
under elective cardiopulmonary bypass support due to poor ventricular function. The
observed survival rate at 30-days, 1 year, 3 years and 5 years was 97.5%, 87%, 71%
and 54%, respectively. Survival analysis found no difference between trans-apical
and trans-subclavian approaches (logrank p = 0.981). Cox regression analysis found
no influence of key co-variates on survival, including age, renal function, peripheral
vascular disease and LV function (p > 0.05).
Conclusion
Different surgical approaches for TAVI including subclavian, transapical and carotid
approaches, are viable alternative approaches for patients who are not suitable for
the trans-femoral approach.
A30 Minimal Access Aortic Valve Replacement: Impact on Outcome in Elderly Patients
Sharma, Sobaran, Mr
Morriston Hospital, Swansea, Swansea, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A30
Objective
We assessed the Impact of mini-AVR (j sternotomy) aortic valve replacement for isolated
Aortic valve replacement against Full sternotomy in Elderly patients and compared
the outcomes.
Methods
We retrieved the operative records of elderly patients aged 70 years and over undergoing
isolated aortic valve replacement between 2006 to March 2020.demographic and peri-operative
data between two group undergoing Full sternotomy (Group A) and mini-AVR (Group B)
were compared.
Results
658 patients (Group A) and 182 patients (Group B) underwent isolated aortic valve
replacement with Full sternotomy and J partial sternotomy incisions respectively.
There was an increased proportion of comorbidities in Group B as reflected in the
significantly greater Logistic EuroSCORE (8.9% vs 10.4%,p < 0.05).Cardiopulmonary
bypass (101.8 vs 77 min, p < 0.001) and Cross-clamp times (82.7 vs 64.3 min,p < 0.01)
were shorter in Group B. The cardiac intensive care utilisation more than 24 h (49.7%
vs 38.3%was significantly lower in Group B, p = 0.050), who interestingly also had
a significantly shorter post-operative hospital stay(11 vs 7.6 days,p < 0.05). There
was a significantly lower re-operation for bleeding (5.5% vs 1.7%, p < 0.05). There
was a significantly lower usage of packed cell units in Group B (2.3 vs 1.5 units,
p = 0.009).
Conclusions
We have demonstrated that minimal access (mini-AVR) approach for aortic valve replacement
can provide substantial clinical benefits in the elderly and comorbid patients, in
addition to utilising fewer hospital resources such as postoperative care facilities,
length of stay and blood transfusion.
A31 Blood Transfusion and 10-year Survival After Minimally Invasive AVR Versus Conventional
AVR: A Propensity-matched Analysis
Poon, Sam, Mr; George, Joseph, Mr; Sharma, Sobaran, Mr; Kumar, Pankaj, Mr
Morriston Hospital, Swansea, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A31
Objective
This study sought to investigate whether minimally invasive aortic valve replacement
(Mini-AVR) required fewer blood transfusions and its impact on long term survival
compared to conventional aortic valve replacement (AVR).
Method
A retrospective cohort study was carried out in a single centre. 274 patients received
Mini-AVR and 1036 had AVR. A matched logistic regression study was carried out for
these patients.
Results
The mean age of patients was 70 years old. 53% of patients in the Mini-AVR group received
blood transfusion in comparison to 63.1% in the AVR group (p < 0.05). The mean unit
of blood transfused was 1.8 and 2.5 units ( p = 0.045) in the mini-AVR and AVR group
respectively. Both groups have comparable in-hospital mortality (Mini AVR 1.38% vs.
AVR 1.06%, p > 0.05). After adjusting differences in peri-operative risk factors,
there was no significant difference in 10 years survival (66% vs 60%, p > 0.05).
Conclusion
Mini-AVR is associated with fewer blood transfusions compared to AVR. There is a trend
toward lower blood transfusion and better 10-year survival but these differences were
not statistically significant.
A32 The Impact of Blood Transfusion on Survival Following Isolated Aortic Valve Replacement:
A ten-year Follow-up Result
Poon, Sam, Mr; Suhail, Sadiq, Dr; Chan, Jeremy, Mr; George, Joseph, Mr; Sharma, Sobaran,
Mr; Kumar, Pankaj, Mr
Morriston Hospital, Swansea, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A32
Objective
Blood transfusion is common in cardiac surgery and the long-term impact remains unclear.
We aim to investigate the impact of red blood cells transfusion on survival following
aortic valve replacement.
Method
A retrospective cohort study on 490 consecutive patients who underwent isolated aortic
valve replacement (AVR) from January 2007 to September 2011 was undertaken. The mean
duration of follow-up was 10 years and the mean age of patients was 69. The overall
10-year survival was analyzed in relation of red blood cells transfusion. A matched
propensity score based on logistic regression analysis was performed.
Results
Overall 39% of patients received blood transfusion. The mean pre-operative haemoglobin
was 13.2 gm/dL and mean unit of blood transfused was 2 units. Following propensity
matching, perioperative blood transfusion was associated with poorer survival in 10 years
compared to patients who had no blood transfusion (71.4% vs. 61%, p < 0.001, HR 1.24
95% CI 1.13–1.37, p < 0.001). A subgroup analysis on the number of blood units transfusion
showed that 1 and 2 units of blood transfusion did not adversely impact on survival
but for patients receiving 3–4, and more than 5 units of blood products, there is
a positive correlation for significant reduction in 10 years survival. (Hazard ratio
(HR) for 3–4 units was 2.0 (95% CI 1.2–3.3, p = 0.005) and more than 5 units HR 2.9
(95% CI 1.8–4.7, p < 0.001).
Conclusion
Blood transfusion is associated with reduced long-term survival following aortic valve
replacement. Patients receiving more than 3 units of blood had a significant decrease
in survival compared to expected survival. Pre-operative patient optimization may
improve long-term outcomes by reducing the likelihood of blood transfusion.
Figure 1. A 10-year Kaplan–Meier (KM) survival curve following blood transfusion in
AVR was plotted. A subgroup analysis on the impact of the number of blood products.
Adult Cardiac Coronary
A33 Modelling Long Term Outcomes in Patients with Heart Failure Revascularized with
CABG or PCI using Hospital Episode Statistics
Pathak, Suraj
1, Dr; Lai, Florence1, Mrs; Miksza, Joanne1, Ms; Petrie, Mark2, Prof; Murphy, Gavin1,
Prof
1Glenfield Hospital, Leicester, UK; 2University of Glasgow, Glasgow, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A33
Objectives
The REVASC-HF-UK trial, a trial of revascularisation strategies (PTCA/CABG) for ischemic
heart failure (IHF) patients, was modelled using the Hospital Episode Statistics (HES)
Admitted Patient Care (APC) data set and the national death registry.
Methods
Patients undergoing isolated CABG and high-risk stenting (HR-PTCA) in England between
April 2012 and March 2015, with a preceding diagnosis of IHF within 2 years of the
index procedure, were identified. Outcomes of interests included all-cause mortality
and MACE. Treatment effects were estimated using regression adjustment (RA), propensity
score matching (PSM) and instrumental variable analysis (IVA).
Results
2462 patients were identified in the CABG arm and 1033 patients were identified in
the HR-PTCA arm. Risk of death was lower for CABG than HR-PTCA (unadjusted OR for
1, 3, 5-year mortality = 0.54, 0.38, 0.39 respectively). Risk of MACE outcomes was
lower for CABG (unadjusted OR for 1, 3, 5-year MACE = 0.52, 0.40, 0.38 respectively).
This treatment effect favoring CABG persisted after RA, PSM and IVA methods were applied.
Conclusion
In patients with IHF, risks of death and MACE events at 1, 3 and 5 years were lower
after CABG than HR-PTCA.
A34 Impact of Preoperative Atrial Fibrillation on Outcomes After Elective Coronary
Artery By-pass Grafting: A Large Database Analysis
Fudulu, Daniel
1, Mr; Dimagli, Arnaldo1, Mr; Dong, Tim1, Mr; Gemelli, Marco1, Mr; Chan, Jeremy2,
Dr; Sinha, Shubhra1, Miss; Benedetto, Umberto1, Prof; Angelini, Gianni1, Prof
1Bristol Heart Institute, Bristol, UK; 2Bristol Royal Infirmary, Bristol, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A34
Objectives
Atrial fibrillation (AF) is the most common sustained arrythmia in adults with a prevalence
of 2–4% in adults with significant impact on mortality and mortality. In the cardiac
surgery population, perioperative AF is associated with increased mortality, morbidity
and excess of healthcare costs. Currently, pre-operative AF is not included as a risk
factor in the most commonly used risk prediction tools (EuroSCORE II or STS). The
objective of our study was to assess if preoperative, non-valvular AF is predictor
for mortality and post-operative stroke by interrogating a very large cardiac audit
dataset from Europe (UK National Cardiac Audit Dataset).
Methods
We included all isolated, elective coronary artery by-pass grafting procedures performed
between February 1996 and March 2019. Incidence of AF was 3% on a total sample size
of 244,801 patients. We have used a generalised linear mixed model to assess the effect
of preoperative AF on mortality and stroke after adjusting for the relevant confounders
derived from EuroSCORE 2. Confounders considered included: age, gender, neurological
dysfunction, renal dysfunction, recent myocardial infarction, pulmonary disease, unstable
angina (CCS4), NYHA class, pulmonary hypertension, diabetes on insulin and peripheral
vascular disease. We have treated the hospital and operating consultant as random
effect variables. We have also tested interactions between the pre-operative AF and
pre-operative LV function our model.
Results
Preoperative AF was significant predictor for increased mortality (OR: 1.65, CI 1.42–1.91,
P < 0.001) and postoperative CVA (OR:1.31, CI 1.07–1.59, P = 0.008) after CABG (attached
figure). We found no significant interaction between pre-op AF and LV function for
mortality or stroke outcomes.
Conclusion
Our study suggests that preoperative atrial fibrillation is associated with an increased
risk for perioperative mortality and stroke in patients undergoing coronary artery
bypass grafting.
A35 Transit Time Flowmetry During off-pump Coronary Artery Bypass Surgery: How to
Make Clinical Data Findable, Accessible, Interoperable and Reusable
Halfwerk, Frank
1, Dr; Mariani, Silvia2, Ms; Hagmeijer, Rob3, Dr; Clare, Connie4, Dr; Grandjean, Jan1,
Prof
1Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands; 2Department
of Cardio‐Thoracic Surgery, Maastricht University Medical Centre (MUMC), Maastricht,
The Netherlands; 3Dept. of Engineering Fluid Dynamics, University of Twente, Enschede,
The Netherlands; 44TU.ResearchData, Delft University of Technology, Delft, The Netherlands
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A35
Objectives
Increasingly more clinical studies are published under the Open Access publishing
model making them accessible online to everyone for free. Often, the only aspect that
is not yet open is the data underlying these publications. Publishing data improves
reproducibility and reliability of research, it increases visibility of research,
and accelerates innovation. Furthermore, unique and highly valuable data from i.e.
rare cardiac diseases or surgical techniques is not available to everyone.
The aim of this study is to present a best practice for publishing clinical data.
A clinical study on intraoperative transit-time flowmetry during off‐pump coronary
artery bypass surgery and the impact of coronary stenosis on competitive flow is used
as an example.
Methods
Data is published according to the FAIR principles: Findable, Accessible, Interoperable
and Reusable. To be ‘Findable’, a unique digital object identifier (DOI) was assigned
to the dataset, and metadata described the content, contact information, location,
items and definitions. The data is ‘Accessible’ for everyone under Open Access. To
be ‘Interoperable’, MeSH and STROBE standards were used. Finally, to be’Reusable’,
the data were made readable by others, and a license permitting data reuse was assigned.
Results
Data for 50 study patients were refined, and patient data anonymised. Date of birth
information was grouped by age intervals, so it can be openly published in an external
repository. Transit time flow measurements, definitions, study protocol, and the variable
list were described. The dataset was made publicly available in the 4TU.ResearchData
repository. Researchers should be attributed when data is reused under a CC-BY licence.
Conclusion
For cardiac surgery studies, it is feasible to publish data alongside Open Access
peer-reviewed journal articles. The FAIR principles for clinical data management should
be incorporated in the design and implementation of future clinical studies.
A36 0ff-pump Coronary Artery Bypass Grafting Reduces Inhospital Mortality & Need for
Renal Replacement Therapy in Patients with Moderate Renal Dysfunction
Garg, Sheena
1, Ms; Raja, Shahzad1, Mr; Bhudia, Sunil1, Mr; De Robertis, Fabio1, Mr; Marczin, Nandor1,
Dr; Layson, Rhae2, Dr; Lim, Ru jin2, Dr; Adikoesoema, Mohamad Shafiq2, Dr
1Royal Brompton & Harefield NHS Trust, London, UK; 2University College London, London,
UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A36
Objective
Moderate renal dysfunction (eGFR 30–59 mL/min/ 1.73 m2) has been consistently identified
as a major predictor for postoperative renal failure and increased mortality after
on-pump coronary artery bypass grafting (CABG). We analysed our institutional database
to determine the impact of offering off-pump CABG on in-hospital mortality and need
for renal replacement therapy (RRT) for this high-risk cohort of patients.
Methods
From January 2007 to December 2019, 2850 patients with moderate renal dysfunction
underwent isolated first-time CABG at our institution. Multivariable logistic regression
was used to investigate the effect of off-pump CABG on in-hospital mortality and need
for RRT. Propensity score matching was used to compare the 2 matched groups.
Results
Over the study period, 1383 off-pump CABG and 1467 on-pump CABG were performed for
this cohort. Fewer in-hospital deaths (11 [0.80%] vs 25 [1.81%]; p = 0.029) and reduced
need for RRT (3 [0.22%] vs 9 [0.65%]; p = 0.048) was observed for the matched off-pump
group compared to on-pump group. Off-pump CABG was associated with a significantly
lower incidence of in-hospital death (odds ratio: 0.44; 95% confidence interval [0.21–0.89])
and need for RRT (OR: 0.33; 95% CI [0.09–1.23]).
Conclusion
Off-pump CABG should be preferentially offered to patients with moderate renal dysfunction.
A37 Making CABG Less Invasive: Lessons Learned from Setting up an Endoscopic Vessel
Harvesting Programme
Gradinariu, George
1, Mr; Sobhun, Ganesh2, Mr; Olivar, Marimel2, Miss; Sereda, Victor3, Dr; Mahmood,
Zahid1, Mr; El-Shafei, Hussain4, Mr; Sutherland, Fraser1, Mr
1Golden Jubilee National Hospital, Glasgow, UK; 2Getinge UK; 3BMI Ross Hall Hospital,
Glasgow, UK; 4Aberdeen Royal Infirmary, Aberdeen, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A37
Objectives
Endoscopic vessel harvesting (EVH) for coronary artery bypass grafting (CABG) is known
to offer patients faster recovery, fewer wound complications and shorter hospital
stay. Our aim was to make CABG less invasive and we set out to establish an EVH programme
in our unit. We describe the obstacles and challenges encountered as well as results
from our first series of cases.
Methods
We first performed a comprehensive analysis of the expectations, needs and views shared
across all involved players in the patient’s journey. Areas of concern were highlighted
and addressed in a systematic fashion. We used a novel on-table high-definition surgical
monitor, along with latest generation EVH harvesting tools and standard image capture/CO2
insufflation. Consecutive patients undergoing isolated CABG with EVH were recruited.
Data on risk factors, wound complications, patient satisfaction and length of stay
were collected.
Results
Three main areas of concerns were identified and addressed before the programme started:
Resistance to change, Fear of the learning curve and Perception of added cost. Eleven
patients were recruited. Mean age was 61 years [95% CI 55–67 years]. 7 out of 11 (64%)
patients had one or more risk factors for post-operative wound complications. The
long saphenous vein was harvested endoscopically in 8 patients (73%) and the radial
artery in 3 (27%) patients. The median number of grafts was 3 [range 2–5]. There were
no wound complications. All patients expressed a high level of satisfaction. Median
post-operative length of stay was 5 days [range 4–6 days]. At a median follow-up of
3 months there were no late wound complications, no admissions to hospital or adverse
events reported.
Conclusion
In our quest to make CABG less invasive, we successfully established an EVH programme
and performed our initial series of cases with excellent outcomes. The combination
of devices was easy to use and integrate into the standard CABG theatre footprint
and procedure.
A38 Emergency Off-pump Coronary Artery Bypass Grafting: A Myth or Reality?
Coppola, Giuditta, Miss; Farmidi, Abu Ali, Mr; Garg, Sheena, Miss; De Robertis, Fabio,
Mr; Bahrami, Toufan, Mr; Bhudia, Sunil, Mr; Raja, Shahzad, Mr
Harefield Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A38
Objectives
Emergency coronary artery bypass (CABG) is still considered a high-risk procedure
due to the mortality and the post-operative morbidity compared to elective CABG. Although
off-pump CABG(OPCABG) is a relative contraindication in emergency, we analyzed outcomes
of 12-year-single center emergency OPCABG experience and compared it with om-pump
CABG.
Methods
We retrospectively analysed prospectively collected data from institutional database
from January 2007 to December 2019. During the study period 249 patients underwent
an isolated emergency CABG.
Results
Mean age of study population was 66.14 years (± 11.86) and 193 patients (77.5%) were
male. OPCABG was performed in 107(43%) patients. More distal anastomoses were performed
in on-pump cohort (47.7% vs 69%; p = 0.001). Fewer patients required postoperative
IABP in off-pump cohort (2.8% vs 9.9%; p = 0.053). All other outcomes including in-hospital
mortality and mean length of hospital stay were similar for the two cohorts.
Conclusions
Emergency CABG still remains a challenge for the cardiac surgeon even in expert hands.
However, OPCABG can be offered with comparable outcomes to patients needing emergency
surgical revascularization in a high volume OPCABG centre.
A39 Role of CX3CR1 in Patients with Myocardial Ischaemia and Reperfusion Injury
Panahi, Pedram, Mr; Cormack, Suzanne, Dr; Mohammed, Ashfaq, Dr; Spyridopoulos, Ioakim,
Prof
Newcastle University, Newcastle, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A39
Objectives
Revascularisation of the blocked coronary artery in new onset ST segment elevation
myocardial infarction (STEMI) can be achieved by primary percutaneous coronary intervention
(PPCI). A complication of this is ischaemia–reperfusion injury (I/R-injury) which
results in further damage to the ischaemic myocardium, accounting for up to 50% of
the final infarct size in animal experiments. Interferon-γ secreting CD4 + T-cells,
expressing the chemokine receptor CX3CR1, have been shown to mediate I/R-injury in
animal models. Accordingly, CX3CR1 involvement in I/R-injury has been implicated in
animal studies. The aim of this study was to determine the role of CX3CR1 in STEMI
patients with I/R-injury.
Methods
42 acute STEMI patients undergoing PPCI were prospectively recruited. Blood samples,
collected at various time points relative to reperfusion, were analysed using flow
cytometry.
Results
(i) Effector T-cells had the highest CX3CR1 expression and a cytotoxic phenotype.
(ii) Effector T-cell absolute count dropped after reperfusion. Effector T-cell CX3CR1
expression also dropped immediately after reperfusion, but then increased up to 24 h
after reperfusion. Effector T-cells in HCMV seropositive individuals expressed higher
levels of CX3CR1. (iii) Presence of microvascular obstruction was associated with
lower CX3CR1 expression in the effector compartment.
Conclusion
CX3CR1, expressed at higher levels in HCMV seropositive individuals, is activated
after reperfusion and coincides with an acute reduction in the effector T-cell population
size. It is conceivable that these cytotoxic effector T-cells marginalise within the
coronary microvasculature after reperfusion and contribute towards development of
microvascular obstruction, a component of I/R-injury.
A40 A Single-Centre Analysis of the use of Bilateral Internal Mammary Artery Graft
in a Y-configuration in Coronary Artery Bypass Graft Surgery in Ireland
Whooley, Jack, Dr; Weedle, Rebecca, Dr; White, Alexandra, Dr; Soo, Alan, Mr
University Hospital Galway, Galway, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A40
Objectives
Internal mammary artery grafts are the most durable conduits in coronary artery bypass
graft (CABG) surgery resulting in improved long-term survival. The use of bilateral
internal mammary artery (BIMA) grafts is especially advocated in younger patients.
Concerns surrounding sternal wound dehiscence and technical difficulty have slowed
the adoption of this technique. We aimed to assess our 5-year experience in performing
BIMA grafting in a Y-configuration for CABG.
Methods
A retrospective review of patients undergoing CABG using BIMA in a Y-configuration
between May 2016 and May 2021 was performed. All patients under 60 who underwent non-emergency
CABG with at least two grafts that did not involve BIMA in the study period were also
reviewed. Patient demographics, EuroSCORE II, operative details, post-operative length
of stay (LOS), deep sternal wound infection (DSWI) and other complications were collected.
Unpaired student t-test was used to compare the groups.
Results
Twenty-eight patient underwent CABG using BIMA in the 5-year study period. Eighty
patients younger than 60 years of age underwent non-emergency CABG with other conduits
in that time period. Patient demographics were similar between the groups. There was
no difference in bypass time, but there was a significantly shorter cross-clamp time
in patients. There was no significant difference in transfusion requirements or length
of stay post-operatively between the groups. DSWI occurred in three patients in the
BIMA cohort.
Conclusion
Using BIMA grafting in a Y-configuration is feasible, with shorter cross-clamp time
and comparable length of stay. There is however an increased risk of deep sternal
wound infection in patients with BIMA grafts. Patient selection remains an important
consideration.
A41 Enhanced Recovery After Surgery Protocols in Patients Undergoing Coronary Artery
Bypass Graft Surgery: A Systematic Review and Meta-analysis
Elango, Madhivanan
1, Dr; Kotta, Prasanti Alekhya
2, Dr; Papalois, Vassilios1, Prof
1Imperial College London, London, UK; 2King's College London, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A41
Objectives
Enhanced recovery after surgery (ERAS) protocols are a multi-modal, multi-disciplinary
approach to the management of the surgical patient in the pre-operative, intra-operative
and post-operative phases. These protocols aim to reduce post-operative complications
while decreasing the length of hospital stay. This study aims to systematically review
the evidence for ERAS implementation in coronary artery bypass graft (CABG) surgery.
Methods
A database search was performed on MEDLINE and Embase to look for all studies comparing
ERAS/fast-track protocols with standard protocols in patients undergoing CABG (both
off-pump/on-pump). Observational and randomised controlled trials were included; studies
including other cardiac operations and incomplete ERAS protocols were excluded. The
primary outcome was hospital length of stay (LOS). Secondary outcomes included ICU
LOS and time to extubation. Data were analysed on Review Manager 5.4.1 with a random-effects
model.
Results
Seven studies were identified with a total of 2683 patients (1242 in ERAS group, 1441
in non-ERAS group). ERAS protocols were associated with a significant decrease in
LOS (mean decrease 2.21 days, 95% CI 1.59–2.84 days). ERAS protocols were also associated
with a significant decrease in ICU LOS (mean decrease 16.0 h, 95% CI 8.93–23.1 h)
and time to extubation (mean decrease 11.2 h, 95% CI 4.01–18.3 h).
Conclusions
ERAS protocols were associated with a decreased time to extubation, ICU LOS and hospital
LOS, all of which are known to be beneficial to patient satisfaction and reduced cost
operation. ERAS protocols have been implemented in other fields of surgery and this
analysis suggests the ERAS prinicples should be incorporated in coronary artery bypass
grafting. More prospective work is needed to ascertain which elements should be included
in a potential ERAS protocol given the heterogeneity of protocols in these studies.
A42 Using Hospital Episode Statistics Data to Investigate the Effect of Frailty on
Revascularisation Rates of Patients with Acute Coronary Syndrome
Miksza, Joanne, Ms; Lai, Florence, Ms; Roman, Marius, Dr; Murphy, Gavin, Prof
University of Leicester, Leicester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A42
Objectives
We investigated the impact of frailty on survival and revascularisation rates in patients
with acute coronary syndrome (ACS) and whether frailty explained the regional differences
in revascularisation rates.
Methods
Patients with an ACS diagnosis between 2010 and2015 were identified from Hospital
Episodes Statistics (HES). Frailty was defined by the Hospital Frailty Risk Score
(HFRS) using HES records within two years prior to ACS diagnosis. All-cause mortality
at 1 and 5 years were compared among patients with low (HFRS < 5), mid (5–15) and
high (15 +) frailty scores. Regional revascularisation rates by Clinical Commissioning
group (CCG) adjusted for frailty and patient factors including age, sex, ethnicity,
and comorbidities were investigated using funnel plots.
Results
The final cohort included 1,422,004 ACS patients of whom 3.5% had a high frailty risk
and 10.1% an intermediate frailty risk. ACS patients with a high frailty risk had
higher mortality during the year after their ACS event (low risk: 12.4%, intermediate
risk: 34.5%, high risk: 48.2%, p < 0.05). Patients with high frailty were 84% (CI:
83%-86%) less likely and intermediate risk 67% (CI: 66%-69%) less likely to receive
a revascularisation procedure compared to low risk patients. 6 out of 210 (2.3%) CCGs
had a standardised ratio which was outside the limits of the 99.8% confidence interval.
Conclusion
Frailty is associated with poorer survival and a difference in revascularisation rates
in ACS patients. Regional variation in revascularisation persisted after adjustment
for frailty and other patient factors suggesting unwarranted variation in the provision
of care for ACS patients.
A43 Predictors of Permanent Pacemaker Implantation Following Coronary Artery Bypass
Graft, a 20 Year Experience of a Single UK Centre
Leone, Francesca, Dr; Elshafie, Ghazi, Mr; Loubani, Mahmoud, Prof
Hull University Teaching Hospitals, Hull, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A43
Objectives
To identify predictors of permanent pacemaker implantation (PPMI) following coronary
artery bypass graft (CABG) over the last 20 years.
Methods
We undertook a retrospective review of all patients who underwent isolated CABG between
1999 and 2020 in a single UK centre, excluding patients with preoperative complete
heart block or pacemaker in situ, and identified those who had PPMI in hospital postoperatively.
The data was taken from a large hospital registry. We analysed the data using IBM
SPSS Statistics Version 27.
Results
7881 patients had CABG and did not require PPMI after surgery (CABGA only group),
67 patients (0.85%) required PPMI after surgery. Predictors for PPMI post CABG were
preoperative arrythmia (p < 0.001), number of previous myocardial infarction (MI)
(p < 0.001), post-operative MI (p < 0.001), unstable angina within 30 days (p < 0.001)
and the extent of coronary artery disease (p = 0.025).
Conclusions
Patient who are at high risk of PPMI post CABG are patients with preoperative arrythmia,
previous MI, post-operative MI, preoperative unstable angina and the patient with
complex coronary artery disease. We recommend that this risk should be addressed in
the preoperative assessment and to be included in the consenting process.
A44 Management of Anomalous Right Coronary Artery Arising From Left Sinus of Valsalva
with Interarterial Course—Movie
Divya, Aabha, Dr; De Silva, Ravi, Mr
Royal Papworth Hospital NHS Trust, Cambridge, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A44
https://www.youtube.com/watch?v=sFr6J6ACeqI
A45 Stuck on You; Entrapment of a Coronary Catheter Following Previous Transcatheter
Aortic Valve Replacement
Ike, David Ikenna, Dr; Balmforth, Damian, Mr; Jarral, Omar, Mr; Roberts, Neil, Mr
St Bartholomew's Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A45
Introduction
The number of patients undergoing percutaneous coronary intervention (PCI) post-TAVI
is increasing. Entrapment of diagnostic catheters is a rare complication that presents
significant challenges to clinicians.
Results
We present a case of an 89-year-old lady who underwent a coronary angiogram post TAVI
which was subsequently abandoned due to entrapment of the JL catheter. Multiple manoeuvres
by the interventional team to dislodge the JL catheter proved unsuccessful. A subsequent
multi-disciplinary team (MDT) discussion deemed surgical retrieval of the retained
catheter with cardiopulmonary bypass high risk due to her advanced age and co-morbidities.
A decision was made to perform a right brachial arteriotomy and the proximal portion
of the catheter lying in the radial artery was excised. This allowed flexion of the
arm at the elbow but the distal remnant of the catheter between the ascending aorta
and mid-brachial artery remained in-situ. The thrombosis risk of the catheter remaining
in-situ was mitigated by the commencement of a direct oral anticoagulatant. After
five-months of follow-up, the patient reports no neurovascular abnormalities or symptoms
associated with either the surgery or the retained catheter.
Conclusion
As TAVI expands into the low-surgical risk cohort, such complications may be expected
to become more common place. The development of both TAVI and catheter technology
should be focused towards reducing this complication. In the absence of an existing
evidence base, the MDT can provide essential guidance on the best treatment options
on a case-by-case basis.
Informed consent to publish had been obtained.
A46 Endoscopic Radial Artery Harvesting Without Using a Tourniquet is Feasible
Joseph, Benny, Mr; AlShiekh, Mahmoud, Dr; Petrou, Mario, Dr; De Robertis, Fabio, Dr;
Bahrami, Toufan, Dr; Gaer, Jullien, Dr; Bhudia, Sunil, Dr; Raja, Shahzad, Dr; Stock,
Ulrich, Prof; Smail, Hassiba, Dr; Khoshbin, Espeed, Dr
Harefield Hospital, Uxbridge, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A46
Background
The endoscopic radial artery harvesting results in good cosmetic results and minimal
neuralgias. It is also more acceptable to the patients therefore better than traditional
open technique. The procedure is typically performed using a tourniquet pressurized
to 250 mmHg for the duration of radial harvest. We present our experience of endoscopic
radial harvesting with and without the use of a tourniquet.
Methods
This is a cross-sectional single institutional study of endoscopic radial artery harvesting
with or without the use of external arm tourniquet. The study period was between June
2016–October 2021. Since January 2018 all endoscopic radial artery harvesting was
performed without the use of tourniquet. The harvest was performed by the same surgical
practitioner. Data was collected and analysed using an excel programme.
Results
There were 131 endoscopic radial artery harvests. The proportion of cases done without
vs with tourniquet was 101 to 30 respectively. There were no incidents of reopening
for bleeding or haematoma in either group. There were no incidents of radial artery
damage. The visibility in each method was adequate however slightly better when a
tourniquet was applied. Furthermore, there was no time pressure for harvesting the
conduit within twenty mins as is the case when tourniquet is used.
Conclusion
Harvesting of radial artery endoscopically without external tourniquet is feasible
and produces comparable results with the technique using tourniquet in this series.
A47 Ultra-fast Track Protocol after Left Mini-thoracotomy OPCAB
Guida, Gustavo
1, Dr; Bruno, Vito D1, Dr; De Garate, Estefania1, Dr; Dixon, Lauren1, Ms; Di Tommaso,
Ettorino1, Dr; Angelini, Gianni1, Prof; Guida, Maximo2, Prof
1Bristol Heart Institute, Bristol, UK, University Hospitals Bristol NHS Foundation
Trust, Bristol, UK; 2Fundacardio charity, Valencia, Venezuela
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A47
Objectives
Ultra-fast track (UFT) is a protocol with potential benefits to reduce the length
of stay of patients after CABG.
The aim of this study was to identify potential predictors of delayed discharge for
UFT in patients undergoing left mini-thoracotomy OPCAB.
Methods
Retrospective single-center cohort analysis of 1095 consecutive patients who underwent
left mini-thoracotomy OPCAB (870 male, 79.2%, mean age 62 ± 9) from 2002 to 2017.
The average number of grafts was 2.89 ± 0.99, and the mean EuroSCORE was 3.48 ± 2.97.
A postoperative hospital length of stay < 48 h, was defined as UFT and > 48 h non-UTF.
A multiple logistic regression model was developed to identify preoperative factors
affecting UTF.
Results
530 (48%) patients were discharged within 48 h (UTF group). Overall mean ITU stay
was 21.79 ± 4.83 h for the UFT group and 24.88 ± 6.88, for the non-UFT group (p > 0.001).
There was no difference in terms of average number of bypass grafts between groups
(p = 0.7). Seven patients required re-exploration (1.3%) in the UFT group, and 15
in the non-UFT (2.7%, p = 0.12). Post operative atrial fibrillation was three times
more frequent in the non-UFT than the UFT patients 3.8% vs 1.4% (p = 0.03). At multivariable
analysis factors associated with delayed discharge in UFT group were preoperative
NYHA class, preoperative smoking, and EuroSCORE.
Conclusions
UTF is a feasible strategy for left mini-thoracotomy OPCAB. NYHA class, smoking status,
and EuroSCORE are independent predictors of UTF.
A48 Post Infarction Left Ventricular Aneurysm Repair
Mayooran, Nithiananthan, Mr; Jakub, Marczak, Mr; Tyson, Nathan, Mr; Apicella, Giulia,
Ms; Abbas, Sherif, Mr; Qureshi, Saquib, Mr; Boulemden, Anas, Mr; Birdi, Inder, Mr;
Szafranek, Adam, Mr; Naik, Suren, Mr
Nottingham City Hospital, Nottingham, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A48
Introduction
Surgical remodelling of Left ventricular aneurysm secondary to ischemic heart disease
remains a viable option since 1950’s. Surgical ventricular restoration (SVR) reduces
LV volume and creates a more helical chamber by excluding scar in akinetic segments
as well as restores intrapapillary diameter which can improve cardiac function, thus
improving symptoms and life expectancy. We aim to report our 25 years’ experience
of LV aneurysm repair and in-hospital outcomes.
Methods
In this retrospective study, we analysed patients’ demographics, preoperative variables
including echocardiographic findings, intraoperative data as well as post-operative
outcomes.
Results
We found from 1996 until 2021, 45 patients (male n = 32;female n = 13) underwent LV
Aneurysm repair. Mean age was 66 years. Pre op LVEF was < 30% in 48.8% (n = 22) of
the patients [BA(S1]. 40 out of 45 patients had concomitant CABG with the LVA repair,
patients underwent aortic valve replacement and three patients underwent concomitant
mitral valve replacement [BA(S2].
LVA repair comprised of either patch plasty (DOR procedure) n = 29, External plication
repair n = 9 or linear excision and repair n = 7. In-hospital mortality was 8.3% (n = 4),
including two patients who died from low cardiac output and two from multiorgan failure
and 3 patients developed stroke. Intra-aortic balloon pump was utilised in 28 patients
(intra op n = 8, post-op n = 2, pre-op n = 18) and 28 patients had follow up echocardiogram
in our records [BA(S3]. Post-op LV EF% was poor in six patients, moderately impaired
in 15 patients, mildly impaired in seven patients [BA(S4].
Conclusion
Surgical remodeling of the left ventricular aneurysm is a feasible therapeutic option
for post-ischemic left ventricular aneurysm, with acceptable early results.
A49 10-year Survival After Isolated CABG: Does the Presence of Left Main Stem Disease
Have Impact on the Long-term Outcome?
Chan, Jeremy, Dr; Poon, Shi Sum, Mr; Cianci, Vincenzo, Mr; Ashraf, Syed, Prof; Bhatti,
Farah, Prof; Youhana, Aprim, Mr; Zaidi, Afzal, Mr; Kumar, Pankaj, Mr
Morriston Hospital, Swansea, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A49
Introduction
The impact of Left main stem (LMS) disease at the time of CABG on the long-term survival
after CABG is unclear. The long-term follow-up for patients with LMS who have undergone
coronary revascularisation remains scattered. We aim to report the 10 year follow-up
results for patients who underwent isolated CABG with or without left main stem disease.
Method
We performed a single centre, retrospective study including all patients underwent
isolated coronary artery bypass grafting (CABG) from 2006–2010. Patients were categorised
into LMS or non LMS disease. The survival rate was reviewed and collected using the
Welsh Clinical Portal. Kaplan–Meier log rank and Cox-proportional hazard analysis
were plotted to demonstrate the 10-year survival rate between the two groups.
Result
One thousand three hundred fourteen patients underwent surgical revascularisation
within the selected period. 260/1314 (19.79%) of the patients had LMS disease. The
mean age was 66.30 and 65.91 for non-LMS and LMS group respectively. There is no difference
between the need for transfusion requirement (p = 0.31). The 10-year survival rates
for non-LMS and LMS patients were 69.1% and 64.2% (HR 1.19, 95%CI 0.95–1.50, p = 0.14).
The trend in survival between the two groups appear to diverge after 8 years, although
this failed to reach statistical significance.
Conclusion
Our data demonstrated no significant difference in the 10-year survival between patients
with/without LMS disease. However, there is a trend towards lower survival in LMS
group after 8 years. CABG yields a good 10-year survival rate in all patients and
long-term outcomes should be taken into consideration in patient needing myocardial
revascularisation.
A50 The Impact of Red Blood Cells Transfusion on Long-Term Survival After Isolated
Coronary Artery Bypass Grafting (CABG)
Poon, Sam, Mr; Chan, Jeremy, Mr; Cianci, Vincenzo, Mr; Sharma, Sobaran, Mr; Kumar,
Pankaj, Mr
Morriston Hospital, Swansea, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A50
Objective
Allogenic blood transfusion in cardiac surgery is associated with adverse outcomes.
We investigated the impact of blood transfusion on long-term survival after isolated
CABG.
Method
A retrospective cohort study on 1546 consecutive patients who underwent isolated CABG
from October 2007 to October 2011 was undertaken. The mean duration of follow-up is
10 years. The unit of blood transfusion was categorized into 5 groups. No transfusion,
1 unit, 2–4 units, more than 5 units, more than 10 units in order to correlate the
survival outcomes based on the units of blood transfusion received. A Kaplan–Meier
survival curve, log-rank analysis, logistic regression and Cox proportional hazard
analysis were conducted with propensity-matched analysis.
Results
One thousand five hundred forty-seven were included in the study. The mean age was
66.24 (range 26–89). Overall the 1,5,10-year survival rate was 95.51%, 87.52% and
68.07%, respectively for the entire cohort. Patient who received 2–4 units (HR 1.344,
95% CI 1.083–1.668, p = 0.007), > 5 units (HR 2.46, 95% CI 1.70–3.55, p < 0.001) and > 10
units (HR: 56.08, 95% CI: 25.73–122.23, p < 0.001) of RBC transfusion have a significantly
worsen 10-year survival outcome when compared with patient received no transfusion.
There was no difference in survival between who received no and 1 unit of red blood
cell transfusion.
Conclusion
In patients who underwent isolated CABG, transfusion of two or more units of red blood
cells is associated with poorer survival at 10 years. Effort should be therefore be
made to minimize red blood transfusion after CABG.
Adult Cardiac Miscellaneous
A51 Minimally Invasive versus Conventional Sternotomy for Primary Benign Cardiac Tumours:
A Meta-analysis
Hussain, Azhar, Mr; Mittal, Aaina, Ms; Uzzaman, Mohsin, Mr; Iqbal, Yasir, Mr; Butt,
Salman, Mr; Deshpande, Ranjit, Mr; Khan, Habib, Mr
Kings College Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A51
Objective
The contemporary trend towards a more minimally invasive approach in general cardiac
surgery have extended to involve the resection of primary benign cardiac tumours,
particularly in the hands of experienced surgeons. We performed a meta-analysis of
comparative studies using both approaches to highlight the differences in outcomes
for primary benign cardiac tumour surgery.
Methods
A literature search was performed using PubMed, EMBASE and Google Scholar until January
2021. 12 publications were analysed, including a total of 877 patients in this meta-analysis.
359 (40.9%) had a minimally invasive (MT) approach compared to 518patients (59.1%)
who had a median sternotomy (MS) approach during primary benign cardiac tumour surgery.
The outcomes analysed include mortality, post-operative stroke, renal failure, atrial
fibrillation (AF), length of hospital stay, reoperation for bleeding, wound infection,
cardiopulmonary bypass (CPB) times, cross-clamp times, transfusion of red blood cells
(RBC), intubation, chest drainage, and Intensive Therapy Unit (ITU) stay.
Results
There was a significantly reduced length of hospital stay, ITU stay, RBC transfusion,
and post-operative AF with the minimally invasive approach, but increased CPB and
cross-clamp time, when compared with median sternotomy.No significant difference was
found in mortality or incidence of post-operative stroke.
Conclusion
Surgical resection of primary benign cardiac tumours via a minimally invasive approach
is a safe and effective method with comparable outcomes. ICU stay, post-operative
length of hospital stay and the need for reduced transfusion requirements are potential
benefits with this approach.
A52 Investigating the Factors That Influence and Deter Medical Students from Pursuing
Cardiothoracic Surgical Career
Sherif, Mohamed
1, Mr; Linehan, Kathrine2, Prof
1Leeds General Infirmary, Leeds, UK; 2University of Sheffield, Sheffield, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A52
Objectives
To investigate what factors influence and deter medical students from pursuing a Cardiothoracic
surgical career. Also, to find out the most popular career among our medical students
and the percentage of students who wants to pursue a surgical career.
Method
Survey consisted mainly of open-ended questions were distributed among medical students
in clinical years at the University of Sheffield (phase 2 b to phase 4) and experienced
Cardiothoracic Surgeons at Northern General Hospital. Qualitative and quantitative
data were collected and analysed statistically with SPSS version 27 and thematically.
Outcome
52 (7.1%) students and 13 consultants (22%) responded to the survey. Only ten students
(19%) were interested in pursuing a surgical career, only one student (1.9%) expressed
their interest in pursuing a Cardiothoracic career. There was no statistical difference
between gender, age, ethnicity, year of study and the plans to join a surgical job.
Three themes emerged as factors that influence students to a career in surgery: personal
experience, speciality related factors, and rewards. These themes contain subthemes
where we found early positive exposure to surgery as the most critical factor in pursuing
a surgery career. In contrast, work-life balance was the main discouraging factor
for surgery.
Conclusion
Our study identified three thematic factors that influence students career choices
(personal experience, speciality related factors and Rewards). Cardiothoracic centres
can facilitate more positive exposure to medical students to drive them toward the
speciality. Focusing on providing early surgical exposure, defining more role models
and highlighting intellectual and financial rewards of Cardiothoracic surgery are
the keys to attracting more medical students toward the speciality.
A53 Establishing a Video Education Library for Mitral Valve Repair: What do Trainees
Think?
Casey, Anna
1, Ms; Ahmed, Ishtiaq2, Dr
1Brighton and Sussex Medical School, Brighton, UK; 2Royal Sussex County Hospital,
Brighton, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A53
Objectives
E-learning is increasingly used in surgical training but there is a lack of understanding
about the needs of local cardiothoracic surgery (CTS) trainees with regards to this
modality.
We aimed to understand the needs of local CTS trainees, and in future use this to
develop a tailored video library of CTS procedures to improve the quality of CTS training.
Methods
Online questionnaires and invitations to interview were sent to all 36 CTS trainees
in the South East/London area. These collected quantitative and qualitative data which
was analysed using descriptive statistics and implementation theory.
Results
Of 36 trainees, 17 responded to the questionnaire, and 3 interviews were conducted.
8 trainees were in their ST8 year of training. Trainees felt that their use of E-learning
had increased due to the Covid-19 pandemic and felt positively about the development
of a new video library.
Trainees reported a rise in demand for E-learning resources over recent years, accelerated
by the pandemic, which has not been matched by UK-specific development. Key features
that trainees would value included: offline mobile access, explicit linkage to UK
training outcomes, and self-testing capacity. Trainees reported using other video
libraries, but these were linked to requirements in the United States, revealing a
needed gap in the E-learning landscape for UK CTS training. Mitral valve repair was
a key procedure which trainees felt would benefit from the video library format.
Conclusions
This project aimed to understand the potential role of a new E-learning video library
resource for CTS trainees, and to describe their opinions and attitudes towards this.
Our results suggest that there is a definite gap in the market for a UK-based CTS
E-learning resource, especially with the impact of Covid-19 on training. Further exploration
of national CTS trainees’ opinions is needed, as well as further understanding of
ways to meet CTS training outcomes with E-learning modalities.
A54 Infrastructural Failure and Equipment Malfunctions Occurring During Elective Cardiac
Surgery. A Three-year Prospective Study
Efthymiou, Chris, Mr
Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A54
Objectives
A cardiac operation can only commence after a Surgical Safety Checklist (NHS) is performed. The
checklist was launched by the World Health Organisation (WHO) in 2008 and utilises
a 3-time point pause where changes can be made before it’s too late.
There is however no auditing of infrastructure or surgical instrument failures occurring
during procedures and little data exists regarding the effects of malfunctions. Owing
to this lack of information we studied the frequency and classified the category of
intraoperative equipment malfunction occurring during cardiac procedures.
Methods
Over a 36-month period equipment malfunctions were recorded during each procedure.
Operating equipment was divided into 3 categories based on portability and function.
Group 1: Theatre infrastructure and components. Group 2: Large medical equipment.
Group 3: Surgical instruments.
Results
In 75% (196/260) of cases there was an issue with equipment failure occurring. Theatre
infrastructure failures (Group 1) resulted in the cancellation of 5 cases (2%). Malfunctioning
large equipment (Group 2) occurred in 2.3% of cases and included issues such as broken
operating tables or TOE malfunction. In the surgical instrument category (Group 3),
issues with malfunctioning needle holders accounted for the bulk of failures recorded
by the study (60%). Some intraoperative instrument failures such as spontaneously
closing retractors were potentially catastrophic.
Conclusions
Failure of infrastructure or equipment occurs in an unacceptably high proportion of
cases. Some issues are overtly dangerous while others affect the flow of an operation.
The most common failures are with needle holders, forceps and scissors. Preventative
maintenance of key instruments and infrastructure should therefore be undertaken to
prevent cancellation of cases and to reduce adverse events from occurring during a
procedure.
A55 A Survey of the Run-through Training Programme in Cardiothoracic Surgery in Great
Britain and Northern Ireland Between 2013–2018
Dawson, Alan G.
1, Mr; Tyson, Nathan J.2, Mr; Tan, Carol3, Ms; Rathinam, Sridhar1, Mr; Jahangiri,
Marjan3, Prof
1Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK; 2Nottingham
City Hospital, Nottingham, UK; 3St George's University Hospitals NHS Foundation Trust,
London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A55
Objectives
The Cardiothoracic Surgery run-through training programme was initiated in August
2013 in Great Britain and Northern Ireland. We aimed to evaluate the experiences of
a cohort of trainees in the Cardiothoracic Surgery run-through training programme
to identify its strengths and weaknesses.
Methods
All trainees in Cardiothoracic Surgery who were appointed at ST1 from 2013 to 2018
were invited to complete an electronic survey (SurveyMonkey). The survey comprised
69 questions and was endorsed by the SCTS and SAC in Cardiothoracic Surgery. The link
to the survey was disseminated by the SCTS through Isabelle Ferner from 01 September
2020 and 31st October 2020 with weekly reminders sent. Five sections were covered
in the survey: trainee demographics; ST1 application; early ST1/ST2 years; after ST2;
and reflections on ST1 run-through training. Data was analysed using SPSS Version
26.0.
Results
Between 2013–2018, 46 trainees were appointed to the Cardiothoracic run-through programme
and 34 responses were received (response rate of 74%). The majority of trainees were
male (65%) with a median age of 27 years. Two-thirds decided on a Cardiothoracic career
in medical school and 22 had completed an undergraduate BSc degree. The majority of
trainees (41%) entered run-through from FY2. A Cardiothoracic Educational Supervisor
was assigned to 88% and 81% of ST1 and ST2 trainees, respectively. The time spent
in adult cardiac, thoracic, congenital and transplant was 16, 8, 6 and 9 months, respectively.
The majority of respondents felt that ST1/2 prepared them well for ST3 + training
and felt supported in their training. There were concerns raised regarding post-CCT
employment.
Conclusions
This comprehensive survey of Cardiothoracic run-through training has shown that the
programme prepares trainees well for ST3. Furthermore, the results of this survey
will provide valuable information and guidance for the SCTS and SAC on ways that the
run-through programme can be developed.
A56 Warfarin Prescribing at a Tertiary Cardiac Unit – Why is One of the Cheapest Drugs
So Expensive?
Yap, Trixie, Miss; Shehata, Monicka, Dr; Rizzo, Victoria, Miss; Hafiz, Imran, Mr;
Avlonitis, Vassilios, Mr
Guy's & St Thomas' NHS Foundation Trust, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A56
Objectives
Cardiac surgery patients are often discharged on warfarin due to valve procedures
or atrial fibrillation. Despite the high volume of prescriptions, it appears we often
get it wrong. The objective was to establish the cost implications of incorrect dosing
and excess INR tests, and identify how to improve this service for our patients.
Methods
A retrospective analysis of prospectively collected database was carried out. All
adult cardiac inpatients prescribed warfarin between 1st November – 31st December
2020 were included. Patient records were assessed for warfarin dosing errors on a
predetermined proforma. The number of coagulation tests per patient was also analysed.
Results
A total of 29 patients were included in the analysis. Warfarin was started approximately
2.9 (± 4.26) days after surgery in intensive/high dependency care. 125 dosing errors
(median 3 per patient, range 0–22) were identified (Fig. 1). There were 107 (18%)
excess INR tests costing £1208.03 and 20 (mean 4 ± 2.23) excess inpatient bed days
(approximate cost £8000) for 5 patients awaiting INRs to become therapeutic.
Figure 1
Conclusions
Excess dosing errors highlight poor understanding of the pharmacokinetics of warfarin,
leading to excessive INR testing and prolonged patient stay, generating significant
cost. Widespread education for prescribers, as well as pharmacy-led prescribing, may
be the answer.
A57 Safety of Training – A Propensity Matched Analysis of the UK National Database
Sinha, Shubhra
1, Miss; Dimagli, Arnaldo2, Mr; Fudulu, Daniel2, Mr; Bruno, Vito Domenico, 2, Mr;
Chan, Jeremy2, Mr; Vohra, Hunaid2, Mr; Benedetto, Umberto2, Prof; Angelini, Gianni
D2, Prof
1Derriford Hospital, Plymouth, UK; 2Bristol Heart Institute, Bristol, UK
Objective
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A57
Training the next generation of cardiac surgeons is a challenging aspect of surgical
practice.
Increased scrutiny of individual results and alterations in patient profiles and trainee
working patterns may have impacted on training and post-operative outcomes. We conducted
an analysis of a large national database to compare outcomes between cases performed
by consultants and trainees.
Method
Retrospective review of prospectively gathered database of adults undergoing cardiac
surgery in the UK between January 2012&March 2019.The primary outcome was mortality
within the same admission or 30 days of surgery. Cases were propensity scored and
matched 1:1 without replacement. Multivariable regression models for mortality were
performed. Comparisons between procedure-specific outcomes were also made.
Results
During the study period 216,994 patients were operated upon. Of these 42,173(19.4%)
were performed by trainees. Consultants when compared with trainees operated on patients
with higher EuroSCORE2 (1.74 vs 1.26, p < 0.001), more emergency/salvage patients
and those with more complex operations (mitral, aortic and double/triple/redo procedures).
Trainees performed less off-pump and arterial grafting and less minimally-invasive
valve procedures. The operative times were lower in trainee cases (CPB:91 vs 96 min,
cross-clamp:59 vs 64 min). In the matched populations the overall mortality (1.3%
vs 2.5%, p < 0.001) and need for dialysis (1.6% vs 2.8%,p < 0.001) was lower in trainee
cases. The outcomes were equivocal for the incidence of stroke, sternal wound infection
and length of stay post-operatively. Regression analysis showed a protective effect
of trainee first-operators (odds ratio 0.5,95% confidence interval:0.45–0.56). Mortality
was not influenced by the consultant nor hospital unit but operative times were shorter
with consultants as the first-assistant.
Conclusions
Appropriate patient selection and supervision can render training in cardiac surgery
safe and reproducible.
A58 Rare LV Masses: Technical Challenges—Movie
Deglurkar, Indu, Mr; Syed Nong Chek, Syed Aidil Hizman, Mr; Karthikeyan, Sivagnanam,
Dr
University Hospital of Wales, Cardiff, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A58
https://www.youtube.com/watch?v=h8vydxPOU2w
A59 Comparison of Machine Learning Techniques in Prediction of In-Hospital Mortality
Following Cardiac Surgery: Analysis of Over 220,000 Patients
Sinha, Shubhra
1, Miss; Dong, Tim2, Mr; Dimagli, Arnaldo3, Mr; Vohra, Hunaid3, Mr; Sterne, Jonathan2,
Prof; Angelini, Gianni D3, Prof; Benedetto, Umberto3, Prof
1Derriford Hospital, Plymouth, UK; 2University of Bristol, Bristol, UK; 3Bristol Heart
Institute, Bristol, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A59
Objectives
Comparative study of statistical techniques for formulation of an in-hospital mortality
risk stratification tool for adults having cardiac surgery in the UK based. The purpose
of this study was to perform a thorough systematic comparison between the predominant
scoring system in use [i.e. European System for Cardiac Operative Risk Evaluation
(ES)II], logistic regression retrained on the present database and alternative machine
learning techniques–namely random forest (RF), neural networks(NN), XGBoost and weighted
support vector machine.
Methods
We conducted retrospective analyses of prospectively routinely gathered data on adult
patients undergoing cardiac surgery in the UK between January 2012 and March 2019.We
temporally split the data 70:30 into training and validation subsets. Mortality prediction
models were created using the aforementioned techniques utilising the 18 variables
for EuroSCORE II. Comparisons of discrimination, calibration and clinical utility
were then conducted. We also reviewed changes in model performance over time.
Results
Of the 227,087 patients there were 6,258 deaths (mortality 2.83%). In the testing
cohort, we noted an improvement in discrimination XGBoost (AUC:0.8337–0.8343, F1 score:0.276–0.280)
and RF (AUC:0.833–0.834,F1:0.277–0.281) compared with ESII (AUC:0.817–0.818,F1:0.252–0.255).
There was no significant improvement in calibration with machine learning and retrained
logistic regression as compared with ESII, but ESII overestimated risk across all
deciles of risk and over time. The calibration drift was lowest in NN, XGBoost and
RF compared with ESII. Decision curve analysis showed XGBoost and RF to have greater
benefit than ESII.
Conclusions
Machine learning techni showed statistical improvements in discrimination, calibration
drift and accuracy compared with ESII. Further analysis incorporating a wider range
of predictor variables would be beneficial.
A60 A Single-centre 21st Century Experience of Triple Valve Surgery
Raj Krishna, Gokul, Mr; Taylor, Marcus, Mr; Nwaejike, Nnamdi, Mr; Barnard, James,
Mr; Venkateswaran, Rajamiyer, Prof
Wythenshawe Hospital, Manchester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A60
Objectives
Triple valve surgery has previously been shown to be associated with high rates of
mortality and morbidity. Nevertheless, patients requiring concomitant intervention
on three valves represent an important subgroup of cardiac surgery patients for whom
alternative non-surgical options may not be suitable. We aim to review our contemporary
experience of triple valve surgery.
Methods
A total of 29 consecutive patients undergoing triple (concomitant aortic, mitral and
tricuspid) valve surgery at a single quaternary cardiac surgery centre between 2003
and 2020 were included. Primary outcomes were in-hospital mortality, post-operative
complications, post-operative length of stay (PLOS) and 1-year mortality.
Results
The mean age was 63.0 years (± 9.5 years) and 65.5% (n = 19) of patients were male.
In total, 20.7% (n = 6) underwent urgent surgery and 79.3% (n = 23) had surgery on
an elective basis. Overall, 31.0% (n = 9) patients underwent an additional concomitant
procedure (coronary artery bypass grafting [n = 3], aortic surgery [n = 1], atrial
fibrillation surgery [n = 5]). The mean cardiopulmonary bypass and cross-clamp times
were 189.4 min (± 47.7 min) and 136.1 min (± 37.4 min), respectively. Mean logistic
Euroscore was 7.4% (± 5.1%). Post-operative complications were experienced by 69.0%
(n = 20) of patients and the median PLOS was 15 days (IQR 9–21 days). In-hospital
and 1-year mortality were 6.9% (n = 2) and 10.3% (n = 3), respectively.
Conclusion
Despite a high rate of post-operative morbidity, the observed in-hospital mortality
rate was relatively low and broadly similar to the expected mortality rate, as calculated
by the Euroscore. For those patients surviving to discharge, the risk of death up
to 1 year after surgery is also minimal. These results demonstrate that triple valve
surgery remains an appropriate cardiac surgical intervention in carefully selected
patients.
A61 Cardiac Surgery in the Over in the Over 85 Population: A Single Centre Retrospective
Cohort Analysis
Badran, Abdul
1, Dr; Shah, Owais1, Dr; Badran, Dania2, Dr; Velissaris, Theodore1, Mr
1University Hospital Southampton, Southampton, UK; 2Imperial College London, London,
UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A61
Objectives
Rising average life expectancy in the developed world, increased incidence of cardiovascular
disease with age and improved peri and postoperative care has expanded provision of
cardiac surgery to an increasingly elderly population. We evaluated the outcomes of
cardiac surgery in this high-risk population.
Methods
We retrospectively investigated patient characteristics and outcomes of those over
the age of 85 years who underwent a cardiac surgical procedure over an 18-year period
at our busy cardiac surgical unit.
Results
The total number of patients 558 with a mean age of 88 years (86–94). 323 of these
patients were male with 235 female. Surgical coronary revascularisation was performed
in 54% (304) with an average of 2 grafts (5–1). 70% (390) underwent an aortic valve
replacement, 8% (n = 44) had a mitral valve repair/replacement and 3% (n = 15) had
a tricuspid valve repair /replacement. An aortic interposition graft was performed
in 1% (n = 8). Premorbidites included 44% (n = 244) were hypertensive, chronic kidney
injury in 13% (n = 73), history of CVA in 8% (n = 46), 8% (n = 46) had COPD, 8% (n = 49)
were diabetic and. Postoperative complications included chest infection in 20% (n = 110)
chest infections, 3% (n = 16) wound infections, 16% (n = 90) developed an AKI with
5.4% (n = 30) on a background of chronic renal disease., 6.8% (n = 38) had re-exploration
for post-operative bleeding.
Conclusions
Cardiac surgery in this patient group is safe providing definitive, reproducible results
with acceptable mortality figures. Age and certain comorbidities should not be a deterrent
in offering surgery to this growing cohort.
A62 Retrograde Arterial Perfusion is Safe for Endoscopic Heart Valve Surgery in Both
Young and Elderly Patients
Elhassan, Hind, Dr; Abdelbar, Abdelrahman, Mr; Zacharias, Joseph, Mr
Blackpool Teaching Hospital, Blackpool, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A62
Objective
Minimal invasive cardiac surgery via right anterolateral thoracotomy compared with
the conventional median sternotomy proven to have lower post-operative complications.
We aimed to compare the neurological complications and post-operative outcomes in
2 cohort groups as well as mortality rate and survival rate up to 10 years post operatively.
Method
Retrospective observational study using propensity matched score for patients who
had minimally invasive cardiac valve surgery between 2007–2021(n = 596) with retrograde
femoral arterial perfusion.
Result
In our study, despite the significant difference between the two groups in their baseline
individual characteristic and EuroSCORE, there were no differences between the two
groups in term of post-operative outcomes both in unmatched and matched set. In data
analysis we found that patients 70 years old or above had no increased risk for neurological
complications (p = 0.75) compared with those below 70 years old. The same result was
found after matching the data set (p = 0.60). Morality rate was also not significant
between the two groups in unmatched data set (p = 0.12) and matched data set (p = 0.37).
Although length of hospital stay was statistically significant in the unmatched data
set (p < 0.001), there was difference between the two groups in matched data (p = 0.38). Elderly
patient group do get discharged home the same as the adult group rather than been
referred for further rehab or repatriated to another hospital for recuperation. (unmatched
data p = matched data p = 32). Interestingly, the CPB time was significantly lower
in the elderly group compared to the adult group (p = 0.036). This may be that particularly
complex procedures were avoided in this age group.
The crude survival suggests no significant difference in survival rates between age
groups when they are similar in term of basic characteristic.
Conclusion
Minimally invasive approach with retrograde arterial perfusion is a safe for a spectrum
of primary cardiac valve procedure in elderly patients.
A63 Experience and Outcomes of Redo Cardiac Surgery at a Tertiary Centre in the UK
Naruka, Vinci
1, Mr; Chaubey, Sanjay1, Mr; Chacko, Jacob1, Mr; Liu, Guiqing1, Mr; Bola, Harroop2,
Mr; Dixit, Prithvi2, Mr; Rathod, Virensinh2, Mr; Sabeshan, Pratheeshan2, Mr; Afoke,
Jonathan2, Mr; Punjabi, Prakash P1, Prof
1Hammersmith Hospital, London, UK; 2Imperial College London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A63
Objective
In recent years transcatheter interventions have increasingly been used to treat patients
requiring repeat cardiac intervention. However, it is important that surgery is not
disregarded as what maybe the best option for these patients. We report our experiences
and outcomes of redo cardiac surgery over 9 years.
Methods
A prospectively collated database was analysed between 2013 and 2021 in a single centre.
Outcomes were compared between the first 4.5 years to the latter 4.5 years. The primary
outcome was in-hospital mortality. Secondary outcomes included stroke, new atrial
fibrillation (AF), new pacemaker insertion, new renal replacement therapy (RRT), length
of stay (LOS), and long-term mortality.
Results
166 patients underwent redo operations of which 13 (8%) had CABG, 38 (23%) AVR, 39
(23%) Aortic, 39 (23%) MV surgery, 24 (14%) Multi-valve, 13 (8%) CABG + Valve. The
average EuroSCORE II was 8.31%, 34% were urgent, 19% for infective endocarditis.
Postoperative outcomes included: 3 (2%) stroke, 1 (1%) RRT, 25 (15%) AF, 10 (6%) pacemaker,
LOS (10 days (7–15)), 15 (9%) hospital mortality, 62.5% alive at 3000 days.
Comparing the first 4.5 years to the second half, we performed significantly more
redo-AVR (14% vs 30%), more redo-aortic (18% vs 28%), less redo-CABG (12% vs 4%) and
redo-MV surgery (36% vs 13%) (p < 0.001). Our patient risk profile and operative strategy
remained similar. We operated on more urgent patients (29% vs 38%,p = 0.42) with similar
outcomes but less post-operative strokes (4% vs 0%,p = 0.05). There is significantly
lower hospital mortality (15% vs 4%,p = 0.02) between the 2 periods, but long-term
survival remains similar (p = 0.47) (Fig. 1.)
Conclusions
Over time, significantly lower hospital mortality and postoperative strokes were observed,
while the overall long-term survival remains similar. Redo coronary and mitral valve
surgery reduced across the study period whilst the proportion of redo aortic and aortic
valve surgery increased.
A64 Neurological Presentations in Endocarditis, a Cause of Delay to Surgery?
Badran, Abdul, Dr; Rowe, Henry, Mr; Badran, Dania, Dr; Nwakwu, Cynthia, Miss; Ohri,
Sunil, Prof
University Hospital Southampton, Southampton, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A64
Introduction
Infective Endocarditis can be a cause of cerebral emboli and mycotic aneurysms. Timing
of surgery in patients with endocarditis who have suffered a cerebrovascular accident
remains a matter of debate.
Methods
Data was collected retrospectively over a 4-year period and involved 198 patients.
Demographic and clinical details were gathered from the patient medical records.
Results
A minority of patients presented with neurological symptoms 8.6% (n = 17). The majority
of patients was male 82% (n = 14). The mean age was 55.4 (21–79). Of these patients
35% (n = 6) died and 65% survived to last follow-up. 65% (n = 11) were operated. The
mean length of time waited before an operation was 17 days (0–51) Vs 11 days (0–62)
in other presentations. Of the patients with neurological symptoms that had an operation,
27% (n = 3) died compared to 50% (n = 3) of those that did not. The survival rates
for differing lengths of wait time for surgery were 80% for 7 days, 85.7% for £14 days,
75% for 28 days and 70% for 42 days.
Conclusion
Operating on IE within 14 days of admission provides the best survival outcomes for
patients, even in recent haemorrhagic stroke. Surgical treatment is associated with
a better survival rate than medical approaches.
A65 A Systematic Review of Safety and Patient/Healthcare Provider Satisfaction with
Virtual Clinics
Shehata, Monicka
1, Dr; Rizzo, Victoria2, Miss; Sabetai, Michael1, Mr; Athanasiou, Thanos3, Prof
1St Thomas Hospital, London, UK; 2Guy's and St Thomas' NHS Foundation Trust, London,
UK; 3Hammersmith Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A65
Objectives
Cardiac surgery outpatient appointments were conducted via telephone during COVID-19
in our unit. We have reviewed patient and healthcare provider satisfaction with virtual
clinics in surgical specialities as a basis for a more permanent move to virtual clinics
in cardiac surgery.
Methods
MEDLINE and Embase databases were searched for all studies evaluating virtual clinics
for adult patients in surgical specialities within the past ten years. Qualitative
analysis of overall patient satisfaction and safety was carried out. The Cochrane
Risk of Bias Tool version 2 was used to assess risk of bias for randomised controlled
trials.
Results
21 studies met the inclusion criteria: 16 cohort studies and 5 randomised controlled
trials. 18 studies assessed patient satisfaction, two assessed healthcare provider
satisfaction and one assessed both. Similar to our unit, the majority (57%) used virtual
clinics for post-operative or follow-up patients. Number of patients per study ranged
from 22 to 590, with a reported response rate of 20–100%. Patient and healthcare provider
satisfaction ranged from 71.6%-98% and 76.5%-98% respectively. Only four studies used
validated surveys, with 15 studies using study-specific surveys. Patient safety was
assessed in 15 studies with no significant safety issues identified.
Conclusions
This review has helped to establish that virtual clinics are safe and acceptable to
patients. Building on this framework, we will establish an ongoing virtual cardiac
surgery service post-Covid. The use of validated questionnaires will help ongoing
assessment of our service and identify contextual features that increase success of
virtual clinics.
A66 Readability of Cardiothoracic Surgery Consent Forms in Queensland
Dutta, Sanjay
1, Dr; McManus, Bryan2, Dr; Iyer, Anand1, Dr
1Princess Alexandra Hospital, Brisbane, Australia; 2St Vincent's Hospital, Sydney,
Australia
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A66
Objectives
Written consent forms are a key component of obtaining informed consent from patients
prior to surgery. Reading literacy among Australians is generally poor, and it is
recommended that written content is at a year 7 level to make it usable for most people.
The aim of this project was to assess the readability of consent forms for cardiac
surgery in Queensland, Australia.
Methods
Queensland Health consent forms for "Aortic Surgery", "Coronary Artery Bypass Grafting
and/or Valve Surgery", and "Generic Cardiac" were obtained. The readability of the
sections relating to risks of surgery (Section C), patient consent (Section G), and
the patient information sheet were assessed via an online readability software program,
using five separate validated methods: (i) Flesch-Kincaid grade level, (ii) the SMOG
(Simple Measure of Gobbledygook), (iii) Coleman-Liau index, (iv) Automated readability
index, (v) Linsear Wriste formula. Statistical analysis was performed using Microsoft
Excel.
Results
The mean ± standard deviation reading grade level from all algorithms for risks of
surgery, patient consent, and patient information was 7.78 ± 2, 10.74 ± 0.76, and
7.83 ± 1.55 respectively. The "Generic Cardiac" form had the highest average grade
level (9.8 ± 1.41), followed by "Coronary Artery Bypass Grafting and/or Valve Surgery"
(8.67 ± 2.26) and "Aortic Surgery" (8.54 ± 2.18).
Conclusions
The readability of key sections of the Queensland Health consent forms is above the
recommended reading grade, and a large percentage of the population would be unable
to fully comprehend the information. Consideration should be made to lower the reading
grade level of patient consent forms.
A67 Carcinoid Heart Disease: Early Outcomes after Surgical Valve Replacement in Thirteen
Patients
Mujtaba, Syed Saleem
1, Mr; Clark, Stephen2, Prof
1Morriston Hospital, Swansea, UK; 2Freeman Hospital, Newcastle, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A67
Objective
To describe the early outcomes of carcinoid patients undergoing valve replacement.
Methods
In a retrospective study, patients with symptomatic carcinoid heart disease undergoing
surgery between 2012 and 2021 were reviewed.
Results
13 patients (mean age 64 years (range 55–79 years) underwent surgery. Three patients
had quadruple valve replacement, seven had tricuspid and pulmonary valves changed,
two had tricuspid valve replacement, while one had tricuspid, pulmonary, and aortic
valves replaced. Right-sided valves were replaced with biological valves in 12 patients
and a mechanical valve in one patient. Left-sided valves were replaced with a mechanical
valve in two patients and with a biological valve in 1 patient. Mean postoperative
follow-up was 56 months (range 2-102 m, median 65 m). All had good left ventricular
function except one (mildly impaired). The right ventricle was severely dilated in
four patients, moderate in four, and mild in three. One patient died of heart failure
10 days postoperatively and one patient succumbed to acute carcinoid crisis 8 days
after surgery. Functional improvement was noted in all survivors. All were NYHA class
1–2 at last follow up. None required a pacemaker. One patient died of their neuro-endocrine
tumour at six years for a survival rate of 91%. No valve re-interventions were needed.
Conclusion
Carcinoid syndrome is a rare and progressive disease but valve replacement in symptomatic patients
has functional and survival benefit, low early postoperative mortality, is without
valve-related complications and shows functional improvement. Cardiac assessment is
required in all patients with carcinoid disease to ensure that appropriate patients
are put forward for surgery when symptomatic.
A68 Effects of Inhibitor of –Catenin Responsive Transcription on Platelet-endothelial
Interaction: A Molecular and Functional Study
Chan, Jeremy, Dr; Wadey, Kerry, Dr
University of Bristol, Bristol, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A68
Introduction
Despite its high failure rate, saphenous vein graft (SVG) remains the most used conduit
in coronary artery bypass grafting. Platelet activation and aggregation is involved
in the early pathological pathway of SVG failure. Integrin αvβ3 was shown to be involved
in platelet adhesion on the endothelial cell. Previous work showed Inhibitor of β–catenin
responsive transcription (iCRT) improves endothelial barrier function and reduces monocytes
recruitment in TNF α stimulated human umbilical vein endothelial cells (HUVECs). Its effect
on platelet-endothelial interaction was evaluated to determinate the risk of thrombus
formation prior further clinical use.
Method and results
Fluorescent labelled platelets were added into HUVECs with either unstimulated or
stimulated with 10 ng/ml TNF-α and treated with either DMSO vehicle control or iCRT. iCRT
significantly enhanced platelet-endothelial interaction in HUVECs. Similar results
were seen in ex-vivo saphenous vein organ culture.
Further experiments were performed to seek for an explanation in a molecular level. Western
blotting showed a reduction of integrin αv and free vWF in condensed media but not β3 in
TNFα-stimulated HUVECs treated with iCRT. Quantitative PCR showed a raise integrin αv
mRNA expression in TNFα-stimulated HUVECs with iCRT.
Conclusion
Our results demonstrated iCRT reduced protein expression of integrin αv and free vWF in condensed
media in TNF-α-activated endothelial cells. However, such effects were not translated
to functional assays. Nonetheless, I have reported a valid model and protocol for
assessing platelet-endothelial interaction in HUVECs and ex-vivo saphenous vein organ
cultures.
A69 Are Super Obese Patients At Higher Risk for Cardiac Surgery? Results from the
Last Decade
Mustafa, Ammar, Mr; Palima, Jeni, Ms; Hayre, Simran, Miss; Boateng, Michael, Mr; Elsiddig,
Mahmoud, Mr; Rescigno, Giuseppe, Mr
Royal Wolverhampton NHS Trust, Wolverhampton, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A69
Objectives
Very high BMI represents a concerning factor in Cardiac Surgery. However, previous
studies have not shown a significantly increased risk. Yet, these were mainly focused
on CABG operations and frequently with limited number of patients. The aim of this
study was to review our in-hospital results of open-heart procedures for all comers
with a BMI > 40 kg/m2 during the last 10 years.
Methods
Retrospective analysis of prospectively collected data of super obese patients who
underwent open heart procedures (elective, urgent or emergency) of any kind between
April 2011 and March 2020 in our Department. Participants’ demographics, preoperative
risk factors, operative data, in-hospital mortality, postoperative complications were
analysed.
Results
179 patients were identified. Patients preoperative characteristics are summarised
in the Table. Briefly, the majority were male (56%) and Caucasians (91.6%). Mean age
was 61.2 ± 9.4 years; mean SCTS Euroscore was 1.6 ± 4.1. The type of admission was
elective in 65.9%, in-hospital transfer in 31.2% and emergency in 2.7%. The types
of operations were isolated CABG (45.8%), isolated valve surgery (34.0%), CABG + Valve
(12.8%), major aortic (3.9%) and others (3.3%). In hospital mortality was 1.6% (3
patients). Mean hospital stay was 8.4 ± 9.7 days. We recorded 2 permanent strokes
(1.1%). Eight patients (4.4%) required temporary haemofiltration. In 14 patients (7.8%)
some sort of ventilation support was necessary (CPAP, reintubation or both). There
were 2 deep sternal wound infections (1.11%).
Conclusions
In-hospital results for super obese patients were good in our 10 years series. The
dreadful sternal complications were not frequent. Expected and observed mortality
were similar. A thorough preoperative assessment of the patient risk profile is warranted
in these technically complex subjects.
Characteristics
Mean SD or N (%)
Male
100 (55%)
Age (years)
61.2 9.48
Caucasian/BAME
164/15
BMI (Kg/m2)
41.9 1.6
SCTS Logistic Euroscore (%)
1.6 4.17
Elective/Urgent/Emergency
118/56/5
Diabetes
100 (55)
Peripheral vascular disease
25 (13.9)
Atrial fibrillation
28 (15.6)
Renal impairment (moderate to severe)
32 (17.8)
LV ejection fraction < 30%
8 (4.4%)
A70 Patient Recovery from Cardiac Surgery During the Covid-19 Pandemic: 1-year Outcomes
from The CardiacCovid Study
Sanders, Julie
1, Professor; Bueser, Teofila1, Ms; Beaumont, Emma2, Ms; Dodd, Matthew2, Mr; Owens,
Gareth3, Mr; Murray, Sarah4, Mrs; Clayton, Tim2, Prof; Oo, Aung1, Prof
1St Bartholomew's Hospital, London, UK; 2London School of Hygiene and Tropical Medicine,
London, UK; 3Aortic Dissection Awareness UK and Ireland; 4SCTS Lay representative
and NICOR Patient Engagement Lead
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A70
Objectives
The outbreak of Covid-19 was potentially stressful for everyone, and possibly heightened
in those having cardiac surgery during the pandemic. We sought to explore the effect
of the pandemic on recovery up to 1-year from cardiac surgery.
Methods
A prospective observational study (Ethics:20/YH/0132. Clinicaltrials.gov:NCT04366167)
was established. Eligible patients were > 18 years old undergoing any form of cardiac
surgery between 23rd March 2020 (UK lockdown) and 4th July 2020 (large lifting of
lockdown). Those too unwell or unable to give consent/complete the questionnaires
were excluded. Participants completed the EQ-5D (quality of life, QoL), impact of
event (IES-R) (anxiety related to COVID-19), depression (CES-D) questionnaires at
baseline (T0), 1 week after hospital discharge (T1), and 6 weeks (T2), 6 months (T3)
and 1 year post-surgery (T4). Questionnaires were completed electronically (Amplitude
system) or on paper and returned by post.
Results
196 patients participated. Questionnaire completion was 196(100%), 132(67.3%), 159(81.1%)
and 149(76.0%) at T0-T4, respectively. Most participants were male (147(75.0%)), white
British (156(79.6%)) with an average age 63.4 years (SD 11.2) and underwent urgent
surgery (104(53.1%). No patients had COVID-19 and in-hospital mortality was 1(0.5%).
Overall, anxiety due to the pandemic was high (T0-T3) and was greater in women and
younger patients (T0-T4). Women also had lower QoL and higher depression, although
overall rates of depression were within ranges observed in other studies in non-COVID-19
times.
Conclusions
The COVID-19 pandemic caused greater anxiety in patients undergoing cardiac surgery
with women and younger participants particularly affected. Psychological support pre-
and post-operatively in further crises or traumatic times, should be considered to
aid recovery.
A71 Identifying Predictors of Short- and Long-term Outcome After Surgery for Infective
Endocarditis
Salmasi, M Yousuf
1, Dr; Rizzo, Victoria2, Dr; Comanici, Maria3, Ms; Abdul Khader, Ashiq1, Dr; Athanasiou,
Thanos1, Prof; Marczin, Nandor3, Dr; Raja, Shahzad3, Mr
1Imperial College London, London, UK; 2St Thomas Hospital, London, UK; 3Royal Brompton
and Harefield Trust, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A71
Background
This study aimed to evaluate the clinical predictors of patient outcome after surgery
for infective endocarditis.
Methods
We conducted a retrospective analysis of all consecutive patients undergoing surgery
for infective endocarditis in the period January 2015 to February 2021. Multivariate
analysis and survival analysis (including Cox-regression) were conducted to assess
predictors of short- and long-term outcomes.
Results
In the study period, 148 patients had surgical management of endocarditis. Mean age
was 60.1 ± 13.9 years, 31 were females (21%), 43 patients (29%) had had previous cardiac
surgery, 34 patients (25%) had prosthetic valve endocarditis, 50 patients were reported
as having subacute/chronic endocarditis (vs 99 patients acute). 15 patients had double
valve endocarditis, 53 (44%) patients had at least a single positive blood culture
prior to surgery, of these 18 were staphylococcus. Valve tissue provided a positive
culture in 66% of patients.
Short-term outcomes were as follows: 67 patients (45%) suffered at least 1 post-operative
complication. There were 13 in-hospital deaths (8.7%). 23 patients required post-operative
haemofiltration. 27 patients suffered pulmonary complications post-surgery. Long-term
survival (at 5 years) was 88.9%.
Haemofiltration post surgery was a significant predictor for worse survival outcome
(filtration 45% vs no-filtration 96%, logrank test, p < 0.001). The existence of prosthetic
valve endocarditis, blood culture positivity or redo surgery were not predictors of
mortality (logistic regression, P > 0.05) or survival outcome (logrank, p > 0.05).
Conclusions
The study highlights the strong influence of renal dysfunction on short and long-term
outcomes after cardiac surgery. This calls for a more in-depth analysis of vasoplegia
markers to assess the influence of vasoplegia status and end-organ perfusion on short/long-term
outcomes and potential methods for patient-specific management.
A72 How Accurate is Cardiac Surgeons' Prediction of Operative Mortality Rate?
Oo, Shwe, Ms; Chan, Jeremy, Dr
University of Bristol, Bristol, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A72
Introduction
Accurate outcome prediction is important during both counselling and consenting processes.
The accuracy of cardiac surgeons predicting operative risk is not well known. We aimed
to perform a literature review to compare surgeons’ and risk models’ prediction of
operative mortality.
Method
A systematic review was performed in accordance with the updated 2020 PRIMSA guideline.
Four major electronic data bases were reviewed. The outcome was defined as 30-day/in-hospital
mortality. Comparison was made between surgeons’ pre-operative prediction, risk model
scoring system and patients outcomes.
Results
4 studies with a total number of 6795 patients were included. Both surgeons and risk
prediction models over-estimated the observed mortality rate. The mean mortality estimated
by surgeons and the risk prediction models was 6.90% and 6.94%, respectively. This
was higher than the observed mortality (4.74%).
Conclusion
Both surgeons and risk assessment models overestimated the mortality rate. When compared
with the risk assessment model, surgeons tended to over-predict low and moderate risk
and underestimated the mortality rate for high-risk patients.
A73 How to Maintain a Cardiac Surgery Service Amidst a Global Pandemic?
Mouyer, Zakariya1,2,
1 Imperial College London2, London, UK; 2 University of Manchester Medical School,
Manchester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A73
Objectives
What is the SARS-CoV-2 virus?
How has the COVID-19 pandemic affected cardiac surgery globally?
How did a leading cardiac surgery centre in England cope and endure the pandemic?
What suggestions have been looked into for future planning and service protection?
Introduction
The COVID-19 outbreak emerged in December 2019, it has since had a devastating effect
on all health services globally. One key leading cardiac centre in UK, that provides
a world-class service to its 3.2 million patient database; was heavily affected by
the pandemic.
Methods
In this report the cardiac surgery service was assessed by analysing data collected
in the fashion of an audit from four different time points: Pre-COVID, England’s 1st
Peak, England’s 2nd Peak and the Present Day. Parameters included: total surgeries
conducted, cancellations, cancellations due to a shortage of cardiothoracic critical
care unit (CTCCU) beds and weekly averages for the aforementioned.
Results
Results showed a significant drop in surgical output during the first peak (79.6%
decreased output from Pre-COVID—see attached figure) and a large increase in cancellations
both generally (from 25.1% to 28.2%) and due to CTCCU bed shortage (from 36.2% to
45.5%). However, a strong comeback was seen during the second peak (47.8% decreased
output from Pre-COVID and 2.4% fewer cancellations), and an almost complete optimisation
of service was observed in the Present day (45.1% increased output from Pre-COVID
and 8.9% fewer cancellations).
Conclusion
This trust's cardiac surgery service has adapted immensely to its adverse circumstances;
this audit has reported the list of measures taken to achieve this and the recommendations
to achieve future surgical optimisation. The Trust managed to optimise its service
and outperformed itself both from Pre-COVID and internationally. With further refining
using PLECS and Canadian Society of Cardiac Surgeons guidance, full optimisation is
feasible.
A74 Current Trends in the Surgical Management of Infective Endocarditis: The UK-IE
Survey
Bakr, Lubna, Miss; Raja, Shahzad, Mr
Harefield Hospital, Uxbridge, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A74
Objectives
Surgical valve replacement is the cornerstone of infective endocarditis (IE) management
in the presence of severe valvular destruction, uncontrolled infection, or large vegetation.
The prosthetic valve choice, however, is not easy. Our aim is to explore the current
trends in the surgical management of IE in the UK to improve our understanding of
the current practice.
Methods
We developed the UK-IE survey and disseminated it to consultant cardiac surgeons around
the UK through SCTS Weekly Updates.
Results
Biological valve was the most considered choice in the aortic position whether it
was native or prosthetic valve IE. It was offered by 74% of responders to patients < 70 years
and 98% to patients ≥ 70 years. Biological valves remained favourable in the mitral
position in 81% of patients ≥ 70. However, mechanical ones were preferred by 76% of
responders for patients < 70. Biological valves were offered to patients with double-valve
IE and right-sided IE (87% and 77%, respectively). Valve repair was considered in
65% of right-sided IE and 45% of native mitral IE patients ≥ 70. Local antiseptics
were considered by 58% of responders, mostly Betadine and/or topical antibiotics.
Mechanical valves were preferred in young adults (18–40 years) while biological ones
were preferred in women of childbearing age, injection drug users, dialysis patients
and patients with liver cirrhosis. 86% of surgeons would not consider a monobloc aorto-mitral
homograft or cardiac transplantation. 77% of surgeons are confident in their valve
choice to prevent IE recurrence basing it on personal preference. Responses were received
from across the UK (England 84%, 3.2% for each of Wales, Scotland and Northern Ireland)
and the Republic of Ireland (7%) with 81% of centres having a specialist IE MDT.
Conclusions
Biological valves were preferred in all IE cases except young adults and mitral IE < 70
where mechanical valves were offered. 77% of choices were based on personal preference.
A75 Right Thoracotomy Versus Conventional Median Sternotomy in Redo Cardiac Surgery:
A 10-year Single-centre Experience
Ng Yin Ling, Clarissa
1, Dr; Chacko, Jacob2, Mr; Bleetman, David2, Mr; Leung, Kristie3, Ms; Khan, Habib2,
Mr; Whitaker, Donald2, Mr; Deshpande, Ranjit2, Mr; Wendler, Olaf2, Prof; Baghai, Max2,
Mr;
1Department of Surgery and Cancer, Imperial College London, London, UK; 2Department
of Cardiothoracic Surgery, King's College Hospital, London, UK; 3University College
London, London, UK; 4Faculty of Medicine, University College London, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A75
Introduction
Minimally invasive cardiac surgery (MICS) has been gaining popularity over conventional
sternotomy due to reduced invasiveness. However, in redo cardiac surgery when the
risks are higher due to adhesions, few studies compare long-term outcomes.
Objective
We aim to compare the perioperative and long-term mortality and stroke/TIA rate in
patients undergoing median sternotomy and right thoracotomy for redo cardiac surgery.
Secondary outcomes were post-operative and total hospital stay, blood products used,
return to theatre and new renal replacement therapy (RRT).
Methods
We retrospectively analysed a cohort of 127 sternotomy patients and 29 right thoracotomy
patients for redo cardiac surgery between 2010–2020. All patients underwent valve
repair or replacement. Patients requiring concomitant cardiac procedures were included.
Results
In-hospital and long-term follow-up were 100% and 98.1% complete and a maximum of
10.4 years. There were 52 deaths (33.3%) within the follow-up period. Perioperative
mortality was 16.5% in sternotomy versus 3.45% in MICS, although this difference was
insignificant after adjustment for logistic EuroSCORE (HR 0.38, [0.05–2.79]). In multivariate
analysis, long-term mortality was significantly lower in MICS (HR 0.30 [0.10–0.85]).
Adjusted Kaplan–Meier curves revealed lower long-term mortality in the MICS group
(p < 0.0001). Differences in stroke/TIA rates were insignificant (odds ratio 3.23
[0.85–12.8]). There were significantly less RBC (p = 0.0001) and total blood products
(p = 0.0032) used in the MICS group. All 12 patients who returned to theatre for bleeding
complications were in the sternotomy group. Although mean post-operative and total
hospital stay and new RRT were lower in the MICS group, these differences were insignificant.
Conclusion
MICS for redo cardiac surgery is a safe and effective alternative to median sternotomy
without compromising both short-term and long-term clinical outcomes.
A76 The Implementation of a Virtual Learning Environment in Facilitating Cardiothoracic
Surgical Teaching – The West Midlands Experience
Iqbal, Yassir
1, Mr; Iqbal, Akshay1, Mr; Bleibleh, Sabri2, Mr; Ghosh, Shilajit3, Mr; Graham, Timothy4,
Mr; Ahmed, Usman4, Mr
1Queen Elizabeth Hospital, Birmingham, Birmingham, UK; 2Department of Orthopaedic
Surgery, Royal Orthopaedic Hospital NHS Trust, Birmingham, UK; 3Department of Thoracic
Surgery, UHNM NHS Trust, Stoke-on-Trent, UK; 4School of Surgery, Health Education
England, West Midlands, Birmingham, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A76
Objectives
The COVID-19 pandemic has resulted in widespread disruption, and overwhelmed healthcare
services globally. In addition to this, we have seen an immediate and dramatic effect
on training for surgical trainees. Ultimately, these challenges have provided a "teachable"
moment for trainers and trainees to advantage of, and has come in the form of innovative
solutions to optimise educational endeavours utilising twenty-first century technology.
Methods
Prior to the pandemic, teaching was delivered to 17 higher surgical trainees through
a programme of monthly lectures and face-to-face workshops, dissection sessions and
cadaveric skills stations at a clinical skills lab placed within one of the regional
trusts. The Postgraduate Virtual Learning Environment (PGVLE) is an online educational
platform using Moodle and BigBlueButton (BBB) web-conferencing software. It has been
utilised to deliver the teaching programme during the COVID lockdown.
Results
The monthly full day teaching programme has now been formally replaced by a virtual
weekly programme covering topics pertinent to the curriculum. The significant advantage
of this new system is that sessions are largely during the evening allowing for maximal
attendance as trainees don’t have the added burden of organising study leave and moreover
the preparatory reading has enabled for maximal gain from each session. We have adopted
a "trainee-directed" approach in that all trainees are individually responsible for
organising teaching sessions on a rolling rotational basis. We envisage that with
time, we will be able to replicate cadaveric and dissection courses virtually with
opportunity for face-to-face wetlabs to consolidate learning.
Conclusions
Implementing a deanery wide specialty teaching programme has given us the opportunity
to develop a standardised set of processes that allow for a consistent level of education
based on the cardiothoracic curriculum.
A77 Left Video-Assisted Thoracoscopic Ablation for Persistent Ventricular Tachycardia,
a Case Report
Moawad, Nader
1, Mr; Harfield, Jack1, Mr; Rogers, Luke1, Mr; Podd, Steven2, Dr; Dalrymple-Hay, Malcolm1,
Mr
1Derriford Hospital, Plymouth, UK; 2Torbay Hospital, Torquay, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A77
https://www.youtube.com/watch?v=fSYMarw8jTY
A78 Techniques for Pulmonary Artery Reconstruction for Pulmonary Artery Aneurysm:
Case Report and Review of the Literature
Holmes, Charlotte
1, Miss; Freystaetter, Kathrin, Miss; Goodwin, Andrew, Mr
1The James Cook University Hospital, Middlesbrough, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A78
Objectives
Pulmonary artery aneurysm (PAA) is rare. Natural history of PAA is poorly understood
and there are no treatment guidelines. Surgical repair is done due to risk of rupture
and dissection. Due to the infrequency of these cases there is no established surgical
technique. We aim to present a case study of a pulmonary artery reconstruction for
a PAA and a review of the literature.
Methods
A case study presentation and a PubMed search using MESH terms "surgical treatment"
or "reconstruction" and "pulmonary artery aneurysm" was conducted.
Results
A 46-year-old female presented with an 63 × 56x85 mm incidental pulmonary artery aneurysm.
Pulmonary artery pressure 30mmHG. The repair was performed on cardiopulmonary bypass
without cardiac arrest. The pulmonary trunk was excised 1 cm above the valve. The
right and left pulmonary arteries were resected. A 22 mm Hemashield graft was anastomosed
the left pulmonary artery and right pulmonary artery. An oval slit was made and a
size 26 mm Hemashield graft was anastomosed end to side, forming a ‘T’ junction and
then anastomosed to the remainder of the pulmonary trunk.
Surgical repair is recommended for aneurysms > 6 cm or increasing in size > 0.5 cm/0.5yrs,
in symptomatic patients or if compression of adjacent structures. Pulmonary artery
hypertension (PAH) increases risk of rupture and is also an indication for surgery.
A variety of surgical techniques have been described including: aneurysmorrhaphy,
pericardial patch reconstruction, and interposition grafts with synthetic or allografts.
Replacement with a synthetic interposition graft is most common. Our case is the first
to describe a "T junction" technique.
Conclusions
PAA are rare with no guidelines on management. Surgical repair is considered due to
size, symptoms or those with PAH. Due to the paucity of cases surgical techniques
vary and depend on operative findings. Our case had good outcomes and is the first
describe the interposition "T junction" graft technique used.
Informed consent to publish had been obtained.
A79 Are There Differences in Mortality and Morbidity Outcomes for Cardiothoracic Surgical
Procedures Performed by Trainee Versus Attending?
Comanici, Maria, Dr; Salmasi, M Yousuf, Dr; Raja, Shahzad G., Mr; Attia, Rizwan Q.,
Dr
Harefield Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A79
Objectives
There are increasing pressures to decrease training time in the operating room. We
sought to assess the safety of training in cardiothoracic surgery comparing cases
performed by trainee’s vs consultants.
Methods
EmBase, Scopus, PubMed and OVID MEDLINE were assessed in August 2021 independently
by two authors while a third author arbitrated decisions to resolve disagreements.
Inclusion criteria were articles on cardiothoracic surgery, training, and outcomes.
Studies were assessed for appropriateness as per CBEM criteria. 892 results were obtained,
51 meet the specified criteria. 27 represented best evidence (2-Meta-analyses, 1-RCT
and 24 retrospective cohort studies).
Results
474,160 operative outcomes were assessed including 434,535 CABG (431,329 on-pump vs
3206 off-pump), 3090 AVR, 1740 MVR/repair, 26,433 mixed, 3565 congenital and 4797
thoracic. 398,058 cases were performed by trainees and 75,943 by consultants. 159
cases were indeterminate. There were no statistically significant differences in the
patients’ pre-operative risk scores. All studies excluded extreme high-risk patients
in emergency setting, those with poor left ventricular function and re-operation cases
that were operated on by consultants. There were no differences in CPB and clamp times
for CABG, times for valve replacement and repair cases were longer for trainees. There
were no differences in the post-operative outcomes including peri-operative myocardial
infarction, resternotomy for bleeding, stroke, renal failure, ITU and total length
of stay. One study reported no differences on angiographic graft patency at 1-year.
There were no differences in in-hospital or mid-term mortality out to five-years.
Discussion
Published data indicate that trainees can perform cardiothoracic surgical procedures
in dedicated high-volume units with outcomes comparable to those of trainers. Academic
programs should focus on strategies to maximise trainees’ exposure as primary operating
surgeons.
A80 Left Ventricular Aneurysm Repair: Long-Term Results of a Beating Heart Autologous
Endoventriculoplasty Compared to Current Common Practice
Halfwerk, Frank, Dr; Jansen, Martin, Mr; Plonek, Tomasz, Dr; Grandjean, Jan, Prof
Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A80
Objectives
Left ventricular aneurysm (LVA) formation is a severe complication after transmural
myocardial infarction. Over the last 60 years, different surgical ventricular reconstruction
(SVR) techniques have been developed, but there still is no clear consensus about
the most appropriate technique. This study analysed short and long-term outcomes of
a new SVR technique by using autologous endocardium compared to other more commonly
used techniques (e.g. plication, patch).
Methods
We retrospectively reviewed 95 patients receiving SVR due to a LVA between 2005 and
2019 in our centre. Patients underwent either on-pump beating heart endoventriculoplasty
using autologous endocardium as described by Grandjean (see Figure) or a more commonly
used technique (e.g. patch, plication). Early surgical outcomes, long-term survival
and postoperative cardiac function were compared.
Results
Mean age of patients was 67 [61–74] years. Pre-operative left ventricular ejection
fraction (LVEF) was 33% [22–40%]. 52 (55%) patients had NYHA III/IV classification.
No significant difference in baseline characteristics, in-hospital mortality or in-hospital
complications were found. 1, 3 and 5-year postoperative LVEF in the autologous group
were 40%, 43% and 36% compared to 45%, 44% and 39% in the control group (p = 0.21).
Survival rates at 1, 5 and 10 year were 93%, 62% and 24%, and did not differ between
groups.
Conclusions
The new SVR technique, using autologous endocardium was noninferior compared to longer
existing SVR techniques. Beating-heart SVR is feasible and can be used in patients
with poor left ventricular function where aortic cross-clamp and subsequent ischemia
might lead to problems with weaning from cardiopulmonary bypass.
A81 What Impact Does Enhanced Recovery After Surgery (ERAS) Have on Caregivers of
Lung Cancer Patients and How is This Reflected in Their Experience?
Johns, Joelle, Miss; Longbone, Tyler, Mr; Boele, Florien, Dr; Pompili, Cecilia, Dr
University of Leeds, Leeds, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A81
Introduction and Objectives
Enhanced recovery after surgery (ERAS) is a multimodal care pathway which focuses
on patient-centered interventions and reduces both post-operative complications and
patient morbidity. Research has highlighted the profound implications of a cancer
diagnosis and treatment on caregiver quality of life (QoL). Therefore, our objective
is to explore the impact of ERAS implementation on caregiver experiences after lung
cancer surgery.
Methods
A qualitative prospective study was done to explore caregiver experiences after lung
cancer surgery in a single institution. Remote semi-structured interviews (SSI) were
conducted, transcribed and thematically analysed.
Results
Eight caregivers aged 43–84 participated. Thematic analysis yielded 5 main themes:
(1) Impact of caregiving experiences on QoL; (2) Emotional distress; (3) Impact of
COVID-19 on caregiver experiences; (4) Support; (5) Communication with the healthcare
team. Caregivers highlighted detrimental impacts on caregiver QoL and emotional distress.
Caregivers were generally satisfied with pre-operative care but not post-operative
care. A proportion of caregivers felt support provided could be improved through better
communication from staff, better management of pain and more caregiver education.
Conclusions
COVID-19 has affected the care provided with more remote consultations. Better support
for caregivers could improve caregiver and patient outcomes. Further research is required
to improve patient and caregiver experience.
A82 Factors Predictive of Adverse Outcomes in Patients Undergoing Surgery for Infective
Endocarditis
Varghese, David1, Mr; Gradinariu, George
1, Mr; Awad, Wael2, Mr; Sheikh, Amir2, Mr; Mohite, Prashant1, Mr; Sadia Aftab, Sadia1,
Mrs; Oyebanji, Tunde3, Mr; Phillips, Derek1, Dr; Doshi, Hari1, Mr; Morcos, Karim1,
Mr; Curry, Philip1, Mr
1Golden Jubilee National Hospital, Glasgow, UK; 2St Barts Hospital, London, UK; 3Royal
Victoria Hospital, Belfast, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A82
Background
Infective endocarditis (IE) is associated with high morbidity and mortality. Surgery
can be challenging but highly effective. The aim of this study was to identify preoperative
risk factors associated with adverse outcomes after surgery.
Methods
We conducted a retrospective analysis of all patients undergoing surgery for IE between
2012 to 2020 at our unit. We collected patient demographics, laboratory and imaging
results, operative details and post-operative outcomes. The primary outcome was in-hospital
mortality. Data was analysed using SPSS and Unistat statistical software. Binary logistic
regression was used to identify factors associated with the primary outcome. Results
are expressed as median values (Q1 to Q3), percentages and total number of cases for
categorical variables.
Results
158 patients underwent surgery for IE, median age was 59 years (48 to 68), Logistic
EuroSCORE was 10.3% (6.0 to 22.7), 115 (73%) were male and 141 (89%) were non-emergency
operations. There were 65 isolated aortic valve procedures, 61 isolated mitral procedures,
7 isolated tricuspid, 23 combined double valve procedures and 2 triple valve procedures.
There were 142 valve replacements (88 tissue, 54 mechanical), 30 repairs and 3 other
procedures performed either alone or in combination. The in-hospital mortality was
5.7% (9/158 patients). Univariate logistic regression identified WCC (OR 1.140 [1.020–1.274],
p = 0.021), albumin (OR 0.832 [0.737 – 0.939], p = 0.001) and total protein (OR 0.899
[0.830–0.974], p = 0.009) as factors associated with mortality.
Conclusion
High WCC, low albumin and low total protein levels are predictors of adverse outcomes
after surgery for infective endocarditis. Many factors are involved in timing of surgery.
These findings underline the importance of preoperative medical optimization of the
nutritional status as well as maximising the attempt to control the infective process
with targeted antibiotic therapy within the window of time available.
A82 A UK First Use of Remote Video Assisted Surgical Training for Cardiac Surgery.
An NTN Experience
Karsan, Rick, Mr; Beattie, Gwyn, Mr
Royal Victoria Hospital, Belfast, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A82
With Cardiothoracic Surgery within the UK becoming more condensed with implementation
of a 7-year curriculum, the importance of hands-on training has never been more pertinent
to develop surgical skills and increase logbook numbers to attain CCT. The use of
simulation and models; as well as reviewing digital media continues to have a greater
and more expansive role in training however, there is always the limitation these
cannot replicate the experiences encountered in patients.
We present our experience of the first UK use of live-streamed video assisted training,
with a specialised camera equipped headset worn by the trainee to allow trainers to
visualise a trainee’s actions live and supply instruction whilst away from theatre.
This was particularly helpful in difficult to observe areas such as internal mammary
artery harvesting. As with all technological advancement and the dynamic nature of
training in Cardiac Surgery, there are both pros and cons to this tool.
Through our experiences, we have found trainees have built up their logbooks to include
significantly more trainer unscrubbed. Ultimately trainees have found they developed
skills and confidence faster.
We have utilised this new tool to train trainees allowing them to build their skills
and logbook. We provide a detailed account of our experiences with live-streamed training
and the potential future role for such tools in Cardiothoracic Surgery training.
A83 The Effects of Dietary Iron Deficiency on Mitochondrial Function and Iron Metabolism
in Murine Model
Tomkova, Kristina
1, Miss; Cabolis, Katerina2, Miss; Wozniak, Marcin1, Dr; Sajic, Marija2, Dr; Murphy,
Gavin1, Prof
1University of Leicester, Leicester, UK; 2University College London, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A83
The relationships between global iron deficiency, cellular iron metabolism, and mitochondrial
function are poorly defined. Therefore, we proposed to explore the link between these
processes in a murine model with iron deficiency induced through an iron-restricted
diet. A total number of 88 mice were divided into three groups: 1) control group (n = 39),
2) iron deficient (ID) group (n = 21), and 3) iron repleted (IR) group (n = 28).
The results showed that dietary iron deficiency results in decreased iron levels in
heart tissue and serum; however, the iron content of the mitochondrial fractions was
not altered. Iron concentration in heart tissue but not in serum was corrected by
iron repletion. Tissue ferritin and haemoglobin levels were decreased in both ID and
IR groups. The IRP1 expression, IRP1 activity, mtDNA copy number and mtDNA damage
were not affected by either iron deficiency or iron repletion. The enzymatic activities
of mitochondrial complex II and III were decreased in ID mice, but were returned to
normal levels in the IR group. The activities of complex I and IV as well as the protein
expression of all four complexes was not affected by iron deficiency.
Based on these results, we conclude that dietary iron deficiency deregulates global
iron metabolism as evidenced in decreased iron, haemoglobin and ferritin levels. However,
this dysregulation is not sufficient to trigger the expected increase in IRP1 mRNA
binding. This dysregulation in iron availability also led to disruption of mitochondrial
function. As overall mitochondrial health was not affected, we hypothesise that this
disruption affects the mitochondrial respiratory chain directly on protein level,
resulting in inefficient energy production. We believe this link between iron metabolism
disruption and mitochondrial dysfunction provides insights into potential molecular
mechanisms of physical symptom of iron deficiency and anaemia.
A84 Rigid Sternal Fixation to Prevent Sternal Instability & Dehiscence in High-risk
Patients After Cardiac Surgery: Early Experience
Alam, Ruhina, Miss; Holland, Luke, Mr; Modi, Amit, Mr; Hyde, Jonathan, Mr
University Hospital Sussex, Brigton, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A84
Background
Median sternotomy is the standard approach for most cardiac surgical procedures. Wire
cerclage remains the primary median sternotomy closure technique where side-to-side
movement is the only process addressed with no focus on stabilisation (fixation) to
prevent cranio-caudal micromovement. In a multicentre randomized trial, rigid plate
sternal fixation (RPF) compared with wire cerclage resulted in improved sternal healing
and reduced sternal complications, as well as significantly less pain. Introduction
of a structured and clinically based patient-adjusted risk score to predict the likelihood
of sternal instability or dehiscence can help the surgeon in their choice of sternal
closure technique and inform the use of rigid plate fixation in patients with a high
risk- score.
Predictive Risk-score
We developed a literature-based predictive risk-score system (Table 1). A score of
8 or more suggests a significantly higher risk of sternal dehiscence and indicates
supplementary fixation.
Early Experience
These patients are, by definition, a very high-risk demographic for sternal problems.
3 patients with a score of 8 or above were eligible and underwent RPF with SternaLock
Blu RPF system (Image 1). They were assessed by daily pain score (Day 1/2/3/4/7 and
at 6 weeks),use of morphine PCA and ease of return to daily activity. All 3 had a
pain score of 4 or less after 24 h, 2 didn’t require PCA and 0 required oral opiates
on discharge. They all only required paracetamol after 2 weeks. All 3 mobilised easily
on D1 and were fit for discharge on D4. By 6 weeks, all 3 had returned to their pre-operative
activity level.
Conclusion
Our limited early experience is very promising, and we feel RPF should be incorporated
into the ERAS pathway to aid early recovery. The technique is easily learnt & reproducible,
and despite adding a small relative cost, the avoidance of long-term stays associated
with sternal dehiscence makes it very financially effective.
A85 Circulating Cell-Free Mitochondrial DNA and Cytokines as Predictors of Cardiovascular
Susceptibly for Atrial Fibrillation after Cardiac Surgery
Naase, Hatam
1, Mr; Caruso, Vincenzo2, Mr; Evans, Paul3, Prof; Athanasiou, Thanos1, Prof
1Imperial College London, London, UK, St Mary's Hospital, London, UK; 2Guy's and St
Thomas' NHS Foundation Trust, London, UK; 3University of Sheffield, Sheffield, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A85
Objective
To identify any relationship between postoperative atrial fibrillation (POAF) and
level of specific inflammatory markers, such as circulating cell-free mitochondrial
deoxyribonucleic acid (ccf-mtDNA), circulating cytokines or transcription factors.
Methods
This prospective cohort study was constituted by 88 patients (mean age 67 ± 7 years)
who underwent coronary artery by-pass graft (CABG) or aortic valve replacement (AVR).
The levels of inflammatory markers were measured preoperatively in all the patients.
Results
The prevalence of POAF after AVR, on-pump and off-pump CABG was 50%, 27.3% and 27.2%,
respectively. All the biomarkers tested were significantly elevated preoperatively
in patients who later developed POAF; at multivariate analysis, ccf-mtDNA and immune
interferon-alpha(IFN-α) were the only independent predictors for the development of
POAF.
The preoperative levels of ccf-mtDNA were higher in patients with ischemic heart disease
than in those with no ischemic coronary disease. However, the overall incidence of
developing POAF was higher in AVR than CABG (AVR:50%; on-pump CABG: 28%; off-pump
CABG:27%).
Conclusions
An increase in the circulating levels of either ccf-mtDNA or IFN-α may predict POAF
development, preoperatively. Prophylactic therapy with anti-inflammatory may be beneficial
to reduce the incidence of POAF in patients with a high preoperative level of ccf-mtDNA.
A86 Cultural Competence is Essential for a Good Patient Experience; how do we get
There?
Layton, Georgia R., Miss; Marsico, Roberto, Mr; Low, Mei Ken, Dr; Abbasciano, Riccardo,
Mr; El-Dean, Zein, Mr; Bingley, Patricia, Ms; Zakkar, Mustafa, Mr
Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester
NHS Trust, Leicester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A86
Introduction
Lack of culturally competent (equitable, accessible and non-discriminatory) care may
contribute to patient dissatisfaction with treatment and hinder compliance to therapy
and outcomes.
We set out to assess patient satisfaction with doctor-patient interaction in the out-patient
cardiac surgery clinic of an ethnically and socio-economically diverse city (Leicester)
and whether mismatch of doctor-patient culture contributed to the patient experience.
Methods
All new patients attending in-person cardiac surgery out-patient clinic between May
and August 2021 were provided with a two-stage questionnaire to complete anonymously;
the first prior to consultation, the second after.
Results
116 patients completed the questionnaire (65% response rate). Patient demographics
are listed in Table 1. 6% (n = 7) of respondents did not provide data on gender, employment
status, ethnicity or preferred language. 8.6% (n = 10) did not provide data of their
qualifications.
Category
Total number, n = 116
% of total respondees
Male: Female
76: 33
65.5: 28.4
Eployed
31
26.7
Unemployed
15
12.9
Retired
63
54.3
Qualifications
65
56.0
No qualifications
41
35.5
Preferred language English: Non-English language
106: 3
91.4: 2.6
Ethnicity: White British
95
81.9
Ethnicity: other than White British
14
12.1
Patients reported a mean satisfaction with their doctors’ communication skills of
4.7 (range 3–5) and a mean overall satisfaction of 4.8 (range 3–5), on a scale where
1 was very poor and 5 was excellent. Respondents were more than 80% Caucasian. Ethnicity
of participants did not match the ethnic diversity of the region.
Conclusions
Patients of non-white British ethnicity are either not accessing or not being identified
for referral to our cardiac surgery unit. Although a good level of patient satisfaction
was reported, the demographics of the participants demonstrate potential barriers
preventing the provision of culturally competent care. Further work is needed to identify
and address the barriers in healthcare environments which are disproportionately impacting
patients from non-white ethnicities.
A87 The Perceived Influence of COVID-19 on Core Surgical Training in the UK
Panahi, Pedram
1, Mr; Seraj, Shaikh Sanjid2, Dr; Veeralakshmanan, Pushpa
3, Miss; Unsworth-White, Jonathan1, Mr
1University Hospitals Plymouth NHS Trust, Plymouth, UK; 2Walsall Healthcare NHS Trust,
Walsall, UK; 3University Hospitals Birmingham NHS Trust, Birmingham, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A87
Objectives
Surgical training has been affected by COVID-19 from the early stages of the pandemic.
Here, we aim to carry out a detailed investigation of its perceived impact on core
surgical trainees and their surgical career progression in the UK.
Methods
An online survey was devised using Google Forms which was distributed to core surgical
trainees across the UK.
Results
75 trainees responded, 35 were in the first year and 40 in the second year of their
surgical training programme. There was a median number of 10 days (Interquartile range
0–30) of redeployment and 2 days (Interquartile range 0–14) of sick leave due to confirmed
/ suspected COVID-19. A drop was observed in respondents’ global perception of their
portfolio quality and 42 respondents (56%) felt that operative experience was the
most impacted portfolio domain. The least impacted domains according to a calculated
summary statistic were the ability to deliver teaching and work on leadership / management
qualities. Eight respondents (11%) achieved an Annual Review of Competence Progression
outcome 10.1 and 3 (4%) achieved an outcome 10.2. 63 respondents (84%) felt more stressed
as a result of the pandemic and 44 respondents (59%) indicated that they have lost
confidence as a surgeon due to the pandemic.
Conclusion
Amongst the respondents, a marked negative impact was observed in several domains
affecting both surgical training and career progression. Allocated theatre time was
the most adversely affected domain. These factors need to be addressed in surgical
training schemes as the pandemic passes.
A88 A Review of Radical Nephrectomy with Caval Thrombectomy for Renal Cell Carcinoma
Over Ten Years
Panahi, Pedram, Mr; Enemosah, Ibrahim, Mr; Yao, Lucy, Dr; Aroori, Somaiah, Mr; McInerney,
Paul, Mr
University Hospitals Plymouth NHS Trust, Plymouth, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A88
Objectives
Renal cell carcinoma (RCC) with inferior vena cava (IVC) extension demands surgical
excision to achieve a curative outcome. This retrospective study reviewed the immediate
and long-term outcomes of radical nephrectomy and IVC thrombectomy in a tertiary centre.
Methods
Nine patients underwent radical nephrectomy with IVC thrombectomy from 2009 to 2019
at University Hospitals Plymouth NHS Trust. Five of these patients had IVC thrombus
extending to the intrahepatic IVC; of these, one extended further into the right atrium.
One patient required cardiopulmonary bypass (CPB).
Results
The mean operation duration was 224 min (range 155–498). One death was observed during
index admission at 18 days post-operatively; this was the CPB patient who developed
significant post-operative complications including haemorrhage and mesenteric ischaemia.
For other patients, the survival range was 16 months to 8 years (75% two-year survival,
12.5% five-year survival). Worse outcomes were observed in patients with pre-operative
metastatic disease beyond the IVC: one case affecting aortocaval lymph nodes and two
others with pulmonary involvement. Despite adjuvant chemoradiotherapy, three (75%)
had cancer recurrence within eight months.
Conclusions
Radical nephrectomy and caval thrombectomy without CPB is a safe procedure. The amount
of tumour burden does not equate to a lower long-term survival.
A89 Validity and Reliability of Radial Artery Assessment Techniques in Coronary Artery
Bypass Grafting—A Systematic Review
De Franco, Vincenzo, Mr
Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A89
Objectives
Accuracy and consistency of screening tests implemented for the pre-operative assessment
of radial artery (RA) graft, prior to surgical coronary revascularisation, has been
debated for many years. Correct RA assessment is crucial prior to their surgical harvesting
to avoid post-operative complications. A systematic review was conducted with the
aim of evaluating and comparing the validity and reliability of the most commonly
adopted RA assessment techniques.
Is ultrasonography more accurate and reliable than the modified Allen test, pulse-oximetry
and plethysmography, in RA assessment for patients undergoing coronary revascularisation?
Methods
A systematic search was undertaken, appraising relevant primary research studies published
between 2010 and 2020. MEDLINE, PubMed, CINHAL, Scopus and EMBASE databases were consulted,
to access studies relating to the assessment of RAs during coronary artery bypass
grafting. Included articles were reviewed and selection criteria applied, data findings
were extracted for analysis, narrative synthesis and conclusions drawn. Critical appraisal
of the included studies was performed using the modified Downs and Black checklist.
Results
Nine studies addressing the research question were included in the review. Seven studies
identified the reduced validity and/or reliability of the MAT, four of which highlighted
the poor sensitivity, poor specificity and the subjectivity of the screening test.
Two studies established that pulse-oximetry and plethysmography, used in combination
with the MAT, offer more objective results than an isolated MAT, also impacting on
sensitivity and specificity. Ultrasonography provides important insight into the morphological
characteristics of RAs, providing an accurate and reliable anatomical RA assessment.
Conclusions
The review suggests that ultrasonography is superior in RA assessment, enabling selection
of RA segments with favourable morphological features, optimising surgical outcomes.
A90 A Rare Case of Bi-atrial Myxoma via Multiple Fenestrations in the Atrial Septum
Salem, Agni, Miss; Shanmugananthan, Selvaraj, Mr
Liverpool Heart and Chest Hospital, Liverpool, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A90
Objectives
Myxomas are a rare type of benign intracardiac tumour (between 66–80% occur in the
left). Bi-atrial myxomas are even rarer (< 2.5% occurrence) and we would like to present
such a rare and different case.
Methods
A 48 yr old female presented to her local hospital with a 6-month history of weight
loss, pre syncopal episodes and shortness of breath. Computed tomography was performed
that showed a large bi-atrial mass passing the mitral valve with partial extension
into the left ventricle. The echocardiogram was suggestive of a 70 mm myxoma which
was impinging on the mitral valve, resulting in mitral pseudo-stenosis. Through midline
sternotomy and under cardiopulmonary bypass the tumour was confirmed to be bi-atrial
invading through a multiple-fenestrated septum and involving the roof of the left
atrium. Both atrium and septum were opened like a book and the myxoma was carefully
excised in its entirety along with a rim of the septal tissue and part of the roof
of left atrium. The septum and both atrium were reconstructed using bovine pericardia
patch.
Results
The patient recovered well and the post-op echocardiogram showed no inter-atrial shunt
and a normal mitral valve with no residual mass.
Conclusions
Although extremely rare, bi-atrial myxomas in a fenestrated atrial septum are amenable
for safe surgical resection and successful reconstruction. It is therefore important
to be aware of such cases and identify them early to provide appropriate surgical
management.
Informed consent to publish had been obtained.
A91 Audit and Quality Improvement of the Management of Hyponatraemia in Post-cardiopulmonary
Bypass Surgical Patients
Samaraweera, Dulan
1, Mr; Duval, Jean-Luc1, Dr; Crush, Jos2, Dr; Taghavi, John1, Mr
1Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK; 2West Suffolk NHS Foundation
Trust, Bury Saint Edmunds, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A91
Objectives
Hyponatraemia is the most common electrolyte abnormality in hospitalised patients
and is associated with increased morbidity and mortality. Post-cardiopulmonary bypass
(CPB) patients are particularly prone to developing hyponatraemia due to massive fluid
shifts, diuresis, and the possibility of co-existing pump failure. We sought to increase
the recognition and appropriate management of hyponatraemia to reduce its adverse
sequelae.
Methods
Hyponatraemia was defined as serum sodium below 133 mmol/L. All patients undergoing
surgery with CPB in a calendar month were retrospectively examined for the development
and management of hyponatraemia. Interventions included teaching sessions, the introduction
of a flow chart for early recognition/management of hyponatraemia by junior staff
and optimisation of medicinal prescriptions were done over four months period. Their
effectiveness was reassessed in the following calendar month.
Results
The first and second cycles included 146 and 123 patients with comparable demographics.
Parameter
First cycle
Second Cycle
Total
Preoperative risk factors
Mean Age (years)
66.5
66.8
No. of Females (%)
31(21.2%)
34(27.6%)
65(24.5%)
Pre-op renal impairment
16(11%)
12(9.8%)
28(10.4%)
Hypothyroidism
12(8.2%)
7(5.7%)
19(7.1%)
Type of surgery
CABG (isolated and combined)
70(47.9%)
59(48.0%)
129(47.9%)
Valve surgery (including redo)
38(26.0%)
34(27.6%)
72(26.8%)
PTE (pulmonary thromboembolectomy)
17(11.6%)
13(10.5%)
30(11.1%)
Complex aortic surgery including aortic dissection
16(11%)
14(11.4%)
30(11.1%)
Other
5(3.4%)
3(2.4%)
8(2.9%)
Ten had preoperative hyponatraemia (3 and 7 from each group). Fifty-eight (39.7%)
and 46(37.4%) developed hyponatremia, with eight (5%) and one (0.8%) classified as
severe (Na < 125 mmol/L) from respective groups. Symptoms were observed amongst Seven
and three from patient groups while three and one patients from each exhibiting complications
attributable to hyponatraemia.
Overall, patients would commonly develop hyponatraemia on postoperative day 3 (median).
Those with hyponatraemia would stay an extra day in the hospital (11 vs 10). Thirty-day
mortality was five (3.4%) and four (3.3%) for two groups, and one from each group
had hyponatraemia. Female sex, advanced age, preexisting renal failure and hypothyroidism
increased the risk for developing hyponatraemia.
Conclusions
Hyponatraemia is a common finding amongst post-CPB patients. Increasing awareness
and promoting early intervention may reduce the severity and improve outcomes.
A92 Atrial Fibrillation Ablation: A Single Surgeon Real-world Experience
Massey, John, Mr; Sharkey, Annabel, Ms; Hunter, Steven, Mr
Northern General Hospital, Sheffield, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A92
Objectives
Atrial fibrillation (AF) is a major cause of morbidity and mortality. Surgical ablation
for AF has shown to be effective at restoring sinus rhythm with resulting improvement
in quality of life. There have been a number of studies comparing varying lesion sets,
ablation modalities and techniques for dealing with the left atrial appendage. Our
objective is to show that a single surgeon with a high volume of AF ablation practice
can demonstrate high rates of freedom from AF.
Methods
Data was gathered retrospectively from a prospectively populated database between
September 2013 and March 2021. Patients were stratified according to whether AF ablation
was undertaken as a lone procedure or with concomitant cardiac surgery. The primary
endpoint was freedom from AF at discharge from surgical follow-up (6-12 months). Secondary
endpoints included 30-day mortality, long-term survival, rate of permanent pacemaker
implantation and rate of DC cardioversion.
Results
317 patients underwent AF ablation (88 AF ablation only, 229 as a concomitant procedure).
60.8% of patients had long-standing persistent AF. Freedom from AF; at first follow-up
(6 weeks to 3 months) 79.9%, at clinic discharge (6 months to 1 year) 83%. Rate of
DCCV; in-patient 5.7%, out-patient 11.7% (58.8% success rate). 3.8% of patients had
a catheter ablation post-operatively with 66% maintaining sinus rhythm at one year.
Rate of PPM 5.9%, 30-day mortality 2.2% (average logistic EuroSCORE 6.55%) (overall
survival see Fig. 1).
Conclusions
This study shows that in a real-world setting surgeons undertaking high volumes of
AF ablation can achieve high rates of success with minimal complications. Our standard
practice is test for entry and exit block at the end of every procedure.
A93 The Single Clamp Box With Radio-frequency Device vs Conventional Box Lesion for
Atrial Fibrillation Ablation
Massey, John, Mr; Sharkey, Annabel, Ms; Hunter, Steven, Mr
Northern General Hospital, Sheffield, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A93
Objectives
Bipolar radiofrequency devices are commonly used to perform the pulmonary vein isolation
and left atrial posterior wall lesions during surgical atrial fibrillation ablation.
Usually, this is performed by clamping each line of the lesion set separately. The
single clamp box lesion (which avoids opening the left atrium) has been described
by our centre. We aim to show that the single clamp box is as effective as the standard
box lesion in terminating atrial fibrillation.
Methods
Data was gathered retrospectively (September 2013 and March 2021). Patients were stratified
according to whether they underwent a standard box lesion or a single clamp box lesion;
patients were subdivided as to whether they underwent a full Cox-Maze IV or just the
left-sided lesion set. The primary endpoint was freedom from atrial fibrillation at
discharge from surgical follow-up (6-12 months). Secondary endpoints were x-clamp
time, cardio-pulmonary bypass times, length of stay in hospital and rate of implantation
of permanent pacemaker.
Results
138 patients (123 cox maze IV, 15 left-sided lesions only) underwent a single clamp
box radiofrequency ablation, with freedom from atrial fibrillation at discharge from
clinic of 88%. 123 patients had single clamp cox maze IV and 76 had standard cox maze
IV (separate lesions to complete the box), freedom from atrial fibrillation 86.8%
vs 88% (p = 1.0). No statistically significant difference in x-clamp time, cardio-pulmonary
bypass time, length of stay in hospital or permanent pacemaker rate. 15 patients underwent
a single clamp left-sided box only vs 116 patients who underwent standard left side
lesion set alone. Freedom from atrial fibrillation 100% vs 79.2% (p = 0.58). No statistically
significant difference in x-clamp time, cardio-pulmonary bypass time, length of stay
in hospital or permanent pacemaker rate.
Conclusion
We have shown that the single clamp box is equivalent to the standard box when using
radio-frequency for AF ablation.
A94 Consent in Cardiac Surgery: A National Multicenter Audit Cardio-Thoracic Interdisciplinary
Research Network
Abbasciano, Riccardo1, Mr; Al Attar, Nawwar2, Prof; Alam, Ruhina3, Miss; Alkalbani,
Rawa4, Miss; Ansaripour, Ali5, Dr; Anzaar, Ahamed Akkeel6, Mr; Argyriou, Amerikos7,
Mr; Avlonitis, Vassilios8, Mr; Bhudia, Sunil9, Mr; Booth, Karen10, Ms; Brown, Joshua11,
Mr; Chan, Jeremy12, Mr; Dandekar, Uday13, Mr; Dearling, Jeremy14, Mr; Deehan, Blathnaid15,
Mr; Di Tommaso, Ettorino16, Mr; Dixon, Lauren17, Miss; Gradinariu, George18, Mr; Green,
Jordan19, Dr; Harky, Amer20, Mr; Harrington, Bertie21, Mr; Hasan, Ragheb22, Mr; Horsfall,
Gregory23, Dr; Jawarchan, Angila24, Miss; Jones, Mark25, Mr; Kho, Jason26, Mr; Kumar,
Pankaj27, Mr; Layton, Georgia R.28, Miss; Limbachia, Devan D.29, Mr; Mahoud, Loubani30,
Prof; Makam, Rishab31, Mr; Moawad, Karim R.32, Mr; Modi, Amit33, Mr; Morais, Carlos34,
Mr; Murphy, Gavin35, Prof; Nguyen, Bao36, Mr; Nwaejike, Nnamdi37, Mr; Petrou, Mario38,
Mr; Philip, Bejoy39, Mr; Rajakaruna, Cha40, Mr; Rizzo, Victoria41, Miss; Rochon, Melissa42,
Miss; Rogers, Luke J.43, Mr; Sayeed, Rana44, Mr; Singhania, Asmita45, Miss; Vaja,
Ricky46, Mr; Wali, Anuj47, Mr; Wilson, Keith
48, Mr; Wilson, Ian49, Mr; Zakkar, Mustafa50, Mr
1Leicester Clinical Trials Unit, Leicester, UK; 2University Hospitals of Leicester,
Leicester, UK; 3Golden Jubilee National Hospital, Glasgow, UK; 4Royal Sussex County
Hospital, Brighton, UK; 5Oxford University Hospital, Oxford, UK; 6Liverpool Heart
and Chest Hospital, Liverpool, UK; 7Manchester Royal Infirmary, Manchester, UK; 8Guy's
and St Thomas' NHS Foundation Trust, London, UK; 9Royal Brompton & Harefield NHS Foundation
Trust, London, UK; 10The Newcastle upon Tyne Hospitals NHS FT, Newcastle, UK; 11Belfast
Royal Victoria, Belfast, UK; 12Swansea Bay University Healthboard, Swansea, UK; 13University
Hospital Coventry and Warwickshire NHS Trust, Coventry, UK; 14Patient & Public Involvement
Initiative; 15Bristol Heart Institute, Bristol, UK; 16Hull and East Yorkshire Hospitals
NHS Trust, Hull, UK; 17University Hospitals Plymouth NHS Trust, Plymouth, UK; 18Wythenshawe
Hospital, Manchester, UK; 19John Radcliffe Hospital, Oxford, UK; 20Imperial College
London, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A94
Objectives
Patient and Public Involvement and Engagement events coordinated following the Priority
Setting Partnership and identification of "Infection Prevention" as a key research
priority has recently generated intrigue around the consent process for adult cardiac
surgery. Discussions have eluded to the sentiment that "patients cannot provide wholly
informed consent without being aware of all the associated risks and their incidence".
This view has been upheld with updates in the legal standard expected following the
Montgomery case in 2015. This Supreme Court judgement ruled that doctors "must take
reasonable steps to ensure that patients are aware of all the risks that are material
to them". This national multicentre audit aimed to illustrate and describe the current
practise of the consent process in adult cardiac surgery.
Methods
Consent forms and clinic letters were prospectively reviewed for all consecutive patients
undergoing cardiac surgery over a 2-week period between 18th – 31st October '21. Data
relating to the type of surgery, grade of individual taking consent, documented risks
and quantification of this risk were collected.
Results
Seventeen (/35) UK cardiac centres participated and a total of 420 consecutive patients
were included. The urgency of the cases was elective (44.5%), urgent (50%) and emergency
(6.2%). 236 patients were reviewed in clinic preoperatively and of these the risks
of surgery were documented in 60.2% of clinic letters. Four centres used a pre-filled
document/sticker whilst the remainder were handwritten. The consent form was signed
by a consultant (27.1%), SpR (69.8%) and SHO (3.1%). A summary of the commonly documented
risks and quantification of these risks is provided.
Conclusions
Variation in both the complications documented and quantified risk of these complications
occurring exists across UK practise in adult cardiac surgery. What do patients want
and need to know to provide informed consent?
Complication
Documented (%)
Quantified risk documented (%)
Mortality
99.3
80.8
Stroke
92.9
57.9
MI
54.5
20.5
Renal failure
67.4
17
Arrhythmias
77.6
17.8
Wound infection
82.6
12.7
Bleeding
86.4
18.7
A95 Association of Low Haemoglobin Prior to Elective Cardiac Surgery With Need for
Blood Transfusion and Outcomes
Shoeib, Mohamed, Mr; Mahmood, Zahid, Mr
NHS Golden Jubilee, Glasgow, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A95
Introduction
Pre-operative anaemia is a common finding in patients undergoing cardiac surgery (20–30%)
(Hogan M. et al., 2014). The degree of preoperative and intraoperative anaemia is
correlated to increased morbidity and in-hospital mortality in patients undergoing
elective cardiac surgery (Ranucci M et al., 2013). Blood markers suggest that > 50%
of cases of pre-operative anaemia are related to Iron deficiency, with outcome improvement
following IV iron replacement therapy (Hung, M. et al., 2015).
Objectives
Assess the association of anaemia with use of pre-and post-operative blood transfusions,
length of ICU and hospital stays and mortality. To improve recognition and management
of anaemia prior to elective cardiac surgery.
Methods
Retrospective study of 1577 patients post elective cardiac surgery (CABG and/or valve
surgery) in our institution during the period from January 2016 till January 2018.
We examined the associations anaemia has with; the need of blood transfusions (PRBC),
lengths of stay (ICU and in-hospital) and mortality (30 day and 1 year).
Results
Compared to patients without anaemia, those who had anaemia required transfusion more
often (60% vs 35%, P < 0.001) and received more units of bloods (median (IQR): 1 (0–2)
vs 0 (0–1); p < 0.001). Pre-operative Hb levels were inversely correlated with Age
(P < 0.001), total days in hospital (p < 0.001) and hours in intensive care unit (p < 0.016).
Conclusions
Preoperative screening and optimization of haemoglobin level would significantly preserve
resources and minimize the risks linked to postoperative blood transfusion. Preoperative
anaemia was linked to significant increase of postoperative blood transfusion in both
men and women. However, no significant difference in prevalence of preoperative anaemia
based on gender.
A96 Severe Factor XII Deficiency in the Context of Cardiopulmonary Bypass: The Challenges
of Intraoperative Heparin Monitoring
Theodore, Sigrid, Dr; Haworth, Kobi, Dr; Scarrott, Helen, Ms; Butler, Chris, Dr; Shah,
Pallav, Dr
Townsville University Hospital, Queensland, Australia
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A96
Objective
Severe factor XII (FXII) deficiency causes an elevated baseline activated clotting
time (ACT). Options for intraoperative heparin monitoring during cardiopulmonary bypass
(CPB) include normalising the ACT with fresh frozen plasma (FFP) prior to heparinisation
or the use of anti-factor Xa (anti-Xa) levels. We present a case comparing these methods
with the use of rotational thromboelastometry (ROTEM).
Methodology
Baseline blood samples were collected from a patient with severe FXII deficiency undergoing
CPB. A single dose of FFP was given prior to heparinisation, followed by successful
CPB and protamine reversal. Matched ACT, anti-Xa and ROTEM samples were collected
intraoperatively and the results compared. Serial post-operative activated partial
thromboplastin time (aPTT) samples illustrated the time course of FXII level decline.
Results
Elevated baseline aPTT and ACT normalised following the administration of FFP. Subsequent
ACT, anti-Xa and ROTEM levels reflected the anticipated coagulation status. Anti-Xa
levels were labour intensive and delayed the initiation of CPB. ROTEM results were
proportional to the ACT and anti-Xa results, but did not influence clinical management.
The patient had no major complications and was discharged six days postoperatively.
The discharge aPTT level remained below baseline (82 s at 144 h) following a single
intraoperative FFP dose.
Conclusion
Administration of FFP followed by point-of-care ACT testing was the most efficient
method of intraoperative heparin monitoring. ROTEM provided confirmation of coagulation
status but was inadequate as a sole technique for intraoperative heparin monitoring.
A97 A Proposed Method to Widen Participation in Cardiothoracic Surgery Across UK Medical
Schools
Sahdev, Nikhil, Dr; Zibdeh, Omar, Dr; Raja, Shazad, Mr
Royal Brompton and Harefield Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A97
Objectives
Cardiothoracic surgery (CTS) does not form part of the undergraduate curriculum in
majority of medical schools across the UK. Of the small proportion that do, there
is still relatively minor exposure compared with other specialties. This coupled with
the fact there are fewer centres that offer CTS, makes it challenging for students
to access the speciality. Furthermore, from 2023, CTS is only accessible via ST1 entry;
therefore, students have a limited time frame to explore the speciality to enable
informed career planning. Proposed is an educational model that can be implemented
across the country that would allow students to discover CTS and its pathway to entry.
Methods
In most MBBS programme specifications there is flexibility for students to choose
a specific module to study (student-selected component). This 6-week model would allow
students opportunities to assist on the wards, clinic and theatre, becoming active
members of the cardiothoracic team. Importantly they will spend time with doctors
of all grades to understand what the speciality entails. Teaching sessions will encourage
active learning in the form of bedside teaching, simulation sessions and on-calls.
Uniquely, there will also be workshops surrounding the entry pathway into CTS.
Results
To measure the efficacy of the model, we will analyse short and long-term results.
In the short-term we will assess the effectiveness of the clinical content taught
by arranging a pre and post-course examination. Similarly, a pre and post-module questionnaire
will be utilised to gauge interest in CTS and knowledge pertaining to the entry pathway.
In the long-term we will assess whether our model contributed to students to apply
to CTS by following students up in 3 years’ time.
Conclusion
This peer-reviewed educational model can easily be replicated across medical schools
allowing students to gain increased exposure to CTS. Thus, attracting hardworking
and committed individuals to the speciality.
Adult Cardiac Mitral Valve
A98 Use of Anti-Thrombotic Medications After Heart Valve Surgery: A Cross-Sectional
Survey of Contemporary Practice in the UK
Shah, Benoy1, Dr; Laskar, Nabila
2, Dr; Akowuah, Enoch3, Mr; Briffa, Norman4, Prof; Cartwright, Neil4, Mr; Kendall,
Simon3, Mr; Chambers, John5, Prof
1University Hospital Southampton, Southampton, UK; 2Barts Heart Centre, London, UK; 3South
Tees Hospitals NHS Trust, Middlesbrough, UK; 4Northern General Hospital, Sheffield,
UK; 5Guy's & St.Thomas' Hospitals, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A98
Objectives
North American and European guidelines vary in their recommendations on use of anti-thrombotic
drugs after heart valve surgery. The aim of this cross-sectional survey was to understand
current practice amongst UK (UK) cardiac surgeons.
Methods
Using the SCTS database, NHS hospital websites and direct e-mail confirmation, all
UK consultant cardiac surgeons were e-mailed a link to an online survey. The survey
asked their current practice regarding use of anti-platelet and/or anticoagulant drugs
(and their duration) following bioprosthetic aortic valve replacement (AVR), mitral
valve replacement (MVR) and mitral valve repair (MVrep) for patients in sinus rhythm
with no other clinical indication for antithrombotic medications. We also asked about
choice of anticoagulant (warfarin vs NOAC) in patients undergoing MVrep that are in
atrial fibrillation (AF).
Results
We identified 260 consultant cardiac surgeons in the UK, of whom 103 (40%) replied
to the survey. We found wide variation in practice amongst surgeons in all fields.
After AVR, the main answers were: lifelong aspirin (64%); 3 months aspirin (25%);
and 3 months anticoagulation followed by lifelong aspirin (8%). After MVR, the choices
were: anticoagulation for 3 months then lifelong aspirin (37%); lifelong aspirin only
(35%); 3 months anticoagulation only (16%); and 3 months aspirin only (10%). After
MVrep in sinus rhythm, the choices were: lifelong aspirin (42%); 3 months anticoagulation
then lifelong aspirin (26%); and 3 months anticoagulation only (19%). After MVrep
for AF patients: surgeons recommended warfarin (38%), a NOAC (37) or either warfarin
or a NOAC (25%).
Conclusions
There are wide variations in practice across the UK regarding use of anti-thrombotic
drugs after heart valve surgery. This reflects a lack of high-quality evidence and
underscores the need for randomized trials to address these questions.
A99 In-hospital Mortality From Right Ventricle (RV) Failure Post Mitral Valve Surgery,
an Observational Exploratory Analysis
Apicella, Giulia, Miss; Abbas, Sherif, Mr; Szafranek, Adam, Mr; Naik, Surendra, Mr;
Boulemden, Anas, Mr; Nicou, Niki, Miss; Birdi, Inderpaul, Mr; Qureshi, Saqib, Mr
Nottingham City Hospital, Nottingham, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A99
Introduction
Acute RV dysfunction post mitral valve surgery can have catastrophic outcome and the
pathogenesis remains unclear. We reviewed our experience with aims of identifying
the underlying explanatory clinical characteristics.
Methods
Multivariate logistic regression analyses of peri and post-op including echocardiographic
characteristics of mitral valve cases either isolated or concomitant (coronary, tricuspid
and aortic valve surgery) between 1996 and 2019 that died in hospital after index
mitral valve surgery were undertaken.
Results
A total of 1748 patients underwent mitral valve surgery. Overall sixty-three (3.6%)
patients died during index hospital admission. Forty-two (62%) patients retained their
normal RV function post-op and died of unrelated causes. Sixteen patients (23.5%)
had impaired RV function pre-op and 43% of them died of cardiac failure. Pre-op RV
impairment was strongly associated with significant tricuspid regurgitation requiring
concomitant correction: odds ratio (95% confidence interval); 6.6(1.1, 38.5) p = 0.03
and ischemic mitral pathology; 6.2 (1.4, 27.5) p = 0.016. Five patients (7.4%) had
new onset post-op RV failure of unexplained etiology and died of this. In the multivariate
regression analyses; age, sex, logistic EuroSCORE, bypass and cross-clamp times, pulmonary
hypertension, mitral with or without concomitant tricuspid valve surgery, mitral repair
vs. replacement and ischemic or non-ischemic etiologies were deemed non-significant
predictors of acute post mitral RV failure.
Conclusions
Whereas impaired RV is often encountered in mitral valve ± tricuspid valve cases,
sudden catastrophic RV failure in these patients with preserved RV pre-op is uncommon.
The traditional operative and non-operative factors fail to be strong contenders to
predict this behaviour of the right ventricle.
A100 Mitral Valve Surgery for Degenerative Mitral Valve Regurgitation in Patients
with Left Ventricular Dysfunction: A Systematic Review and Meta-analysis
Mohamadzade, Navid
1, Mr; Montaque, Morgan
1, Mr; Bruno, Vito D.2, Dr; George, Sarah1, Prof
1Bristol Medical School – Translational Health Sciences – University of Bristol, Bristol,
UK; 2Bristol Heart Institute, Bristol, UK, University Hospitals of Bristol and Weston
NHS Foundation Trust, Bristol, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A100
Introduction
Degenerative mitral regurgitation (DMR) precipitates left ventricular dysfunction
(LVD), which deleteriously impacts post-operative outcomes following mitral valve
(MV) surgery. Current clinical guidelines provide weak evidence supporting surgery
in patients with LVD. This meta-analysis aimed to investigate the short/long-term
outcomes after MV surgery for DMR patients with a reduced left ventricular ejection
fraction (LVEF) compared to a normal LVEF.
Methods
In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis
statement, a pre-defined protocol was used to conduct a systematic review of the literature
across three databases. Raw data extraction and pooled analyses for odds/hazard ratios
(OR/HR) were performed for: in-hospital/30-day mortality; long-term survival; and
post-operative major adverse cardiovascular and cerebrovascular events (MACCE).
Results
A meta-analysis was conducted using 10 observational cohort studies. Pooled analyses
for the following outcomes were calculated by combining all reduced LVEF percentage
cut-offs from all studies. In-hospital/30-day mortality had a pooled OR of 6.50[2.87–14.72].
Pooled HRs for overall long-term survival and post-operative MACCE were 2.36[1.82–3.06]
and 1.97[1.43–2.70], respectively. Long-term survival in only patients with LVEF ≤ 60%
had a pooled HR of 2.00[1.47–2.73].
Conclusion
DMR patients with reduced LVEF experience significantly worse short/long-term post-operative
outcomes compared to those with normal LVEF. Future studies are required to elucidate
whether surgery is more beneficial than conservative management in these patients.
A101 Propensity Matched Comparison of Outcomes Following Minimally Invasive vs Conventional
Mitral Valve Repair
Folaranmi, Omowumi
1, Dr; Allam, Mohamed1, Mr; Kendall, Simon1, Mr; Goodwin, Andrew1, Mr; White, Ralph1,
Mr; Takyi, Christopher2, Dr; Akowuah, Enoch1, Mr
1South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK; 2Newcastle University
Medical School, Newcastle, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A101
Objectives
Recent NICE guidelines suggest minimally invasive mitral valve repair surgery should
be offered to all patients who are suitable but comparative data supporting this approach
is lacking. The aim of this study was to compare outcomes following both minimally
invasive and conventional approaches to mitral valve repair.
Methods
This study retrospectively compared outcomes between patients undergoing isolated
mitral valve repair at our institution between 2015 to 2020. Euroscore II was used
to generate the propensity scores for patients in the conventional and minimally invasive
groups. Of 238 patients, 1:1 propensity score matching was performed for the closest
neighbours yielding 152 matched cases in total with 76 patients in each group.
Results
For the 152 matched patients, there was no difference in mean Euroscore II (1.53 ± 1.02
(p = 1.000). There were no cases of in-hospital mortality in the minimally invasive
group, and 1 case out of 76 in the conventional group. Mean total length of hospital
stay was significantly lower in the minimally invasive group (6.68 ± 3.61vs8.62 ± 6.08,
p < 0.014). Following surgery, patients with mild residual mitral regurgitation or
less were 94.7% in the minimally invasive group vs 96.1% in the conventional group,
p = 0.6804. Incidence of re-operation for bleeding was not significantly different
(2.6% in the minimally invasive group vs 3.9%, p = 0.6513) neither was the rate of
blood transfusion at 9.2% in both groups.
Conclusion
This study shows that minimally invasive mitral valve repair is as safe as conventional
mitral valve repair. A significant difference in length of stay after surgery may
have resource and quality of life implications.
A102 Redo Surgery for the Mitral Valve: Can be Performed Safely and Offers Good Long-term
Survival
Massey, John, Mr; Sharkey, Annabel, Ms; Braidley, Peter, Mr
Northern General Hospital, Sheffield, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A102
Objectives
Redo-surgery to address mitral valve pathology in patients who have undergone previous
cardiac surgery remains the gold standard. Although the procedure is demanding we
aim to show that it can be performed safely with good long-term survival in an era
where transcatheter procedures are becoming more available.
Methods
Data was gathered from a prospectively populated database between January 2007 and
July 2021. All patients undergoing redo-surgery to deal with the mitral valve, performed
by a single consultant were included. The primary endpoint was mortality. Secondary
end-points include in-hospital length of stay, in-hospital mortality and catastrophic
surgical re-entry.
Results
93 patients met the inclusion criteria; 57 isolated mitral valve surgery, 23 mitral + concomitant
surgery, 13 repair of paraprosthetic leak. 76% of patients had undergone a previous
mitral procedure (35% replacement, 58% repair, 7% valvotomy), 17% had a patent LIMA
to LAD. 18% had pulmonary hypertension, 4% of patients had ischaemic MR and 12% had
functional MR (26% had previous coronary artery surgery). 99% had redo-sternotomy,
1% had right thoracotomy. 2% of patients had a catastrophic re-entry, median length
of stay 9 days (3–135), 2% in hospital mortality (average logistic euroscore 18.67%),
median long-term survival 182 months by Kaplan–meier.
Conclusion
This study illustrates that redo-surgery to deal with the mitral valve is safe with
a low in-hospital mortality despite this being a high-risk patient population. We
have also demonstrated that these patients go on to have good long-term survival.
A103 Does Concomitant Tricuspid Valve Repair Impact the Outcomes of Minimal Access
Endoscopic Mitral Valve Surgery?
Karuppannan, Mukesh, Mr; Abdelrahman, Abdelbar, Mr; Saravanan, Palanikumar, Dr; Knowles,
Andrew, Dr; Laskawski, Grzegorz, Mr; Argyle, Rachel, Dr; Zacharias, Joseph, Mr
Blackpool Victoria Hospital, Blackpool, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A103
Objective
The objective of this study was to review the impact of concomitant tricuspid valve
surgery (TVS) on short and long-term outcomes of endoscopic mitral valve surgery (EMVS).
Methods
Patients who underwent endoscopic minimally invasive mitral valve surgery between
2007 and 2020 at a single institution were reviewed. Patients were primarily grouped
by those undergoing isolated EMVS against EMVS + TVS. Short and long-term outcomes
were analysed from a prospectively collected departmental database.
Results
A total of 329 patients underwent EMVS out of which 52 (15.90%) underwent concomitant
TVS. Patients undergoing EMVS + TVS were at higher risk at baseline (LogEUROscore
6.97 vs 3.74 for EMVS group). Cardiopulmonary bypass times (180.14 ± 32 vs. 164 ± 42 min;
p < 0.001) and aortic occlusion times (125.92 ± 30 vs. 108.04 ± 36 min; p < 0.001)
were longer in the EMVS + TVS group. Operative mortality was higher but acceptable
and below the predicted mortality (1.92% for EMVS + TVS vs 0.72% isolated EMVS, p = 0.55).
Permanent pacemakers were required more frequently in the EMVS + TVS group (0.37%
vs 5.36% p < 0.03). All other complication rates were similar. Mean length of postoperative
hospital stay was 9.34 days for EMVS + TVS while it was 7.19 days for EMVS group.
Long term survival at 8 years was comparable (82.70% EMVS + TVS vs 88.09% for EMVS,p = 0.45).
Conclusion
Despite longer operative times, EMVS + TVS has similar postoperative outcomes to isolated
EMVS.We would recommend addressing the tricuspid valve, if indicated, during an endoscopic
mitral valve procedure.
Perioperative variables
EMVS + TVS (n = 52)
EMVS(n = 277)
p-value
Age range(years)
37–88(70.65)
20–92(62.11)
0.03
Female {n, (%)}
35 (67.30%)
119 (42.96%)
0.02
Logistic Euroscore,{Mean (Range)}
6.97 (1.5–24.04)
3.74(1.5–43.23)
< 0.001
CPB time,mins (mean)
180.14 (SD 32)
164 (SD 42)
< 0.001
Aortic occlusion time,mins (mean)
125.92 (SD 30)
108.04 (SD 36)
< 0.001
30 day mortality {n, (%)}
1 (1.92%)
2 (0.72%)
0.54
Mean ICU stay(days)
1.27 (SD 0.64)
1.41 (SD 3.22)
0.003
Heart block requiring PPI {n, (%)}
3 (5.76%)
1 (0.36%)
0.03
Prolonged ventilation(> 48 h) {n, (%)}
1 (1.92%)
9 (3.24%)
0.02
A104 Current Practices in Mitral Valve Interventions Across the UK and Ireland
Naruka, Vinci
1, Mr; Arjomandi Rad, Arian2, Mr; Chacko, Jacob1, Mr; Liu, Guiqing1, Mr; Afoke, Jonathan1,
Mr; Punjabi, Prakash P1, Prof
1Hammersmith Hospital, London, UK; 2Imperial College London, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A104
Objectives
In recent years, major findings on concomitant procedures and perioperative management
have occurred in Mitral Valve (MV) surgery. Therefore, we sought to evaluate the current
practices in MV interventions across the UK and Ireland.
Methods
In September 2021, all consultant cardiac surgeons were identified through an electronic
search of the SCTS database and sent an online survey of 14 questions. Data was recorded
on a central database and analysed.
Results
80% out of 50 consultants participating indicated MV repair as their specialty. 66%
performed > 150 operations/year and 54% had 10+ years of experience.
Anticoagulation post-MV repair: if sinus rhythm 40% use Aspirin while 20% use Vitamin
K antagonist (VKA), both alone for 3 months only; if atrial fibrillation (AF) 44%
use DOAC and 20% VKA, for life. In bioprosthetic MV replacement (MVR): if sinus rhythm
26% use VKA and 24% Aspirin, for 3 months only; if AF 38% use DOAC for life and 28%
use VKA for 3 months followed by DOAC for life. 76% performed concomitant tricuspid
valve repair for moderate tricuspid regurgitation with annular diameter > 40 mm. 54%
indicated ischaemic MV surgery in patients undergoing CABG if moderate mitral regurgitation
with ERO > 20mm2 and regurgitant volume > 30 ml. The preferred management was: MVR
if predictors of repair failure identified (52%), downsizing annuloplasty ring (26%)
with additional subvalvular procedures (14%). 63% of surgeons with 0–15 years’ experience
prefer MVR if predictors of repair failure were identified while 60% with 15 + years’
experience preferred downsizing annuloplasty ring. For AF in cardiac surgery, 40%
perform ablation with biatrial lesion and 22% with left-sided only. 86% perform concomitant
Left Atrial Appendage Occlusion irrespective of AF ablation with a left atrial clip.
Conclusion
These results demonstrate a variable practice for MV surgery, and a degree of lack of
compliance with surgical intervention guidelines and anticoagulation strategy.
A105 Medium-term Outcomes of Surgical TOE-guided Mitral Valve Repair Surgery
Kho, Jason
1, Dr; Metwalli, Amr2, Mr; Amin, Fouad3, Dr; Missouris, Constantinos3, Prof; Jin,
Xu Yu4, Dr; Petrou, Mario2, Mr
1St Thomas's, London, London, UK; 2Royal Brompton Hospital, London, UK; 3Wexham Park
Hospital, Slough, UK; 4John Radcliffe Hospital, Oxford, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A105
Objectives
To review the early to medium-term outcomes of patients who underwent mitral valve
(MV) surgery performed by a dedicated mitral team.
Methods
We retrospectively reviewed the operative and survival data of consecutive patients
who underwent MV surgery over a 10-year period (November 2011–2021) performed by a
single surgeon (MP) guided by the same surgical TOE specialist (XYJ).
Results
This team performed a total of 272 MV operations; 163 were repairs (MVr) with mean
age 63 ± 15 years and calculated mean EuroSCORE-II was 2.7 ± 3.0. All cases underwent
two-stage planning of repair strategy by detailed TOE and surgical assessment. The
repairs were resectional (49.7%) or non-resectional (50.3%); 97.5% included an annuloplasty.
Cross-clamp and cardiopulmonary bypass times for isolated MVr ranged from 44 to 110
and 58 to 150 min respectively. Success rate after 166 attempted MVr was 98.2% (163/166)
demonstrated as no or trivial mitral regurgitation, normal pressure gradient and valve
area on post-bypass TOE. Mean survival after isolated MVr was 100% at 30 days and
98.0 ± 2.0% at 5 and 9 years. Freedom-from-reintervention at 9 years was 100% in entire
cohort.
Conclusion
In our experience, meticulous pre-bypass TOE analysis and correlation with surgical
patho-anatomy involving the same cardiac surgeon and dedicated TOE specialist results
in excellent MV repair rates and medium-term outcomes.
A106 Roboti Versus Conventional Mitral Valve Surgery: Do the Costs Outweigh the Benefits?
Ahern, Shane, Dr; NiDhonnchu, Tara, Ms
Department of Cardiothoracic Surgery, Cork University Hospital, Cork, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A106
Objectives
Comparisons between robotic and conventional mitral valve surgery have varied. The
former confers many clinical benefits to patients. However, the high costs associated
with the robotic approach act as a deterrent to its uptake. Therefore, the objectives
of this research are to identify the intraoperative and post-operative differences,
as well as cost differences between robotic and conventional mitral valve surgery.
Methods
A systematic review of five databases was performed to identify research comparing
robotic and conventional mitral valve surgery. Meta-analysis of clinical and cost
data was carried out.
Results
Fourteen studies with a combined population of N = 3,635 were included. Meta-analysis
revealed significantly longer cardiopulmonary bypass and cross-clamp times for robotic
surgery, but many significantly improved clinical outcomes. These included improved
all-cause mortality, decreased duration of ventilation, shorter ICU and overall length
of stay. Operative costs were significantly higher for robotic surgery but were offset
by post-operative savings.
Discussion
The increased complexity associated with robotic mitral valve surgery significantly
increase operative times and expense. Despite this, robotic surgical led to improved
post-operative outcomes. This translated to significant saving in costs in the post-operative
period, enough to offset the high intraoperative costs, making robotic surgery increasingly
attractive.
A107 Open Transatrial Transcatheter Mitral Valve Replacement in Patients with Mitral
Annular Calcification Undergoing Concomitant Aortic Valve Replacement
Holland, Luke
1, Mr; Narayana, Ashok2, Mr; Hildick-Smith, David2, Prof; Trivedi, Uday2, Mr
1Guy's Hospital, London, UK; 2Royal Sussex County Hospital, Brighton, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A107
Objectives
Mitral valve (MV) surgery in the presence of mitral annular calcification (MAC) remains
a surgically challenging procedure with well-recognised complications including paravalvular
leak, atrioventricular fistula, left ventricular rupture and coronary artery injury.
Morbidity and mortality from surgical valve replacement in this context is significant,
reflective of the technical challenges and co-morbidities often present in this patient
population. In recent years, reports of antegrade transcatheter MV implantation using
balloon-expandable prostheses have emerged.
Methods
We present a series of four patients with MAC who underwent double (mitral and aortic)
valve replacement with a surgical aortic valve and an open transcatheter mitral valve.
We discuss technical points of surgery and reflect on lessons learned from our experience.
Results
All four patients underwent surgery via median sternotomy. All four had technical
and procedural success, as defined by the Mitral Valve Academic Research Consortium.
The 30-day mortality was zero, although there was one late mortality after a prolonged
intensive care admission. The three patients who survived to discharge had no paravalvular
leak on follow-up echocardiography.
Conclusions
Our experience suggests patients with aortic and mitral stenosis in the presence of
MAC can be treated with a combined operation incorporating surgical AVR and a balloon-expandable
"TAVI-in-MAC". This adds to the growing body of evidence supporting the use of these
valves during open cardiac surgery.
A108 Surgical Outcomes for Patients With and Without Mitral Annular Disjunction who
Undergo Mitral Valve Surgery
Kwok, Chun Shing, Dr; Bennett, Sadie, Mrs; Tafuro, Jacopo, Mr; Brumpton, Marcus, Dr;
Bardolia, Caragh, Dr; Heatlie, Grant, Dr; Duckett, Simon, Dr; Ridley, Paul, Mr; Nanjaiah,
Prakash, Mr
University Hospitals of North Midlands, Stoke-on-Trent, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A108
Objectives
The objective of the study is to determine the prevalence of mitral annular disjunction
(MAD) in patients who undergo mitral valve surgery and surgical outcomes for these
patients.
Methods
All patients who underwent mitral valve surgery between 2013 and 2020 and had pre-surgical
transthoracic echocardiographic images that could be reviewed were included.
Results
A total of 185 patients were included in the analysis and 32.4% (n = 60) patients
had MAD (average length 8.5 mm). No differences were observed comparing MAD to no
MAD according to age, sex and comorbidities but patients without MAD had significantly
higher surgical risk scores. Coronary artery bypass grafting took place in 19.5% of
patients and 60.5% had a ring annuloplasty. A greater proportion of patients with
MAD had to return to theatre but this was not statistically significant (10.0% vs
4.1%, p = 0.18). There was no difference in in-hospital complications and one-year
mortality. Two patients out of 51 patients with follow-up echo scans had MAD post-surgery.
Conclusions
MAD is common in patients who undergo mitral valve surgery. Patients with MAD have
similar surgical outcomes to patients without MAD. Surgery on the mitral valve in
patients with MAD appears to correct the structural abnormality at follow-up.
A109 Minimally Invasive Mitral Valve Repair: A Systematic Review and Meta-analysis
of Randomised, Active Control Trials
Ganesananthan, Sharmananthan
1, Mr
1University College London, London, UK; 2West Middlesex University Hospital, Middlesex
UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A109
Objectives
The conventional approach for mitral valve surgery is midline sternotomy (MS), but
recent observational data have suggested comparable safety of minimally invasive (MI)
approaches. Hence, we sought to pool the outcomes of randomised, active control trials
(RCTs) to better elucidate outcomes of the MI approach.
Methods
Embase, Medline, Google Scholar and PubMed databases were searched from conception
to October 2021 for RCTs comparing MI and CS approaches in patients requiring mitral
valve surgery. Non-randomised and non-English studies were excluded. The primary outcomes
were all cause mortality, operating time, length of hospital and ICU stay, Aortic
Cross Clamp Time and cardiopulmonary bypass time. Analysis was conducted using Random
Effects Model of meta-analysis using R software.
Results
Four studies were included in the final quantitative analysis with a total of 440
patients (Males: 206; Females: 234). Mean follow-up period was 1.31 years. There was
no significant differences between MI and MS approach for all-cause mortality [relative
risk (RR) 1.23, 95% Confidence Interval (CI) 0.02–70.84; P = 0.63].
Conclusions
Our study provides evidence that MI approach for mitral valve surgery is safe. However,
larger sample sized RCTs with longer follow-up data are needed to better elucidate
efficacy outcomes. We await UK Mini Mitral RCT that aims to serve as a robust, well-powered
trial to answer this question.
Adult Cardiac Scientific & Experimental
A110 Developing Patient-specific Arterial Disease Models Using Endothelial Colony
Forming Cells
Thammandra, Vamsi, Mr
St George's University of London, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A110
Objectives
Endothelial colony forming cells (ECFC) offer an unparalleled opportunity for understanding
endothelial physiology in health and disease. However, whether ECFC phenotype is representative
or entirely different to that of venous or arterial endothelium is unknown. Furthermore,
the putative progenitor-like nature of ECFCs may provide an opportunity for their
instruction towards a specific endothelial sub-type of interest for disease studies
e.g. arterial endothelium.
Methods
The arterio-venous phenotype of ECFC, arterial EC (HAEC) and venous EC (HUVEC) was
assessed using qPCR, western blot and immunofluorescence of several canonical markers.
Methods for the induction of an arterial phenotype in ECFCs were explored using recombinant
DLL4 (rDLL4) and a protocol developed for arterialisation of induced pluripotent stem
cells using arterial differentiation media.
Results
Differential gene expression was not observed between HAEC and HUVEC except for the
"gold standard" marker for arterialisation, HEY2. ECFCs did express both arterial
and venous markers at a protein and mRNA level. Induction of arterial markers in ECFCs
using rDLL4 was weak in comparison to HUVEC. Arterial differentiation media resulted
in the marked induction of several arterial markers however L690 (IMPase inhibitor)
consistently had high expression of all markers except DLL4.
Conclusion
We cannot ascertain the phenotypic resemblance of ECFC to either arteries or veins
due to the lack of distinction between HAEC and HUVEC. However, ECFCs did express
moderate levels of both arterial and venous markers potentially indicating their uncommitted
endothelial status. Initial experiments of induction in ECFCs have shown promising
results, thus with further optimisation, we propose that ECFCs could be used to form
robust in vitro arterial endothelial disease models.
A111 Single-cell Sequencing to Investigate Metabolic Stress in the Pathology of Organ
Injury Following Cardiac Surgery
Sheikh, Sophia, Miss; Wozniak, Marcin, Dr; Murphy, Gavin, Prof
University of Leicester, Leicester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A111
Objectives
Organ injury is a major cause of health complications and in-hospital mortality following
cardiac surgery. Our research explores whether patients’ baseline metabolic status
is the principal contributor to organ injury and dysfunction following surgery. We
hypothesise differential transcriptome and corresponding chromatin accessibility profiles
are identified in patients of differing metabolic states through using single-cell
sequencing technologies.
Methods
We optimised methods for single-cell RNA sequencing (scRNA-seq), single-nuclei RNA
sequencing (snRNA-seq) and single-nuclei ATAC sequencing (snATAC-seq) using murine
heart tissue and right atrial biopsies from patients recruited to our ongoing Ob-CARD
trial (NCT02908009). Chromatin immunoprecipitation (ChIP) qPCR using Ob-CARD leukocytes
was optimised to confirm epigenetic heterogeneity between metabolic states relative
to acetylated H3 and H4 histone subunits.
Results
Results showed different preparation methods of cardiac tissue using mouse and Ob-CARD
samples produced a poor representation of cardiomyocytes in scRNA-seq data. Certain
nuclei preparation methods provided greater cardiomyocyte representation in snRNA-seq
data compared to cells. Ob-CARD patient leukocytes derived from peripheral whole blood
collected at pre- and post-operative time points similarly underwent scRNA-seq to
investigate transcriptome differences in circulating immune cells. snATAC-seq was
successfully performed in mouse heart tissue, requiring validation in Ob-CARD samples.
ConclusionssnRNA-seq and snATAC sequencing are viable methods for patient cardiac
tissue samples to provide insight into cell-type specific differential gene expression
and chromatin accessibility profiles of all major cardiac cell types. This will help
to delineate differences between patients of different metabolic states and perhaps
later inform the development of effective therapeutic strategies.
A112 The Role of Calcitonin in Prevention and Management of Postoperative Atrial Fibrilation
Krasopoulos, George
1, Professor; Moreira, Lucia2, Dr; Sayeed, Rana3, Mr; Robinson, Paul2, Dr; Mehat,
Neelam2, Mrs; Reilly, Svetlana2, Prof
1Oxford Heart Centre, Oxford, UK; 2Radcliffe Department of Medicine (Cardiovascular
Division), University of Oxford, Oxford, UK; 3Cardiothoracic Surgery, Oxford Heart
Centre, Oxford, UK, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A112
Objectives
Atrial fibrillation (AF) is the commonest cardiac arrhythmia and a major therapeutic
challenge. We recently discovered that atrial cardiomyocytes (CMs) secrete cardiac
calcitonin (CT). The direct effects of CT signalling on CMs function, arrhythmogenicity
and post-cardiac surgery AF (poAF) are unknown.
Methods
An cohort of 38-patients that underwent cardiac surgery had their pre-operative/postoperative
circulating CT levels and their incidence of poAF recorded. A further study involving
110-patients has been designed to evaluate the changes in circulating CT and Pro-Calcitonin
(PCT) on the new-onset of poAF.
Results
The pre-operative levels of CT are associated with a ~ 2.8-fold reduction in the incidence
of poAF. Patients with poAF also failed to recover supressed CT levels 3-days after
the surgery. In vitro experiments in freshly isolated atrial guinea pig atrial cardiomyocytes
have shown that CT exerts its effects via binding to CT-receptors (CTR). Functional
studies in animal found that CT administration inhibits spontaneous calcium-release
events and calcium transient amplitude induced by pacing in CMs.
Conclusions
Our findings suggest that CT potently supresses cell arrhythmogenicity. We are planning
to evaluate this further with our new study that is focused on poAF, aiming to translate
our findings into direct benefiting the clinical management of AF.
A113 In-hospital Patient Mobilization Quantification After Cardiac Surgery Using Accelerometers:
What do Patients do?
Halfwerk, Frank
1, Dr; Klaassen, Randy2, Dr; Lynch, Winston1, Mr; van Delden, Robby2, Dr; Veltink,
Peter3, Prof; Grandjean, Jan1, Prof
1Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands; 2Human
Media Interaction Lab, University of Twente, Enschede, The Netherlands; 3Dept. of
Biomedical Signals and Systems, University of Twente, Enschede, The Netherlands
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A113
Objectives
After heart surgery patients stay for 4–7 days in the hospital and start their rehabilitation
the day after surgery with physiotherapy training. Patients infrequently mobilize
during their surgical ward stay, as patients are unaware why mobilization is important.
Furthermore, patients’ progress of mobilization activities is not available. The aim
of the MOVEMENTT study was to use accelerometers with artificial intelligence algorithms
for quantification of in-hospital mobilization after cardiac surgery.
Methods
Patient activities lying in bed, sitting in a chair, standing, walking, cycling on
an exercise bike, and walking the stairs were defined to measure patient mobilization.
An accelerometer (AX3, Axivity) was postoperatively placed on both the upper arm and
upper leg. An artificial neural network algorithm classified the activities. The primary
endpoint was each activity duration performed between 7 a.m. and 11 p.m. Secondary
endpoints were intensive care unit and surgical ward stay. A subgroup analysis was
performed for male and female patients.
Results
29 cardiac surgery patients were classified with an intensive care unit stay of 1
(1–2) night and surgical ward stay of 5 (3–6) nights. Patients spent 41 (20–62) min
less time in bed for each following hospital day (p < 0.001). Although patients practiced
in the morning, they laid more in bed in the afternoon. Standing (p = 0.004), walking
(p < 0.001), and walking the stairs (p = 0.001) increased during hospital stay. No
differences between men (n = 22) and women (n = 7) were observed for all endpoints.
Conclusion
The approach presented in this study is applicable for measuring all six activities
and for monitoring postoperative recovery of cardiac surgery patients. A next step
is to provide remote monitoring with wearable sensors to guide patient-specific cardiac
rehabilitation.
A114 Innovating a Brain Protection Device for Cardiac Surgery and Cardiac Arrest:
A Cool Solution Using Diffusion-Absorption-Refrigeration Technology
Slim, Naim, Mr; Salmasi, Mohammad Yousuf, Dr; Harraz, Asma, Ms; Markides, Christos,
Prof; Athanasiou, Thanos, Prof; Casula, Roberto, Mr
Imperial College London, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A114
Objectives
Cardiac surgery and cardiac arrest are associated with ischaemic cerebral injury secondary
to microemboli and global cerebral haemodynamic changes during cardioplegia. Systemic
neuroprotective strategies achieve an effective reduction in core temperature but
are associated with pneumonia, myocardial dysfunction and coagulopathy. This study
aimed to create a computational model of a smart brain cooling device.
Methods
We investigated the feasibility of a novel cooling system that induces selective cooling
with diffusion-absorption-refrigeration (DAR) technology—a refrigeration method with
an array of existing commercial uses. A computational model was developed using the
gPROMS platform, whereby the application of a topical coolant at freezing point was
simulated on a head and neck model, with adaptation of the cerebral circulation to
reflect the haemodynamic changes of cardiac arrest. Core brain temperature was measured
against time, and the unit power requirement to provide cooling and running costs
were also calculated.
Results
During the cardiac arrest simulation, core brain temperature fell by −0.37C without
neck cooling and −2.31C with neck cooling. Grey matter temperature fell by −0.71C
with neck cooling and −2.63C with neck cooling. The cooling power required to sustain
these temperatures was approximately 69.15W at onset and 36.13W to maintain cooling
throughout device application, which is achievable with one DAR unit with a cost of
£144–180 and ongoing running costs of 5–8p/h.
Conclusion
Our study has demonstrated that brain cooling can be achieved with a combination of
head and neck cooling using existing commercially-available refrigeration technology.
The low power requirement and running cost suggest the feasibility of a portable battery-operated
device that can be deployed in hospitals and in the pre-hospital setting.
A115 The Role of Extracellular Matrix in The Regulation of Vascular Smooth Muscle
Phenotype ad Function During Vascular Calcification
Chan, Shie Wei, Miss
Cardiff University, Cardiff, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A115
Objectives
1. Characterize expression and alterations in HA and related proteins in VSMCs before
and after osteoblastic differentiation.
2. Evaluate the effects of cytokines associated with heightened inflammation in PD on: a)
VSMC differentiation b) calcium/phosphate generation and c) alterations in HA and
related proteins.
3. Investigate the causal relationship between alterations in HA identified in Aim-1
and Aim-2 to VSMC-osteoblast differentiation and calcium/phosphate generation.
Methods
Quantitative reverse transcriptase PCR (RT-qPCR) and immunocytochemistry were used
to confirm osteogenic differentiation by assessing for osteogenic markers (RUNX2,
osteopontin, attenuated alpha-smooth-muscle-actin). Primary human vascular smooth
muscle cells were grown in-vitro and osteoblastic differentiation of these cells was
promoted by incubating with osteogenic medium (ascorbic acid 2 phosphate, glycerol
2 phosphate, dexamethasone). Alternations in HA and related proteins were investigation
using RT-qPCR and immunocytochemistry.
Results
RESULTS 1: Differentiation of VSMCs to Osteoblastic Phenotype.
RUNX2 and osteopontin are established markers of VSMC-osteoblast differentiation and
of VC. Alpha-SMA is a marker of VSMC.
RESULTS 2: HA expression following VSMC to osteogenic differentiation.
RESULTS 3: Alterations in HAS Synthase expression following VSMC to osteogenic differentiation.
Osteogenic differentiation is associated with marked changes in HAS3 isoenzyme expression.
(Images for results 1,2 and 3).
VSMC to osteogenic differentiation is associated with marked changes in HA expression
and in the enzymes/proteins involved in HA synthesis, degradation and binding, suggesting
that alteration in HA matrix may play a role in VSMC pathobiology during vascular
calcification. Establishing a causal link between these changes and VSMC differentiation
during VC may identify novel therapeutic targets for CKD specific cardiovascular disease.
A116 Investigating Estimated Blood Loss and Haemoglobin Level After Cardiac Surgery;
A Potential New Transfusion Trigger?
Soliman, Nadine
1, Miss; Hayes, Timothy2, Dr; Rajamiyer, Venkateswaran2, Mr; Grant, Stuart W1, Mr
1University of Manchester, Manchester, UK; 2Manchester University NHS Foundation Trust,
Manchester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A116
Objectives
Currently haemoglobin (Hb) is used as the primary trigger for post-operative blood
transfusion following cardiac surgery. Haemodilution secondary to administration of
intravenous fluids both intra- and post-operatively can contribute to a fall in Hb
irrespective of any blood loss. This study aimed to investigate the relationship between
post-operative Hb levels and estimated blood loss after cardiac surgery.
Methods
A review of the literature was performed to identify methods to estimate blood loss
that only require routinely observed post-cardiac surgery data. Data were collected
for patients who underwent adult cardiac surgery over a consecutive six-week period.
Estimated blood loss (VLRBC) was calculated using the OSTHEO method. VLRBC was compared
to percentage change in Hb (g/dL) from baseline to the post-operative nadir Hb. Pearson’s
correlation coefficients were computed for Hb and VLRBC.
Results
A total of 40 patients were included. The majority (n = 27) were male and the mean
age was 67.1 (SD ± 9.2). Mean pre-operative Hb was 138.4 g/dL (SD 14.4), the mean
post-operative Hb nadir was 93.3 g/dL (SD 12.9). The mean percentage fall in Hb from
pre-op to nadir was 32.3% (SD 8.4), which was significantly greater than the mean
percentage VLRBC of 12.6% (SD 4.0), p < 0.001. Percentage fall in Hb correlated well
with percentage VLRBC (R2 = 0.824). A total of 4 patients had a fall in Hb below 80 g/dL,
in these patients the mean fall in Hb from baseline was 38.5% (SD 9.5), and the mean
VLRBC was 15.3% (SD 4.2).
Conclusions
VLRBC calculated using the OSTHEO method correlates well with post-operative changes
in Hb after cardiac surgery. Estimated blood loss is consistently less than the fall
in Hb. This method can be calculated using easily available data that accounts for
changes in circulating blood volume and patient weight. Further work is required to
explore whether VLRBC could replace Hb as a transfusion trigger after cardiac surgery.
A117 How to Test Adhesive Strength: A Novel Biomechanical Testing for Aortic Glue
Used in Type A Dissection Repair
Zientara, Alicja
1, Ms; Tseng, Yuan-Tsan2, Dr; Salmasi, Mohammad Yousuf1, Dr; Quarto, Cesare1, Mr;
Stock, Ulrich3, Prof
1Royal Brompton Hospital, London, UK; 2Imperial College & Magdi Yacoub Institute,
Harefield, UK; 3Harefield Hospital, Harefield, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A117
Objective
The widely used Bioglue (Cryolife®) represents the gold standard component in the
repair of type A dissections. Despite broad acceptance the adhesive strength of the
glued aortic layers has not been tested and quantified so far. The aim was to demonstrate
the preliminary results of the peel force of a standard tissue glue in an in vitro
model simulating a type A dissection.
Methods
This study is based on the adaptation of the adhesive T-peel test (EN ISO 11339:2010)
for the determination of the peel strength of adhesives by measuring the peeling force
of a T-shaped bonded assembly of two flexible tissues. Measurements were performed
on juvenile ascending porcine aorta using a Bose Electro Force Planar Biaxial Test
Bench Instrument®. Aortic samples, glued with Bioglue, were tested and compared to
normal unpeeled controls. Four conditions of different sample pressure were tested:
zero pressure according to the manufacturer’s recommendation (n = 7), slight pressure
(504 Pa) (n = 11), moderate pressure (1711 Pa) (n = 7) and pressure applied by a Borst
clamp with a force of 1764 Pa (n = 19). T-test was applied for statistical significance.
Results
The median peel force (± SD) with zero pressure was 0.027 N/mm (± 0.018), with slight
pressure 0.05 N/mm (± 0.086), and with moderate pressure 0.214 N/mm (± 0.157). The
samples using the Borst clamp reached 0.085 N/mm (± 0.096). The unpeeled controls
reached a force of 0.11 N/mm (± 0.031). Bioglue with moderate pressure performed better
than samples without (p < 0.0001) and with slight pressure (p = 0.0005) and had also
a higher force than the unpeeled controls (p = 0.0008).
Conclusion
The performance of Bioglue in a model for aortic dissections demonstrated increased
peel force after applying a moderate pressure on the aortic sample in contrast to
slight or no pressure as per the manufacturer’s recommendation. The novel T-peel test
offers an attractive method to test tissue glues in general in a defined in vitro
environment.
A118 Utilisation of National Early Warning Score (NEWS) and Assessment of Patient
Outcomes Following Cardiac Surgery
Jacob, Abiah S, Ms; Kumar, Niraj S, Mr; Trevarthen, Thomas, Mr; Awad, Wael I, Mr
Barts Heart Centre, London, UK, St. Bartholomew's Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A118
Objectives
NEWS was introduced to standardise triaging of patients with clinical deterioration
to reduce mortality, with NEWS > 5 initiating Critical Care Outreach Team (CCOT) engagement.
We investigated involvement of CCOT based on NEWS following cardiac surgery and subsequent
patient outcomes.
Methods
Patients undergoing cardiac surgery between October 2020 and October 2021 were studied.
Patient characteristics, clinical and physiological causes triggering CCOT review
were probed. Outcomes following CCOT review were evaluated.
Results
72 of 1588 (4.53%) patients (mean age 64.9 ± 2.5 years, EuroSCORE 7.13) initiated
91 calls to CCOT following surgery. Mean NEWS score on CCOT activation was 5.78 (95%
CI: 5.29–6.26), with 21/91 (23.1%) activations from patients with NEWS < 5. The most
common NEWS parameters contributing to activations were oxygen therapy (mean: 1.76)
and systolic blood pressure (mean: 1.20). CCOT activations led to 12 transfers to
ITU and 18 to HDU; 4/72 (5.56%) patients suffered cardiac arrest; 4/72 (5.56%) had
emergency resternotomy; mean length of post-operative hospital stay was 18.3 ± 3 days;
in-hospital mortality was 6.94% (5/72 patients).
Conclusion
NEWS is a useful way of initiating CCOT involvement for patients with acute clinical
deterioration. The early involvement of CCOT and standardised recommendations on patient
management thereafter, may lead to improved patient outcomes.
A119 snoRNAs: A Genetic Marker to Inform the Choice of Conduit for Coronary Artery
Bypass Grafting (CABG) and Potential Mechanism of Action
Kumar, Ujjawal, Mr; Hamilton, Russell, Dr
Department of Genetics, University of Cambridge, Cambridge, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A119
ObjectivessnoRNAs at the 14q32 genetic locus are associated with failed venous grafts
after CABG (Håkansson et al., 2019). It is hypothesised that the snoRNAs show structural
similarity to the spliceosome, a cellular assembly involved in pre-mRNA transcript
splicing. We aimed to investigate the similarity of snoRNAs to the spliceosome and
propose a mechanism for their role in cardiovascular disease.
MethodssnoRNA and spliceosomal RNA sequences from the human reference genome (GRCh38)
were obtained from Rfam, an online database of non-coding RNAs. 2D and 3D structural
modelling of the snoRNAs were undertaken using ViennaRNA and SimRNA respectively.
Utilising multiple computational tools, sequential (1D) and structural (2D and 3D)
similarities between individual snoRNAs and the spliceosome were investigated in order
to identify candidate snoRNAs for in-depth pairwise comparison.
Results
We identified that a vast majority of the forty snoRNAs (in the 14q32 locus) showed
some structural similarity to the spliceosome. 3D structural prediction was undertaken
for snoRNAs that showed the greatest 1D and 2D similarity, identifying specific snoRNAs
with high degrees of structural similarity to the catalytically active site of the
spliceosome.
Conclusions
We, therefore, propose that these snoRNAs mimic the spliceosomal structure and interfere
with spliceosomal function. Variation in the snoRNAs could lead to mis-splicing of
pre-mRNA and subsequent pathological tissue remodelling. Remodelling is a key part
of tissue response in the venous grafts after CABG. The mis-splicing due to variation
in these snoRNAs could explain the significantly raised graft failure rates. These
snoRNAs are not associated with high graft failure rates with arterial conduits for
CABG. Thus, genetic screening for these snoRNAs could inform the choice of conduit
for CABG, improving patient outcomes by reducing likelihood of graft failure and need
for reintervention.
A120 Variation in Cellular Regulation with Patient Weight Categories within Atrial
Tissue
Adebayo, Adewale
1; Eagle-Hemming, Bryony1, Ms; Lai, Florence1, Mrs; Joel-David, Lathishia1, Mrs; Murphy,
Gavin2, Prof; Wozniak, Marcin1, Dr
1University of Leicester Glenfield Hospital, Leicester, UK; 2Glenfield Hospital, Leicester,
UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A120
Objectives
We examined the hypothesis that cellular regulation dysfunction underlies observed
paradox in which higher body mass index may be beneficial for categories of surgery
patients.
Methods
Adult cardiac surgery patients were recruited and demographic data obtained. Atrial
biopsies were collected during cardiopulmonary bypass. Transcriptome data was acquired
for samples from 53 patients, and a panel of targeted metabolites was analysed in
samples from 57 patients.
Results
Sixteen patients had a BMI below 25, 31 had a BMI between 25 – 30 and 19 above 30.
Weight groups significantly differed in age and haematocrit levels. Normal-weight
patients were more diverse in their metabolite expression, while overweight and obese
patients appeared more homogeneous. Statistical analysis identified more differentially
expressed (DE) biological pathways in overweight vs normal-weight comparison as well
as obese vs normal-weight. It also identified genes involved in regulation of translation,
lipids and muscle contraction were expressed in a biphasic pattern, which potentially
mimics the obesity paradox. Metabolite analysis identified 9 compounds with differing
levels in obese, normal-weight and overweight groups including specific carnitines
and pentose-pathway metabolites.
Conclusions
The results support our hypothesis of multi-omic changes in myocardium. Specific links
with transcripts, biological mechanisms and direct clinical impact require further
investigation.
Congenital
A121 Outcomes from Ross Procedure in Adults with Previous Aortic Valve Intervention
Visan, Alex, Dr; McPherson, Iain, Mr; Generali, Tommaso, Mr; De Rita, Fabrizio, Mr;
Jansen, Katrijn, Dr; Coats, Louise, Dr; Hasan, Asif, Mr; Nassar, Mohamed, Mr
Freeman Hospital, Newcastle, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A121
Objectives
Modified Ross procedure continues to deliver excellent outcomes for aortic valve disease
in the young adult population. Our objective was to assess if a stepwise approach
with repair and replacement strategies prior to Ross protects autograft longevity
and function.
Methods
Single tertiary, congenital centre with 158 patients (age 16–60) undergoing Ross procedure
from 1997–2019. Patients divided into primary Ross (no previous aortic valve intervention)
and secondary Ross groups, with coarsened exact matching used to ensure balanced distribution
of age, sex, weight and valve pathology. Primary outcome was autograft failure (a
composite of time from Ross to diagnosis of severe aortic regurgitation, redo aortic
valve repair or replacement). Secondary outcomes included survival, autograft reoperation
rate, and presence of dilated autograft (> 40 mm). Time to event outcomes analysed
using the Kaplan–Meier method and compared using log-rank testing. Univariate and
multivariate Cox-proportional hazard models were used to identify time-dependent predictors
of autograft failure.
Results
103 (65.2%) patients underwent primary Ross and 55 (34.8%) underwent secondary Ross.
After matching, the secondary Ross group showed superior freedom from autograft failure
(p = 0.039). 20-year survival was 96.5% (92.8–100) and 20-year freedom from re-operation
was 53.5% (36.6–78.2). Male sex was associated with increased risk of neo-aortic root
dilatation (OR 4.05, p = 0.02). Newer operative techniques (after 2011) were associated
with lower risks of neo-aortic root dilatation (OR 0.20, p = 0.002).
Conclusion
In patients who have undergone previous aortic valve interventions, Ross procedure
has a lower risk per year follow-up of pulmonary autograft failure compared with primary
Ross. Our results appear to justify a stepwise approach to aortic valve disease, with
conservative strategies for the treatment of aortic valve disease adopted in the first
instance.
A122 Necrotising Enterocolitis Pre Cardiac Surgery. Damned if you, Damned if you don't
Boyle, Mark
1, Dr; Khodaghalian, Bernadette2, Dr; Jones, Caroline2, Dr; Guerrero, Rafael2, Mr
1St Thomas's Hospital, London, UK; 2Alder Hey Children's Hospital, Liverpool, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A122
Objectives
Infants with congenital heart disease (CHD) have the potential to develop Necrotising
Enterocolitis (NEC) with devastating consequence. However, simply a suspicion of NEC
can delay cardiac surgical intervention causing increase in mortality and morbidity
in patients awaiting a "time critical" procedure. This highlights the necessity of
accurate diagnosis. We assessed the incidence of NEC in infants with CHD awaiting
surgery and the subsequent impact on outcomes at our centre.
Methods
This retrospective cohort study over a 24-month period utilised data obtained from
NICOR and local surgical databases. We included infants < 90 days of age with a diagnosis
of CHD and a diagnosis of NEC prior to cardiac surgery requiring bypass. We collected
data on demographics, cardiac lesion, feeding patterns, biochemical markers, diagnostic
imaging, clinical assessment and patient outcomes.
Results
24 patients were diagnosed with NEC prior to a cardiac operation involving bypass
in this period, 38% of whom were born prematurely. Within this cohort, 38% of patients
had transposition of the great arteries, 21% arch lesions and 17% pulmonary atresia’s
with lesser incidence of other lesions. Feeding was mixed and 71% were on prostaglandin
at time of diagnosis. Clinical signs and biomarkers were varied. 7 patients had an
abnormal x-ray, 4 patients ultrasound changes (3 of which had normal abdominal films).
7 cardiac operations were definitively delayed and 4 patients underwent surgical management
for NEC. Mean ICU stay post cardiac surgery was 11 days with 0% mortality at 30 days.
Conclusions
The question remains are the typical diagnostic pathways appropriate for our population?
Certainly, in our centre the utilisation of ultrasound is under review in light of
these findings, as is a review of the feeding recommendations in all our cardiac infants.
Is it time to look at new ways of diagnosing these infants, incorporating risk stratification
in our usual practice?
A123 Surgical Mitral Valve Replacement with Melody Valve in Paediatric Patients: Single
Centre Experience
ElSherbini, Ahmed, Mr; Salih, Caner, Mr; Austin, Conal B, Mr; Jones, Matthew I, Mr;
Kabir, Saleha, Mrs; Speggiorin, Simone, Mr
Evelina London Children's Hospital, London, UK, Guy's and St Thomas' NHS Foundation
Trust, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A123
Objectives
To demonstrate the efficacy of a modified stented bovine jugular vein graft (Melody
valve) for surgical mitral valve replacement in paediatric patients.
Methods
A single centre retrospective study of patients who underwent mitral valve replacement
using a modified Melody valve during the period from 2016 to 2021.
Results
A total of nine patients with a median age of 2.03 years (range, 3 months to 4.69 years)
underwent surgical implantation of a Melody valve in the mitral position. Seven patients
had previously undergone cardiac surgical procedures. Three patients had the valve
implanted on an 18 mm balloon, three at 16 mm and one each at 12 mm, 14 mm and 20 mm
A Ross-Konno operation was undertaken at the same in two patients. At discharge, all
valves were competent with low mitral valve inflow gradients (median 5 mmHg). Median
duration of intensive care unit stay after procedure was 6 days (range, 1 to 14 days).
One patient, who had also undergone a Ross-Konno operation developed cardiogenic shock
and required extracorporeal membrane oxygenation support for 10 days. Valve redilatation
was performed in two patients for somatic growth around one year after implantation
and transcatheter valve replacement for acute valve failure was undertaking in one
patient around 5 years after implantation. Endocarditis occurred in 1 requiring explantation
and replacement with mechanical prosthesis. At a median follow up of 1.6 years, seven
patients are free from structured valve deterioration. No mortality has been reported
to date.
Conclusion
Surgical implantation of a Melody valve in the mitral position provides a safe and
durable solution for valve replacement in paediatric patients with small mitral annulus
dimensions. A large prospective study is recommended and further refine of valve design
are needed.
A124 The Bilateral Remote Ischaemic Conditioning in Children (BRICC) Trial: A Two-centre,
Double-blind, Randomised Controlled Trial in Young Children
Drury, Nigel
1, Mr; van Doorn, Carin2, Ms; Woolley, Rebecca3, Ms; Amos-Hirst, Rebecca3, Ms; Jaber,
Osama2, Mr; Kassai, Imre2, Mr; Pelella, Giuseppe2, Mr; Khan, Natasha1, Ms; Botha,
Phil1, Mr; Jones, Timothy1, Mr
1Birmingham Children's Hospital, Birmingham, UK; 2Leeds Children's Hospital; 3University
of Birmingham, Birmingham, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A124
Objectives
To determine whether adequately delivered bilateral remote ischaemic preconditioning
(RIPC) is cardioprotective in young children with or without chronic cyanosis undergoing
elective cardiac surgery.
Methods
Two-centre, prospective, double-blind, randomised controlled trial of children aged
3 months to 3 years undergoing complete repair of tetralogy of Fallot (ToF) or surgical
closure of an isolated ventricular septal defect (VSD). Participants were randomised
to receive either: bilateral RIPC (3 × 5-min cycles) using a pressure-controlled tourniquet;
or sham, delivered immediately prior to surgery, with follow-up until hospital discharge
up to 30 days. The primary outcome was area under the curve (AUC) for hs-troponin-T
release in the first 24 h after reperfusion. Secondary outcomes included vasoactive
inotrope score, arterial lactate, and lengths of stay in the ICU and hospital.
Results
Over 4 years, 121 children were randomised, 61 children allocated to RIPC and 60 to
sham; one child in the RIPC group did not proceed to surgery so was excluded from
analysis. Mean AUC hs-troponin-T was higher in the RIPC group, mean: 70.0 µg/L/hr,
SD: 50.9, n = 56 versus sham, mean: 55.6, SD: 30.1, n = 58 (Mean diff: 13.2; 95% CI:
0.5–25.8; p = 0.04) (figure). Sub-group analyses did not show a differential treatment
effect in cyanotic and acyanotic children (interaction p-value = 0.2); however, there
may be evidence of a difference by congenital heart defect, though numbers were small
(interaction p-value = 0.04): unstented ToF, mean diff: 30.9, 95% CI: 12.2–49.6; stented
ToF, mean diff: 7.8, 95% CI: -27.7–43.4; VSD, mean diff: -3.2, 95% CI: -22.0–15.5.
There were no differences in any secondary outcome measures.
Conclusions
In young children undergoing elective cardiac surgery, we found children randomised
to RIPC had greater hs-troponin-T release in the early postoperative period, which
may reflect increased myocardial injury, especially in ToF.
A125 Are Chest Radiographs Necessary After Chest Drain Removal in Paediatric Cardiac
Surgical Patients? – A Retrospective Analysis of 1076 Patients
Shetty, Gautham
1, Dr; Zouki, Jason2, Mr; Lee, Geraldine2, Miss; Betts, Kim3, Mr; Justo, Robert1,
Dr; Marathe, Supreet1, Dr; Alphonso, Nelson1, Dr; Venugopal, Prem1, Dr
1Queensland Children’s Hospital, Brisbane, Australia; 2Queensland University, Queensland,
Australia; 3Curtin University, Bentley, WA, Australia
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A125
Objectives
Chest drains are routinely placed in children following cardiac surgery. Studies have
questioned the need for routine chest radiograph after chest drain removal in terms
of re-interventions, radiation exposure and cost-effectiveness. The purpose of this
study was to determine whether a chest radiograph can be avoided following chest drain
removal.
Methods
A single-centre retrospective cohort study. Inclusion criteria were patients between
0 days and 18 years of age who underwent cardiac surgery between 1/1/2015 and 31/12/2019
with insertion of mediastinal and/or pleural drains. Exclusion criteria were chest
drain/s in situ ≥ 14 days and mortality prior to removal of chest drain/s.
Results
1076 patients {median age: 292 days (IQR 62, 1956); median weight: 7.8 kg (IQR 4.1,
18.5)}; 1587 drain removal episodes—2365 drains [1347 (57%) mediastinal drains, 598
(25%) right pleural drains and 420 (18%) left pleural drains]. Chest radiographs were
performed following 1301 (82%) drain removal episodes. There was no mortality related
to chest drain removal. Chest radiograph was abnormal after 152 (12%) drain removal
episodes [pneumothorax (n = 43, 3%), pleural effusion (n = 98, 8%) and hydropneumothorax
(n = 11, 1%)]. Of these patients, clinical signs or symptoms were absent in 122 (n = 152,
80%) patients and present in 30 (n = 152, 20%). 14 (n = 152, 8%) required a change
in management. 11 (n = 152, 7%) required medical management (non-invasive respiratory
support or diuresis); 1 required reintubation and ventilation; 2 required chest drain
reinsertion.
Conclusion
The incidence of clinically significant pneumothorax/pleural effusion following chest
drain removal after paediatric cardiac surgery is low (0.02%). The majority of these
patients were managed medically and did not require chest drain reinsertion. We conclude
that not all paediatric cardiac surgical patients require chest radiographs following
chest drain removal.
A126 CardioCel for Repair of Congenital Heart Defects – Multicentre Results of Over
1000 Implants
Daley, Michael
1, Dr; Marathe, Supreet1, Dr; Gamal, Mohamed2, Dr; Betts, Kim1, Mr; Andrews, David3,
Dr; Brizard, Christian4, Prof; Venugopal, Prem1, Dr; Alphonso, Nelson1, Dr
1Queensland Children's Hospital, Brisbane, Australia; 2Queensland Health, Queensland,
Australia; 3Perth Children's Hospital, Perth, Australia; 4Royal Children's Hospital,
Melbourne, Australia
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A126
Objectives
CardioCel is decellularized tissue-engineered bovine pericardium that has undergone
the ADAPT® process to remove nucleic acid remnants, to reduce in-vivo calcification.
Although there has been increasing use of CardioCel in the repair of congenital heart
defects over the last decade, long-term outcomes remain to be defined.
Method
A multicentre review of 754 patients who underwent repair of congenital heart defects
using 1047 CardioCel implants was performed. Data were collected from hospital, operation
and outpatient reports. The primary endpoint was CardioCel-related surgical or catheter
reintervention.
Results
Median age at implantation was 12 months (IQR: 3.6–84 months). Multiple patches were
implanted in 214 patients (28.4%). Patches were used for PA augmentation (n = 284,
27.1%), septal defects (n = 266, 25.4%), aortic root/ascending aorta/arch repair (n = 186,
17.8%), valve repair (n = 157, 15.0%), and other (n = 154, 14.7%). Median follow-up
was 20 months (0–116 months). One patient died from a CardioCel-related complication
(dehiscence of RVOT patch). Freedom from CardioCel-related reintervention was 95%
(95%CI: 93%-97%) and 91% (95%CI: 87%-94%) at 1 and 5 years, respectively. Thirty-six
CardioCel-related reinterventions were performed, including 13 on the PAs and 9 on
the aorta. Cox regression showed that neonates and infants were more likely to require
reintervention than children > 1 year of age (HR = 3.96, p = 0.003; HR = 2.34, p = 0.036,
respectively). Patients with implants in the aorta and PAs were more likely to undergo
reintervention compared to those with septal implants (HR = 3.07, p = 0.034; HR = 2.86,
p = 0.033, respectively).
Conclusion
CardioCel provides acceptable results for the repair of a variety of congenital heart
defects. Neonates and infants required more CardioCel-related reinterventions compared
to children > 1 year of age. Patients with aortic and PA implants required more CardioCel-related
reinterventions.
A127 Outcomes After Mechanical Mitral Valve Replacement in Young Congenital Group:
A Single Centre 10 Years Results
Abousteit, Ahmed
1, Mr; Harky, Amer2, Mr; Bhag, Garima1, Dr; Samaddar, Avisheck1, Dr; Kutty, Ramesh1,
Mr; Lotto, Atillio1, Mr; Guerrero, Rafael1, Mr; Dhannapuneni, Ram1, Mr
1Alder Hey Children Hospital, Liverpool, UK; 2Liverpool Heart and Chest Hospital,
Liverpool, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A127
Objectives
Mitral valve repair and reconstruction are favoured in congenital group especially
in very young subgroups to avoid complications related to mechanical mitral valve
replacement (MVR), however valve replacement with a mechanical prosthesis is still
a necessity in some patients. We report our experience in this cohort of patients.
Methods
A retrospective single-centre study for patients who underwent MVR only with a mechanical
prosthesis between 2010 and 2020. Data are presented as median, range and percentage.
Results
Our cohort consisted of 31 patients. Median age 4.24 years (76 days- 18.8 years), < 2 years n = 11
(35.48%). Pre-operative AVSD diagnosis n = 10 (32.25%), Shone Complex or LVOTO n = 9
(29%). Previous mitral valve repair n = 16 (51.6%) and replacements n = 6 (19.6%).
Median interval from attempted repair to replacement 8.13 years (12 days -15 years).
Bi-leaflet mechanical mitral valves n = 30 (96.77%) and one bi-leaflet mechanical
aortic valve was used in mitral position n = 1 (3.23%). Valve prosthesis sizes ≤ 19 mm
n = 10 (32.25%).
Post-operative prolonged mechanical ventilatory support > 7 days n = 6 (19.35%). Post-operative
renal failure requiring dialysis n = 3 (9.97%). Septicaemia n = 2 (6.45%). Re-operation
for valve thrombosis n = 2 (6.45%). ECMO required n = 3 (9.97%). Two patients died
within 30 days (6.45%) (8 and 30 days). Two further in-hospital mortalities > 30 days
(39 and 156 days). Mortalities age median 16.2 month (9.7- 35.7 months). Median follow-up
was 2.8 years (2.5 months—9.7 years) and with no late reoperation or mortalities recorded. Ten
years survival was 87.1%.
Conclusion
MVR with a mechanical valve is still a safe option with challenging mitral valve pathologies
which are not suitable for a good repair or after failed repair attempts. Higher risk
of postoperative mortality and complications are encountered in children less than
2 years old with small valve sizes.
A128 Repair of Obstructed Supracardiac TAPVD and Rare Compression of Left Main Bronchus
Between Pulmonary Venous Confluence and Aorta
Bader, Vivian, Miss; Noonan, Patrick, Dr; Peng, Edward, Mr
Royal Hospital for Children Glasgow, Glasgow, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A128
A 2.5-month old baby, who presented with respiratory distress and poor feeding, Echo
showed supracardiac TAPVD with obstruction. Patient needed intubation and his blood
pressure was marginal. CXR showed bilateral lung congestion with left lung collapse.
The Repair was achieved via primary sutureless technique, the vertical vein was not
easily identifiable from the confluence hence this was initially left alone. First
two attempts to come off bypass were not sustainable with low BP and distended RV
despite on iNO and high inotropes. Epicardial echo showed laminar flow at PV confluence
with no sign of obstruction of flow from both left and right PV branches. There was
trivial TR. LV was very under-filled with compression from severely dilated RV.
We elected to explore the vertical vein at the level of innominate vein, which was
found to be engorged as well as the vertical vein. The vertical vein was tied off.
The third attempt of coming off bypass was associated with good LV ejection. Patient
returned to ICU with good haemodynamics and intropes were weaned to minimal. He failed
extubation due to right-sided pneumothorax. He later developed left-sided lung collapse
and elevated diaphragm. Bronchoscopy showed pulsatile left main bronchus compression.
USS showed appropriate diaphragm motion with reduced excursion but fluoroscopy confirmed
paradoxical motion. Preop CT showed slit-like compression of left main bronchus between
PV confluence and descending aorta. Following plication of hemidiaphragm, and posterior
aortopexy under bronchoscopy guidance, he was extubated 2 days later and discharged
home after 5 days.
Conclusion
The need of vertical vein ligation remains debatable, and in this case, this was the
mechanism of failure to come off bypass. Exploration of vertical vein risks phrenic
nerve injury. Compression of left main bronchus from PV confluence is very rare and
in this case, the only surgical solution is a posterior aortopexy.
A129 Outcome of Patients Following Presentation with Tetralogy of Fallot, Pulmonary
Atresia with Ductal Dependent, Confluent Pulmonary Arteries
Kesieme, Emeka
1, Mr; Danton, Mark2, Prof; Bader, Vivian2, Miss; McLean, Andrew2, Mr; Knight, Brodie2,
Dr; Smith, Ben2, Dr; Noonan, Patrick2, Dr; Peng, Edward2, Mr
1Golden Jubliee National Hospital, Glasgow, UK; 2Royal Hospital for Sick Children,
Glasgow, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A129
Objective
To evaluate our outcome of management in patients with pulmonary atresia, ventricular
septal defect (PA-VSD) with ductal dependent, confluent pulmonary arteries.
Methods
A total of 66 patients, who presented with PA-VSD between 1997–2021, met the following
inclusion criteria: confluent branch PA, ductal dependency, no major aorto-pulmonary
collaterals that required unifocalisation. All patients were reviewed from the point
of first presentation to last follow-up. Late survival was estimated from Kaplan–Meier
curve.
Results
55 patients had palliative procedure (45 shunt, 8 PDA stent, 2 RF valvotomy vs 7,11%
early primary repair following IV Prostin, 4,6% died before any procedure). Overall interstage
mortality was 6(11%) (13.3% post-shunt vs 0% post-catheter; p = 0.6), with no difference
between eras (15%, 4/27 after year 2005 vs 7%,2/28 prior; p = 0.4). 49%(27) post-palliated
patients required reintervention; one-third had > 2 reinterventions: shunt reintervention
(13/45), additional shunt (14/45), PDA stent (shunt-2, dilatation-1). 3 had concomitant
arterioplasties during shunt, 7 required branch PA reintervention (6 post-shunt, 1
PDA stent) with a total of 13 reinterventions (11-catheter, 2-surgical). The median duration
between palliation and primary repair was 15.6 months (range 2.8–72.3). In-hospital mortality
rate after complete repair was 3.6% (2 previous palliation, 0 in primary repair group).
No in-hospital mortality occurred post-repair after year 2005 (0/49 vs 2/6, 33% prior;
p = 0.01). 33(60%) of patients had a total of 58 re-interventions post-repair, most
commonly for branch PA(23,40%) and conduit (18, 31%). The overall survival rates for
all patients at 10 and 20 years were 78% after being born with the diagnosis.
Conclusion
Interstage reintervention and mortality remained significant. With low in-hospital
mortality post-repair in the current era, the role of early corrective surgery should
be considered.
A130 Outcome After Neonatal Bilateral Pulmonary Artery Banding and Ductal Stenting
as Initial Palliation to Balance Pulmonary and Systemic Circulations
Abba, Paola
1, Miss; Jaber, Osama2, Mr; Friedrich, Orsolya2, Dr; Bentham, Jamie2, Dr; Valesco-Sanchez,
Daniel2, Dr; Pelella, Giuseppe2, Mr; Kassai, Imre2, Mr; van Doorn, Carin2, Miss
1University of Turin, Turin, Italy; 2Leeds General Infirmary, Leeds, UK, Leeds Teaching
Hospitals NHS Trust, Leeds, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A130
Objectives
The Hybird Norwood (HN) procedure involves bilateral pulmonary artery banding and
stenting of the arterial duct with the aim to balance the pulmonary and systemic circulations.
Its main use is in high-risk newborns with a duct dependent systemic circulation and
single ventricle, as a temporising measure prior to Norwood 1 (N1) type repairs on
cardiopulmonary bypass. To a lesser extend it is used in high-risk newborns with biventricular
circulations. Decision to proceed to HN is also influenced by parental insistence
for active treatment. We reviewed our results in this challenging group of patients.
Methods
Single centre retrospecive study of all consecutive patients that underwent HN between
January 2013 and October 2021.
Results
There were 15 patients, nine with single ventricle, and most underwent treatment in
recent years. Median weight 2.5 (range 1.6–3.6) kg and median age 12 (3–27) days.
Patient characteristics are in the Table. Three Patients, including two with single
ventricle, died after HNN (at 0, 15 and 61 days, respectively). All deaths were in
very small weight patients. Two patients progressed to N1 during the same admission,
and 10 were discharged home. There was one interstage death at six weeks during anaesthesia
for cross-sectional imaging in a single ventricle patient. Of the six single ventricle
patients that survived HN, all successfully completed N1. Of these, one is now interstage,
four have completed a Glenn shunt, and one has definitive pallation with a Sano Shunt.
Of the five surviving HN patients with biventricular circulation, one died five months
after a Ross-Konno procedure and the remaining four had successful biventricular repair.
Conclusions
HN gives reasonable short and intermediate survival in this group of high-risk patients.
Very low body weight appears a significant risk factor for adverse outcome.
A131 VATS Lobectomy for 14-Month Baby
Wang, Lu, Ms; De Rita, Fabrizio, Mr; Pagliarulo, Vincenzo, Mr
Freeman Hospital, Newcastle, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A131
https://www.youtube.com/watch?v=0fV7vKnEC_A
A132 Robotic Reconstruction of Agenesis of the Left Hemi-diaphragm in a Patient with
Trisomy 21
Kouritas, Vasileios, Mr; Hogan, John, Mr; Saad, Haisam, Mr; Alqudah, Obada, Dr; Szafron,
Bartlomiej, Mr; Francis, Jonathon, Dr; Fuentes-Warr, Joana, Mrs; Kadlec, Jakub, Mr;
Bartosik, Waldemar, Mr
Norfolk and Norwich University Hospital, Norwich, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A132
Objectives
We present the case of a Trisomy-21 patient who was diagnosed with agenesis of his
left hemi-diaphragm which was successfully reconstructed via a robotic approach.
Case presentation
A 47-year-old Trisomy 21 patient was referred to our department because of a huge
posterolateral agenesis of his diaphragm causing severe breathlessness. He underwent
a robotic reconstruction with the DaVinci X robotic system using 3 × 8 mm and 1 × 12 mm
ports. A Parietex 15 × 15 cm was initially fashioned inside the abdomen and then a
dual mesh strengthened the reconstruction. A single 24Fr drain was left in situ. The
patient reported minimal pain after the procedure which was mainly managed with oral
analgesia. His drain was removed on day 2 and so did his nasogastric tube and his
urine catheter as he was mobilizing adequately. He was discharged home on day 4. On
follow up he was found with a small pleural collection which was drained without any
further issues.
Conclusions
We present the case of a successful robotic reconstruction of a complicated agenesis
of the diaphragm in a patient who benefited from avoiding a thoracotomy/thoraco-abdominal
incision. This case demonstrates the merits of persevering with a key-hole approach.
Informed consent to publish had been obtained.
A133 Evaluating the Role of Surgical Resection and Reconstruction in the Management
of Paediatric Ewing Sarcoma of the Chest Wall; A Systematic Review
Rice, Darragh
1, Dr; Barrett, Sean1, Dr; Khan, Niall1, Dr; Fleck, Robert1, Dr; McGuinness, Jonathan2,
Mr
1Mater Misericordiae University Hospital, Dublin, Ireland; 2Children's Health Ireland
at Crumlin, Dublin, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A133
Background
The management of Ewing sarcoma in children has evolved over the last 30 years with
surgical role and approach following the collaborative oncology group (COG) guidelines.
This review of the literature aimed to assess how these surgical guidelines have been
applied in the modern era.
Methods
A systematic review was conducted in accordance with PRISMA guidelines across four
major literature databases. Data regarding overall survival, rate of recurrence, role
of surgery, adjuvant therapy role was extracted.
Results
17 single centre observational studies and 8 retrospective reviews of multicentre
trials met criteria for final analysis. There were 1028 patients identified, with
a male predominance in their adolescent years. 5-year overall survival ranged from
35 to 89%. A review in 2003 established the role for neo-adjuvant chemotherapy before
surgery with improved negative margins (77% vs 50%) and reduced post-op radiotherapy
requirement(48% vs 71%). There was high variation in the degree of resection of surrounding
tissue to obtain free margins so the COG guidelines for resecting a normal rib above
and below and 2-3 cm margins along the rib were not really followed. If negative margins
were achieved, further radiotherapy was not shown to improve survival further. However,
if microscopic positive margins were present then additional radiotherapy could improve
survival in some studies similar to microscopic free margin resections.
Conclusion
The review suggests that surgery should be included as part of multimodality treatment
for most patients, with the current COG guidelines for surgical margins probably being
too aggressive which may limit surgery being applied for some patients. Macroscopic
free margins are an absolute, but microscopic positive margins can be compensated
for by radiotherapy, and neo-adjuvant chemotherapy is an absolute requirement.
A134 Antineutrophil Cytoplasmic Antibody-Associated Valvular Heart Disease: Unicuspid
Aortic-valve Ozaki and Trans-aortic Mitral Valve Repair
Sinha, Shubhra
1, Miss; Endean, Alison2, Dr; Kandasamy, Karikalan2, Dr; Ooues, Georgina2, Dr; Robson,
Joanna3, Dr; Platt, Martin3, Dr; Turner, Mark3, Dr; Caputo, Massimo4, Prof; Mussa,
Shafi4, Mr
1Derriford Hospital, Plymouth, UK; 2Royal Cornwall Hospitals NHS Trust, Truro, UK; 3University
Hospitals Bristol and Weston NHS Trust, Bristol, UK; 4Bristol Heart Institute, Bristol,
UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A134
We present the case of a previously well 18-year-old man who presented with a 3-week
history of fever, epistaxis, earache, hearing loss, haemoptysis,per-rectal bleeding
and haematuria. Examination identified a murmur. Further investigations led to a diagnosis
cANCA/PR3-positive associated vasculitis/GPA with multiorgan involvement. Pre-operative
echocardiography and cardiac magnetic resonance imaging showed a fenestration in the
right coronary cusp(RCC) of a trileaflet aortic valve and an anterior mitral valve
leaflet(AMVL) defect with severe regurgitation of both valves and a mildly dilated
left ventricle with preserved function. Discussions were undertaken between the cardiology,
cardiac surgery, rheumatology, ENT, microbiology and anaesthetic teams to optimise
the patient prior to surgery and discuss the potential risk of haemorrhage, infection
and recurrence of valvular regurgitation. He underwent unicuspid aortic leaflet replacement
using glutaraldehyde-treated autologous pericardium (Ozaki) and transaortic mitral
valve repair with a bovine patch. Avoiding the use of prosthetic material negated
the need for lifelong anticoagulation and reduced the infection risk in a young immunosuppressed
patient. The pre-discharge echocardiogram showed mild AR and no MR with good biventricular
function. The patient was followed-up in clinic 6 weeks post-operatively and continued
to make a good recovery. The echocardiogram showed normal left ventricular dimensions,
no significant valvular abnormalities and excellent aortic valve haemodynamic function
(peak gradient 5.3 mmHg; maximum velocity 1.2 m/s). Regular echocardiograms and close
rheumatological follow-up are planned.
Informed consent to publish had been obtained.
A135 The Impact of COVID-19 on Surgery for Congenital Heart Disease in the UK: Pilot
Study
Sinha, Shubhra
1, Miss; Cocomello, Lucia2, Ms; Suseeladevi, Arun K2, Mr; Baquedano, Mai2, Ms; Struzik,
Ewa3, Ms; Austin, Conal3, Mr; Lawlor, Deborah A2, Prof; Caputo, M assimo4, Prof
1Derriford Hospital, Plymouth, UK; 2University of Bristol, Bristol, UK; 3Guy's and
St Thomas' NHS Trust, London, UK; 4Bristol Heart Institute, Bristol, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A135
Objective
We report a pilot study to quantify the change in case-mix and operative volumes in
congenital heart disease (CHD) surgery in the UK secondary to the first COVID-19 lockdown.
This has clear implications for health provision planning and may have an impact on
the clinical outcomes of this patient cohort.
Methods
Prospective multi-centre, cross-sectional, observational study based in the UK on
consecutive patients with CHD admitted for heart surgery from 02/01/2020 to 06/07/2020.
We examined changes in patient characteristics (i.e. age and clinical urgency) and
complications pre- and post- the first lockdown on 23/03/20.
Results
317 patients underwent cardiac surgery during the study. There was an average decrease
of 4 cases per week (pre-lockdown: 166; post-lockdown: 151, Fig. 1) and mean age at
operation (pre-lockdown:8.2 ± 15.5 years,post-lockdown:2.7 ± 6.2 years; 95% confidence
interval(CI) of difference: 3–8.1 years; p < 0.001) following lock-down. Surgical
priority was also different pre and post-lockdown (Elective-55% vs 39%; Urgent-39%
vs. 58%; Emergency-6% vs 3.3%). There was a 2.6% increase in hospital mortality (pre-lockdown
0%;post-lockdown 2.6%; 95% CI of the difference:-0.54% to -5.8%;p0.11) and an overall
an increase in all other major complications, except sepsis. However these latter
differences were not statistically significant.
Conclusions and Relevance
During lockdown CHD operations were more likely to be urgent and involve younger patients,
resulting in a shift toward increased mortality and complications. These results need
to be confirmed at national level.
A136 Our experience on Personalised External Aortic Root Support (PEARS) application
to paediatric population
Redondo, Ana, Ms; Austin, Conal, Mr
Evelina London Children's Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A136
Objectives
The PEARS technique, has been safely used in over 500 patients worldwide. The original
concept was to stabilize dilatational aortopathy in Marfans syndrome, and with its
proven efficacy its use has been expanded to other aortopathies. Here we report our
unique experience in the paediatric age group.
Methods
We have reviewed our single institutional results in the application of PEARS in patients
aged 18 years old and younger. We review the baseline diagnosis, aorta dimensions,
intraoperative data, and short-term morbidity.
Results
21 patients in the paediatric cohort have undergone PEARS procedure since 2012. Mean
age was 15.28 years (range 9 to 18). Most patients (42.85%) had Marfan’s Syndrome
with aortic root dilatation (mean diameter 4.25 cm). Other diagnosis included bicuspid
aortic valve aortopathy (n = 5), DORV (n = 2), interrupted aortic arch and post dilated
Free root Ross (n = 2), dysplastic aortic valve having paediatric Free Root Ross PEARS
(n = 2) and TGA (n = 1). 7 patients had previous sternotomies. 5 had a reduction aortoplasty
before PEARS application. 10 had their surgery done off bypass. Mean postoperative
maximum aorta diameter was 3.4 cm. Mean reduction in aortic diameter post-PEARS application
was −0.87 cm. Follow-up imaging consisted of echocardiogram, MRI or CT-scans, showing
stable diameters. One patient had to be reopened for pericardial effusion, while another
one had to be re-operated three years later for severe aortic regurgitation which
had been corrected during the PEARS post delayed arterial switch.
Conclusions
PEARS is an effective procedure in the paediatric Marfan’s syndrome patients and even
other complex congenital conditions developing aortic dilatation.
We have proven PEARS to be a safe procedure providing stable aortic dimensions and
non-interference with the aortic valve in the paediatric population.
An interesting subset has shown reversal of aortic insufficiency with PEARS application
that reduces the aortic dimensions.
A137 On-table Extubation as Part of Enhanced Recovery After Cardiac Surgery in Paediatric
Population in a Tertiary Centre
Ashry, Amr
1, Dr; Boyle, Mark2, Dr; Sunny, Jesvin2, Dr; Arnold, Philip2, Dr; Kutty, Ramesh2,
Mr; Lotto, Attilio2, Prof; Guerrero, Rafael2, Mr; Dhannapuneni, Ramana2, Mr
1Assiut University Hospital, Assiut, Egypt; 2Alder Hey Children's Hospital, Liverpool,
UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A137
Objective
To report outcomes following on-table extubation after cardiac surgery in paediatric
population.
Methods
Retrospective study for paediatric patients who underwent on-table extubation as part
of enhanced recovery at Alder Hey Children’s Hospital, Liverpool between January 2019
and December 2019. Outcomes were to assess postoperative complications, i.e., re-intubation,
bleeding, renal failure and arrhythmia in PICU.
Results
A total of 154 patients who were extubated on table were included. Mean age at time
of operation was 4.9 ± 10.4 years. 38% of cases (n = 59) were < 1 year old. Ventricular
septal defect (17.5%, n = 27) was the most common lesion, followed by atrial septal
defect (11.7%, n = 18). Cardiopulmonary bypass and aortic cross-clamp time were 68.8 ± 49.4
and 32.6 ± 35.3 min, respectively. There was no mortality in our cohort, whereas 85%
(n = 131) had no complications during PICU stay. Eight patients (5.2%) required re-intubation
for respiratory failure and two patients (1.3%) needed re-intubation following arrhythmias.
The mean length of PICU and postoperative hospital stay were 1.5 ± 1.5 and 7.6 ± 8.9 days,
respectively.
Conclusion
On-table extubation as part of enhanced recovery after cardiac surgery is feasible
and safe in paediatric population. There was no mortality and low rate of complications.
A138 PEARS (Personalised External Aortic Root Support) Applicated at a Late Stage
to Recover Failing Autograft after Ross Operation
Redondo, Ana, Ms; Austin, Conal, Mr
Evelina London Children's Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A138
Objective
Ross operation is the aortic valve replacement procedure of choice in growing paediatric
patients and young adults. Free root Ross operation is associated with autograft dilatation
and ultimately valve failure in some patients.
PEARS has been successfully deployed since 2004 in Marfan patients, and this concept
lead to our utilisation of this technique to support, reduce aortic size and recover
aortic valve insufficiency in failing Ross patients.
Methods
Three male teenagers aged between 15 and 16 years had several echo studies showing
increasing autograft dilatation and new moderate aortic valve insufficiency in two
of them, 3 to 4 years after having undergone free root Ross operation. Maximum aortic
root diameter ranged between 4.5 and 4.8 cm. They had up to 5 previous cardiac procedures,
including interrupted aortic arch repair and VSD closure.
CT scans were performed and PEARS were manufactured by Exstent to produce a 20% reduction
sized prosthesis of the current aortic dimensions.
Reduction PEARS were applied to the whole aortic root from the subcoronary ventriculoarterial
junction to beyond the distal suture line of the autograft. One was applied off bypass
and two required beating heart cardiopulmonary bypass.
Results
All patients had successful application of the 80% PEARS prosthesis and in both cases
of moderate aortic valve insufficiency this was abolished or reduced to trivial. The
first patient had a transient arm weakness. Aortic root size was reduced for more
than 1 cm in all cases, and it showed stable dimensions in further imaging. Post-operative
hospital stay ranged from 4 to 9 days.
Conclusion
PEARS can be applied in a ‘reduced’ fashion to stabilise the dilating aortic root
in failing Ross operations and recover and abolish moderate aortic valve insufficiency.
This new technique should be considered early in Ross patients undergoing follow-up
with dilating autograft root and associated worsening aortic valve insufficiency.
Nursing & AHP Forum
A139 The Cardiac surgery internatiONal Nursing and alliEd professional researCh network:
CONNECT
Sanders, Julie
1, Professor; Fredericks, Suzanne2, Prof; Martorella, Geraldine3, Dr; Wynne, Rochelle4,
Prof
1St Bartholomew's Hospital, London, UK; 2Ryerson University, Toronto, Canada; 3Florida
State University, Florida, USA; 4Western Sydney University, Penrith, NSW, Australia
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A139
Objectives
The number of nursing and allied professional (NAP) clinical academics is low, particularly
in cardiovascular surgery. This undoubtedly affects the ability of the profession
to advance and improve healthcare delivery and patient outcomes and experience. Since
there is global recognition that increasing NAP clinical academics is needed, we sought
to establish an international NAP network to strengthen collaborative NAP cardiovascular
surgery research through shared initiatives including supervision, mentorship, workplace
exchange programs and multi-site clinical research.
Methods
CONNECT is a virtual network established by NAP clinical academics from the UK, Canada,
Australia and USA. A website (https://www.qmul.ac.uk/whri/research/connect/) and twitter
profile (@CONNECTcardiac) were established and the network was launched at the European
Society of Cardiology Association of Cardiovascular Nursing and Allied Professional
(ACNAP) EuroHeartCare conference in June 2021.
Results
CONNECT has attracted members from the UK, Denmark, Norway, Canada and Australia and
followers from around the World. The first of a series of webinars will be hosted
in November 2021. A program of collaborative research work is being mapped. Efforts
to increase the awareness of CONNECT, while continuing to attract new members globally,
continue. By March 2022 we plan to present an update on membership and showcase opportunities
for NAP cardiovascular researchers.
Conclusions
Although early in development, CONNECT has attracted global interest and is providing
opportunities for international supervision/collaboration. In time, it is anticipated
the network will foster and develop NAP-led cardiovascular surgery research to address
global cardiac surgery challenges.
A140 Results from the Implementation of a Modified Enhanced Recovery Programme in
a Cardiac Surgical Intensive Care Unit—A Comparative Study
Tuff, Cheryl
1, Mrs; McNeilly, Graham2, Dr; Brown, Donna3, Dr; Chaney, Ursula3, Ms
1Belfast Health and Social Care Trust, Belfast, UK; 2Royal Victoria Hospital, Belfast,
UK; 3University of Ulster, Londonderry, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A140
Objective
To evaluate the impact that a modified enhanced recovery program has had on ventilation
times, critical care length of stay and hospital length of stay in a Cardiac Surgical
Intensive Care Unit (CSICU). Project implemented in response to data received from
NCBC re critical care length of stay being higher than the national average.
Methods
Quantitative approach taken and data were retrospectively collected from two years
(April 2015- March 2016 and April 2018-March 2019). Data collected included gender,
age, risk scores, surgical procedure, bypass and cross clamp times. Data was also
collected for ventilation times, critical care stay and hospital length of stay. Data
analysis was performed using SPSS (version 27).
According to the Raosoft online sample calculator, a sample size of 278 in each group
was required to provide 95% confidence level with 5% margin of error.
Inclusion criteria was data from cardiac surgical cases between the dates given. Exclusion
criteria included TAVIs, cases nursed with open chests, intra-aortic balloon pump,
nitric oxide and continuous renal replacement therapy post-operatively.
Results
Year
Ventilation Time (Hours)
Critical Care Length of Stay (Days)
Hospital Length of Stay (Days)
2016–2016 (Pre-ERAS)
11.57
5.21
13.32
2018–2019 (Post-ERAS)
9.08
4.26
13.85
Statistically significant reduction in critical care length of stay (data abnormally
distributed therefore Mann–Whitney U Test performed, significance level < 0.050, result < 0.001).
Insignificant reduction in ventilation times (11.57 h vs 9.08 h).
Hospital stay was unchanged (13.32 days vs 13.85 days).
Readmissions to critical care were similar for both years (1.07% each year).
Conclusions
Enhanced recovery measures show promising results in cardiac surgery patients, and
have contributed to the reduction of critical care length of stay and ventilation
times. Further work to be carried out in an attempt to uncover barriers to progress
on hospital length of stay. Future work should include complication rates and experiences
of patients and staff in the delivery of an ERAS programme.
A141 What are the Experiences of Health Care Professional's (HCP) Providing Guidance
for Patients Following Surgery for Emergency Type A Aortic Dissection?
Hewitt, Kathryn
1, Ms; Inman, Chris2, Dr
1Queen Elizabeth Hospital, Birmingham, UK; 2Birmingham City University, Birmingham,
UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A141
Background
Following surgical intervention for Type A Aortic Dissection (TAAD), the remaining
aorta is predisposed to further disruption, thus, life-long surveillance, patient
guidance and support should exist.
Method
Following ethical approval, semi-structured, face-to-face interviews using an IPA
methodology were conducted. Eight purposely selected participants, four nurses and
four surgeons, meeting inclusion and exclusion criteria were identified to provide
views emerged from HCPs most involved with care. Participants’ experiences were explored
to answer the research question. Interviews were recorded and transcribed verbatim
and analysed using an IPA approach.
Findings
Three super-ordinate themes were identified; Holistic Awareness, Information Provision
and Clinical Uncertainty, alongside further sub-ordinate-themes. Original ideas were
identified including the importance of family involvement post TAAD for continuing
care and need to support patient recall. The prevalence of patient stress, anxiety
and depression, exacerbated by the shock of unsuspected, debilitating diagnosis and
the emergency situation were identified as original and key themes, with importance
placed on consistent patient education and psychological support to address this.
The study highlighted concern surrounding the concept of ‘postcode lottery’ care,
including staff education and awareness, and a paucity of national and local guidance
to help institutes reach and maintain a standard of patient-centred-care. The findings
identified shortfalls in current practice and acknowledged the importance of the MDT
and the potential for ACPs to address these shortfalls.
Conclusion
This IPA study offers a contribution to understanding of the phenomenon outlined and
provides insight to challenges faced by HCPs to provide quality guidance. This study
is concluded by ascertaining areas of improvements within healthcare policy and thus
identifying recommendations for practice and need for further research.
A142 Short Duration ECMO as a Saviour for Pulmonary Hemorrhage in Post Chronic Thrombo
Embolic Pulmonary Hypertension (CTEPH) Cases
Selvaraj, Sam, Mr; P V S, Prakash, Mr; Rajamani, Selvakumar, Mr; Shetty, Varun, Dr;
Venu, Gokul, Mr; Thekumkattil T, Thomas, Mr
Narayana Health Hospitals, Bangalore, India
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A142
Objective
The role of Short Term ECMO (Extra Corporeal Membrane Oxygenation) in Chronic Thrombo
Embolic Pulmonary Hypertension (CTEPH) cases as a saviour in post-surgery complication
of pulmonary Hemorrage.
Methods
CTEPH cases are extremely challenging to operate and in some circumstances it possess
a high incidence of pulmonary Hemorrhage soon after the endarterectomy. We report
our modest experience of six cases which required VA ECMO due to severe pulmonary
hemorrhage post-surgery. Central VA ECMO was instituted in all the cases to tackle
the crisis scenario of Hypoxia, Hypercarbia, Hypotension and Bleeding. The VA ECMO
enabled us to come off from Cardio Pulmonary Bypass and gave us a fighting chance
to encounter the emergency situation. Patients were offered single lung ventilation
to isolate the soiling of healthy lung from the severe pulmonary bleeding getting
into the air compartment of the lungs. We could completely reverse the Heparin on
ECMO with Protamin(Target ACT ~ 140 Sec). ECMO provides better ventilation perfusion
ratio with good tissue perfusion TEG played a vital role to transfuse the blood products
to the patient appropriately. Topical agents were used to arrest the bleed. The cell
saver was used to salvage the red blood cells.
Results
All the six cases were weaned off from ECMO Successfully with the Average ECMO run
of 6 Hours; Lowest being 67 min and the Maximum of 12 h. ACT was brought down to 120–140
secs in all cases. Delta P and the Ecmo Circuit was monitored closely as we reversed
the heparin completely. A backup circuit was also kept ready in case of any eventuality.
Conclusion
Short duration of VA ECMO in patients with pulmonary haemorrhage after CTEPH helped
us to reverse the heparin and to control the bleeding. VA ECMO offered to address
the problem of hypotension with better hemodynamics and provided good gas exchange
in this critical condition. VA ECMO was the only choice for this subset providing
100% survival results.
A143 A Review of Mechanical Insufflation-Exsufflation as a Treatment for Patients
Following Extended Pleurectomy-Decortication Surgery
Husemann, Zelie, Ms; Streets, Emma, Miss
Barts Health NHS Trust, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A143
Objectives
Extended Pleurectomy-Decortication (EPD) surgery is a radical treatment option for
epithelial mesothelioma and can be associated with an increased risk of post-operative
complications including sputum retention (Martino et al., 2018). Mechanical-Insufflation-Exsufflation
(MI:E) can be used as a treatment intervention to aid sputum clearance in other patient
populations (Chatwin et al., 2003). However, there is a paucity of high-grade evidence
supporting MI:E in this cohort. The aim of this review was to investigate the feasibility
and safety of the use of MI:E with EPD patients and to evaluate any adverse effects.
Methods
All patients undergoing EPD surgery were retrospectively evaluated using electronic
records over a 12-month period between June 2020–21. Outcomes included patient tolerance
to the intervention and evidence of adverse effects during or after treatment.
Results
A total of 21 patients were included in the analysis, 1 patient was excluded due to
in-hospital mortality. 9 out of 20 patients (45%) received MI:E treatment. The mean
number of treatment sessions was 6 (SD ± 5.13). Of the patients who received MI:E,
1 patient experienced a transient adverse event of haemo-dynamic instability but required
no medical intervention.
Conclusions
In this review, MI:E was safe and feasible for patients undergoing EPD surgery and
highlighted no lasting adverse effects. However, a larger observational review is
required to further validate this finding.
A144 Preventable Post Discharge Problems in Thoracic Surgery Patients
Kenyon, Lisa, Ms; Cahill, Jo, Ms; Naidu, Babu, Mr; Kalkat, Maninder, Mr
Queen Elizabeth Hospital Birmingham, Birmingham, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A144
Objective
The objective of the audit was to ascertain what problems patients experience after
discharge having undergone Thoracic surgery and to discover if these were preventable
by auditing adherence to our local discharge protocol.
Method
The last 20 patients discharged from the service were audited by reviewing their Advanced
Clinical Practitioner (ACP) post discharge telephone appointment documentation and
cross referencing any problems encountered with their discharge letter and medications.
The National Lung Cancer Telephone Assessment tool was completed for all patients: this
aids identification of post discharge problems in the areas of pain, activity, wounds,
infection, diet/appetite, nausea, constipation, mobility/exercise, psychological issues,
sleep and other concerns.
Results
Four main problems were identified: pain, constipation, wound/suture issues and lack
of activity. One week after discharge 35% of patients were in significant pain, 20%
of those had not been prescribed sufficient analgesia. 20% were constipated but had
not been prescribed any laxatives despite being discharged with opiates. 33% were
inactive; mainly due to pain, shortness of breath, fear and constipation. 25% still
had wound dressings in place and a drain suture more than 7 days after drain removal.
30% had missing or incorrect suture instructions on their discharge letter.
Conclusions
Unfamiliarity of protocols/Enhanced Recovery After Surgery goals caused post discharge
problems which were mostly preventable. Education is key for nursing, medical staff
and patients. Following this audit a simple discharge checklist was introduced for
staff and patients to read and sign and a discharge medication bundle and instructions
were created on electronic prescribing, aiming to reduce the incidence of such problems.
A145 Cloud-based Clinical Charting – A Technological Revolution Service Improvement
to Assist in the Cardiothoracic Organ Retrieval Process
Nunes, Joao Pedro, Mr; Rubino, Antonio, Dr; Berman, Marius, Mr; Pettit, Stephen, Dr;
Quigley, Richard, Mr; Baxter, Jennifer, Mrs
Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A145
Objective
Leading world technological innovation is one of the goals of the NHS. At a leading
UK Cardiothoracic Transplant Centre, the Donor Care Physiologist (DCP) team has created
a new cloud-based clinical chart to be used during Scouting and Donation after Brainstem
Death (DBD) retrieval. Documentation is fundamental for donor monitoring, management,
the decision-making process and auditing; enabling DCPs to optimise cardiothoracic
organs and improving outcomes for transplant recipients.
Methods
To simplify documentation during Scouting and DBD retrievals, the DCP team have built a cloud-based tool.
This innovative chart combines various aspects of retrieval and standardises input
of real-time data. When fully implemented members of both retrieval and recipient
teams will be able to access this data real-time contributing to a swift decision-making process.
Results
This monitoring tool will be implemented during Scouting and DBD retrievals allowing consistent data
collection in order to maintain the highest standards of record keeping and safe practice.
Furthermore, feedback will influence regular updates to enhance user experience.
Conclusion
Cloud-based Charting hopes to revolutionise local and hopefully national record-keeping
during Scouting and DBD retrieval. Moreover, the creation of this tool serves as another
example of how the DCP is an invaluable member of the National Organ Retrieval Services
(NORS) team.
A146 Multi-centre Comparison of Routinely Collected NHSD/HES Rates for Surgical Site
Infection with Prospective Surveillance
Rochon, Melissa1, Ms; Ahmed, Ishtiaq2, Mr; Chiwera, Lilian3, Ms; Gannon, Robert4,
Mr; Hutton, Sandra5, Mrs; Morais, Carlos6, Mr; Peters, Molly7, Ms; Magboo, Rosalie
8, Mrs; Raja, Shahzad9, Mr
1Royal Brompton and Harefield hospitals, part of Guy's and St Thomas' NHS Foundation
Trust, London, UK; 2Brighton and Sussex University Hospitals NHS Trust, Brighton,
UK; 3Guy's and St Thomas' NHS Foundation Trust, London, UK; 4Royal Papworth Hospital
NHS Foundation Trust, Cambridge, UK; 5Oxford University Hospitals NHS Foundation Trust,
Oxford, UK; 6Royal Brompton Hospital, London, UK; 7University Hospitals Bristol, Bristol,
UK; 8Barts Health NHS Trust, London, UK; 9Harefield Hospital, Harefield, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A146
Identifier
SSI Dashboard SSI rate (%)
Prospective Surveillance SSI rate (%)
X2
value
Rank SSI Dashboard
Rank Prospective Surveillance
Trust A
3.4
2.2
2.138
0.1437
1
1
Trust B
4.3
3.4
0.838
0.3598
3
3
Trust C
5.1
4.0
0.49
0.4840
5
4
Trust D
9.3
6.8
2.627
0.1051
7
6
Trust E
7.0
8.0
0.113
0.7367
6
7
Trust F
4.6
5.3
0.48
0.4883
4
5
Trust G
3.6
2.4
0.861
0.3534
2
2
Objective
Surgical site infection (SSI) is an important quality indicator however, collecting
and reporting for SSI surveillance can be resource intensive. Our aim was to compare
(unadjusted) rates of SSI using a new, 'resource-light' national SSI Dashboard with
data collected via trained surveillance personnel at seven Trusts undertaking coronary
artery bypass (CABG) surgery.
Methods
Our Cardiac SSI Network determined a national dataset based on classification and
diagnostic codes in Tableau™ for the period January – December 2017. National data
was suppressed (5.0001). SSI were included up to 30 days, detected on primary admission
and readmission to own hospital or other hospital. Chi-square testing was used to
determine whether there was a significant difference between SSI rates. Probability
was set at p < 0.05. Data from both sources was ranked from lowest to highest rates.
Results
Across the seven hospitals, there was no statistically significant difference between
the unadjusted SSI rates from the Dashboard and that collected prospectively by trained
surveillance personnel at each Trust (Table 1). Both sources ranked the same Trusts
with the two lowest and two highest SSI rates, with variation in the middle ranks
noted.
Conclusions
Despite controversy regarding the identification, completeness, and verification of
a simple binary approach as compared to prospective surveillance, our experience suggests
that Hospital Episode Statistics (HES) using our SSI Dashboard provides reasonable
information on SSI rates. Research studies coding routinely collected data for efficiency
and cost-savings could look at look at this source of information for SSI data, as
well as looking at how to further improving SSI data capture in clinical coding. However,
prospective surveillance remains superior in terms of type and causative pathogen
SSI, with the additional benefit of patient-reported SSI.
A147 Fast Tract Service Development to Improve Patient Flow
Bartley, Tara, Ms; De Costa, Joana, Ms; Sadler, Carl, Mr; Dunn, Nicola, Ms; Hewitt,
Kathryn, Ms; Wilkinson, Gemma, Ms; Patel, Ranj, Ms; Singh, Harjot, Dr; Bate, Cerys,
Ms; Rooney, Stephen, Mr
University Hospitals Birmingham, Birmingham, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A147
Abstract
Patient flow through the Cardiac surgical setting is becoming increasingly challenging,
this has been exacerbated by COVID and staff attrition.
This service development established an alternative cardiac surgery pathway outside
critical care environment utilising the fast track concept.
Objectives
To develop a fast tract pathway for post operative cardiac surgery patients that doesn’t
require a Critical Care bed thus mitigate against cancelation. We have created in
an alternative environment in which to recover patients with early transfer to step
down on the ward.
Method
A multidisciplinary team approach has developed as pathway through the recovery unit.
A data set was established confirming a patient selection criteria, booking system,
a criteria for transfer to recovery following surgery then aim for discharge the patient
to the ward stepdown area at 08.30 the following morning. Patients were seen by the
surgical and anaesthetic teams who documented all parameters had been meet for transfer.
The recovery staff have undergone a focused education programme.
Results
The data set documents if the patient was listed on the bed booker and when, if the
patient met the preoperative criteria for surgery and post-operative parameters for
transfer to recovery and then to the ward. Weekly meetings reviewed each case identifying
delays in the pathway, with real-time response to improve flow. Early results suggest
the service development has enabled surgical cases that would have otherwise be cancelled,
the success indicates there is the potential to expand the number of cases undertaken
via this pathway.
Conclusions
The service development was driven by the current crisis of reduced activity being
experienced in cardiac surgery units across the country. We have developed a pathway
that has successfully reduced cancelations and increased cardiac surgery cases. We
have demonstrated team working across units and professional groups that prioritises
patient need.
A148 A Self Assessment Tool to Evaluate the Impact of an Interactive Course Cardiac
Course on Knowledge and Clinical Confidence
Bartley, Tara
1, Ms; CSU-ALS, Adrian Levine2, Mr; CSU-ALS, Joel Dunning2, Mr; Bibleraaj, Bhuvaneswari3,
Ms
1University Hospitals Birmingham, Birmingham, UK; 2CSU-ALS; 3Wythenshawe Hospital,
Manchester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A148
Abstract
The development of a Self Assessment Tool to evaluate pre-course and post-course learning
to underpin confidence in the clinical setting for the Cardiac Advanced Life Support
Course.
Objectives
An evaluation of students’ perception in relation to their pre and post-knowledge
was developed using a Likert scale to inform the development and impact of SCTS Nurses
and Allied Health Professionals Courses. This paper will review the tool as it has
been adopted for use on the Cardiac Advanced Life Support Course and expanded to incorporate
participants’ confidence in performing the 6 key roles.
Method
A self assessment tool using a Likert scale of 1 – 5 was given to course participants
to score their perception of pre and post course knowledge. Questions were in regard
to each lecture and practical session and also included additional questions of level
of confidence in knowledge and performing each of the six key roles.
Results
The Likert scale asked candidates to score each session on a scale of 1 to 5, with
1 being strongly disagree and 5 strongly agree about their increase in knowledge.
Responses to each lecture and practical session demonstrated 100% of candidates felt
their knowledge has improved all every aspect of the course. Further analysis demonstrated
that 54.03% to 90.31% felt they knowledge had increased to a 4 or 5 on the scale.
78.85% stated that they felt ‘confidence’ or ‘very confident’ in performing the six
key roles post course.
Conclusions
The results demonstrate the importance of evaluating educational courses to inform
content, level of content and of impact for candidates and their provider organisation’s
perspective. In the current health care economy, it is imperative that courses are
evaluated and adapted to meet both the educational, development and service delivery
needs. This study provides the evidence to demonstrate these outcomes.
A149 Implications and Challenges of Working as a Senior Cardio-thoracic Physiotherapist
in a Mixed Covid-19 and Cardio-thoracic Unit
Plunkett, Daire, Mr; Danaher, Dervilla, Ms
Mater Hospital, Dublin, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A149
Background
Our cardio-thoracic department consists of a ward with 33 single rooms and an 11 bed
high dependancy unit. The ward was converted to a Covid-19 ward in March 2020 as the
single rooms allowed for isolation of patients. The majority of cardio-thoracic surgeries
were moved off-site, meaning our caseload became mostly non-surgical for a number
of months. As elective surgery returned to our centre, many challenges have arisen
surrounding the provision of physiotherapy care to both surgical patients as well
as the medical Covid-19 admissions we continue to have.
Methods
It has been important to ensure appropriate prioritisation of our caseload in order
to manage both cardiothoracic surgery patients as well as Covid-19 patients. A specific
focus has been placed on scheduling of patients to limit the potential spread of infection,
in collaboration with our infection prevention and control team. Staff education has
been important throughout the pandemic to keep up to date with considerations for
physiotherapy management of Covid-19.
Results
We continue to manage a fluctuating number of Covid-19 admissions, up to 20 beds at
the time of writing, as well as a consistent cardio-thoracic service. Many skills
have been applicable across both patient cohorts including knowledge and indications
for different oxygen delivery devices and non-invasive ventilatory support, oxygen
prescription, airway clearance techniques and management of underlying respiratory
conditions.
Conclusion
It has been possible to maintain a safe and sustainable service with no identified
cross-infection between patients in our unit. There continue to be challenges to service
provision which require ongoing adaptation and flexibility.
A150 How Far Can We Go …….. Nurses Involvement In Novel Technologies
Baxter, Jennifer, Mrs; Osman, Mohamed, Mr; Berman, Marius, Mr; Kaul, Pradeep, Mr;
Quigley, Richard, Mr
Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A150
At our centre we have recognised and identified the importance of nurse involvement
in the use of the organ perfusion device to ensure we have a resilient service and
are able to evidence the fundamental role nurses play in assessing heart function
following donation after circulatory death (DCD). The success of this established
nursing initiative has prompted a further development with a member of our NORS nursing
team being trained to dismount the heart from the device following support and training
from our retrieval surgeons. This trial further evidences the vital role, innovative
thinking and constantly extending roles of our nursing team along with the desire
for our surgeons to help empower our nursing team.
Training and support enabled a nurse to dismount hearts from the perfusion device
ready for transplantation; this was achieved under the guidance from experienced in-house
surgeons. Through the use of reflection on best practice we have designed and introduced
a competency pack including Standard Operating Procedure (SOP) to reflect this novel
development in our nursing practice. The SOP contains; a step by step guide to the
process, questions and answers, a troubleshooting guide, videos and pictures of equipment
and process and competencies to ensure safe practice.
We now have a nurse who is competent in leading the dismount of a heart from the perfusion
device, with the clinical ability to give instruction of the process and independently
dismount the heart and pass to the implanting surgeon.
By sharing this experience from a centre which has the greatest volume of DCD heart
retrievals in the world, lessons can be learnt to benefit other transplant centres
by evidencing the contribution and benefits of extended roles within the nursing team.
Guidelines are in place for best practice based upon this experience and the aim moving
forward will be to increase nurse involvement in this technique empowering nurses
and increasing both skills set and knowledge.
A151 The Introduction of a Chest Drain Protocol Post Cardiac Surgery in the National
Centre for CardioThoracic Surgery in Ireland
McKeon, Elaine, Ms; McKeon, Elaine, Ms; Kinsella, Aisling, Ms
Mater Misericordiae University Hospital, Dublin, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A151
Objectives
The aim of this study is to evaluate the introduction of a chest drain protocol in
the National centre for Cardiothoracic surgery. The protocol prescribes the prompt
removal of chest drains post-surgery and evaluates if this was safe or could lead
to complications such as an increase in pleural effusions.
Methods
This is a pilot study, data collected for this study includes patients over 16 years
of age admitted for cardiac surgery. The inclusion criteria are elective surgery,
first cardiac operation, CABG or single valve surgeries and patients with an EF > 40%.
Data was collected between postoperative day one and four on all enrolled patients.
Further data included day of discharge, any post drain removal complications such
as recurrent effusions and pain scores.
Results
Preliminary results from the initial pilot evaluation of 10 patients have illustrated
no increase in pleural effusions with the use of the chest drain removal protocol.
It is anticipated to have complete data on the initial six months of this study available
for March 2022.
Conclusion
The introduction of a chest drain protocol is paramount to evaluating current practice,
ensuring this is both safe, sustainable and in keeping with best practice.
A152 The Importance of Physiotherapy in Elective Thoracic Surgical Patients: Data
Collection
Nielsen, Louisa, Miss; Cooper, Taylor, Miss; Badran, Abdul, Mr; Alzetani, Aiman, Mr
University Hospital Southampton, Southampton, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A152
Objective
Review of thoracic physiotherapy interventions, current referral criteria and service
need.
Method
Prospective data collection of 180 elective thoracic patients treated by a physiotherapist
from January 2021 to June 2021.
Results
Overall our referral criteria appears to appropriately highlight those high-risk thoracic
patients requiring physiotherapy. 88% of elective patients were reviewed day 1 postoperatively
(D1PO) by a physiotherapist. Barriers to this were weekend staffing (53%), patients
in level 2 or 3 areas (37%) and human error (10%). Weekend D1PO caseload accounted
for 25% of the elective thoracic service, yet only 62% were reviewed. Mean Hospital
length of stay (LOS) was increased for those not reviewed D1PO compared to those that
were. In level 2/3 areas, mean hospital LOS was longer with no physiotherapy review
D1PO (6.25 vs 5 days). Advanced respiratory techniques were required in 36% of patients
not reviewed D1PO compared to 7% who were. LOS was increased for patients who had
open surgery (5.6 days) compared to VATS (3.6 days), and LOS was reduced in both groups
when the patient was seen by physiotherapy D1PO.
Conclusion
Our current thoracic referral criteria appears appropriate. We found that elective
thoracic patients are more likely to have a reduced LOS and are less likely to require
advanced respiratory techniques when reviewed D1PO. This highlights a need for potential
service developments within our weekend and Level 2/3 elective thoracic caseload to
optimise all patients within service.
A153 The Experience of Managing a CardioThoracic Surgery Ward in the Covid-19 Pandemic
Jones, Mary Elizabeth, Miss; Sheridan, Nina, Miss; Brown, Rachel, Mrs
Mater Misericordiae University Hospital, Dublin, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A153
Introduction
In March 2020 the cardiothoracic (CT) ward was identified to be one of the hospitals
Covid-19 units. 18 months later and the ward has remained Covid-19 (20 beds) combined
with 13 CT beds.
Methods
Patient safety, safe staffing, team well-being and retention are some of the considerations
that have challenged the CT managers over the past 18 months. The increase in acuity
and the skills required for the care of the deteriorating Covid-19 patient has been
well placed in a CT ward. The knowledge and skills of CT nurses was paramount to the
successful transition of caring for this acute and diverse population.
Results
100% of staff were upskilled to care for patients requiring non-invasive ventilation
compared to 50% previously. No cross infection of Covid-19 was identified between
March 2020 and October 2021. Despite the high level of care provided by the CT nursing
team, 25% have resigned due to the loss of their speciality coupled with the impact
of the pandemic professionally.
Conclusion
The CT ward and team have been well placed to care for this diverse group of patients
however staff well-being is a consideration that needs to continue to be supported
as the numbers of resignations have indicated.
A154 Lessons Learnt: Implementing ISLA Proactive Surgical Wound Surveillance in Three
Cardiac Hospitals
Rochon, Melissa1, Ms; Connolly, Katie2, Ms; Fabroa, Sheena2, Ms; Morais, Carlos3,
Mr; Nkolimbo, Casim4, Mr; Masood, Sehar4, Ms; Lukban-Bunalade, Russel4, Mrs; Ferrett,
Jessica4, Ms; Bagona, Lhea4, Ms; Metwalli, Amr
1, Dr
1Royal Brompton and Harefield Hospitals, part of Guy's and St Thomas' NHS Foundation
Trust, London, UK; 2King's College Hospital NHS Foundation Trust, London, UK; 3Royal
Brompton Hospital, London, UK; 4Harefield Hospital, Harefield, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A154
Objectives
A nurse-led initiative to design, procure and implement a digital SSI surveillance
using a visual component (photographs) across the patient pathway.
Methods
Following a successful application for funding, 1) we ran a competitive procurement
process for an SSI app for in-hospital and community use by patients and clinicians;
2) we designed, tested and implemented the system at multiple sites, 3) we trained
staff to use the app and 4) we set up standard operating procedures for reviewing
(and if necessary referring) patient submissions. To determine overall technology
acceptance, we used a five-point Likert scale electronic survey which patients could
self-select to complete.
Findings
Between April – October 2021, 66 nursing staff were trained on ISLA at three hospital
sites. A total of 454 cardiac surgical patients received a photo at discharge using
ISLA, and a total of 756 patient submissions were received. Overall, patient feedback
has been extremely positive (mean 4.56 out of a possible 5 for patient satisfaction
with the app based on 133 responses). Key challenges identified were redeployment
of champions due to Covid, training, resources, and testing and refining the new technology.
Local champions, senior support, IT project leads and patient engagement were key
drivers to successful implementation.
Conclusions
This nurse-led project for SSI surveillance focuses on improving patient experience
and outcomes after surgery. From our experience we have designed a blended implementation
strategy (toolkit) to help spread and sustain the project.
A155 Introduction of a Nurse-Led Chest Drain Clinic
Kelly, Michelle, Ms; Eaton, Donna, Prof; Redmond, Karen, Prof; Shanahan, Ben, Mr; Brown,
Rachel, Ms
Mater Misericordiae University Hospital, Dublin, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A155
Introduction
Chest drain management and outpatient review has previously been carried out ad-hoc
by the Thoracic surgical team. The advantages of a nurse-led outpatient review for
specific conditions have been well established in other areas such as nurse-led respiratory
clinics. A need for a protocol-driven nurse-led ambulatory chest drain service was
identified within our unit.
Methods
The Thoracic CNS underwent training for management of chest drains. A retrospective
review of patients discharged home with either an intercostal drain or indwelling
pleural catheter insitu who required outpatient follow-up was performed.
Results
144 clinical episodes involving outpatient/ambulatory chest drain management were
identified over a 12-month period. In addition, the indwelling pleural catheter cohort
are daycase procedures which require follow up at 1–2 weeks post-procedure and at
the time of catheter removal. This accounts for a further 160 outpatient episodes
over the past year. Of these patients, there were no reports of any safety issues
on discharge.
Conclusion
It is a safe and cost-saving initiative to introduce a nurse-led chest drain outpatient
service for this population. Furthermore, this will reduce outpatient appointment
episodes and allow for increased new referrals to be seen in a timely fashion in the
consultant-led clinics.
A156 The Use of Simulation Training to Provide Advanced Emergency Nursing Management
of Deteriorating Cardiothoracic Patients in a High Dependency Unit
McKeon, Elaine; Ms; Brown, Rachel, Ms
Mater Misericordiae University Hospital, Dublin, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A156
Introduction
Simulation is widely used for training in healthcare. It was expected that simulation
would address training needs and improve the clinical assessment and treatment skills
of nurses in a cardiothoracic high dependency unit (HDU).
Methods
Pre and post-training evaluation was completed. Training sessions took place in the
HDU and were facilitated by the clinical facilitator who provides bedside education
and support for all nursing team members. Interactive mannequins were manipulated
to change physiological variables based on clinical scenarios mirroring real patient
situations within this patient cohort.
Results
Attendees were asked to assess and treat an interactive mannequin based on real patient
scenarios. 100% of attendees reported simulation addressed their training needs, improved
skills, confidence, and inter-professional communication when in real-world situations.
Conclusion
Integration of simulation in nursing is widely recommended, it helps combine theory
and practical skills for solving increasingly complex scenarios and preparing for
future clinical practice in a supportive learning environment. It is planned to explore
engaging the wider MDT and involving consultant led scenarios and feedback and developing
CALS within the unit.
A157 Proactive Surgical Wound Surveillance Using ISLA: Preliminary Findings from Two
Hospitals
Metwalli, Amr1, Mr; Garg, Sheena
2, Ms; Rochon, Melissa3, Ms; Morais, Carlos1, Mr; Jawarchan, Angila2, Mrs; Quarto,
Cesare1, Mr; Petrou, Mario4, Mr; Raja, Shahzad2, Mr
1Royal Brompton Hospital, London, UK; 2Harefield Hospital, Harefield, UK; 3Royal Brompton
and Harefield Hospitals, part of Guy's and St Thomas' NHS Foundation Trust, London,
UK; 4Royal Brompton and Harefield Hospitals, part of GSTT, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A157
Objectives
Surgical site infections (SSI) are a leading cause of surgical revision, readmission,
surgical sepsis and an important source of antimicrobial resistance. GIRFT has called
for postoperative wound monitoring as an intervention to prevent SSI and reduce the
severity. We introduced ISLA for proactive surgical wound surveillance and retrospectively
audited opportunities for earlier detection of concerns.
Methods
Wound images submitted ≥ 7 days after discharge from 269 patients were scored by two
independent reviewers (SpR Grade). Reviewer agreement for image quality, healing or
non-healing status was calculated using Cohen’s kappa. Readmission days and surgical
revision data was collected for patients who used ISLA and patients with routine follow
up care (non-ISLA). Comparison was made using Fisher exact test and significance was
set at p < 0.5.
Findings
Reviewer agreement for images which would prompt referral for face-to-face review
by healthcare worker was Moderate (95.91% agreement; Cohen’s k: 0.455) and Fair for
concerns over potential infection (92.16% agreement; Cohen’s k: 0.333). Reviewer agreement
regarding image quality was 94.80%. No patients submitting to ISLA required readmission
for SSI or reoperation for wound infection (0/269) compared with 10 out of 914 patients
who received routine follow up. Non-ISLA patients required a combined total 253 bed
days and 23 theatre slots for wound management. Although the risk of readmission for
SSI was not significant (p = 0.129), the risk for return to theatre for wound revision
was significant between the two groups (p = 0.0043).
Conclusion
Proactive surgical wound surveillance via ISLA may help to identify wounds at risk
of infection and provide an opportunity for early intervention to reduce the risk
of more serious infection. Future work to refine categories and the standard operating
procedure for image reviews (including reply to patient and referrals) is planned.
A158 The Clinical Impact of the NHSEI Covid-19 Harm Review on Patients Currently on
the Cardiac Surgical Waiting List: One Unit's Experience
Bannister, Christina, Ms; Clapon, Ioana, Miss; Shinn, Oksana, Miss; Ohri, Sunil, Prof
University Hospital Southampton NHS Foundation Trust, Southampton, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A158
Objectives
In Sept 21 a Harm Review was undertaken to clinically review P2 patients waiting for
cardiac surgery in the Covid-19 era. P2 patients, according to the RCS, need surgery
that can be deferred for up to 4 weeks; patients with severe AS, MR & unstable coronary
symptoms. The aim was to identify patients who were increasingly symptomatic; to maintain
safety for those waiting, to reassess in clinic any patient with worsening symptoms,
& to reprioritise any deteriorating patient due to clinical need &/or admit them directly
for urgent surgery.
Methods
117 P2 patients received a call to ascertain their current clinical symptoms. According
to the NHSEI guideline used each patient's waiting time was identified along with
the reasons for the delay, patient/GP involvement & the current clinical harm rating
(none, mild, moderate or severe harm). Patients with similar or no worsening symptoms
were rated as mild & those with progressive symptoms but who felt they did not want
a surgical review were rated as moderate. The third group with progressive symptoms
needing an outpatient review were planned to be rated at time of reassessment to accurately
identify their clinical harm rating & reprioritise if necessary.
Results
Of 117 patients contacted 34 were given a mild & 33 a moderate rating. The 3rd group
of 50 are currently being reassessed within the outpatient footprint over the Autumn
period. A snapshot outpatient clinic with 3 Harm Review patients seen resulted in
2 patients continuing on the waiting list as P2 priorities, however the 3rd patient
had deteriorated significantly & was admitted from the clinic & listed as an inpatient
for urgent cardiac surgery.
Conclusions
The Harm Review is a useful tool to ensure safety for patients waiting for cardiac
surgery. Most patients found the calls reassuring & welcomed the continued contact
during prolonged waiting times. The review enables the surgical team an effective
means of expediting deteriorating patients surgery.
A159 Demonstrating the Need for an Occupational Therapy Saturday Working Service
Chadwick, Amy, Mrs; Magpantay, Amil, Mr
Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A159
Objectives
The purpose of the study is to determine the need for an occupational therapy Saturday
service, in a tertiary cardio-thoracic hospital. It is acknowledged that without AHPs
in hospital settings, there would no flow, as patient’s length of stay would be increased
and discharges would grind to a halt (NHS Improvement and NHS England, 2018). Part
of this involves providing rehabilitation, which is crucial for people aged 80 years
and over, as ten days spent in a hospital bed equates to ten years of muscle wasting
(NHS England, 2016).
Furthermore, Wu (2020) explains that increasing evidence is demonstrating that the
social isolation and loneliness from COVID-19, is having profound effects on people’s
physical and mental health. This has been noticed in the authors' practice setting,
as patients who are living with frailty are more deconditioned and taking longer to
recover post-surgery.
Methods
An audit of patients referred to the occupational therapy department during July –
August 2021 will be completed by 10/12/21.
Multi-disciplinary team (MDT) opinion on the perceived benefits and challenges of
occupational therapy Saturday working will also be sought via a questionnaire, to
assist forming the justification for funding extra staffing.
Results
The following information will be obtained from the audit:
How many new patients could have been assessed on a Saturday, compared to the following
Monday
How many patients could have been discharged from the service and/or hospital over
the weekend
How many ongoing patients could have received a follow-up session
The questionnaire data will be collated to determine the main benefits and challenges
to providing a Saturday working service.
Conclusions
The study will conclude through analysis of results, whether providing an occupational
therapy Saturday service is potentially able to enhance quality of care, shorten length
of hospital stay and be cost-effective.
A160 First Assistant for the Thoracic Robotic Surgery Programme
Brown, Rachel, Mrs; Redmond, Karen, Prof; Eaton, Donna, Prof
Mater Misericordiae University Hospital, Dublin, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A160
Introduction
In 2019 a multi-speciality robotic programme was introduced to the hospital. A service
need was identified for a trained first-assistant to optimise the thoracic programme.
We determined that this need would be best met by a nurse-led service.
Methods
The Thoracic ANP underwent training to be the first-assistant, this included theoretical
and practical skills supported by a thoracic consultant. Training included a competency-based
programme; a basic surgical skills course, the robotic first assistant course, hands-on
robotic training with observation and supervision from the thoracic consultant.
Results
111 Robotic procedures (80 in main hospital, 31 in other centres) have been completed
since the start of the programme. The robotic programme was suspended during the Covid-19
pandemic. April 2021 allowed a limited re-introduction with the option to operate
in other institutions. Over 90% of all cases the ANP has scrubbed as first-assistant
or supporting a junior doctor. There have been no intra or post-operative adverse
events; 1 conversion to open for surgical bleeding with no significant blood loss
and a smooth transition from robotic to open.
Conclusion
It is a safe and cost-saving initiative which has facilitated streamlining and trouble-shooting
of current practice improving peri and post-procedural care for this population.
A161 Non- Pharmacological Nursing Interventions to Relieve Pain in Adult Critical
Care
Giblin, Siobhan, Ms
Galway University Hospital, Galway, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A161
Introduction
Pain remains an unmet need for many critically ill patients, with up to 70% of patients
reporting moderate to severe pain during their ICU stay.
Unrelieved acute pain causes patient distress and can transition to chronic pain with
long lasting physical, psychological and emotional implications.
Following an extensive literature review the following interventions were found to
have the most robust evidence base:
- Simple Massage.
- Music therapy.
- Cognitive engagement.
- Family involvement.
- Cryotherapy.
- Early mobility.
- Reducing environmental stressors.
Implications for Nursing
Increased awareness and time management skills required to integrate aspects into
routine care.
Acquiring physical resources to implement interventions.
Evaluating results of intervention on alleviation of pain.
Implications for the Patient/Family
Reduced need for breakthrough analgesia, increased efficacy from analgesic regime.
Increased satisfaction in critical care journey.
Reduced risk of complications during their ICU stay e.g. pneumonia, delirium.
The Future
Further rigorous research.
Development of nursing intervention protocol for pain management within critical care.
Virtual Reality.
A162 Every Little Success: Learn Well, Help More, Explore Further, Influence Greater
Wang, Yi, Ms.
Royal Brompton and Harefield hospitals, part of Guy's and St Thomas' NHS Foundation
Trust, London, UK.
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A162
This abstract presents a fulfilment in nursing educational career development and
achievement in lifelong learning as a nurse. It describes a journey from a laybacked,
under-developed nurse working way up towards to nurse educator and facilitator. It
demonstrates the paramount in motivation and determination intrinsically while expressing
inspiration and encouragement extrinsically in every little success throughout the
learning journey. The presentation shares the author's learning experience as a learner
and addresses the significance of being a good teacher in academic and clinical settings.
After years of layback and so-called relaxed life, the author finally became fed up
with being low self-valued and out of date in technologies. A loud voice from the
depth of the author's heart screamed for a change. Having been inspired and encouraged
by lecturers and clinical teachers in their advanced educational achievement, the
author has been motivated and determined to fulfil nursing education goals and future
development in nursing research. Thoughout a hard but gaining leanring jouenry, the
author has achieved some academic status with all supports, such as winning the professional
fellowship and successfully being appointed an educatioal role to support and facilitate
educational events and activities within the Education Committee as well as holding
an educational position in another nursing professional body. The author strongly
believes that only when we learn well, we can help more, and to be brave to explore
further, to make greater influence on others, and together, we make change!
A163 Designated Preoperative Assessment Clinic for Cardiac Surgery- Pathway to Enhanced
Recovery After Cardiac Surgery
Rajan, Lekha, Mrs; Kinsella, Aisling, Mrs.
Mater Misericordiae University Hospital Dublin, Dublin, Ireland.
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A163
Introduction
Enhanced Recovery after Cardiac Surgery (ERAS) is a multimodal, transdisciplinary
approach to promote recovery of patients undergoing surgery throughout their surgical
journey. Introduction to ERAS was rolled out in February 2019 in the national cardiac
surgery unit where 900 cardiothoracic surgeries done each year.
Aim
The ERAS program aims to reduce complications and promote earlier return to normal
activities for our patients. It also aims to reduce the hospital length of stay, to
reduce cancellations due to inadequate patient workup for surgery and therefore optimise
activity.
Methods
A dedicated pre-op assessment clinic was set up to optimise patient assessment and
workup prior to surgery. This included collecting length of stay (LOS) data, surgical
site infection (SSI) rates and patient satisfaction score.
Results
The Post-operative LOS improved in 2019 in compared to 2017 with 20% improvement in
discharge within 7 days; this has been difficult to measure in 2020 as all surgical
activity was reduced during the covid 19 pandemic. Despite the pandemic impacting
activities with ERAS almost 50% of patients were discharged within 7 days post-surgery.
Furthermore, the introduction of pre- op decolonisation illustrated a reduction in
the SSI 7.6% in 2019 to 3% in 2020. The patient feedback reported 90% of the patient
and family received adequate information to prepare for surgery and discharge planning.
Conclusion
The introduction of a dedicated cardiac ERAS programme has shown a reduction in length
of stay, reduced SSI and improved patient information, education and support by dedicated
ERAS Clinical Nurse Specialist in Cardiac Surgery.
A164 SSI Champions: Managing Surgical Site Infection Prevention Strategies Through
Inter-disciplinary Network Collaboration
Magboo, Rosalie, Mrs; Antolin, Randolph, Mr; Arcegono, Trixia Mikaela, Ms; Basilio,
Kristia, Ms; Blair, Joyce Beverly, Mrs; Sebastian, Luzviminda, Mrs; Uy, Cheryl, Mrs.
St Bartholomew's Hospital, London, UK.
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A164
Objective
Surgical site infection (SSI) is the most dominant healthcare-associated infection
affecting surgical patients. A recent national survey of SSI prevention strategies
demonstrated significant variation in care in cardiac surgery centres, which is also
reflected locally. The aim of this project was to standardise local practices for
the prevention of SSI after heart surgery.
Methods
A cross-department network of SSI champions has been established to facilitate the
implementation of a revised protocol and standardisation of local practices for SSI
prevention. A series of multidisciplinary teaching was delivered to keep the staff
informed and promote adherence to the new local SSI prevention protocol. Regular audits
on ten SSI prevention strategies were conducted to assess compliance. Run charts were
produced to analyse trends, with annotations marking the interventions made.
Kurt Lewin’s model of unfreezing, changing and refreezing was utilised to guide the
champions’ initial strategy to implement the SSI prevention protocol. Subsequently,
his force field analysis framework was used to critically examine the driving and
restraining factors affecting stakeholders’ acceptance of change.
Results
Compliance rate to each prevention strategy varied considerably between 23–100%. The
main driving forces in the implementation include: visibility of the SSI champions
in the clinical area, ongoing feedback on each department’s practices and collaborative
working with the multidisciplinary team. Differences in patient management, quick
changeover of staff and staffing shortages were seen as significant restraining factors.
Conclusion
There is a variable uptake of the protocol but the visibility of SSI champions has
been instrumental in embedding the agreed standard local practice for SSI prevention
after cardiac surgery. The challenges faced will be addressed in further PDSA cycles.
Future audit will include comparison of SSI rate pre and post protocol implementation.
A165 Introduction to the shared role of the Lung Cancer Nurse (Between two Dublin
Hospitals)
Gallagher, Deirdre
1, Miss; Redmond, Karen1, Prof; Eaton, Donna1, Prof; Cormican, Liam2, Prof; Sheridan,
Nina1, Ms; Fitzpatrick, Tracey1, Ms; Brown, Rachel1, Ms.
1Mater Misericordiae University Hospital, Dublin, Ireland; 2Connolly Hospital Blanchardstown,
Dublin, Ireland.
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A165
Background
In Ireland there are 8 designated centres for LRAC. While an increasing number of
patients with lung cancer will be referred to a LRAC, it is acknowledged that an increasing
cohort of patients will be diagnosed through other referral streams straight to MDT.
The shared role of the LCN was introduced in 2019. Two Dublin Hospitals are involved,
and this includes the centre of excellence for Thoracic Surgery & Oncology and a non-surgical
non LRAC site. The diagnostic and treatment services between these two sites have
been linked since the 1980s.
Aim
The aim of this abstract is to evaluate the value of the role of the LCN and how the
service and patients have benefited.
Methods
This study is a retrospective review of data across both sites. This data will inform
how many patients required input from a dedicated LCN.
Results
The introduction of the LCN had a positive impact on the thoracic surgery service
and meets the needs of this patient cohort. Across the two sites, 500 new patient
referrals have been received by the LCN over a period of 22 months to date.
Conclusion
It could be argued that considering patient numbers, it may justify the need for a
dedicated trained LCN at centres not designated to the treatment of patients with
lung cancer.
A166 A 3 case- Series Review of Intra- operative Nursing Care During Combined Navigational
Bronchoscopy Cone Beam CT and Image-guided Robotic Surgery
Arcegono, Trixia, Ms; Colombino, Anna Maria, Ms; Jingco, Florence, Ms.
St. Bartholomew's Hospital, London, UK.
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A166
Objective
With the increasing public preference for minimally invasive thoracic surgeries, innovative
approaches to conducting lung resections have been fast-rising. A novel approach of
combined Navigational bronchoscopy Cone Beam CT Guided Fiducial Marker insertion and
image-guided robotic-assisted lung resection had been conducted in 2020. This warranted
the need for collaborative discussion within the intra- operative nursing team to
establish patient safety throughout the case.
Method
The team analyzed a 3-case series using the seven-step Knowledge-to-Action (KTA) Process
Framework by Graham, et al. (2006) to reflect on intra- operative safety and patient
care during the complex surgical procedures.
Findings
The four main concepts emerged during the discussions were (a) patient care and safety,
(b) radiation protection, (c) specialist skills proficiency and (d) collaborative
team communication. Deliberations on these core topics were used to evaluate surgical
outcomes, consider more cost-effective measures and standardize intra- operative nursing
practice.
Conclusion
The increasing frequency of novel surgical approaches concurrently highlights the
need for collaborative communication in ascertaining intra- operative safety and patient
care. A problem-based learning approach as displayed in evidence-based practice models
encourage critical thinking and active learning not only within the nursing groups
but also within the wider multidisciplinary teams.
A167 Developing the Use of Ultrasound-Guided Peripheral Cannulation in a Team of ACPS
in Cardiothoracic Surgery: A Practice Development Project
Webb, Vicky, Mrs.
University Hospitals Plymouth NHS Trust, Plymouth, UK.
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A167
Objectives
To conduct a practice development project to design and implement an education package.
This education package will introduce the skill of ultrasound-guided peripheral cannulation
(USGPC) to a team of Advanced Clinical Practitioners (ACPs) in Cardiothoracic Surgery.
Methods
This project uses a practice development methodology as it aims to improve the clinical
effectiveness of the team and patient experience of care, by teaching individual ACPs
a specific, evidence-based skill. NHS Improvement recommends the use of a Plan, Do,
Study, Act (PDSA) cycle to structure implementation of a proposed change (NHSI, 2018).
For this project, the education package is the focus of the PDSA cycle. Each stage
in the cycle employs relevant theory and methods; learning theory, facilitation, simulation
and questionnaire.
Results
The primary outcome of the project is a revised and refined education package for
USGPC. The education package was subjected to a PDSA (NHSI, 2018) methodical approach
to improve its content and delivery. The questionnaire and reflection results recommend
immediate changes that can be applied to the education package before future deliveries;
source a new video for the audio-visual component, and elaborate on the topic content
for ANTT, use of local anaesthesia and evidence-base.
Conclusions
Overall, this PDP has achieved the aim of developing USGPC in cardiothoracic surgery
by producing and implementing an education package. Clear recommendations for future
practice have been drawn from a critical discussion of the process. Further, the methodology
and methods used to form a template for other similar projects within cardiothoracic
surgery.
A168 How To Set Up a Nurse—Led Small Aneurysm Clinic
Ahearn, Una, Miss; Harrington, Deborah, Miss; Field, Mark, Prof; Kuduvalli, Manoj,
Mr; Nawaytou, Omar, Mr; Othman, Ahmed, Mr.
Liverpool Heart and Chest Hospital, Liverpool, UK.
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A168
Objectives
The nature of aortic disease means regular surveillance imaging is required pre and
postoperatively, therefore volumes of patients seen in conventional consultant-led
aortic clinics continually expand. In addition, referrals with incidental findings
of borderline aortic aneurysms on CT scans have increased, particularly with the adoption
of lung surveillance programmes. Overbooked clinics, extended waiting times and the
requirement for two Consultant Surgeons in addition to three registrars in the traditional
aortic clinic prompted interest in developing a nurse-led small aneurysm clinic model
for patients with stable aortic disease who did not require surgical intervention.
Methods
The number of new patient referrals with aneurysms was audited for a year. The percentage
of patients requiring surgical intervention for their aneurysm versus the percentage
of patients requiring surveillance, lifestyle advice and medical management of their
aneurysms was reviewed. A robust programme of nurse education and assessment was initiated.
All aortic new patient referrals were initally reviewed via the usual electronic referral
system by the Aortic Consultants. Patients who did not require surgical intervention
were crossed referred to the Aortic Advanced Practitioner.
Results
Of 232 new patients who were referred with newly identified aneurysms to be reviewed
in the aortic clinic, 27% required surgery and 73% required routine imaging surveillance,
medical management and lifestyle advice. Our Nurse-Led Small Aneurysm Clinic, with
a face to face model, opened 6 months ago and has received very positive feedback.
Conclusions
Despite some initial challenges our Nurse-led Small Aneurysm Clinic is very popular
with staff and patients and a pragmatic solution to the burgeoning number of patients
with aortic disease requiring follow-up. It has also decreased the burden in the aortic
clinic, leading to a reduction in the number of Consultants required to run it.
A169 Educating the Future Physiotherapists in Thoracic Surgery. The More the Merrier?
Gibb, Michelle, Miss; Chandarana, Karishma, Miss; Nakas, Apostolos, Mr.
Glenfield Hospital, Leicester, UK, University Hospitals of Leicester NHS Trust, Leicester,
UK.
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A169
Objectives
The existing national shortage of clinical placements for physiotherapy students,
further worsened by redeployment of qualified physiotherapists to critical care settings
has led to disruption in training, and challenges in the production of a newly qualified
physiotherapy workforce. Placements in Thoracic Surgery offer experience and the development
of clinical decision making for patients with complex respiratory conditions in the
postoperative period developing skills to work across Level 1 and Level 2 environments. We
sought to evaluate the implementation of a 2:1 clinical placement physiotherapy model
at a Thoracic Surgery unit in the UK.
Methods
From October 2020, the 2:1 clinical placement physiotherapy model was incorporated
into routine Thoracic Surgery practice at our unit. 2 students were assigned to 1
educator for a 4–6-week placements (150 to 225 working hours). Feedback was obtained
from both the students and the clinical educator at the end of each placement.
Results
Over a 12-month period, 8 students completed clinical placements on Thoracic Surgery
using the 2:1 student model of training by 2 qualified physiotherapists, a 100% increase
in physiotherapy students exposed to Thoracic Surgery from the previous year. All
students passed the clinical placement. Qualitative feedback was recorded from both
physiotherapist educators and students via confidential feedback forms (Table 1).
The most common advantage identified by the students was the benefit for peer support
and learning which enhanced their learning experience.
Conclusion
The trial of a 2:1 physiotherapy model in a busy Thoracic Surgery unit has improved
clinical exposure for students with no hinderance to pass rate, promoting implementation
of the model into other specialties in our Trust and evaluation of other teaching
models to maximise training opportunities in the current climate.
Advantages
Disadvantages
Increase in student placements offered and improved junior physiotherapist recruitment
Increased time taken to complete assessments and paperwork
Students provided peer support to each other, especially during times of self-directed
practice
Less confident students felt they were being over shadowed by more confident students
80% of students reported having another student on placement felt supportive
Clinical educators felt initially hard to split time between 2 students equally
Students worked well as a pair to assist in physiotherapy projects on the ward
When students had very different learning needs the educators felt this did increase
their workload
A170 Endoscopic Harvesting Techniques are Safe and Reliable. The Oxford Experience
of 9-years of Practice.
Djordjevic, Jasmina, Ms; Turton, Michael, Mr; Nair, Jyothi, Mrs; Eaglestone, Estelle,
Mrs; Skulbedova, Nina, Mrs; D'Alessio, Andrea, Mr; Krasopoulos, George, Mr.
Oxford University Hospitals NHS Foundation Trust John Radcliffe Hospital, Oxford,
UK.
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A170
Objectives
Endoscopic vein harvesting (EVH) and endoscopic radial harvesting (ERAH) for coronary
artery bypass grafting is the most common harvesting technique at the Oxford Heart
Centre. We are reporting the Oxford experience with EVH and ERAH, over a period of
9 years.
Method
Prospectively collected data of EVH and ERAH were retrospectively analysed. A subgroup
analysis of 148 patients underwent postoperative CT-angiography assessment of the
patency of their grafts at 3-6 months.
Results
2378 patients underwent CABG procedure. 2048 patients (86%) had EVH and/or ERAH. 13.5%
had open vein harvesting (OVH) and 0.5% were converted to OVH. Average harvesting
time per vein length is < 15 min, with negligible blood loss. ERAH was performed in
264 patients, 2 cases (< 1%) had to be converted to open technique and 17 patients
had open radial harvesting. Average harvesting time for ERAH is 25 min. 4.2% of the
EVH cohort developed haematomas at the harvest site (not requiring intervention) and
no site infections were recorded. The OVH group had 11 (3%) cases with severe surgical
site infection. 148 patients had their graft patency evaluated by CT-angiography at
6 months revealed an early occlusion rate for EVH was 8% (15 out of 187) and 2 out
of 13 ERAH. The reason of occlusion was identified as competitive flow for 11 EVH
and 2 ERAH. Only 4 EVH were found occluded with no obvious explanation.
Conclusion
Endoscopic conduits harvesting, is a safe harvesting technique with excellent reported
patency rates and minimum complications rates.
A171 Pneumatic Tourniquet in Endoscopic Radial Artery Harvesting. The Oxford Experience
on How and When to do it
Djordjevic, Jasmina, Ms; Eaglestone, Estelle, Mrs; Turton, Michael, Mr; Nair, Jyothi,
Mrs; Skulbedova, Nina, Mrs; D'Alessio, Andrea, Mr; Krasopoulos, George, Mr.
Oxford University Hospitals NHS Foundation Trust John Radcliffe Hospital, Oxford,
UK.
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A171
Objectives
Endoscopic radial harvesting (ERAH) is the second most common endoscopic harvesting
technique at the Oxford Heart Centre. We are reporting the Oxford experience with
the use of pneumatic tourniquet for ERAH along with technical and other considerations.
Method
Prospectively collected data of ERAH were retrospectively analysed. The ERAH cases
were divided into two groups and the results were directly compared. The technique
of the tourniquet application along with tips and pitfalls were reviewed.
Results
247 patients with ERAH were included. ERAH procedure is done without application of
systematic Heparin of 2.500 IU unless performed simultaneously with the endoscopic
vein harvesting. 2 cases (< 1%) were converted to open due to the bleeding at the
early phase of training, without tourniquet application. Average harvesting tome for
ERAH in early experience was 50 min for first 20 cases to improve to 25 min for experienced
SCP. 15 patients had ERAH with application of pneumatic tourniquet, with Heparin administration,
absence of bleeding and harvesting time of 15 min. No post-operative compilations
were recorded in both groups for past two years. The full indications, technique,
and pitfalls in using the tourniquet for ERAH will be presented.
Conclusion
Endoscopic artery harvesting is a safe and reproducible technique. The use of pneumatic
tourniquet during ERAH is safe when used appropriately.
A172 Continuing Service in the Heart & Lung Transplant Ward During the Covid-19 Pandemic
Brennan, Michelle, Ms; Brennan, Michelle, Ms; Brown, Rachel, Mrs.
Mater Misericordiae University Hospital Dublin, Dublin, Ireland.
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A172
Introduction
At the start of the COVID-19 pandemic the National Heart & Lung Transplant ward was
due to open an additional 7 new beds (increased from 7 beds previously). The new rooms
along with all patients exercise bikes / foot pedals ensured a robust service at a
very difficult time. Transplant patients were identified as being at high risk of
acquiring the virus and having a more severe COVID-19 disease.
Methods
As well as opening the additional beds, we introduced new measures to keep patients
and staff safe. These measures included restriction on visitors, admission risk assessments,
enhanced cleaning protocols, staff vaccinations, priority vaccinations for transplant
patients and weekly COVID swabbing. There was also limited staff redeployment to COVID
units to ensure the ward was in the best possible position to care for immunosuppressed
patients.
Results
We had no cross-infection of COVID-19 on the ward and maintained our service throughout
the period of March 2020 to October 2021. No patients within the transplant unit swabbed
positive on weekly screening.
Conclusion
Many wards were facing pressure on beds, we were able to double our occupancy whilst
maintaining patient safety and providing a continuous service to the Transplant population.
Pat Magee Competition
A173 A Retrospective Review of the Prevalence of Tracheal Oesophageal Dysfunction
Associated with Anomalies of the Aortic Arch
Bakir, Adnan, Mr; Viola, Nicola, Mr; Bharucha, Tara, Dr; Alzetani, Aiman, Mr
University Hospital Southampton, Southampton, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A173
Objectives
Vascular rings cause tracheo-oesophageal compression presenting as aerodigestive symptoms.
This study investigated whether therapeutic aortic arch surgical intervention alone
is truly curative by detecting any persistence of aerodigestive sequelae.
Methods
Data were retrospectively collected for all aortic arch anomalies referred for surgery
at our institution between 2005–2020. Patients were identified and categorised into
a vascular ring or complex arch anomaly. Post- operative follow-up included a symptom-focused
questionnaire and the most relevant outpatient clinic letters. Data were analysed
with SPSS statistics.
Results
Our series included 117 patients; 80 (68.4%) had complex arch anomalies and no aero-digestive
symptoms, 37 (31.6%) had a vascular ring and severe aero-digestive symptoms. We had
an 81.2% response rate to the questionnaire. Minimal aerodigestive complications were
observed in 5 complex arch anomalies (6.25%), but 16 patients with vascular rings
(43.2%) had persistent aerodigestive symptoms at follow up. The mean length of follow
up was 3.25 years.
Conclusions
Aortic arch surgery alone does not seem to completely resolve ongoing symptoms in
those with preoperative tracheo-oesophageal abnormalities associated with vascular
rings. Further investigations are needed to precisely identify the mechanism of persistence
of symptoms in this group.
A174 Morphology and Surgical Outcomes of Neonates with Double Inlet Left Ventricle:
A Single-Centre Retrospective Study
Mughal, Aishah
1, Miss; Stickley, John2, Mr; Crucean, Adrian2, Dr; Botha, Phil2, Mr; Khan, Natasha2,
Ms; Seale, Anna2, Dr; Jones, Tim2, Mr
1University of Birmingham, Birmingham, UK; 2Birmingham Children's Hospital, Birmingham,
UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A174
Objectives
Double inlet left ventricle (DILV) is a complex form of functionally univentricular
heart (FUVH). Most patients require three-stage univentricular palliation. DILV is
frequently grouped with other FUVH despite morphological differences and post-surgical
data fails to account for mortality before palliation. We aim to evaluate outcomes
of neonates diagnosed with DILV.
Methods
A retrospective observational study was performed on 59 DILV patients at a tertiary
paediatric cardiology unit (2006–2020) to assess cardiac morphology and outcomes.
Echocardiographic imaging was reviewed and validated by a paediatric cardiologist.
Results
Most neonates had usual atrial arrangement (98%), two atrioventricular valves (78%)
and discordant ventriculo-arterial connections (70%). Pulmonary and systemic outflow
obstruction was observed in 49% and 41% of patients, respectively. 10% of patients
had an unobstructed outflow. Extra-cardiac abnormalities were recorded in 9 (15%)
patients. One neonate died before cardiac intervention. Of the remaining patients,
75% received cardiac intervention within 1 month of life.
Stage 1 surgery was performed in 43 (73%) neonates consisting of: a Norwood procedure
(n = 21/43), systemic-to-pulmonary shunt (n = 10/43) or pulmonary artery banding (n = 12/43).
Stage 2 cavopulmonary shunt was performed in 53 (90%) patients and 29 (49%) reached
Fontan completion (36% awaiting Fontan) (Fig. 1). Stage 1 surgery had the longest
hospital admission (median 19 days, IQR 13–26). Post-operative complications were
recorded in 44%, 30% and 69% of patients following stage 1, stage 2 and stage 3 surgery,
respectively. An unobstructed outflow was associated with lower survival (p = 0.04).
Overall estimated survival at 10 years was 87%.
Conclusion
Whilst there is significant heterogeneity of morphologies and clinical courses amongst
the DILV cohort, outcomes of neonates born with DILV are relatively favourable and
should not be reported with other FUVH.
A175 Robotic Left Upper Lobectomy with ICG Guided Wedge Resection of Lower Lobe—Movie
Fleet, Ben
1, Mr; Dunning, Joel2, Mr
1Lancaster Medical School, Lancaster, UK; 2James Cook University Hospital, Middlesbrough,
UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A175
https://www.youtube.com/watch?v=kU8psLQ2XSA
A176 Cardiothoracic Surgery as a Career Choice by Medical Students—Differential Response
by Males and Females but not Ethnicity
Gnanalingham, Sathyan, Mr
UCL Medical School, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A176
Objectives
Cardiothoracic surgery is perceived to be a Caucasian-male dominated speciality. This
study explores how differences in gender, ethnicity, and disability influence medical
student’s interest in considering cardiothoracic surgery as a career.
Methods
A 26-item online survey using Google forms was distributed amongst all 37 UK medical
school’s cohorts, via social media outlets. Different factors of interest were assessed
and ranked in terms of importance on a Likert scale of 1–5 (1 = not important at all,
5 = very important). Free text responses were also collated. Data was analysed using
an SPSS package.
Results
From a total of 258 responses 62% were female and 38% were male. Males were more likely
to "consider a career in cardiothoracic surgery" than females (32 Vs 19%; P < 0.001).
When analysing factors that contributed to this decision, "My gender" was perceived
as "not important" by more male respondents than females (78vs 42%; P < 0.0001). Furthermore,
"a lack of cardiothoracic mentor of the same gender" was perceived as "important"
by more females than males (24 vs 6%; P < 0.0001).
Of participants 45% were Caucasian, 44% were Asian and Asian British and 11% were
other ethnic groups. There were no significant differences among the different ethnic
groups, including to the question "importance of working in an ethnically diverse
field" (52% Caucasians vs 57% Ethnic minorities; P = 0.7).
10% of respondents confirmed "long-standing illness or disability". Their responses
to the different factors of interest did not reach statistical significance when compared
with the rest of the participants.
Overall, across all participants, 73% did not feel that they had adequate exposure
to cardiothoracic surgery within medical school and agreed that they would benefit
from more exposure.
Conclusions
Our survey amongst medical students confirms that gender and not ethnicity or disability
are important factors when considering a career in cardiothoracic surgery.
A177 A Systematic Review & Meta-analysis of Post-operative Quality of Life Following
Cardiac Surgery via Median Sternotomy vs Minimally Invasive Technique
Sinobas, Anthony
1, Mr; Yousef, Olivia1, Miss; Vohra, Hunaid2, Mr
1Bristol Medical School, Bristol, UK; 2Bristol Heart Institute, Bristol, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A177
Objectives
Whilst there is knowledge of morbidity and mortality comparing minimally invasive
(MICS) versus conventional sternotomy (CS) for cardiac surgery, such evidence does
not exist for post-operative pain, psychological health, and quality of life after
MICS. The aim of this study was to evaluate the above parameters with a meta-analysis
of studies relevant to the subject.
Methods
A systematic literature search was performed of all studies comparing the post-operative
pain, physical function, and psychological health after MICS versus CS. The studies
included applied SF-36 and RAND-36 questionnaires to determine the above. A pooled
meta-analysis was conducted to investigate differences between the two groups.
Results
An initial search identified 9422 papers; of which 6 studies were suitable for the
final analysis. All studies included compared CS with MICS (mini-thoracotomy, thoracoscopically-assisted
and robotically-assisted). Data from 857 patients in total across the 6 included studies
was analysed. Pooled meta-analysis showed a relative risk of 0.24 [-0.00, 0.48; p = 0.05];
0.14 [-0.11, 0.40; p = 0.27]; 0.32 [-0.03, 0.67; p = 0.08]; for post-operative bodily
pain, physical function, and psychological health respectively.
Conclusion
Based on this meta-analysis, there was a statistically significant trend in favour
of MICS in terms of post-operative bodily pain. We eagerly await the results of the
UK Mini-Mitral trial to highlight with a greater degree of certainty the benefits
of MICS over CS for mitral valvular surgery. We also suggest a greater focus on investigating
differences between procedures classified as minimally invasive, with more studies
comparing robotically-assisted surgery to a right minithoracotomy approach to further
hone our understanding as to the best option for patients.
A178 Early and Late Outcomes in Limited Versus Total-arch Replacement in Type A Aortic
Dissection: A Meta-analysis
Harrington, Bertie
1, Mr; Reynolds, Alexander2, Mr; Booth, Karen3, Ms
1Newcastle Medical School, Newcastle, UK; 2Swansea Medical School, Swansea, UK; 3Freeman
Hospital, Newcastle, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A178
Objectives
A consensus has yet to be reached for the correct management of type A aortic dissection.
A large retrospective evidence-base exists comparing limited (LAR) and total aortic
arch repair (TAR). Previous meta-analysis argued the preferential use of TAR in suitably
specialist centres. We aim to update this recommendation following further data publication.
Method
Literature searches were performed to identify studies for abstract screening. Included
studies were compared to identify common outcomes, and data for such outcomes were
pooled using Review Manager 5.3. Heterogeneity and publication bias were reviewed
and suitable statistical adjustments were made.
Results
Nineteen studies underwent data-pooling, for which fifteen outcomes were analysed.
Along with significantly less cardiopulmonary bypass time, LAR had significantly favourable
outcomes for late neurology, low cardiac output syndrome and postoperative dialysis.
All other outcomes (survival, systemic, dissection-related) were insignificant.
Conclusions
The retrospective data for the topic predisposes our conclusions to poor internal
validity, indicating the need for randomised trials. We demonstrated increased significance
in outcomes between both groups compared to the previous meta-analysis, failing to
support their recommendation for TAR. Conversely, we argue that LAR should be employed
in patients who are prone to stroke, AKI or have pre-existing cardiac pathology.
A179 Outcomes of Chest Drain Management Using Only Air Leak (Without Fluid) Criteria
for Removal After General Thoracic Surgery—A Drainology Study
Abdul Khader, Ashiq
1, Dr; Pons, Aina1, Dr; Palmares, Abigail1, Ms; Booth, Sarah Ann1, Ms; Proli, Chiara1,
Dr; De Sousa, Paulo1, Mr; Lim, Eric2, Prof
1Department of Thoracic Surgery, Royal Brompton Hospital, London, UK; 2Imperial College
London, Academic Division of Thoracic Surgery, Royal Brompton Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A179
Objective
Chest drain management is a variable aspect of postoperative care in thoracic surgery,
with different opinion for air and drain volume output. We aim to study if acceptable
safety was maintained using air leak criteria alone.
Methods
A 9-year retrospective analysis of protocolised chest drain management using digital
drain air leak cut off less than 20 ml/min for more than 6 h for drain removal in
patients undergoing general thoracic surgery. We excluded patients if a chest drain
was not required nor removed during admission or if patients underwent volume reduction
or pneumonectomy. Withdrawal criteria was suspected bleeding or chylothorax. Postoperative
films were reviewed to document post-drain removal pneumothorax, pleural effusion,
and reintervention (drain re-insertion).
Results
Between 2012 and 2021, 1,187 patients had thoracic surgery under a single surgeon.
Following exclusion and withdrawal criteria, 797 patients were left for analysis.
The mean age (SD) was 61 (16) years and 383 (48%) were male. Median (IQR) duration
of drain insertion was 1 (1–2) day with a median length of hospital stay of 4 (2–6)
days. Post-drain removal pneumothorax was observed in 141 (17.7%), post-drain removal
pleural effusion was observed in 75 (9.4%) and re-intervention (reinsertion of chest
drain) required in 17 (2.1%).
Conclusions
Our results demonstrate acceptable levels of safety using digital assessment of air
leak as the sole criteria for drain removal in selected patients after general thoracic
surgery.
A180 Heart and Lung Transplant Recipients With Pre-formed Antibodies to the Donor
Can Be Safely Transplanted- A 10 Year Experience
Tsin Yan, Grace Ting
1, Miss; Akbarzad-Yousefi, Arash2, Dr; Clark, Stephen3, Prof; Dark, John4, Prof; Parry,
Gareth3, Dr
1Newcastle University Medicine Malaysia, Johor, Malaysia; 2H&I Deparment, Newcastle,
NHS Blood and Transplant, Newcastle, UK; 3Freeman Hospital, Newcastle, UK; 4Newcastle
University, Newcastle, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A180
Lung Transplantation (Total n = 361)
With Pre-formed DSAs (n = 71), n (%)
Without Pre-formed DSA (n = 290), n (%)
p-value
Survival
52 (73%)
148 (51%)
0.005
Freedom From Bos 3
59 (83%)
252 (87%)
0.554
Lung transplant patients with pre-formed DSA (Total n = 64)
With Persistent Pre-formed DSAs (n = 11), n (%)
Without Persistent Pre-formed DSAs (n = 53), n (%)
Survival
6 (54%)
46 (87%)
0.003
Freedom From Bos 3
8 (73%)
44 (83%)
0.086
Heart Transplantation (Total n = 199)
With Pre-formed DSAs (n = 45), n (%)
Without Pre-formed DSA (n = 154), n (%)
Survival
31 (69%)
116 (75%)
0.541
Heart transplant patients with pre-formed DSA (Total n = 41)
With Persistent Pre-formed DSAs (n = 12), n (%)
Without Persistent Pre-formed DSAs (n = 30), n (%)
Survival
8 (67%)
23 (77%)
0.493
Pre-formed donor-specific antibodies (DSAs) are pre-existing anti-HLA antibodies in
an organ transplant recipient. Generally, pre-formed DSAs are a contraindication to
transplant as they can lead to hyperacute rejection and early graft failure. Recent
studies suggested that crossing low or medium-strength pre-formed DSAs do not negatively
impact post-transplant outcomes. Policy now allows cardiothoracic transplantation
across low or medium-strength pre-formed DSAs to improve waiting time and mortality
in sensitized patients on the transplant list.
This study investigated the impact of pre-formed DSAs on 560 cardiac and pulmonary
transplants in one centre. Outcomes were survival post-transplantation and freedom
from bronchiolitis obliterans stage 3 (BOS 3) post-lung transplantation. 20% of lung
transplant patients and 23% of heart transplant patients had pre-formed DSA (n = 71/361,
45/199). Pre-formed DSA in lung transplant patients was associated with significantly
higher survival (p = 0.005) but not freedom from BOS 3 (p = 0.554). However, when
pre-formed DSA persisted at one year post-lung transplantation, patients had lower
survival (p = 0.003). Pre-formed DSA did not impact survival post-heart transplantation
(p = 0.511).
In conclusion, cardiothoracic transplant across low to medium-strength pre-formed
DSAs should be encouraged to facilitate transplantation in sensitized patients. Persistent
pre-formed DSAs are an important predictor of worse survival post-lung transplantation
and should be regularly monitored.
A181 Exogenous Formaldehyde in the Exacerbation of Coronary Artery Disease. An observational
Study with Meta-analysis
Bhaskaran, India Premjithlal
1, Miss; Bhaskaran, Arya Premjithlal2, Mr; Bhaskaran, Anusuya Premjithlal3, Dr; Bhaskaran,
Premjithlal3, Dr
1Kew House School/Imperial College, London, UK; 2Heathfield House School, London,
UK; 3Imperial College, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A181
Background
Exposure to formaldehyde induces coronary artery disease (CAD), atherosclerosis, arrhythmia,
tachycardia, ventricular or atrial fibrillation, stroke and it is linked to oxidative
stress or inflammation. Higher concentrations of formaldehyde exposure can cause negative
inotropic strength in the heart, sinoatrial dysfunction, which can result in bradycardia
or death. The aim of this study is to identify the risk for CAD due to formaldehyde
exposure and to assess the formaldehyde concentration in the atmosphere.
Materials and methods
PubMed, EMBASE, and ProQuest were searched, by using the terms "formaldehyde and coronary
artery disease". The "Mantel–Haenszel Risk Ratio" was used for meta-analysis. For
the observational component, the formaldehyde levels were obtained from a school and
its peripheral areas based in west London in 17 & 8 h in 2018 & 2020.
Results
Overall, 204 titles or abstracts were identified from the initial search, of which
full manuscripts of 91 studies were retrieved in the first phase. Later, 86 studies
were excluded and five were subjected to meta-analysis. The average formaldehyde concentration
across the studies ranged between 0.37 mg/m3 to 5.4 mg/m3. The risk ratio was 2.31
(95% C.I = 1.19 to 4.09) and hence for every unit (µg/m3) increment in the formaldehyde concentration,
there was a higher risk for CAD (Fig. 1). Theformaldehydelevels were high in the morning
due to the accumulation formaldehyde in the air and low in the evening in 2018. In
2020, the levels were showed almost similar pattern, but less formaldehyde in the atmosphere
during the period of COVID-19 pandemic (Figs. 2–4).
Conclusion
There is an association between formaldehyde exposure and CAD, including myocardial
infarction and stroke. Hence a critical evaluation of electrocardiogram, echocardiogram
and cardiac markers should be performed among exposed cases to prevent further complications.
A182 Improving Access to Surgical Education via Cost-effective Interactive Live-streaming
to Medical Students
Narang, Karamveer, Mr; Ahmadi, Navid, Dr; Hartley, James, Dr; Aresu, Giuseppe, Mr;
Peryt, Adam, Mr; De Silva, Ravi, Mr; Wells, Francis, Mr; Jones, Nicola, Dr; Coonar,
Aman S, Mr
Royal Papworth Hospital, Cambridge, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A182
Objectives
Cancellations of operations and attempts to reduce footfall within hospitals during
the COVID-19 pandemic has greatly reduced the opportunity for students to observe
surgery.
Online live streaming is a novel approach to improve access to surgery and the quality
of surgical education delivered to medical students. It allows students to view surgery
in real-time and provided an interactive learning experience.
Methods
Multiple cameras were used as webcam feeds to be broadcast on a closed network such
as Microsoft Teams with approval from information governance. These ranged from theatre
overhead light cameras, smartphones and webcams found on trust laptops used for educational
purposes.
A pre-operative seminar was arranged after the team brief during each case allowing
the surgeon to interact with the students and provide small group teaching. Students
were sent information about the case beforehand in order to give them an understanding
of what they would be viewing on the live stream. We utilised a Bluetooth headset
to then allow the surgeon to provide an interactive running commentary during the
operation.
Feedback forms where used pre-and post session to gauge student’s interest in surgery
and evaluate the teaching session and learning experience.
Results
A total of 6 live stream sessions were evaluated. 22 students attended these sessions
and provided feedback.
68% (15/22) of the students said that the session was ‘very helpful’ or ‘extremely
helpful’ while 4% (1/22) of students stated that the session was ‘not so helpful’
with 0% claiming it was ‘not helpful at all’. 36% (8/22) of the students claimed that
these sessions had made them more likely to pursue surgery as a specialty in the future.
Conclusions
Interactive live streaming is highly effective using easily available, low cost technology.
There are enormous potential savings with respect to travel and reducing footfall
in theatre.
A183 Biological Versus Mechanical Prosthesis for Valvulopathy in Dialysis-dependant
Patients: A Meta-analysis
Reynolds, Alexander C.
1, Mr; Owen, Rhiannon K.1, Dr; Modi, Amit2, Mr; Asopa, Sanjay3, Mr
1Swansea University Medical School, Swansea, UK.; 2Sussex Cardiac Centre, Brighton,
UK.; 3Southwest Cardiothoracic Centre, Plymouth, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A183
Objectives
Debate continues for prosthesis choice in dialysis-dependant patients undergoing valve
replacement. Biological valves have been implanted in cases of poor long-term survival,
circumventing the warfarin burden. Conversely, mechanical prosthesis is indicated
in those who would otherwise outlive the durability of a bio-prosthetic. Our aim is
to reach consensus using the current data available.
Methods
Literature searches were performed to identify studies for abstract screening. Included
studies were compared to identify common outcomes, and data for such outcomes were
pooled using Review Manager 5.3. Heterogeneity and publication bias were reviewed,
and suitable statistical adjustments were made.
Results
Twelve retrospective studies were included, providing sixteen outcomes for data-pooling.
5-year survival was poor in both groups, and significantly less in the bioprosthetic
than the mechanical group (21.6% versus 32.6% respectively, p < 0.0001. I2 = 21%).
Postoperative mortality was indifferent between both groups, alongside mediastinitis,
sepsis and AF. The late incidence of stroke, gastrointestinal morbidity and venous
thromboembolism was similar in both groups.
Conclusions
The overall survival period for the dialysis-dependant population remains poor. The
retrospective data for this topic predisposes our conclusions to poor internal validity;
greater long-term survival with mechanical prosthesis may be attributed to a significantly
younger population, rather than survival benefit. With otherwise similar outcomes
between both groups, we recommend joint decision-making in the context of case presentation
and patient preference.
A184 Investigating the Obesity Paradox in Cardiac Surgery
Ghazarians, Nareh, Miss; Walker, Antony, Mr
Lancaster Medical School, Lancaster, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A184
Objectives
Obesity is associated with a number of cardiovascular risk factors. Studies have shown
overweight and obese patients to have better prognosis and clinical outcomes, the
obesity paradox. The aim of this study was to investigate the effect of BMI on outcomes
after cardiac surgery.
Methods
All cardiac surgery patients at the Blackpool Victoria Hospital between January and
December 2009 were retrospectively reviewed. Patients were grouped based on BMI classifications,
defined by the WHO and NIH. The six groups were analysed Class III obese (BMI ≥ 40 kg/m2;
n = 29; 2.6%), Class II Obese (35 ≤ BMI < 40 kg/m2; n = 68; 6.0%), Class I Obese (30 ≤ BMI < 35 kg/m2;
n = 243; 21.4%), Overweight (25 ≤ BMI < 30 kg/m2; n = 496; 43.7%), Healthy weight
(18.5 ≤ BMI < 25 kg/m2; n = 288; 25.4%) and Underweight (BMI < 18.5 kg/m2; n = 11;
1.0%). Pre-operative variables and post-operative outcomes were analysed using appropriate
statistical methodology, with p values less than 0.05 being taken as significant.
Results
1135 patients were included. Obese patients were significantly less likely to receive
transfusion Χ2(5, N = 1135) = 40.90, p < 0.001. There was a significant negative association
between BMI and In-Hospital Mortality, with mortality decreasing with increasing BMI Χ2(5,
N = 1135) = 16.29, p < 0.001. A J-shaped curve associating BMI with EuroSCORE, Later
Mortality and incidence of blood transfusion could be observed.
Conclusions
Our study confirms the existence of an obesity paradox in cardiac surgery. This suggests
a need for risk stratification methods in cardiac surgery to take BMI into account.
A185 Short, Mid and Long Term Outcomes of Post-Myocardial Infarction Ventricular Septal
Defects
Pengelly, Sarah, Miss
Cardiff University, Cardiff, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A185
Objective
To evaluate the short/mid/long term survival of patients who underwent repair of post-myocardial
infarction ventricular septal defects. To identify key factors which influence this.
Methods
Analysis spanned 1998–2021 covering 53 patients who underwent surgery for post-infarct
ventricular septal defect at a single centre. Kaplan–Meier and chi-squared statistical
analyses were conducted.
Results
Intra-aortic balloon pump was used in 95.2% of patients. 91.7% of ventricular septal
defects were repaired with a bovine pericardium patch. 66.0% of patients also required
coronary artery bypass graft surgery, with 9.4% requiring valve surgery. Arrhythmia
(69.4%) was the most common complication. Overall crude in-hospital mortality was
38.9%: 38.5% for anterior and 31.0% for inferior. Overall survival at 1 year is 48.9%,
42.8% at 5 years, 30.4% at 10 years and 0.0% at 20 years. At each time point measured
inferior survival probability was greater than anterior survival. Prior to 2010 in-hospital
mortality was 40.0%, dropping to 37.5% from 2010 onwards. Overall survival probability
at each time point was improved from 2010 onwards.
Conclusions
Five risk factors for mortality were identified: age 70 or higher (p = 0.004024);
arrhythmia (p = 0.010658); post-operative new haemofiltration/dialysis (p = 0.046409);
reason for intra-operative intra-aortic balloon pump use (p = 0.041058) for overall;
and intra-aortic balloon pump use (p = 0.012432) for anterior.
A186 Computed Tomography Scanning for Sternal Wound Infections: A Systematic Review
Shirke, Manasi
1; Dominic, Cathy1, Miss; Nawaz, Hamza1, Mr; Debnath, Pradipta2, Mr; Sunny, Jesvin3,
Mr; Haq, Mawiyah4, Mr; Harky, Amer5, Mr
1; 2Bart's and the London School of Medicine, London, UK; 3University of Nottingham,
Nottingham, UK; 4University of Central Lancashire, Preston, UK; 5St. George’s University
of London, London, UK; 6Barts and the London School of Medicine, London, UK; 7Liverpool
Heart and Chest Hospital, Liverpool, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A186
Objectives
Sternal wound infection (SWI) is a significant risk in patients who undergo sternotomies
as part of their cardiothoracic surgical procedures. Computed tomography (CT) imaging
is often used to diagnose and assess sternal wound infections. Its purpose includes
identifying and locating infection and any sternal dehiscence.
Methods
A systematic literature review across PubMed, Embase, and Ovid was performed according
to PRISMA guidelines to identify relevant articles that discussed the utility of CT
scanning for SWI, common features identified, patient outcomes and sensitivity/specificity.
All studies discussing the role of CT imaging in sternal wound infection were included.
Studies discussing both superficial and deep sternal wound infections were included.
Editorials, consensus documents, commentaries, case series of less than three patients,
literature reviews, and studies not in English were excluded.
Results
25 papers were included. 100% (n = 25) of the papers were published in peer-reviewed
journals. CT scans in SWIs can be seen as a beneficial aid in diagnosing as well as
determining the components of infection. Commonalities were identified such as fluid
collection in the mediastinum, free gas, pleural effusions, and sternal dehiscence
which point towards the presence of sternal wound infection.
Conclusion
CT scanning is a novel and emerging methodology for imaging in SWI and post-sternotomy
complications, hence increased research is required to expand the literature on this
area as well as the creation of guidelines and staging criteria for radiology professionals
to identify and determine the extent of infection.
A187 Effectiveness of a Virtual Core Surgical Training Interview Preparation Course
Programme
Veeralakshmanan, Pushpa
1, Miss; Panahi, Pedram
2, Mr; Seraj, Shaikh Sanjid3, Dr
1University Hospitals Birmingham, Birmingham, UK; 2Royal Marsden Hospital, London,
UK; 3Walsall Hospital, Walsall, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A187
Objectives
In the UK (UK), entry into the core surgical training (CST) programme remains a competitive
process. In view of the COVID-19 pandemic, there has been an increase use of online
platforms to ensure educational needs are met despite the cancellations of face-to-face
courses and conferences. We developed an one-day intensive virtual CST interview preparation
course and assessed the effectiveness of the course.
Methods
The one-day CST interview preparation course was designed, implemented and delivered
virtually via Microsoft teams at an international level in November 2020. The course
content were developed and delivered by core surgical trainees. The content delivered
covered all the three stations of the national interview. Additionally, in view of
the COVID-19 pandemic, alterations to the application and interview process were discussed
in detail. All attendees were asked to complete the feedback immediately following
the course.
Results
196 trainees attended the virtual CST interview preparation course. Over 98% of the
attendees found the course to be ‘excellent’ with regards to usefulness of the course
and over 99% of the attendees found the course to be ‘highly relevant’. A two-tailed
paired T-test showed a statistically significant difference between pre- and post-course
level of confidence for the CST interview (T = 9.99, P < 0.0001), demonstrating nearly
a tenfold increase in level of confidence and preparedness for the CST interview after
attending our course. Over 80% of attendees found the use of Microsoft Teams to access
the course to be 'very easy', with over 85% of attendees preferring the course to
be delivered virtually.
Conclusion
Our service evaluation of the CST interview preparation course has shown that using
online platforms like Microsoft Teams for teaching can be highly effective. In view
of the COVID-19 pandemic, the use of online platforms for teaching can be integrated
into delivery of the surgical curriculum.
A188 The Ability of EuroSCORE to Predict Long-term Outcomes After CABG Surgery
Fleet, Ben
1, Mr; Tandon, Eisha1, Miss; Walker, Antony2, Mr
1Lancaster Medical School, Lancastr, UK; 2Blackpool Victoria Hospital, Blackpool,
UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A188
Objectives
The European System for Cardiac Operative Risk Evaluation (EuroSCORE), introduced
in 1999 predicts in-hospital mortality for patients undergoing cardiac surgery. Many
variables associated with increased surgical mortality persist post-operatively. The
aim of this study was to investigate the predictive value of the logistic EuroSCORE
on long-term survival after coronary artery bypass surgery.
Methods
Data were collected retrospectively for all patients undergoing CABG at a single centre
between 1st January 2009 and 31st December 2009. Data submitted to NICOR were used
for EuroSCORE and in-hospital outcomes; longer-term, all-cause mortality from NHS
digital Personal Demographic Service. Low (< 3), intermediate (3–6) and high-risk
(> 6) logistic EuroSCORE groups were identified and analysed using appropriate statistical
methodology, with p values less than 0.05 being taken as significant.
Results
663 patients underwent isolated CABG procedure during the study. The 1-year, 3-year,
5-year and 10-year survival rates were 97.6%, 94.3%, 89.3% and 73.5% respectively.
Kaplan Meier curves for low, intermediate and high-risk groups are shown in Fig. 1
(p < 0.00001). Poor left ventricular ejection fraction, serum creatinine above 200 ml,
chronic pulmonary disease, extracardiac arteriopathy and pulmonary hypertension were
identified as independent predictors of long-term mortality.
Conclusions
Our study demonstrates the logistic EuroSCORE predicted long-term outcomes following
CABG surgery. This finding can inform patients of the long-term risks of CABG surgery
and given the favourable results compared to percutaneous intervention, guide MDT
decision making.
A189 Anatomy of the Subpulmonary Stenosis in Tetralogy of Fallot: The Gateway to Eisenmenger
Syndrome?
Patsalides, Michalis Anestis, Mr; Paterson, Scott, Dr; Spear, Michelle, Prof
University of Bristol, Bristol, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A189
Subpulmonary stenosis resulting from the anatomical distortion observed in Tetralogy
of Fallot may severely limit pulmonary arterial blood flow compromising pulmonary
vasculature development and anatomy, ultimately leading to complications such as Eisenmenger
syndrome.
Stenosis at subpulmonary level involves a hypertrophied antero-superior limb of the
septomarginal trabeculation, antero-superior deviation of the muscular outlet septum
and stenosis of the subpulmonary infundibulum of the right ventricular outflow tract.
Through dissection, these structures are seen closely related, encircling the gateway
to pulmonary circulation. As concluded via further literature review, if anatomically
abnormal, these structures restrict pulmonary arterial blood flow. Thus, there is
a in change blood flow velocity transforming laminar to turbulent flow. In combination
with left-to-right shunting through a non-restrictive interventricular communication,
turbulent blood flow in pulmonary arteries promotes vascular endothelial remodelling.
This leads to hypertrophy of the tunica media of the pulmonary blood vessels via expression
of vascular endothelial growth factor further increasing pulmonary vascular resistance,
a hallmark of Eisenmenger syndrome.
Consequently, by understanding the anatomy of the subpulmonary infundibulum in Tetralogy
of Fallot, its effect on pulmonary blood flow can be quantified, paving the way for
using anatomical configuration and pulmonary blood flow as prognostic tools for the
development of Eisenmenger syndrome.
A190 Education Post-COVID-19; Moving Towards Hybrid Practical Skills Workshops and
Online Learning
Raja, Momna
1, Ms; Modi, Sahil1, Mr; Dhuga, Yasmin1, Ms; Ahmed, Ishtiaq2, Mr
1Brighton and Sussex Medical School, Brighton, UK; 2Royal Sussex County Hospital,
Brighton, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A190
Objectives
Since the COVID-19 pandemic, we have shifted from traditional classroom-based education
to e-learning. Although this pivot has made learning more accessible, surgical education
has historically required practical hands-on teaching with immediate feedback. Previously,
remote workshops have been critiqued due to lack of interaction and difficulty obtained
adequate camera angles. In this pivotal study, we aim to assess the quality of teaching
delivered in a Hybrid format.
Methods
As a part of the International Cardiothoracic Conference hosted by Brighton and Sussex
Medical School’s cardiothoracic surgical society, 24 students were offered the opportunity
to attend hybrid aortic valve replacement workshops (virtual or in-person). Virtual
stations were delivered in a ‘grab-and-go’ box, including a laptop, camera, and prosthetic
material. Attendees received instruments regarding the set-up, software, and the session
programme a week before the workshop.
Results
65% of questionnaires were returned. The feedback was extremely positive with attendees
rating it a 9.7 out of a total of 10. 100% of the attendees in the virtual station
found the virtual set-up "easy" to use and were "extremely satisfied". When asked
to rate it out of ten, scores of 9.6, 9.6 and 9.4 were given for the overall platform,
audio, and video.
Conclusion
Despite the challenges and limitations, the future of surgical education should include
such hybrid events. They are an excellent alternative with the optimal blend of in-person
and remote opportunities, which can be catered to the attendee’s preference. Simulations
and virtual wetlabs enable trainees to develop there purposeful practice from the
comfort of their own homes without warranting concerns regarding quality of teaching.
A191 Single Centre's Experience; Propensity Matched Analysis of Minimally Invasive
vs Full Sternotomy Mitral Valve Repair
Raja, Momna
1, Ms; Ahmed, Ishtiaq2, Mr
1Brighton and Sussex Medical School, Brighton, UK; 2Royal Sussex County Hospital,
Brighton, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A191
Objective
In the past two decades, interest in minimally invasive mitral valve repair (MIMVr)
has grown due to its reported benefits of less surgical trauma, better cosmesis, and
faster recovery times. In this retrospective observational study, we aim to evaluate
the safety and effectiveness of the new minimally invasive mitral valve repair [via
mini-thoracotomy] in comparison with conventional full sternotomy (FSMVr).
Methods
Between 2014 and 2020, data was retrospectively collected for 254 patients (51 MIMVr
and 203 FSMVr) who underwent mitral valve repair at a single institute. All pre- and
post- hospital data was collected using the trust’s internal data base (Panda) and
MetaVision [iMDsoft]. 45 well-matched pairs were identified using propensity score
matching in R. This was done to reduce the effect of confounding baseline patient
demographics on outcomes.
Results
After matching, there were no significant differences in baseline characteristics.
The repair rate was 100%(n = 45) post-operatively in both groups but MIMVr had lower
30-day mortality [0%(n = 0) vs 2.2%(n = 1), p > 0.9]. MIMVr patients had longer cardiopulmonary
bypass time(CBP) and total cross-clamp time(CCT); 75 min(95% CI; 57,88) and 38 min(95%
CI; 25,49) respectively [p < 0.01 for both]. But there was a trend towards less need
for transfusions [42%(n = 19) v 49%(n = 22), p = 0.66]. Moreover, they spent less
time in ICU [74(50, 122) vs 89(55, 110), p > 0.9] and hospital [5(4, 8) vs 7(6, 9),
p < 0.1]. There were no significant differences in post-operative freedom from mitral
regurgitation, arrhythmias, pulmonary, infection and renal complications.
Conclusion
MIMVr is a safe alternative to FSMVr. Despite prolonged CBP and CCT times, it was
associated with lower mortality, fewer blood product transfusions, reduced length
of ICU and hospital stay. There were no significant differences in post-operative
complications such as stroke, infections, pulmonary complications, or arrhythmias.
A192 Promoting Interest in Cardiac Surgery; Integration of Specialised Skills Workshops
in the Undergraduate Medical School Curriculum
Dhuga, Yasmin
1, Miss; Raja, Momna2, Ms; Modi, Sahil1, Mr; Ahmed, Ishtiaq3, Mr
1Brighton and Sussex University Hospital, Birghton, UK; 2Brighton and Sussex Medical
School, Brighton, UK; 3Royal Sussex County Hospital, Brighton, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A192
Objectives
In the UK, less than half of the medical students report getting teaching around cardiothoracic
surgery, with only 10% being exposed to clinical placements. Due to poor satisfaction,
we are seeing a downward trend in students wishing to pursue a career in cardiac surgery.
In this study, we aim to assess if WETLAB workshop encourages the engagement of medical
students in cardiac surgery.
Methods
We hosted a WETLAB workshop, led by a consultant cardiac surgeon. Attendees were taught
how to carry out an end-to-side anastomosis on animal tissue. We used pre- and -post
exposure questionnaires composed of 10 items to assess the ability of a WETLAB workshop
to improve undergraduate understanding and interest in cardiac surgery. The questionnaire
included questions around students’ interest in the speciality, previous exposure
to the speciality and whether students want to pursue a career in the speciality.
Results
Out of the 12 attendees, 10 completed both the pre- and post-questionnaire. The WETLAB
was well received with the overall satisfaction of 9.64 out of 10. It significantly
increased attendees interest in cardiac surgery (z = -0.06, p = 0.01) but did not
show any significant difference in encouraging them to pursue surgery. On quantitative
analysis, 100% of attendees agreed that specialised practical workshops should be
incorporated in the medical school curriculum and that if the opportunity arises,
they will attend another in the future.
Conclusion
Specialised practical workshops have the potential to play a significant role in the
medical school curriculum in order to enhance exposure to the field of cardiac surgery.
This may lead to a positive impact on the number of doctors wishing to pursue this
speciality in the future.
A193 Online Careers Sessions Integrating and Exploring Work-life Balance in Heart
& Lung Specialties
Narang, Karamveer, Mr; Ahmadi, Navid, Dr; Asemota, Oghogho, Dr; Ahmadi, Faisal, Dr;
Purmessur, Rushmi, Miss; Peryt, Adam, Mr; Aresu, Giuseppe, Mr; Jones, Nicola, Dr;
Coonar, Aman S, Mr
Royal Papworth Hospital, Cambridge, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A193
Objectives
Restrictions due to COVID have decreased elective opportunities for medical students
and foundation doctors to gain an insight into the work and life of a consultant.
Work-life balance is increasingly recognised as important for a sustainable and rewarding
career.
Our objective was to give delegates an exposure to both the professional and personal
life of consultants and trainees in the clinical specialties in our unit and to evaluate
delegates’ thoughts surrounding work life balance and how that would impact their
career choices.
Methods
Consultants in cardiac and thoracic surgery, respiratory medicine, cardiology, and
intensive care gave TED style short talks covering their professional work and work-life
balance. Cardiothoracic trainees delivered talks about their work and life.
The event was run using ‘GoTo’ Webinar and questionnaires were completed by delegates
integrated into the same platform.
Results
48 delegates attended the virtual taster afternoon ranging from medical students to
foundation doctors with the majority of delegates interested in cardiothoracic surgery
(73%).
79% of delegates reported an increased interest in pursuing their specialty of choice.
69% of delegates answered 5/5 or 4/5 when rating how important work-life balance would
be to them when considering their future surgical specialty whilst only 4% of delegates
stated that work-life balance would not be important at all (rated 1/5).
59% of delegates felt that the best work-life balance would be achieved as a consultant
compared to other grades of doctors such as foundation, senior house officers and
registrars. Only 12.5% of delegates rated work life balance among junior doctors as
good (5/5 rating).
Conclusions
Work-life balance is an important factor in career choice. Historically this was set
aside or otherwise considered negatively. Further research into which aspects of work-life
balance make particular specialties more popular will help to optimise recruitment.
A194 Impact of Covid-19 and Doctor-led Online Teaching Sessions on the Confidence
of Medical Students
Hawwash, Nadin
1, Miss; Joseph, Daniella
1, Miss; Krishnamoorthy, Bhuvaneswari2, Dr; Hashmi, Syed Faisal3, Mr
1University of Manchester, Manchester, UK; 2Edge Hill University, Ormskirk, UK; 3Manchester
University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A194
Objectives
The COVID-19 pandemic initially halted medical school teaching in March 2020. We aim
to explore the level of confidence medical students have with learning through online
case-based clinical teaching.
Methods
We performed a cross-sectional study of students studying at medical school in the
UK (UK). Eight doctor-led teaching sessions took place on the online Zoom platform
covering general and specialty medicine topics organised by The Teaching Clinic Society.
Results
Overall, 82 participants completed the feedback forms, including students from various
institutions in the UK. 71.4% of students across the series strongly agreed that the
teaching was relevant to their medical school education. On average confidence in
each topic increased by 37.8% after attending the series. This was extremely statistically
significant (t = 16.4999, p < 0.0001, 95% CI = -2.45, -1.92). Overall, 88.6% of attendees
really liked online learning and 22% of attendees were neutral towards learning online.
On average, 66.2% prefer face-to-face learning as opposed to online learning (22.8%).
Conclusion
In conclusion, our online case-based teaching sessions were not only shown to be relevant
to the medical school curriculum but also significantly improved the confidence of
medical students. Nonetheless, most students prefer traditional methods of learning.
A195 The Effect of Residential Postcode on Outcomes Following Cardiac Surgery
Tandon, Eisha
1, Miss; Fleet, Ben1, Mr; Walker, Antony2, Mr
1Lancaster Medical School, Lancaster, UK; 2Blackpool Victoria Hospital, Blackpool,
UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A195
Introduction
A postcode lottery is defined as the unequal provision of services such as healthcare
and education based on geographical location. This is an under-researched area yet
is integral to understanding the healthcare inequalities that exist and the factors
influencing them. The aim of this study is to investigate the potential impact of
residential postcode on post-operative outcomes following cardiac surgery.
Methods
Data were collected retrospectively for all cardiac surgical patients at a single
centre between 1st January 2009 and 31st December 2009. Data submitted to NICOR was
used to identify patient demographics, EuroSCORE and in-hospital outcomes. Subjects
were grouped according to four residential postcodes BB (Blackburn), FY (Blackpool),
PR (Preston), and LA (Lancaster). Pre-operative surgical risk and post-operative outcomes
were compared between the different groups using appropriate statistical methodology,
with p values less than 0.05 being taken as significant.
Results
882 patients were included in the study. We identified significant differences between
the age, gender, nature of surgery, redo cardiac procedures and proximity of surgery
to recent myocardial infarction between the postcode groups. The postcodes were controlled
for overall EuroSCORE. Producing Kaplan–Meier curves demonstrated no significant difference
between the survival rates for the different regional postcodes with p = 0.7870 (Figure
One).
Discussion
Differences in pre-operative risk factors between the different postcode groups did
not translate into differences in overall EuroSCORE or post-operative mortality. More
work is needed to localise these findings according to more specific measures of socioeconomic
status.
Figure One: Kaplan Meier survival curves following cardiac surgery according to patient’s
residential postcode.
A196 Outcomes Following Tracheostomy in Post-cardiac Surgical Patients
Wong, Qing Ning
1, Ms; Avtaar Singh, Sanjeet Singh
2, Mr; Buchan, Keith2, Mr
1University of Aberdeen, Aberdeen, UK; 2Aberdeen Royal Infirmary, Aberdeen, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A196
Background
Tracheostomies in post-cardiac surgery patients are performed for many reasons and
are associated with poor prognosis. We investigated the overall mortality and tracheostomy
related complications in a cohort of patients at a tertiary referral centre.
Methods
A retrospective review of 40 patients was conducted at a cardiac surgery unit between
1st August 2016 to 31st August 2021. There were 40 post-cardiac surgery patients who
underwent tracheostomies during this period. Their demographic information, comorbidities,
pre- intra- and post-operative status, and prospective follow-ups were interrogated
from the electronic medical records and patient database. The outcomes of interest
included in-hospital mortality and all-cause mortality with up to 5 years follow-up.
Results
The in-hospital death in post-cardiac surgery tracheostomy patients’ was 60%. The
overall mortality was 70%[WQN(1] with up to 5 years follow-up. Of the in-hospital
deaths, 16.7%(n = 4) had experienced tracheostomy-related complications 50%(n = 2)
succumbed to them. The only statistically significant finding was the type of presentation
(emergency vs urgent vs elective, p = 0.014). There were no other statistically significant
differences between the preoperative and intraoperative variables between those with
in-hospital mortality and patients who were discharged.
Conclusion
Post-cardiac surgery tracheostomy is associated with a high inpatient mortality rate.
Despite the limited numbers, several trends were noted that were potential risk factors
for post-tracheostomy mortality. Decisions for tracheostomy insertion in these patients
should therefore be guided by a multidisciplinary team discussion as directed by the
National Tracheostomy Safety Project guidelines.
A197 Analysis of Post-operative Intensive Care Stay Length in Coronary Artery Bypass
and Valve Surgery
Dilworth, Joseph Michael
1, Mr; Doddakula, Kishore2, Mr
1University College Cork, Cork, Ireland; 2Cork University Hospital, Cork, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A197
Objectives
Given oversubscription of Irish ICUs, knowledge of risks for prolonged stay is key.
Here, we examine the relationship between valve surgery, CABGs, EuroSCORE II (ESII),
cardiopulmonary-bypass time (CPBT) and cross-clamp time (XCT) and ICU-LOS.
Methods
A retrospective census was taken of 833 patients undergoing CABG and/or valve surgery
between 01/12/2017–31/12/2019. Kruskal-Wallace tests, Spearman correlation, receiver
operating characteristics (ROC) and multiple linear regression were employed as appropriate.
Results
Significant differences existed between valve vs 2 valve surgeries (1.78 vs 3.91 days,
p = 0.022) but not between valve + CABG vs 2 valve (2.75 vs 3.7, p = 0.462). Neither
graft amounts (p = 0.101), nor specific valves operated on (p = 0.177) were significant.
For ICU-LOS > 5 days, ESII’s AUC = 0.690 (p < 0.0005). XCT and CPBT correlated with
ICU-LOS (rs = 0.168, rs = 0.131 respectively, p < 0.0005). Multiple linear regression
predicting loge(ICU-LOS) achieved R2 = 0.112 (p < 0.0005). Significant factors were
XCT (p < 0.0005), age (p = 0.017), and peripheral arteriopathy (p = 0.011). ESII approached
significance (p = 0.056). Surgery type was insignificant (p = 0.263).
Conclusion
ESII’s weak-to-fair predictive ability and variables in this score achieving significance
in multivariate analysis implies its weighting is not suited to ICU-LOS. XCT is superior
to CPBT in ICU-LOS prediction, independent of pre-operative characteristics. Given
the low R2, prolonged ICU-LOS was largely unpredicted, and further risk investigation
and investment in capacity is recommended.
A198 Investigating the Role of Small Nucleolar RNAs (snoRNAs) as an Early Genetic
Marker of Future Adverse Cardiovascular Events
Kumar, Ujjawal, Mr; Hamilton, Russell, Dr
Department of Genetics, University of Cambridge, Cambridge, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A198
Objectives
The PROSPER (PROspective Study of Pravastatin in the Elderly at Risk) study identified
single nucleotide polymorphisms (SNPs) associated with cardiovascular deaths. We aimed
to characterise the SNPs at locus 14q32, investigate their effects on the region’s
snoRNAs and the suitability of these snoRNAs as a genetic marker in individuals at
risk of future cardiovascular events.
Methods
We filtered the published SNPs identified in our locus of interest. SNPs associated
with more than one type of cardiovascular event were identified and then mapped to
the genetic locus. Computational tools from the ViennaRNA suite were used to compare
the variation in strandedness within the genetic locus in the wild-type gene and compared
to the SNP. Using the SimRNA package and RNA contact prediction techniques, we predicted
and compared the 3D snoRNA structures in the absence and presence of the SNPs, as
well as investigating potential RNA–protein complexes.
Results
We found that these snoRNAs bind to fibrillarin, a methyltransferase, integral to
nucleolar remodelling and a component of the cellular response to stresses such as
chronic hypertension. The 14q32 SNPs identified by PROSPER overlap significantly with
the snoRNAs, suggesting effects on snoRNA structure. We found significant differences
in the strandedness of the genetic locus’ RNA between the SNP and the wild-type gene,
which results in significant changes in 3D snoRNA structure with potentially drastic
changes in fibrillarin binding, complex formation and function.
Conclusions
SNPs at the 14q32 locus lead to significant changes in snoRNA structure as well as
aberrant fibrillarin complex formation and function, which may result in pathological
intracellular responses to cellular stresses. Genetic screening offers the ability
to potentially identify those at high risk of future adverse events and who have the
most to gain from early therapy. They are also potential targets for specific genetic
therapies.
A199 Pat Magee Prize Winner—Assessing the Accuracy and Bias of Digital Symptom Checkers
in Diagnosing and Triaging Myocardial Infarction Patients: Cross-sectional Study
Wallace, William, Mr; Chan, Calvin, Mr; Acharya, Amish, Mr; Hanna, Lydia, Ms; Normahani,
Pasha, Mr; Chidambaram, Swathikan, Mr; Sounderajah, Viknesh, Mr; Darzi, Ara, Prof
Imperial College London, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A199
Objective
To assess the accuracy of commercially available symptom checkers (SCs) in diagnosing
and triaging patients presenting with myocardial infarctions (MI).
Methods
In this retrospective diagnostic accuracy study, SC accuracy was assessed by inputting
key symptoms and biodata of 100 consecutive annonymised MI patients from a tertiary
coronary intervention centre. Through a systematic search, eight SCs were identified
and included. Patient biodata and presenting symptoms were inputted into each SC;
outputted diagnoses and triage advice were recorded. Outcomes included (1) diagnostic
accuracy as defined by SCs outputting MI as the primary diagnosis (D1), or one of
the top three (D3), or top five diagnoses (D5) and (2) triage accuracy as defined
by SCs outputting urgent treatment recommendations.
Results
Overall D1 accuracy was 48 ± 31% and varied between SCs (range: 6–85%). D3 and D5
accuracy were 73 ± 20% (34–92%) and 79 ± 14% (63–94%), respectively. Overall triage
accuracy was 83 ± 13% (55–91%). 24 ± 16% of atypical cases had a correct D1. Atypical
MI D3 and D5 accuracy were 44 ± 21% and 48 ± 24% respectively and were significantly
lower than accuracy with typical MI cases (p < 0.01). Atypical MI triage accuracy
was also significantly lower than typical cases (53 ± 20% versus 84 ± 15%, p < 0.01).
D1 accuracy for atypical female MI cases was 10 ± 11%. Female atypical cases had significantly
lower diagnostic and triage accuracy than typical female MI cases (p < 0.01).
Conclusions
Symptom checker accuracy for correctly diagnosing an MI was generally low. 17% of
cases were under-triaged. Accuracy varied between symptom checkers: patients who presented
with atypical symptoms tended to be under-diagnosed and under-triaged, especially
if female. Thus, there is potential gender bias. This study, therefore, raises questions
regarding symptom checker improvement, safety, and regulation.
A200 The Utility of a Half-day Practical Workshop in Improving Medical Student Perceptions
and Exposure to Cardiothoracic Surgery (CTS)
Badran, Abdul
1, Dr; Shah, Owais1, Dr; Badran, Dania2, Dr
1University Hospital Southampton, Southampton, UK; 2Imperial College London, London,
UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A200
Objectives
Undergraduate interest in cardiothoracic surgery (CTS) has stayed the same or declined
over the years. Factors such as a lack of exposure in undergraduate curricula coupled
with negative perceptions of the specialty are likely contributing factors.
Methods
We designed and delivered a hands-on half-day cardiac surgical skills course in a
large medical school with the aim of providing exposure to and increasing medical
student interest in the specialty. Pre and post-workshop questionnaires were utilized
to investigate student perceptions of CTS and self-reported understanding and confidence
in performing various cardiac surgical skills.
Results
There was a total of 11 attendees. All agreed that CTS involved creative/skilful surgery
and being a rewarding career choice. Some negative perceptions of CTS included it
being considered highly stressful (18%), a female unfriendly specialty (27%) and involving
a hostile training environment (27%). Delegate self-reported understanding and confidence
in performing cardiac dissection, coronary anastomosis, aortotomy closure and knot
tying all increased significantly post-workshop (p < 0.05). Number of years of study
did not correlate with improvement in technique (90% of delegates either strongly
agreed or agreed to the statement that they were more likely to pursue a career in
CTS after attending this event. All but one delegate strongly agreed that the course
had positively impacted their views of CTS.
Conclusions
Here we demonstrate that an easily reproducible half-day practical workshop can be
utilized to not only improve undergraduate perceptions of the specialty but by providing
hands-on exposure, improve self-reported confidence and understanding of basic cardiac
surgical skills.
Thoracic Benign
A201 Outcome of Emergency Lobectomy Under Extracorporeal Membrane Oxygenation (ECMO)
Support in Patients with Severe COVID-19 Disease
Schweigert, Michael1, Prof; Almeida, Ana Beatriz
1, Mrs; Dubecz, Attila2, Prof; Spieth, Peter3, Prof; Gama de Abreu, Marcelo4, Prof;
Kellner, Patrick1, Dr
1University Hospital Schleswig–Holstein, Kiel, Germany; 2Klinikum Nuremberg, Nuremberg,
Germany; 3University Hospital Dresden, Dresden, UK; 4Cleveland Clinic, Ohio, USA
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A201
Objective
Not much is known about the results of non-elective anatomical lung resections in
COVID-19 patients put on ECMO. Aim of this study is to analyze the outcome of emergency
lobectomy under ECMO support in patients with acute respiratory failure due to severe
COVID-19 disease.
Methods
All COVID-19 patients undergoing emergency anatomical lung resection with ECMO support
at a German university hospital were included into a prospective database. The university
hospital serves as only ECMO center for a population of approximately 2 million people
in one of Germany´s most severely affected regions. Study period was 01.04.2020 to
30.04.2021 (first, second and third wave in Germany). Patients characteristics, indications
for surgery, clinical course and outcome were analyzed.
Results
A total of 9 patients (median age 61 years, IQR 10 years) were included. There was
virtually no pre-existing comorbidity (Median Charlson Score of Comorbidity 0.2).
The mean interval between first positive COVID test and surgery was 21.9 days. Clinical
symptoms at the time of surgery were sepsis (9/9), respiratory failure (9/9), acute
renal failure (5/9), pleural empyema (5/9), lung artery embolism (4/9) and pneumothorax
(2/9). Mean ICU and ECMO days before surgery were 15.4 and 6, respectively.
Indications for surgery were bacterial superinfection with lung abscess formation
and progressive septic shock (7/9) and abscess formation with massive pulmonary hemorrhage
(2/9). All patients were under veno-venous ECMO with femoral-jugular configuration.
Operative procedures were lobectomy (8) and pneumonectomy (1). Weaning from ECMO was
successful in 4/9. In-hospital-mortality was 5/9. Mean total ECMO days were 10.3 ± 6.2
and mean total ICU days 27.7 ± 9.9. Mean lengths of stay was 28.7 ± 8.8 days.
Conclusion
Emergency surgery under ECMO support seems to open up a perspective for surgical source
control in COVID-19 patients with bacterial superinfection and localized pulmonary
abscess.
A202 Total Pneumonectomy for Pulmonary Gangrene
Schweigert, Michael
1, Professor; Almeida, Ana Beatriz1, Mrs; Witzigmann, Helmut2, Prof; Dubecz, Attila3,
Prof; Stein, Hubert3, Prof
1University Hospital Schleswig–Holstein, Kiel, Germany; 2Städtisches Klinikum Dresden,
Dresden, Germany; 3Klinikum Nuremberg, Nuremberg, Germany
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A202
Objective
Necrotizing pulmonary infections resulting in devitalization of an entire lung are
devastating conditions with excessive mortality. Aim of this study is to shed light
on the role of total pneumonectomy for infectious lung gangrene.
Patients and Methods
In a retrospective multi-center study from a prospective database the outcome of non-elective
total pneumonectomy for infectious lung gangrene was analyzed at 6 centers in Germany,
Spain and the UK.
Results
There were 132 patients. Median age was 58 years (IQR 18,5). Mean Charlson score of
comorbidity was 2.8 (SD 2.54). Surgical procedures were total pneumonectomy (23),
lobectomy (91) and segmentectomy (18). ECMO was used for 11 patients (8 lobectomy,
3 pneumonectomy). There were no significant differences in age, comorbidity and mortality
(3/23 vs. 14/109; OR 1.02, 95% CI: 0.27–3.88, p = 0.98) between the pneumonectomy
and non-pneumonectomy group. Preoperative respiratory failure (12/23 vs. 30/109; OR
2.87, 95% CI: 1.14–7.20, p = 0.02), pleural empyema (20/23 vs. 50/109; OR 7.87, 95%
CI: 2.21–28.03, p < 0.01), sepsis (19/23 vs. 63/109; OR 3.45, 95% CI: 1.11–10.88,
p = 0.03) and acute renal failure (6/23 vs. 11/109; OR 3.14, 95% CI: 1.03–9.64, p = 0.04)
were significantly more common in the pneumonectomy group. Charlson Score > 3 (15/63
vs. 2/69; OR 10.47, 95% CI: 2.29–47.93, p < 0.01) and sepsis (17/70 vs. 1/62; OR 18.07,
95% CI: 2.32–140.85, p < 0.01) were associated with significant higher odds for mortality.
Multivariate analysis identified preop. sepsis, pleural empyema and persistent air
leak but not the extent of resection as significant risk factor for higher mortality.
Conclusions
In non-elective surgery for infectious lung gangrene mortality is not determined by
the extent of pulmonary resection but by the burden of pre-existent comorbidity and
the appearance of sepsis and septic complications. Total pneumonectomy is a life-saving
option for patients with infectious gangrene of an entire lung.
A203 Revolutionizing Surgical Side Infection (SSI) Surveillance with Personalized
Digital Patient Follow-up in Thoracic Surgery
Mayer, Nora, Dr; Alwis, Shehani, Ms; Rochon, Melissa, Mrs; Brown, Clare, Mrs; Birdsall,
Donna, Mrs; Asadi, Nizar, Mr
Royal Brompton & Harefield Hospitals, Part of Guy`s and St. Thomas NHS Foundation
Trust, Department of Thoracic Surgery, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A203
Objectives
SSI is the most costly healthcare associated infection and occurs within 30 days of
surgery. Short hospital stay and remaining drains specifically expose thoracic surgical
patients to SSI. Feasibility studies indicate positive patient experiences using mobile
technology for wound monitoring. Aim of our study is to introduce a personalized digital
SSI surveillance solution.
Methods
Between November 2020 and July 2021, 158 patients were added to the progressive web
app (ISLA Health LTD). Wound photos were taken at discharge by medical staff (Fig. 1
A) and uploaded 7 days after discharge by the patient (Fig. 1
B). Patient response, satisfaction and avoided travel distance were used as early
outcome measures.
Results
Patient response was 42% (N = 67 submissions). 3 patients (6.8% app user, 1.8% in
total) were diagnosed with conservatively manageable SSI. 1985 km travel distance
were avoided (Fig. 1
C). 44 patients (66%) answered the satisfaction evaluation. None of the patients expressed
concerns about sharing anonymised visual information online and 93% preferred uploading
a wound photo (Fig. 1
D) to describing the wound over the phone. 77.2% of the patients found the platform
easy to use and for 88% the photo upload was unproblematic.
Conclusion
The digital SSI surveillance solution was successfully implemented with good response
and high satisfaction rating.
A204 A Multi-lesional Analysis of DIPNECH Lesions Over 6 Years – Should we Routinely
Imaging These Patients?
Khor, Bo, Mr; Patel, Akshay, Mr; Shah, Tahir, Dr; Kalkat, Maninder, Mr; Hughes, Simon,
Dr
Queen Elizabeth Hospital, Birmingham, Birmingham, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A204
Objective
Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia (DIPNECH) is a rare disease
often associated with carcinoid tumours, and is characterized by a diffuse proliferation
of pulmonary neuroendocrine cells of the airway mucosa. The mainstay of diagnosis
and follow-up in this condition is imaging-driven usually with computed tomography
(CT). However, the optimal follow-up imaging intervals in DIPNECH patients are largely
unknown. We conducted a multi-lesional analysis of DIPNECH patients and in particular
the volumetric changes of DIPNECH lesions over a 6-year period.
Methods
We retrospectively analysed yearly CT scans from 22 patients with pathologically confirmed
DIPNECH over a 6 year period. Each patient had a previous pulmonary nodule resection
with confirmed DIPNECH pathologically. In each patient, we identified the 10 largest
DIPNECH lesions, stratified according to anatomical location (two lesions per lobe).
We measured the axial diameter (mm) and volume (mm3) in each lesion and followed these
up in each subsequent CT scan to ascertain any longitudinal changes. We present the
preliminary results of 250 lesions in 5 patients with CT scans over 5–6 years.
Results
We present preliminary data from 250 DIPNECH lesions in 5 patients over 6 years. The
overall median CT follow-up was 1985 days (1450–2290 days). The median inter-scan
interval was 365 days (349–826 days). No significant trend in axial CT diameter (r = 0.14,
p = 0.037) or CT volume (r = 0.0093, p = NS) over time in the 10 lesions examined
in each patient was noted. The overall trend in volume change over 6 years was not
significant (p = 0.71 by ANOVA).
Conclusions
Our preliminary data suggests that pulmonary nodule change in size is slow and we
could not detect any trends, irrespective of size at day zero, over 6 years of CT
follow up. If confirmed by the complete data set, CT follow-up may be able to delayed
rather than routine yearly scanning.
A205 Early Experience with Customized Polydioxanone Biodegradable Tracheobronchial
Stenting in Adult Airway Stenosis Following Lung Transplantation
Mayer, Nora
1, Dr; Perikleous, Periklis1, Mr; Khoshbin, Espeed2, Mr; Asadi, Nizar1, Mr
1Royal Brompton & Harefield Hospitals, Part of Guy`s and St. Thomas NHS Foundation
Trust, Department of Thoracic Surgery, London, UK; 2Royal Brompton & Harefield Hospitals,
Part of Guy`s and St. Thomas NHS Foundation Trust, Department of Heart &Lung Transplantation,
London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A205
Objectives
Airway stenosis following lung transplantation (LTX) adversely affects quality of
life and increases mortality. Established treatment options include bronchoscopic
dilatation, debridement, stenting and lung resection. Customized biodegradable stents
might offer advantages compared to conventional metal stents.
Methods
Patients with bronchial stenosis following LTX between 05/2019 and 10/2021 were included.
Uncovered, customized, biodegradable polydioxanone (PDS) stents were inserted. Surveillance
bronchoscopies for microbacterial and fungal growths were performed. Respiratory function
tests, frequency of readmission and courses of antibiotics used were some of the measured
outcomes.
Results
Seven biodegradable stents were inserted in three patients with non-anastomotic right
bronchus intermedius (RIB) and left main bronchus stenosis diagnosed 2–7 months post
LTX. All patients underwent multiple balloon-dilatations and two bare metal stents
for bridging before BD-stent insertion were required. No bleeding or perforations
were reported. One stent-migration was observed. All patients responded with relief
of symptoms and steady increase in pulmonary function test after BD-stent insertion
(ΔFEV1 1.56 l (50% pred.) to 3.1 l (91.5% pred.)).
Conclusion
Biodegradable customized tracheobronchial stenting is safe and efficient for the treatment
of post-LTX airway stenosis. Stented airways remained patent while BD-stents were
completely absorbed in two out of three patients. The patients presented with significant
stable improvement in lung function.
A206 Redo Minimally Invasive Pectus Excavatum Repair with Antomik Modelling Implant
Mulryan, Kathryn
1, Dr; Redmond, Karen2, Prof
1Beacon Hospital, Sandyford, Dublin, Ireland; 2Mater Misericordiae University Hospital,
Dublin, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A206
https://www.youtube.com/watch?v=0F59MlgBtjg
A207 Management of Post-Operative Atrial Fibrillation After Lung Resection
Ahmed, Aaliyah
1, Miss; Hashmi, Faisal2, Dr; Granato, Felice2, Mr
1Manchester Medical School, Manchester, UK; 2Wythenshawe Hospital, Manchester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A207
This study evaluates the management of POAF in patients undergoing thoracic surgery.
This was a retrospective study which consists of patients (n = 481) including segmentectomy,
lobectomy or pneumonectomy between April 2020–June 2021. 37 of these patients went
into atrial fibrillation post operatively, equating to 7.7% of the total population.
We looked at age, gender, continuation of beta blockers, digoxin use, type/site of
procedure, length of stay (LOS) and post-operative complications. NICE guidelines
(2004, amended 2016) recommend not to use digoxin for POAF.
A range of medications and combinations were used for POAF. The most common was bisoprolol
(65%), followed by amiodarone (49%). 10.8% of patients received digoxin. The mean
LOS was higher (3.1 days) in patients with POAF compared to those without POAF. The
average LOS (days) with digoxin was 10.3, bisoprolol 9.6 and amiodarone 9.2. The CHADSVASC
tool predicted 62.2% of the patients to be high risk of developing POAF.
To conclude, our study found CHADSVASC as a reliable tool to use for POAF risk prediction.
Digoxin is still used as a first line agent in the clinical setting which is against
NICE guideline recommendations and is associated with the longest LOS.
A208 Impact of Preoperative Smoking Status on Outcomes following Lung Resection
Mantio, Kim1, Miss; Ahmed-Issap, Amber
1, Miss; Jain, Shubham2, Dr; Habib, Akolade2, Dr; Spence, Angelica1, Miss; Brazier,
Andrew2, Mr; Mahendran, Kajan2, Mr; Srinivasan, Lakshmi2, Miss; Ghosh, Shilajit2,
Mr; Abah, Udo2, Miss
1Keele Medical School / University Hospitals of North Midlands, Stoke-on-Trent, UK; 2University
Hospitals of North Midlands, Stoke-on-Trent, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A208
Objective
The study was designed to quantify the impact of smoking immediately prior to lung
resection surgery.
Methods
We examined all consecutive lung resections at our institution from 01/01/2012 to
the 07/07/2021. Variables where extracted from a prospectively filled database with
missing data extracted from patient's records. Patients were divided into three cohorts;
those who smoked within 1 month of surgery (current smokers), those who had smoked
in the past (ex-smokers) and those who had never smoked (non-smokers). Length of ward
and HDU stay was used to estimate costs per hospital episode.
Results
In total 2439 patients where identified, of these 481 (19.7%) had never smoked, 1450
(59.5%) were ex-smokers and 507 (20.8%) were smoking within a month prior to surgery.
Pre-operative variables revealed worse lung function in current smokers when compared
to ex and non-smokers. (% predicted FEV1 77, vs. 84.5 vs. 95.8, % predicted TLCO 58.3
vs. 63.4 vs. 72.2 respectively). Preoperative co-morbidity including; cardiac, vascular,
cerebrovascular and respiratory disease was higher in the current and ex-smoking groups,
however history of previous malignancy was higher in the non-smoking group. The average
number of segments resected was 2.8 in the current and ex-smokers group and 2.2 in
the non-smokers (a single wedge was classified as 1 segment). Postoperative complications
were found to be significantly higher in current smokers when compared to ex-smokers.
(36.9% vs. 30.5% P 0.007) In particular prolonged air-leak and postoperative respiratory
tract infection (table 1). Length if ITU and overall hospital stay as well as average
cost was also significantly higher in the current smokers when compared to ex-smokers
and non-smokers.
Conclusion
Smoking immediately prior to surgery is associated with a significant increase in
morbidity, length of stay and cost to the NHS. It is therefore essential to optimise
this group of patients prior to intervention.
Non-smoker
Ex-smoker
Current-smoker
Overall Complications (%)
17
30.5
36.9
Arrhythmia (%)
2.7
5.8
4.7
LRTI (%)
4.6
11.2
18.1
Prolonged air-leak (%)
6.4
12.8
17
Length of stay (days)
5.5
7.6
8.3
HDU length of stay (days)
1.4
1.9
2.2
Average cost of post-operative stay (£)
3250.64
4508.04
5026.97
30-day mortality (%)
0.6
2.8
2.3
A209 Use of Bilateral Paravertebral Blocks for Pain Management in Pectus Nuss Bar
Patients
Williams, Jennifer, Miss; Musab, M., Mr; Devbhandari, M., Mr; Kornaszewska, M., Miss;
Combellack, T, Mr; Pirtnieks, A., Mr; Valtzoglou, V., Mr
University Hospital of Wales, Cardiff, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A209
Objectives
Managing post-operative pain in Pectus Nuss Bar patients can be challenging due to
the complete remodelling of a young patient's chest wall. The initial week following
a Nuss Bar insertion is typically the most painful period and our aim was to gain
better control of this acute period. We aimed to improve early mobility, prevent hospital-acquired
pneumonia, shorten length of hospital stay and improve patient satisfaction.
Method
Data was collected retrospectively from our PATs database for all patients undergoing
a Pectus Nuss Bar insertion from January 2007 to October 2021. 69 patients were identified
between 2007 and April 2016 who did not have bilateral paravertebral blocks inserted.
Their post-operative outcomes were compared with 52 patients from April 2016 to October
2021 who did have bilateral PVB placed.
Pectus Nuss Bars are inserted under video-assisted thoracoscopic guidance which enables
direct vision of PVB catheter placement into the right and left intercostal spaces.
The PVB catheter is usually inserted into the 5th intercostal space bilaterally. Post-operatively,
the bilateral paravertebral catheters remain insitu for four days and each patient
has daily specialist pain team review. After four days, the fentanyl PVBs are discontinued
and patients are stepped down to oral analgesia with a plan to discharge home.
Results
The 52 patients who underwent bilateral PVB during their Nuss Bar insertion had a
0% rate of hospital-acquired pneumonia, compared to 1.8% rate in the 69 patients between
2007 to 2016. The average length of stay was reduced to 4.8 (± 1.2) days from 5.6
(± 1.5) days. The rate of pneumothorax requiring chest drain insertion was also lower;
only 2 patients between 2016 to present required a drain compared to 5 people 2007
to April to 2016.
Conclusions
We found in our single centre experience that bilateral PVB insertion improves Pectus
Nuss Bar patient's speed and quality of recovery.
A210 Review of Patients Discharged Post Thoracic Surgery with Chest Drain in Situ
and Drain Follow-up Clinic
Aljanadi, Firas, Mr; Strickland, Jonathan, Dr; Montgomery, Liana, Mrs; Jones, Mark,
Mr
Royal Victoria Hospital, Belfast, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A210
Objectives
Persistent air leak and prolonged drainage are well-recognised complications of thoracic
surgery. These complications increase the hospital stay and costs of care. Patients
can be discharged with a chest tube in situ and followed up in a ward-based nurse-led
clinic. We reviewed such patients and rate of readmission after discharge with a chest
drain to assess the effectiveness of the drain follow-up clinic.
Methods
Retrospective review of our prospective database for 22 months (March 2019 to January
2021). We identified 62 patients who were discharged from the thoracic surgery ward
with a chest drain and attached bag with one-way valve. Analysis focussed on indication
and duration of chest drainage, complications, and readmission for any reason.
Results
62 patients were discharged with a chest drain in situ representing 5% of all the
patients who had thoracic surgery within the study period. Median age was 67 years
(range 22–85 years) with 24 females and 38 males. 52% of the patients underwent a
video-assisted thoracoscopic approach, 27% of them a thoracotomy and 21% had an isolated
bedside chest drain insertion. Following hospital discharge, median duration of chest
drainage was 11 days [interquartile range (IQR) 7–18.75 days]. Patients had 106 review
episodes in the ward-based nurse-led clinic. Indication was prolonged air leak (71%;
72 clinic reviews), persistent fluid drainage following evacuation of empyema (16%;
24 clinic reviews) and persistent fluid drainage for simple effusion (13%; 10 clinic
reviews). Median length of drain stay was 30 days (IQR 19.75–54 days) for empyema,
10 days (IQR 6–16 days) for air leak and 8 days (IQR 6.5–12 days) days for simple
effusion. 9 patients required readmission (14.5%) and empyema had developed in 3 patients
(4.8%).
Conclusions
Patients discharged with a chest drain in place can be followed up in a dedicated
ward-based nurse-led monitoring clinic for optimal quality of care.
A211 A Service Evaluation of COPD Referral From Community to Secondary Care in a Community
Based Screening Program
Bone, George, Mr; Desouza, Abigail-Sara, Miss; Woo, Edwin, Mr; Alzetani, Aiman, Mr
University Hospital Southampton NHS Foundation Trust, Southampton, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A211
COPD is a prevalent respiratory disease that is insidious with high health and socio-economic
burden. Early diagnosis, specialist referral and smoking cessation have a large influence
on outcomes. A screening programme (Targeted Lung Health Check -TLHC) has been offering
CT scans to ever smokers aged 55 to 74 to detect lung cancer. This has incidentally
picked patients with emphysema and those with moderate to severe radiological changes
were referred to a respiratory clinic/smoking cessation. This study aims to evaluate
the referral pathway and its efficiency.
This study examined a cohort of participants who had a radiological diagnosis of moderate
to severe emphysema as a result of their TLHC CT scan. Their route of referral from
their scan to being seen in a specialist respiratory clinic and what management was
delivered was recorded alongside information such as demographics, smoking status,
comorbidities, ECOG performance status.
Between Sep 2019- Sep 2021 there were 274 participants were screened. Dyspnoea was
noted in 214 with an ECOG > 1 in 37%. There was a diagnosis of emphysema in 42 patients
and COPD in 144. All patients had moderate to severe emphysema on Low dose CT and
were referred to a specialist respiratory clinic. Fifty five patient were seen within
7.7 (range 1–15 month). Covid-19 and the lack of senior respiratory clinicians were
the main reason for the delay and for the minimal number reviewed. There were 143
current smokers who were signposted to local smoking cessation services but only 13
(9%) participants took part.
COPD is a major health concern in the UK and BTS has set guidelines on referring patients
with advanced disease (GOLD 3/4) for specialist management including Lung volume reduction
surgery (LVRS) and the recently NICE approved Endobronchial valve therapy. This study
is a snapshot of how under detected this disease is and the need for a more efficient
pathway from community to specialist secondary and tertiary care.
A212 Effectiveness of Endotracheal or Endobronchial Stenting in Adult Expiratory Central
Airway Collapse: A Systematic Review
Toale, Conor, Mr; Redmond, Karen C, Prof
Mater Misericordiae University Hospital Dublin, Dublin, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A212
Objectives
This study analysed the available literature regarding the effect of endotracheal
or endobronchial stenting on outcome measures in patients with expiratory central
airway collapse (ECAC). The primary outcome measure was the change in FEV1 pre- and
post-stent insertion. Secondary outcomes were changes in other physiological measures,
symptomatology, and quality of life.
Methods
A systematic review was performed of the Embase, Pubmed, Web of Science and Cochrane
library databases, according to the Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) guidelines. Articles were sought which included patients
undergoing stent insertion for ECAC and reported on outcomes of interest.
Results
Seventeen articles were included in a narrative synthesis. Of the five studies reporting
changes in FEV1 after stenting in patients with ECAC only, four could not demonstrate
any significant improvement in FEV1. Only one study including patients with ECAC only
recorded pre- and post-stenting FVC, and noted no significant difference. A total
of 149 of 225 patients (66.22%) across five studies reported subjective improvement
in one or more symptoms. The reported pooled stent-related complication rate was 0.074
per patient-month across six included studies.
Conclusion
Prospective observational studies with clear patient inclusion criteria are required
to determine the effect of stenting on outcomes in ECAC. Available evidence does not
demonstrate improvements in pulmonary function test measures after endoluminal stenting
for patients with ECAC. Patient-reported outcomes such as subjective symptom improvement
and quality of life measures are likely to be more useful than objective spirometry
measures in determining treatment success.
A213 The Impact of the COVID-19 Pandemic on Urgent Referrals to the National Thoracic
Surgery Unit in Ireland
Kelly, Michelle, Ms; Eaton, Donna, Prof; Redmond, Karen, Prof; Brown, Rachel, Mrs
Mater Misericordiae University Hospital, Dublin, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A213
Introduction
The Irish Health Service (HSE) responded to the COVID 19 pandemic by forming a surge
agreement in October 2020 with Private hospitals to provide services to a number of
surgical and medical specialities including Thoracic Surgery.
Objectives
The aim of this study was to evaluate the impact of this agreement during the COVID-19
pandemic on urgent referral waiting times for patients requiring thoracic surgical
intervention.
Methods
The study compares the referral to surgery waiting times in 2019 compared to October
2020- October 2021. All patients referred to either of the thoracic surgeons during
this period were included in this retrospective review.
Results
Patients referred in 2019 prior to the HSE agreement had a median waiting time of
six days from referral to surgery, this is compared to a median waiting time of 2 days
with the HSE agreement in place. 49% of these patients were transferred and underwent
surgery within 24 h of referral.
Conclusion
The HSE agreement has had a dramatic impact on referral to surgery times for patients
awaiting urgent transfer for thoracic surgery in Ireland.
A214 Return to Work and Activity After Rib-Fixation for Acute Chest Trauma: A Retrospective
Matched-Cohort Study
Blythe, Andrew, Mr; Cassidy, Roslyn, Dr; Hill, Janet, Dr; Diamond, Owen, Mr; McManus,
Kieran, Mr
Royal Victoria Hospital Belfast, Belfast, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A214
Objectives
Rib fractures present heavy pain and functional burdens. Surgical stabilisation of
rib fractures (SSRF) improves mortality, morbidity, and length of stay (LOS). However,
the literature is limited regarding functional outcomes after SSRF. Our primary outcome
was to determine if SSRF improved return to work (RTW) in patients with acute rib
fractures. Our secondary outcomes were pain and quality of life (QOL) scores.
Methods
A retrospective matched cohort study was conducted of patients with rib fractures
between 2008–2020 that underwent SSRF. Inclusion and exclusion criteria were applied
to ensure relevance to the study. All eligible patients who underwent surgery were
matched to non-surgically managed patients. Validated PROMs were used to collect data:
specifically, the Work Productivity and Activity Impairment Instrument (WPAI), the
Brief Pain Index (BPI) and the EQ-5D-5L for RTW, pain, and QOL respectively.
Results
Of 1841 trauma patients with rib fractures 66 underwent SSRF. After inclusion and
exclusion criteria, 38 pairs of patients were eligible for the study; 30 pairs completed
the questionnaires, a success rate of 79%. More patients in the SSRF cohort returned
to work, but the difference was not significant. There was a significant decrease
in productivity in the SSRF versus the non-fixed cohort. There was no difference in
pain or QOL scores between the two groups. Importantly, the SSRF group had significantly
higher LOS in hospital and ICU, indicating a difference in the injury profile of the
two groups.
Conclusion
Patients who undergo SSRF for rib fractures have similar RTW rates, pain and QOL scores
compared to patients managed conservatively. However, retrospective comparison studies
in this patient population are challenging due to the confounding factors of polytrauma
injuries and lack of an appropriate comparison group. This is the first study that
uses a validated injury-specific PROM, the WPAI.
A215 Managing Expectations of Endobronchial Valve Insertion
Williams, Jennifer, Miss; King, E, Miss; Musab, M., Mr; Combellack, T, Mr; Pirtnieks,
A., Mr; Kornaszewska, M., Miss; Valtzoglou, V., Mr
University Hospital of Wales, Cardiff, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A215
Patients with severe emphysema can lead a debilitating life, suffering with significant
breathlessness and a reduced quality of life. Those patients suitable for endobronchial
valve (EBV) insertion need appropriate counselling regarding the risks and benefits
of EBVs. The aim is to provide EBV patients with a patient leaflet to help supplement
their consultant lead clinic appointments. The leaflet is designed to help provide
realistic outcomes for the acute and long term benefits of EBV insertion.
There is an industry patient pamphlet for the Zephyr valve however we generated our
own leaflet to describe in more detail the patient pathway in our centre for our EBV
patients. Following EBV insertion our patients will remain on bed rest for the first
24 h, then have daily chest x-rays for 5 days to assess for lobar lung collapse and
are covered with a weeks course of doxycycline. Patients have an upto 25% chance of
a pneumothorax requiring a chest drain and therefore will have a chest drain insertion
kit at their bedside. There is a 25% chance of valve migration and failure of improvement
of symptoms.
Patient leaflets are to be provided in outpatient clinics prior to EBV insertion following
Consultant decision to treat. Prospective data collection in the form of patient feedback
forms are to be collected in their first post-operative follow-up appointments. Long
term follow-up maintained with an upto date chest x-ray to ensure any valve migration
and loss of collapse is identified early.
Our single centre found that some patients who had a poor outcome and little symptom
relief from their EBVs were highly disappointed. Alongside Consultant counselling
in clinic a patient leaflet describing the full pathway should help to manage patient
expections when inserting EBVs. Endobronchial valves are not a cure for their severe
emphysema however can improve symptoms. COPD unfortunately remains a progressive illness
and these patients are high-risk for any intervention.
A216 Chest Trauma- Excess Mortality Review from A Single Trauma Centre
Kew, Ee Phui, Mr; Hunt, Ian, Mr
St George's Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A216
Objectives
The Trauma Audit & Research Network (TARN) has identified 99 trauma patients who died
despite having high Probability of Survival (PS) from 2016 to 2018 in our centre.
Of the 99 patients, 11% (n = 11) had chest trauma as the main injury. Our aim was
to review this group of patients and identify any contributing factors to their mortalities.
Methods
Retrospective review of patients identified by TARN as excess mortality. Imaging,
case notes and coroner’s reports were studied.
Results
Of the 11 patients reviewed, 64% (n = 7) were female and 36% (n = 4) were male, with
mean age of 86.9 years old and mean PS of 87.4. After reviewing all the case notes,
27% (n = 3) of deaths were deemed unexpected. One patient died due to aspiration and
lower respiratory tract infection; another death was due to possible massive pulmonary
embolus; the third unexpected death was a patient who was discharged and readmitted
with sepsis. Further analysis of these 3 cases revealed that there was no significant
incidence or clinical mismanagement related to their unexpected deaths. However, we
found a need for better and quicker anaesthetic service to provide serratus anterior
block for rib fractures. This review also raised the question whether there is any
benefit in fixing the ribs of patients aged 80 and above. 73% (n = 8) of the excess
mortality were deemed to be ‘expected’ despite high PS as those patients were all
either elderly, frail with multiple co-morbidities or were extremely unwell on admission.
Conclusions
Better access to serratus anterior block for rib fractures in our unit is needed.
The PS calculation needs to be reviewed as the score did not correlate with the actual
outcome of our patient cohort. A well-designed study is needed to investigate any
benefit of rib fixation in elderly patients in terms of prognosis and quality of life.
A217 Are we Removing Chest Drains Correctly?
Kew, Ee Phui, Mr; Mangel, Tobin, Dr; Mozalbat, David, Mr; Tan, Carol, Ms; Smelt, Jeremy,
Mr
St George's Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A217
Objectives
There is a risk of air entrainment into the pleural cavity during chest drain removal
thereby causing an iatrogenic pneumothorax. BTS guidelines states that chest drains
should be removed during a Valsalva manoeuvre or during expiration. Bell et.al and
Cerfolio et al. performed randomised controlled trials comparing Valsalva manoeuvre
on maximal inspiration and expiration which did not show any difference in clinically
significant pneumothorax post chest drain removal. The objective of this audit was
to assess how many doctors and nurses in our cardiothoracic unit know how to remove
chest drain using either recognised techniques (Valsalva manoeuvre or during expiration)
using a standard of 100%.
Methods
A survey consisting of 6 questions was conducted in our unit during January 2021.
The survey explored subjects’ confidence and experience in chest drain removal, whether
they have received training, their preferred technique and the rationale. The findings
were presented in April 2021. Re-audit was performed using the same survey during
Oct 2021.
Results
32 subjects were interviewed in the first cycle (16 doctors, 16 nurses). More nurses
than doctors reported having experience in chest drain removal (88% vs. 56%). 87%
of nurses and 69% of doctors knew the recognised techniques. More nurses than doctors
reported confidence score of 4/5 and 5/5 in chest drain removal (82% vs. 44%). Only
3 subjects correctly explained that Valsalva manoeuvre increases intrapleural pressure.
In the second cycle, 45 subjects were interviewed (38 nurses and 7 doctors) and all
of them knew the accepted techniques.
Conclusions
This study revealed the need for more chest drain removal training amongst doctors
and further teaching on basic respiratory physiology to healthcare professionals.
The re-audit showed significant improvement with 100% of the subjects reported using
the correct technique.
A218 Targeted Surgical Management of Slipping Rib Syndrome
Santhirakumaran, Gowthanan, Mr; Shah, Mohammed, Dr; Hunt, Ian, Mr
St George's Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A218
Objectives
Slipping rib syndrome (SRS) is not well recognised by physicians and many patients
have multiple consultations and investigations prior to diagnosis. SRS is caused by
hypermobility of the costal cartilages of the 8-10th ribs. Recent studies have demonstrated
the clinical effectiveness of surgical management via rib(s) excision/stabilisation.
Dynamic ultrasound of the chest wall (DUS) has shown an emerging investigative tool
in aiding diagnosis of SRS, in what is traditionally a clinical diagnosis. We aimed
to determine if a standardised management protocol based on a targeted excision/repair
technique could determine significant symptom improvement using health outcome measures.
Methods
A single centre retrospective analysis of all patients (n = 18) undergoing surgical
intervention for SRS between September 2019 – July 2021. We obtained data using standardised
health & pain questionnaires pre-operatively and post-operatively, outcomes compared
with Mann–Whitney U test.
Results
Figure 1 summarises the patient pathway and the treatment algorithm for SRS devised
in our unit. Median length of history was 6 years—DUS identified the excursion movement
of the specific rib in all cases. All 18 patients underwent a targeted rib excision
with/without stabilisation. Post-operatively, mean improvement in pain at 6 weeks
was 46% (p < 0.01). Other outcome measures demonstrated patients had improvement of
functional symptoms by 60% (p < 0.01) and severity of symptoms of anxiety/depression
by 38% (p < 0.01).
Conclusions
A targeted surgical approach to SRS with DUS as an important investigative tool provides
demonstrable clinical benefit. This management protocol has illustrated its reproducibility
in standardising effective SRS treatment.
A219 Results of Surgical Closure of Chronic Bronchopleural Fistula with Vascularized
Tissues
Hammad, Walid, Mr
El-Hussein University Hospital, Al-Azhar Faculty of Medicine for boys, Cairo, Egypt
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A219
Objectives
This study was carried out to assess the efficacy of surgical closure of the chronic
BPF using vascularized tissue buttress.
Methods
A prospective randomization of 28 patients with chronic BPF with or without empyema.
Postoperative or non-operative etiologies were included. The classical clinical picture
was a patient with pneumothorax on chest tube drainage showing varying bubbling during
respiratory cycle and failure of lung to expand despite adequate pleural cavity drainage
and antibiotic therapy. Fifteen patients had associated stage 2 empyema on the time
of intervention. All patients were subjected to surgical intervention using different
vascularized tissue transferred into the pleural cavity. These tissues were selected
according to the location of the fistula, size of the residual space, and sterility
of the pleural cavity. Based on proper preoperative planning and selection, the tissues
used varied between intercostal muscle flap, latissmus dorsi muscle, Omental flap,
or Pericardial pad of fat. Adequate preoperative drainage of the pleural cavity was
mandatory. Followed by Intraoperative debridement and sterilization of the pleural
cavity before closing the BPF with the tissue coverage.
Results
The duration of persistent air leak before deciding surgical intervention was varied
significantly among our patients with a mean period of 5 ± 2.12 months. No patient
required instillation of sealants through the tubes. There was immediate or early
stoppage of air leak after the intervention in all patients. All patients had their
drains removed before discharge. The mean hospital stay was 4 ± 1 day. Technical difficulties,
deformities, chronic pain were reported.
Conclusion
Once the BPF develops, early recognition, drainage of the pleural space and control
of the inflammatory process are critical. Surgical closure of chronic BPFs with proper
vascularized tissues is an effective technique associated with low cost and lower
hospital stay.
A220 Outcomes of Video-thoracoscopic Minimally Invasive Pectus Excavatum Corrections:
A Single Centre Experience from Wales
Devbhandari, Mohan, Mr; Koskolou, Stamatina, Dr; Williams, Jennifer, Miss; Combellack,
Tom, Mr; Valtzoglou, Vasileios, Mr; Pirtnieks, Ainis, Mr; Kornaszewska, Malgorzata,
Miss
University Hospital of Wales, Cardiff, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A220
Objectives
To assess the outcomes of pectus excavatum repair in our centre and compare with the
results from international centres of excellence.
Methods
Retrospective analysis of prospectively collected data on all patients undergoing
pectus excavatum repair at our centre by a single surgeon from October 2014 to October
2021 were carried out. Continuous data was expressed as mean (± SD) for parametric
data and median (IQR) for non-parametric data using Minitab version 19 statistical
package.
Results
During this period a total of 92 patients underwent pectus repair surgery in out institution
out of which 74 cases were operated for pectus excavatum while 18 operations were
for pectus carinatum. Out of the Pectus excavatum group 10 underwent open modified
Ravitch repair while a total of 64 patients underwent pectus repair surgery using
Nuss bar through video assisted thoracic surgery (VATS) approach (study group). Patients
in the study group were operated after spending a mean of 177 days (± 133 days) in
the waiting list for surgery. There were 53 male and 11 female patients with mean
age of 20.4 years (± 4.6 years). 23 of the patients were below the age of 18 while
41 patients were 18 and above. Their median post-operative stay was 4.9 days (± 1.5 days).
Postoperative wound complications were seen in 5 patients which were managed successfully
with local wound care. Patients were reviewed in the outpatient clinic in 6wk, 6 months,
1 year, 2 year and 3 years after which the bars were removed. Cosmetic improvement
was good to excellent in all patients.
Conclusion
In our experience video-thoracoscopic minimally invasive Pectus excavatum correction
with Nuss bar insertion produce excellent result.
A221 Maintaining Standards of Care in Thoracic Surgery During the Sars-Cov-2 Pandemic
Alshammari, Abdullah, Dr; Hoffman, Ross, Mr; Chavan, Hemangi, Miss; Kaniu, Daniel,
Mr; Gallesi, Jose Alvarez, Mr; Pons, Aina, Ms; Jordan, Simon, Mr; Begum, Sofina, Miss;
Buderi, Silviu, Mr
Thoracic Surgery, The Royal Brompton Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A221
Objectives
During SARS-CoV-2 pandemic measures were implemented to continue delivering high-quality
thoracic surgery service. This study reports our experience in delivering elective
lung resection surgery, including mortality and morbidity.
Methods
This is a retrospective study of all patients between March 2020 to September 2020.
Data were obtained from Patient Assessment and Tracking System (PATS). During this
period, a set of measures were implemented while working across different hospitals
around London, including self-isolation, pre-operative SARS-CoV-2 screening, virtual
consultations and remote pre-assessment. Digital platforms were employed to facilitate
communication between members of the multidisciplinary team. Descriptive statistics
used to analyse the data.
Results
A total of 214 patients included for analysis, of which 99 patients had lobectomies.
The mean age was 64.4 (10–87) years and 57 were females. There was no recorded mortality.
Seven patients had post-operative complications including pneumonia, respiratory failure
requiring ventilatory support in the intensive care unit and one required completion
pneumonectomy. The mean Thoracoscore was 1.66 (0.06 –9.5). The mean length of stay
was 5.5 (1–24) days. When compared to our practice in 2019, these results are similar.
None of the patients developed SARS-CoV-2 infection post-operatively.
Conclusion
It was possible to maintain the expected standards of care with acceptable surgical
outcomes during the pandemic. This was achieved with deliberate implementation of
technology, set measures, and working in collaboration with the multidisciplinary
team.
A222 The Use of Carinal Y-stents in the Emergency Management of Peri-operative Injury/dehiscence
of the Major Airways
Smith, Edel, Dr; Brown, Rachel, Ms; Aladaileh, Mohammad, Dr; Eaton, Donna, Prof
Mater Misericordiae University Hospital Dublin, Dublin, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A222
Objectives
Major airway injury/disruption is rare and can be difficult to manage. Surgical repair
is favoured however, in patients with large/complex defects or in frail patients management
may involve stenting of the airway. We present 5 patients all of whom had a carinal/Y-stent
sited for urgent or emergency management of major airway defects.
Methods
We included all patients who had a Leufen carinal/Y-stent inserted for emergency management of
major airway injury. Stents were inserted using a rigid bronchoscopy under both bronchoscopic
and fluoroscopic guidance.
Results
The aetiology of the injury in 3 cases was intra-operative injury to the major airways;
1 during tracheal resection, 1 during thyroid surgery and 1 following an oesophagectomy.
A further 2 patients had right main airway anastomotic dehiscence post-operatively,
1 post double-lung transplantation and 1 post-right upper lobe sleeve lobectomy.
In all cases the y-stent covered the airway defect, allowing all patients to be extubated
following stent insertion. All patients subsequently underwent uncomplicated elective
stent removal with complete resolution of the underlying defect.
Conclusions
In all cases the major airway disruption was successfully managed using a carinal
Y-stent that was subsequently removed. No further airway interventions were required
in any patient.
A223 Robotic Approach to the Sympathetic Chain
Brown, Rachel, Mrs; Aladaileh, Mohammad, Mr; Toerien, Lara, Ms; Eaton, Donna, Prof
Mater Misericordiae University Hospital, Dublin, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A223
Introduction
A robotic approach to the sympathetic chain provides superior dexterity, magnification
and 3D visualization. This facilitates a highly selective sympathectomy (with division
of only pre- and post-ganglionic fibres) in patients with hyperhidrosis and precise
division of the stellate ganglion in patients requiring cardiac denervation.
Methods
All cases undergoing robotic surgery on the sympathetic chain for hyperhidrosis, facial
flushing and cardiac denervation (except unstable patients) were included.
Results
Analysis from the Intuitive DaVinci robotic system shows the median operating time
for all procedures on the sympathetic chain is 62 min. 92% of the cases cost E270
for consumables, the remaining 8% averaged a cost of E660 due to additional instruments
required to manage more complex adhesions. The length of stay is reduced in the robotic
group with the majority of those undergoing selective sympathectomy being done as
day cases. There have been no complications.
Conclusion
Cost and operator times are comparable, patient length of stay is reduced in the robotic
programme. We found that a robotic approach improves dexterity, visualisation and
precision. This approach allowed accurate division of the sympathetic chain facilitating
a highly selective sympathectomy for hyperhidrosis and allowing precise division of
the stellate ganglion in patients undergoing cardiac denervation.
A224 Reducing the Critical Care Burden of Patients Undergoing Sternotomy for Non-Cardiac
Surgery at our Institution
Earnshaw, Charlotte, Dr; Elston, Victoria, Miss; Abdelhadi, Ahmed, Dr; Gurney, Stefan,
Dr; Kamalanathan, Kajan, Dr
University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A224
Objectives
A change in local practice resulted in non-cardiac sternotomy patients being managed
on the ward post-operatively, rather than defaulting to critical care. We sought to
evaluate our rate of unplanned critical care admission subsequent to this intervention
and make comparison of routine practice to thoracic units nationally.
Methods
We retrospectively reviewed electronic and paper records from our enhanced recovery
database for all non-cardiac sternotomy patients from March 2016 until July 2021.
We then contacted all UK thoracic centres via telephone or email to establish patterns
in current national practice.
Results
There were a total of 23 patients. Nine patients (39.1%) spent ≥ 1 post-operative
day in critical care. Seven patients were electively admitted to critical care due
to co-morbidities or extent of surgery, and there were two unplanned admissions. Nationally,
60% of centres routinely send all non-cardiac sternotomies to a critical care or higher-level
care area and 40% automatically provide post-operative care on the ward, unless significant
patient co-morbidities exist.
Conclusions
The majority of UK thoracic centres manage non-cardiac sternotomy patients in critical
or higher-level care post-operatively. Critical care bed capacity is a limited resource,
especially in the current climate. With appropriate training of nursing and medical
staff these patients can be managed routinely on a normal thoracic ward. In our institution,
this change in practice has led to improvements on patient flow and reduced the burden
on critical care bed capacity.
A225 Minimally Invasive Total Thymectomy in Myasthenia Gravis
Santhirakumaran, Gowthanan, Mr; Hunt, Ian, Mr; Tan, Carol, Ms; Smelt, Jeremy, Mr
St George's Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A225
Objectives
The role of thymectomy via a median sternotomy approach in treatment of myasthenia
gravis has demonstrated long term clinical benefit with a multicentre randomised control
trial. However, as with lung resection, a minimally invasive approach could improve
morbidity and length of stay. We aim to assess the impact of minimally invasive approach
on morbidity and its comparable therapeutic benefit in myasthenia gravis.
Methods
A single centre retrospective review of all myasthenia gravis patients undergoing
minimally invasive total thymectomy between January 2019–November 2020 was performed.
Data consisted of patient demographics, symptoms, pre-operative medications, post-operative
length of stay, complications, 12 month follow up of symptom improvement and medication.
Results
A total of 21 myasthenia gravis patients (Osserman Classification 1–4), with a mean
age of 37 years, underwent a total thymectomy via a minimally invasive approach. None
required a conversion to a sternotomy, median post-operative length of stay was 3 days
and 1 patient had a recognised complication of post chest drain removal pneumothorax
requiring drain re-insertion. At follow-up, 95% of the patient cohort had improvement
or complete resolution of myasthenic symptoms. 82% that pre-operatively required immunosuppression
with prednisolone did not require immunosuppression or received reduced dosage. 60%
had significant symptom improvement with associated reduced daily requirement or discontinuation
of pyridostigmine.
Conclusions
Minimally invasive total thymectomy in myasthenia gravis may offer reduced morbidity
and similar long-term clinical benefit to that found in the traditional open approach.
A226 Pulmonary Complications and Mortality of Veno-venous Extracorporeal Membrane
Oxygenation as Treatment for COVID-19 Pneumonitis
Norkunas, Mindaugas, Mr; Hoffman, Ross, Dr; Somasundram, Khevan, Dr; Aw, TC, Dr; Singh,
Suveer, Prof; Shaarawy, Ezeldin, Dr; Buderi, Silviu, Mr; Begum, Sofina, Miss; Lim,
Eric, Prof; Jordan, Simon, Mr
Royal Brompton and Harefield NHS Foundation Trust, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A226
Objectives
Veno-venous extracorporeal membrane oxygenation (vv-ECMO) is effective treatment for
refractory hypoxemia caused by COVID-19 virus. Our aim was to review the rate of pulmonary
complications, their treatment and survival to discharge for these patients.
Methods
It was a retrospectively conducted analysis of prospectively collected data of patients,
treated with vv-ECMO for Covid-19 infection caused respiratory failure, between March
2020 and October 2021. The end points where incidence, treatment choice and in-hospital
mortality.
Results
During this period 166 patients (mean age 51, SD ± 13.75) required vv-ECMO. In 42
(25.3%) cases patients needed intervention to treat pulmonary complications by radiological
or surgical intervention. 27 (16.2%) patients had pneumothorax and 28 (16.8%) pleural
effusion/haemothorax requiring drain insertion. In 13 (7.8%) cases patients needed
treatment for both. 7 (4.2%) patients required video assisted thoracoscopic surgery,
six of them for haemothorax and one for recurrent pneumothorax. In-hospital mortality
in intervention group was 13 (30.95%;) vs 27 (21.77%; p = 0.355) in no intervention
group.
Conclusions
Timely and multidisciplinary-led interventions allowed this complex group of patients
have statistically similar survival rate compared to no intervention group.
A227 Impact of Extremes of BMI on Outcomes Following Lung Resection
Jain, Shubham, Dr; Ahmed-Issap, Amber, Miss; Habib, Akolade, Dr; Mantio, Kim, Miss;
Spence, Angelica, Miss; Brazier, Andrew, Mr; Mahendran, Kajan, Mr; Srinivasan, Lakshmi,
Miss; Ghosh, Shilajit, Mr; Abah, Udo, Miss
University Hospitals of North Midlands, Stoke-on-Trent, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A227
Objective
BMI has been demonstrated to be an independent predictor of survival following lung
resection for NSCLC, with a low BMI associated with worse survival and a high BMI
associated with a protective effect. We designed this study to quantify the short-term
impact of abnormal BMI on outcomes following lung resection.
Methods
We examined all consecutive lung resections at our institution from 01/01/2012 to
the 07/07/2021. Variables where extracted from a prospectively filled database with
missing data extracted from patient's records. Patients were divided into three cohorts;
those with a low BMI (< 18.5), those with a normal/high BMI (18.5–29.9) and the obese
(BMI > 30) post-operative complications, length of stay and 30-day mortality were
examined.
Results
In total 2439 patients where identified, of these 2341 BMI value available and were
included in the study. 60 patients (2.6%) had a BMI < 18.5, 1586 (67.7%) had a BMI
of 18.5–30 and 695(29.7%) had a BMI > 30. Preoperative comorbidities including HTN,
DM, previous malignancy and elevated cholesterol were higher in the obese group. However
IHD, cerebrovascular disease and cardiac failure were higher in the mid-range group
and peripheral vascular disease, pulmonary disease and high alcohol intake higher
in the low BMI group. Postoperative complications were found to be significantly higher
in the low BMI group when compared to a normal and high BMI which appeared to be protective
(Table 1).
Conclusion
Low BMI is associated with significantly worse postoperative outcomes and a four-fold
increase in mortality when compared with normal and high BMI. Obesity appears to incur
a protective effect in terms of both morbidity and mortality.
Low BMI < 18.5
BMI 18.5–30
Obese BMI > 30
Overall Complications (%)
43.3
30.8
23.2
Arrhythmia (%)
10
5.2
3.7
LRTI (%)
26.7
10.8
8.9
Prolonged air-leak (%)
25
14.4
6.9
Length of stay (days)
10.2
7.5
6.3
HDU length of stay (days)
2.9
1.9
1.5
30-day mortality (%)
8.3
2.0
1.7
A228 Is the 3D Reconstructive Scan a Useful Tool in Lung Cancer Surgery?
Tahhan, Ghis
1, Dr; Combellack, Tom2, Mr; Pirtnieks, Ainis2, Mr; Valtzoglou, Vasileios2, Mr; Kornaszewska,
Malgorzata2, Mrs
1Cardiff University, Cardiff, UK; 2University Hospital of Wales, Cardiff, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A228
Objectives
Lung cancer surgery considers challenging due to the complexity of vascular or bronchial
variations, lesions position and the amount of margin resected. Can the three-dimensional
reconstructive scan preoperatively facilitate the surgical procedure and provide surgeons
with valuable information about the anatomical and tumour locational variations?
Methods
From March 2021-June 2021, we built 3D reconstruction scan pre-operatively for 24
thoracic surgery patients following certain criteria. Which is patient who will undergo
(Segmentectomy, lobectomy or challenging wedge resection) for peripheral or central
lesions, no limitation on age or gender, patients definitive diagnosed and had CT
thorax with contrast preoperatively. Then the main indicator was a scalable questionnaire
survey completed by surgeons postoperatively regarding the impact of scans on facilitating
the procedure, making a different decision of surgical operating approaches and appreciation
of vascular variations.
Results
The project cohort of 24 patients who 5 underwent VATS segmentectomy,16 underwent
VATS lobectomy,1 underwent wedge resection and 1 underwent nucleated of central nodule.
There was one case cancelled due to hidden invasion of main bronchus on the CT. Postoperatively
the surgeons’ sentiments regarding the scans were very positive specially for vascular
variations as all anomalous or uncommon bronchioles and vessels were accurately identified
by 3D imaging. Furthermore, there was consensus about the beneficial value of scans
in segmentectomy, central lesion near hilum and difficult wedge operations.There were
2 cases where 3D scans played a significant decision-making as the surgical approach
was changed and a smaller resection of lung tissue was achieved.
Conclusions
3D reconstructive scans have significant values in segmentectomy, central lesions
and decision-making of resectable amount of lung in borderline patients and constitute
a very handful tool for sergeons.
A229 Does Robotically Assisted Thoracoscopic Volume Reduction Surgery Use Less Hospital
Resources Than Bronchoscopic Lung Volume Reduction?
Evans, Nicholas, Mr; Perikleous, Periklis, Mr; Lee, Michelle, Miss; Colombino, Anna
Maria, Ms; Baranowski, Ralitsa, Miss; Waller, David, Mr
St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A229
Objectives
Lung volume reduction (LVR) can be performed by bronchoscope (BLVR) or surgery (LVRS).
There are no randomized comparisons, but the assumption is that BLVR requires less
use of hospital resources which offsets the higher cost of endobronchial valves. We
have compared the two in patients suitable for both.
Methods
In a 4-year experience, we have performed 176 LVR procedures in 132 patients: 76 patients
underwent Robotically Assisted Thoracoscopic (RATS) LVRS and 56 BLVR. We offered both
approaches as a one-stop treatment, based on intra-operative assessment of collateral
ventilation (CV). BLVR was the treatment of choice in CV negative patients, while
CV positive patients proceeded to unilateral RATS LVRS. We compared use of hospital
resources, including theatre time, high-cost consumables and hospital stay. Data also
included complications, readmission to hospital and requirement for high level of
care.
Results
No patient in the LVRS group required a redo procedure while eight had staged bilateral
procedures. 26 (46%) patients in the BLVR group had two or more redo procedures, including
revision bronchoscopy (n = 3), valve removal/re-insertion (n = 23), VATS for pneumothorax
(n = 8).
Initial failure of EBLVR results in comparative overall hospital stay to initial LVRS.
Conclusions
Uncomplicated preferential BLVR appears to use less hospital resource than RATS LVRS
in comparable groups. However, this advantage is lost if revision BLVR procedures
are needed. Further study is needed to answer whether redo bronchoscopy should be
abandoned in favour of conversion to salvage LVRS.
A230 Comparing the Outcomes of Serially Performed Bilateral Lung Volume Reduction
Surgeries
Hoffman, Ross, Mr; Alshammari, Abdullah, Dr; Alvarez Gallesio, Jose, Dr; Norkunas,
Mindaugas, Dr; Buderi, Silviu, Mr; Jordan, Simon, Mr
Royal Brompton Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A230
Objectives
Lung volume reduction surgery (LVRS) is an established treatment for advanced COPD.
Some evidence suggests simultaneous bilateral lung volume reduction surgery should
be avoided and that a unilateral approach may reduce postoperative morbidity in a
high-risk population. Other evidence suggests staged procedures can prolong the benefit
of LVRS for patients. This paper quantifies the benefits and risks of second serial
LVRS by comparing the outcomes of the first and second serial LVRS operations.
Methods
Data extracted retrospectively for 30 patients who underwent bilateral serial LVRS
from September 2007 to October 2021 at a single surgical centre are used to estimate
the differences-in-differences in outcomes between the first and second serial LVRS
surgeries. The mean time between the first and second surgeries was 2.9 years.
Results
Both groups had significant improvements in their lung function after each serial
surgery, however there was no significant difference-in-difference in outcomes between
serial surgeries.
Conclusion
There is significant benefit to be gained from second side LVRS. The risk profile
of surgery is similar and the relative improvement in lung function is at least as
good.
A231 Blood Product Utilisation in Thoracic Surgery
Chubsey, Rachel
1, Miss; Nithiananthan, Mayooran2, Mr; Rathinam, Sridhar1, Mr
1Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK; 2Nottingham
University Hospitals NHS Trust, Nottingham, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A231
Introduction
Advances in minimally invasive thoracic surgical techniques has reduced the risk of
intra-operative bleeding and requirement for blood transfusion. As a result, over-ordering
of blood products may put additional strain on time and resources. The aim of this
study was to compare blood product ordering and subsequent usage with recommended
departmental Maximum Surgical Blood Ordering Schedule (MSBOS).
Methods
Retrospective data collection from ORMIS Theatre Management software and Sunquest
ICE System for all patients undergoing surgery in August 2020. Data included demographics,
procedure, urgency, co-morbidities, pre-operative haemoglobin and platelets, number
of group and screen samples, units crossmatched and units transfused.
Results
57 patients were included, average age 62.03 years (50–73.5), 30 (52.6%) males. 46
(80.7%) were elective and 38 (66.6%) for malignancy. All patients had one Group and
Screen sample, while 46 (80.7%) were crossmatched units of packed red cells.
Our MSBOS recommended crossmatch for patients undergoing Pneumonectomy/EPD (n = 3),
Decortication (n = 4) and VATs/Open Lung resection (n = 14). Crossmatch was performed
for 100%, 100% and 85.7% respectively. Of these only patients 4 (19%) received a blood
transfusion.
We also regularly crossmatched patients for mediastinoscopy (n = 2), LVRS (n = 2),
VATs bullectomy/pleurectomy (n = 7) and bronchoscopy (n = 13), (50%, 50%, 85.7% and
53% respectively). None of these patients required a blood transfusion.
Conclusions
The results suggest increased ordering of blood products for procedures associated
with smaller bleeding risk such as VATs procedures and bronchoscopy. However, due
to the emergency nature of intra-operative haemorrhage it is difficult to modify practice.
We recommend a reduction in the number of crossmatched units for VATs, bronchoscopy
and mediastinoscopy in line with Trust Guidance and re-audit of practice.
A232 Anatomical vs Non-anatomical Resection in Patients Undergoing Lung Volume Reduction
Surgery
Hoffman, Ross
1, Mr; Alshammari, Abdullah2, Dr; Alvarez Gallesio, Jose2, Dr; Norkunas, Mindaugas2,
Dr; Buderi, Silviu2, Mr; Jordan, Simon2, Mr
1Department of Thoracic Surgery, Royal Brompton Hospital, London, UK; 2Royal Brompton
Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A232
Objectives
Lung volume reduction surgery is classically performed as a non-anatomical sublobar
(wedge) resection of lung tissue. There is some literature that examines the benefit
for patients undergoing a lobectomy for emphysema and co-existing cancer; however,
anatomical lobectomy has not been well studied as a primary intervention for LVRS.
This paper examines whether anatomical resection confers more benefit than non-anatomical
resection.
Methods
Data were extracted retrospectively for patients who underwent LVRS from September
2007 to October 2021, at a single surgical centre. The patients were grouped for comparison
by type of resection performed: anatomical resection (lobectomy/bilobectomy) or non-anatomical
(sub-lobar/wedge).
Results
A total of 274 patients were included. Anatomical resection was performed on 23.7%
(n = 65) of the patients, and for two of these patients it was for lung cancer. There
were no statistically significant differences between the two groups at baseline,
in terms of age, sex, BMI, FEV1, FVC, and RV/TLC ratios. However, patients who were
selected for anatomical resection had a larger TLC and RV preoperatively (p < 0.05). Both
groups had significant improvement in their pulmonary function tests postoperatively
in terms of FEV1, FVC and TLC (p < 0.01). Comparatively, a statistically significant
greater improvement from their preoperative values was found in the anatomical group
vs the non-anatomical group in terms of RV (reduction of 1177.5 ml vs 494.8 ml, p < 0.05),
and RV/TLC ratio (reduction of 11.3% vs 3.9%, p < 0.01). There was no statically significant
difference between the length of stay, morbidity or survival (log rank, p = 0.336)
between the groups.
Conclusions
Anatomical resection for COPD, in carefully selected patients may lead to greater
improvements in postoperative RV and RV/TLC ratio. In this study, there was no significant
difference in length of stay or survival between anatomical and non-anatomical LVRS.
A233 Developing Procedure Specific Consent Forms for Thoracic Surgery
Hoffman, Ross, Mr; Alshammari, Abdullah, Dr; Alvarez Gallesio, Jose, Dr; Buderi, Silviu,
Mr
Royal Brompton Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A233
Introduction
Cardiothoracic surgery can carry a high risk of morbidity and mortality relative to
other commonly performed surgical procedures. It is crucial that the consent process
for surgery is thorough, effective and comprehensive to ensure that the patient's
consent is truly informed and that the surgical team is protected from medical litigation.
Written consent forms are prone to error through omission, poor legibility, inaccuracy
or lack of clarity.
Methods
We have developed and instituted 6 comprehensive procedure specific consent (PSC)
forms for use in our thoracic surgery department, for which we have received excellent
feedback from patients and staff.
The procedure specific consent forms include:
Lung resection
Bronchoscopy, including rigid bronchoscopy
Diagnostic VATS procedure
VATS procedure for pneumothorax
Mediastinoscopy
Chest wall resection
Results and conclusion
The use of procedure specific consent forms helps to ensure that legible and standardised
information about the procedure and its risks are communicated to the patient. Patients
are also able to receive their consent forms in advance of arriving for surgery, which
can faciliate a more informed consent discussion. High-quality PSC form templates
for thoracic surgery are scarce. In sharing this set of forms, we hope to encourage
other surgical departments to shift to a PSC standard.
A234 MGTX Impact on Thymectomy Practice
Badran, Abdul
1, Dr; Allen, Claire1, Dr; Badran, D2, Dr; Pinto, Ashwin1, Dr; Woo, Edwin1, Mr
1University Hospital Southampton, Southampton, UK; 2Imperial College London, London,
UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A234
Objectives
In August 2016, the results of the international randomized, controlled, trial that
studied the safety and efficacy of thymectomy for patients with non-thymomatous myasthenia
gravis (MG), MGTX was published. We sought to review the impact this landmark trial
had on surgical management in MG.
Methods
We retrospectively reviewed the demographics as well as clinical factors of patients
with MG that underwent surgery in a 3-year period pre MGTX (2013–2016) and 3 years
post MGTX (2016–2019). This resulted in a total of 21 patients being identified.
Results
9% (n = 2) were pre MGTX and 90% (n = 19) post. Mean age at thymectomy was 49 (47.5
post vs 58 pre), 9 were males (n = 1 pre) and 12 were female (n = 1 pre). Mean days
to surgery 603 (478 post vs 1393 pre). Thymectomy was performed in 18 patients with
a VATS approach (17 post, 1 pre) with 6 conversions to open which were all in the
post-trial period. In one of the VATS cases (post-trial period) a subxiphoid approach
was utilised. Definitive histology showed thymoma in 48% (n = 10, 8 post and 2 pre).
In 4 cases there was phrenic nerve dysfunction (3 post and 1 pre). There was one laryngeal
nerve injury in the post-trial period. In one patient surgery was abandoned (post-trial
period) after complications during VATS and risk of sternotomy not warranted, Mean
length of stay (LOS) was 4.5 days (7.3 pre and 4 post), in VATS patients LOS was 2.9 days
post and 4 days pre.
Conclusions
There is a shorter time for diagnosis to surgery meaning patients can potentially
have less medication and better control of disease earlier. There has been a significant
uptake of surgery in MG patients post MGTX interestingly this is also being seen in
thymomatous MG. The standard approach adopted is VATS in the post-trial period. The
number of days to surgery was also significantly less in the post-trial period.
A235 The Role of Dexamethasone in Post-operative Pain in Thoracic Surgical Patients
Toerien, Lara
1, Ms; Daly-Devereux, Madeleine1, Dr; Weedle, Rebecca2, Ms; Rice, Darragh2, Mr; Healy,
David1, Prof
1St Vincent's University Hospital, Dublin, Ireland; 2Mater Misercordiae Hospital,
Dublin, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A235
Objectives
Post-operative pain in thoracic surgery is a topical and complex issue. Ineffective
pain relief has been shown to impede coughing, deep breathing, and mobilisation, culminating
in increased morbidity and mortality. Infiltration of glucocorticoids is used in other
fields, but its efficacy in thoracic surgery in improving post-operative pain has
not yet been explored.
Methods
We performed a double blinded, randomised control trial, in patients undergoing elective
thoracic procedures, through robotic, VATS or open thoracotomies. Patients were randomly
allocated to receive 8 mg Dexamethasone, 4 mg Dexamethasone, or saline (control) which
was infiltrated into port/thoracotomy sites prior to incision. Our primary outcome
was to measure pain scores and opiate requirements, in each of the surgical approaches.
Any adverse effects and relation to steroid dose was also observed.
Results
59 patients were included, and allocated to one of the 3 groups, then subdivided into
robotic, VATS and open. Opiate requirements were statistically significantly different
between groups in the 24-to-48-h time period (χ2(2) = 8.4, p = 0.015), where there
were less opiates used in the 4 mg group (21.4 mg) compared to the 8 mg group (36.6 mg)
(p = 0.012) and control group (30,3 mg). However, pain scores did not appear to be
significantly improved by Dexamethasone. Pain scores and opiate requirements were
also lowest in the VATS group, when compared with the robotic and open cohorts. Issues
with wound dehiscence/infection were noted in only 8 patients, but showed no correlation
with use of Dexamethasone.
Conclusions
Wound infiltration with 4 mg of Dexamethasone may decrease opiate consumption post
thoracic surgery in our examined population, with no negative effect on wound healing.
However larger numbers are needed to validate these results.
A236 The Surgical Management of COVID-19 Pulmonary Complication in Patients Requiring
Extracorporeal Membranous Oxygenation (ECMO)
Law, Jacie Jiaqi, Dr; Soh, Karen Chien Lin, Ms; Aresu, Giuseppe, Mr; Coonar, Aman,
Mr; Aresu, Giuseppe, Mr
Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A236
Objectives
COVID-19 induces capillary microthrombi and pulmonary infarction, mediating complications
including pneumothoraces, necrotizing pneumonia and pulmonary haemorrhage. High mortality
exists in COVID 19 patients requiring ECMO rescue therapy. Concurrently, it is recognized
that high postoperative mortality exists in COVID-19 patients undergoing thoracic
surgery. In this case series, we aim to explore the surgical management and post-operative
outcomes in a patient cohort with the highest COVID-19 disease severity.
Methodology
From November 2018 to November 2021, we identified five patients fulfilling the inclusion
criteria. 4 male and 1 female patient was included. The Mean age in this study was
44 years old with a median Charlson Comorbidity Index of 1. Patient demographic and
operative data were retrieved from the database. Electronic patient records and ECMO
database was also reviewed to obtain data on complications and survival.
Results
The Mean time from COVID positivity to ECMO cannulation was 8.2 days. All patients
were commenced on veno-veno ECMO. 3 out of 5 patients presented with haemothorax necessitating
emergency right-sided anterolateral thoracotomy. 1 right-sided salvage lower lobectomy
was performed for a case of COVID-19 induced necrotizing pneumonia. Contrasting to
a predominantly pulmonary haemorrhagic phenomenon pre-operatively, 80% experienced
thromboembolic states post-operatively (cerebral infarct and ECMO cannulation site
thrombosis). Goursaud et al. aptly describes the dilemmas of ECMO heparinisation in
the context of surgical management of COVID lung complications. 2 out of 5 fatalities
occurred in patients characterised by higher Charlson index pre-operatively.
Conclusion
To the best of our knowledge, this is the first case series to analyse patient characteristics,
surgical managements, post-operative complications and survival on cases of severe
COVID-19 pulmonary complications in the ECMO subgroup.
A237 Development and Evaluation of a Novel VATS Endoscopic Camera System
Whittaker, George, Dr; Kogkas, Aleandros, Dr; Mylonas, George, Dr; Hanna, George,
Prof
Imperial College London, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A237
Objectives
We aimed to develop a novel VATS endoscopic camera system to enhance the field of
view, allowing for increased surveillance and earlier identification of complications.
Additionally, we aimed to quantitatively and qualitatively evaluate the prototype
VATS camera with a comparative study and participant questionnaires.
Methods
We developed a final prototype from a USB camera module with a fisheye lens. Images
from this sensor were captured, undistorted, and projected onto a curved screen in
real-time. A prospective comparative study was conducted with surgical trainees from
Imperial College London as participants. Each participant completed a psychomotor
task using prototype and conventional endoscopic systems, followed by an evaluation
questionnaire. Outcome measures were assessed with Wilcoxon signed-rank tests.
Results
Our prototype accomplished a 118-degree field of view at a resolution of 1260 × 708
pixels, though with a compromise of 7 frames per second frame rate and 231 ms latency
when distortion correction was active. Participants identified simulated bleeding
significantly faster (P = 0.0313) with no camera movements (P = 0.0350) compared to
a conventional endoscope, although task completion time did not differ (P = 0.2188).
Qualitative data highlighted benefits of the enhanced field of view and concerns with
frame rate and latency.
Conclusions
We successfully developed and assessed a unique wide-angle VATS endoscopic camera.
Our system shows promising results as a potentially superior alternative to current
systems. Further work needs to focus on resolving frame rate and latency issues, which
could be achieved by reducing resolution.
A238 Drawbacks of Powered Air-purifying Respirators During COVID-19 Pandemic—How Voice
Amplifiers Improve Communication and Outcomes During Resuscitation
Kutywayo, Kudzayi, Mr; Kubiak, Krzysztof, Dr; Korre, Sofia, Dr; Karia, Chiraag, Mr;
Annamaneni, Rajani, Dr; Rathinam, Sridhar, Mr
Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A238
Background
The COVID-19 pandemic has caused massive restructuring in policies regarding use of
personal protective equipment in aerosolised environments within the hospital. Use
of powered air purifying respirators has allowed health provision to continue safely
in the wake of a novel droplet infection (SARS-CoV-2). A trade-off for safety is,
unfortunately, the impediment in communication. We sought to investigate whether portable
audio amplification equipment would help during cardiopulmonary resuscitation (CPR)
in patients with COVID-19.
Objective
To evaluate the usefulness of portable electronic voice amplification units during
resuscitation.
Methods
Teams consisting of 4 members each were evaluated as they ran through 2 Advanced life
support (ALS) cardiac arrest simulation scenarios. One of the scenarios was performed
whilst participants were using a portable electronic voice amplification unit (VAU).
A survey after each scenario was conducted. Video and audio feedback was obtained.
Time taken to arrive at critical points in each scenario was assessed. Verbal consent
was obtained from all participants to record the simulation and the feedback.
Results
83.3% of the participants found it difficult to communicate with fellow members of
the resuscitation team owing to the respiratory personal protective equipment. 91.7%
of participants found the voice amplifier either moderately or significantly better
in improving the quality of communication. Consequently, critical time points were
reached quicker when resuscitation was carried out with voice amplification. Most
participants felt the time added during donning by applying the voice amplifier was
not detrimental when entering a COVID resuscitation area.
Conclusion
Use of VAUs improve communication in cardiac arrest and ultimately may help to improve
resuscitation outcomes. Further study is needed, although initial results are encouraging.
A239 Denepuncture and Requested Investigations Amongst Thoracic Surgery Patients:
Service Evaluation and Cost Analysis
Gopalaswamy, Madhura, Dr; Calvert, Rachel, Mrs; Connelly, Leanne, Mrs; Dunning, Joel,
Mr; Waterhouse, Benjamin, Mr
South Tees NHS Foundation Trust, Middlesbrough, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A239
Objectives
Blood tests are a ubiquitous component of inpatient care and have been since the late
1800’s.
Resources within the NHS are finite, and this has never been more apparent.
When Beckton Dickinson (BD), manufacturers of our most commonly used blood tubes announced
a global shortage of its products in August 2021, it further emphasised a need for
focussing our usage of this resource.
We hypothesised that some tests requested and even some venepuncture episodes were
unnecessary.
Methods
A retrospective service evaluation was performed cross-referencing the medical notes,
pathology requests, and available results to assess appropriateness of each test in
Thoracic Surgery Inpatients.
Estimated costs for each test were taken from NHS Reference Costs and from the trust
pathology lab.
Results
We found an average of 2.8 sets were sent for a 4-day inpatient stay.
Only 35% of requests included a valid indication
95% included additional investigations without justification, common examples included
Urate, Liver Function Tests, C-reactive Protein, and Lipid Profile.
An average of 4 additional investigations were requested per sample resulting in a predicted
unnecessary cost of £69.82 per patient.
Conclusions
Significant savings can be achieved by a change in local policy and staff education.
By extension, this could protect staff time and safeguard patients from unnecessary,
if minor, invasive procedures.
Thoracic Oncology
A240 Anatomical Segmentectomies In A Universal Uniportal VATS Thoracic Centre During
Covid-19 Pandemic: Evaluation of Outcome
Fang, Chen Chuan, Mr; Martin-Ucar, Antonio, Mr; Hernandez, Luis, Mr
University Hospital Coventry and Warwickshire, Coventry, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A240
Group A (n = 33)
Group B (n = 47)
Group C (n = 26)
Total (n = 106)
Age (Median)
74
72
71.5
72
Age (Range)
50
43
36
51
Gender (n) Male
19
23
12
54
Gender (n) Female
14
24
14
52
FEV1 (%) Median, Range
82, 76
84, 108
78, 63
82.5, 108
TLCO (%) Median, Range
77.5, 73
87, 77
77, 95
80.5, 95
Convertion to thoracotomy (n)
2
0
0
2
Respiratory Complication (%)
3.0 (P > 0.05)
3.2 (P > 0.05)
2.8 (P > 0.05)
3.0 (P > 0.05)
Length of stay (days)
5.5 (P > 0.05)
5.0 (P > 0.05)
4.1 (P > 0.05)
4.8 (P > 0.05)
Objectives
Our aim is to determine the feasibility, effectiveness, safety and surgical outcomes
of UVATS segmentectomies performed during Covid-19 pandemic.
Methods
All patients who received UVATS segmentectomy for treatment of lung cancer or benign
diseases from the overall thoracic surgical activity from January 2019 to July 2021
were identified. They were divided into 3 groups: 2019(pre-pandemic), 2020(peak) and
2021(recovery). All cases adopted Covid-free measures which include testings, isolation,
PPE and Covid-free colour-coded zoning with controlled access from preoperative preparation
to post-operative care.
Results
A total of 106 patients underwent UVATS segmentectomy over the study period were grouped
by years: Group A (January–December 2019), Group B (January-December 2020) and Group
C (January–July 2021). Demographic and results of the 3 periods are presented in Table
1.
Histology findings reported 27 non-malignant cases and 79 malignant cases. Postoperative
30-days in-hospital mortality was zero and none of the patients required HDU/ITU care
post-operatively. No patient was infected with Covid-19 throughout their hospital
stay.
Conclusion
By adapting to the crisis and optimizing the skills with resources available, we were
able to perform more cases of UVATS segmentectomies during the pandemic, effectively
and safely.
A241 Laser Pulmonary Metastasectomy—Movie
Chandarana, Karishma, Dr; Caruana, Edward, Mr; Weaver, Helen, Miss; Rathinam, Sridhar,
Mr; Nakas, Apostolos, Mr
Glenfield Hospital, Leicester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A241
https://www.youtube.com/watch?v=yOUIc-CqzoE
A242 Long-term Results From Uni-portal VATS Segmentectomies
Ariyaratnam, Priyad, Dr; Edwards, John, Dr; Rao, Jagan, Dr; Tenconi, Sara, Dr; Komber,
Mohamed, Dr; Agrawal, Sanjay, Dr; Socci, Laura, Dr
Sheffield Teaching Hospitals, Sheffield, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A242
Objectives
Segmentectomies have become a popular method to both diagnose and definitively treat
early stage lung tumours and this in parallel to the increased interest in uni-portal
VATS surgery to treat early-stage lung tumours. However, little data exists on the
outcomes of uni-portal segmentectomies for lung tumours. We therefore wanted to evaluate
our long-term outcomes using this technique for early stage tumours.
Methods
We performed 173 VATS anatomical segmentectomies between April 2015 and April 2021
for patients with suspected cancer. We matched these with uniportal VATS lobectomies
using a 1:1 propensity matching algorithm.
Results
The mean age at surgery was 69.7 years and the percentage of males was 45.5% for segmentectomies.
The mean predicted FEV1 was 91.36% and the mean predicted DLCO was 73.3%. Left-sided
tumours formed the majority of resections (78%). 26% of the segmentectomies were performed
by trainee surgeons under the supervision of a consultant surgeon. Upper trisegments
(38.7%) formed the majority of resections. The mean tumour size was 23.8 mm. Adenocarcinomas
formed the majority of tumours resected (46.8%) whilst metastases formed 9.4%. Of
those that were primary tumours (N = 124), 54.% were T1 and 41.1% were T2. The mean
duration of surgery was 138.9 min and the mean length of hospital stay was 5.2 days
(± 4.1). There was 1 conversion to a thoracotomy. There was 1 30-day mortality. The
survival analysis showed that mean 5-year survival for all tumours was 71% (± 4.9).
When compared to the matched lobectomy group for T1 tumours, the segmentectomy group
was 74% whilst the lobectomy group was 45% at 5 years (log rank, p = 0.02). There
were 2 R1 margins at final histology. There were 2 instances of documented tumour
recurrence in the segmentectomy group.
Conclusion
Uniportal VATS segmentectomies can be safely utilised for early-stage lung tumours
without compromising long-term outcomes.
Segment
Frequency
Trisegment
38.7%
S6
26%
Lingula
14,5%
Basal
11.6%
S2
4.6%
S3
1.2%
S1 & S2
1.2%
S7 & S8
0.6%
Other
1.2%
A243 Is There a Future for Radical Mesothelioma Surgery after MARS2?
Lee, Michelle, Miss; Nardini, Marco, Mr; Hargrave, Joanne, Miss; Waller, David, Mr
Barts Thorax Centre, London, UK, St Bartholomew's Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A243
Objectives
The MARS2 trial completed recruitment in Jan 2021 but the results will not be released
until 2023. As the BTS guidelines state that radical surgery for malignant pleural
mesothelioma (MPM) should not be conducted outside of a trial does this mean there
is a moratorium on this operation until the trial reports? We assessed our surgery
for MPM during and since the MARS2 trial to answer these questions.
Methods
In a retrospective analysis we analysed 45 consecutive patients discussed at the Mesothelioma
MDT undergoing macroscopic complete resection radical surgery for MPM at Barts under
single surgeon. All patients and by extended pleurectomy decortication (PD) or PD.
Comparison of historical cohorts of 15 patients before and after closure of MARS2
trial. We compared referral source, speed of recruitment, patient demographics and
pathology results. We cannot report on survival data.
Results
During MARS2 we recruited the last 15 patients (14 M:1F) for surgery in an overall
period of 453 days. In this period, we operated on the last 15 patient (12 M:3F) outside
of the trial in 372 days. Reasons for non-MARS2: 5 ineligibles (2 concurrent lung;
3 not considered initially pre chemotherapy); 5 patient choices; 5 due to COVID).
Post MARS 2: the first 15 patients were operated upon in 224 days.
The proportion of referrals from local or distant sources has not changed since MARS
2 but 3 large referring academic centres have not referred.
Median (Range)
MARS2 Period: MARS2
MARS2 Period: Non-MARS2
Post-MARS2
P Value
Age (Year)
72 (57–78)
64 (49–77)
67(46–78)
NS
BMI (Kg/m2)
28 (18–37)
26 (17–33)
26 (20–35)
NS
FEV1 (%Predicted)
65 (38–108)
83 (75–90)
63 (59–90)
NS
DLCO (%Predicted)
66 (48–79)
84 (69–98)
57 (51–98)
NS
Pre-Operative: Induction Chemotherapy
15/15 (100%)
13/15 (87%)
4/15 (27%)
0.0366
Pre-Operative: Number of Chemotherapy Cycles
2 (2–2)
3 (0–4)
2 (2–2)
NS
Extended Pleurectomy Decortication (PD):PD
12:3 (80%:20%)
9:6 (60%:40%)
9:6 (60%:40%)
NS
Post-Operative Pathology (Epithelioid:Non-Epithelioid)
10:5 (67%:33%)
8:7 (53%:47%)
14:1 (93%:7%)
0.0484
Post-Operative Pathology: Node Positive
6/15 (40%)
6/15 (40%)
4/15 (27%)
NS
Conclusion
Radical surgery continues after MARS2 at an increasing rate from established sources.
There is a trend towards upfront less extensive surgery in more epithelioid disease.
A244 Discordance in Cell Type after Pleurectomy/Decortication for Malignant Pleural
Mesothelioma—A Possible Detrimental Effect of Induction Chemotherapy
Lee, Michelle, Miss; Baranowski, Ralitsa, Miss; Hargrave, Joanne, Miss; Waller, David,
Mr
Barts Thorax Centre, London, UK, St Bartholomew's Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A244
Objectives
The prognosis following pleurectomy/decortication (PD) for resectable malignant pleural
mesothelioma (MPM) is known to be dependent on histological cell type. We aimed to
evaluate the accuracy of preoperative assessment of histological cell type, factors
affecting its accuracy and the subsequent effect on postoperative survival after PD.
We aimed to identify possible improvements in preoperative workup.
Methods
We analysed the perioperative course of 122 patients [103 M:19F, Age 68 (33–79) years]
who underwent either PD (26 patients) or extended PD (96 patients). Induction chemotherapy
was given to 94 patients while 28 patients had upfront surgery. We recorded discordance
between preoperative and postoperative histological findings and looked at predictive
factors and survival implications.
Results
n
Cell Type Concordance
Cell Type Discordance: Positive
Cell Type Discordance: Negative
Total
P Value
Initial Treatment
83
2
28
113
Induction Chemotherapy
58
1
26
85
0.0291
Primary Surgery
25
1
2
28
Biopsy Method
Cell Type Concordance
Cell Type Discordance
Video-Assisted Thoracoscopic Surgery (VATS)
51 (69.9%)
22 (30.1%)
73
NS
Local Anaesthetic Thoracoscopy (LAT)
15 (57.7%)
11 (42.3%)
26
NS
Percutaneous
17 (60.7%)
11 (39.3%)
28
NS
Disease Extent: Tumour Thickness (mm)
13 (3–66)
16 (5–35)
NS
Disease Extent: N1
42/83 (50.6%)
20/30 (66.7%)
NS
Perioperative cell type discordance was not associated with the method of biopsy nor
the extent of disease but was significantly associated with the use of induction chemotherapy.
There is currently no significant difference in survival from date of diagnosis in
those who received either surgery or chemotherapy first: surgery 31 (95% CI 23.6–41.1)
months vs chemotherapy 21 (95%CI 25.5–36.9) months, (p = 0.3).
Conclusions
We suggest a need to reconsider the routine use of induction chemotherapy in the treatment
protocol in otherwise resectable MPM. If used then re-biopsy should be used to exclude
biphasic disease before radical surgery to maximise postoperative survival.
A245 Clinical Outcome of Limited Resection in Peripheral Small-sized Non-small Cell
Lung Cancer: A Systematic Review
Abbas, Mohammed, Mr; Hashmi, Faisal, Mr; Taylor, Marcus, Mr
Wythenshawe Hospital, Manchester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A245
Objectives
Lobectomy is considered the standard surgical approach for operable non-small lung
cancer (NSCLC). However, limited resection (LR) is becoming a preference in small,
peripheral early stage NCSLC. Lung cancer screening programs combined with advanced
computed tomography increase the likelihood of detecting small sized peripheral lung
cancers. There is no consensus on whether limited resection is superior to lobectomy.
To address this issue, the current study aims to assess the 5-year overall survival
(OS) and recurrence-free survival (RFS) in patients who underwent limited resection
for early stage NCSLC.
Methods
A systematic review of literature was performed using four online databases (Embase,
PubMed, MEDLINE and Cochrane Library databases) according to predefined selection
criteria to identify all relevant articles. We reviewed all available articles from
their date of inception until January 2020. The overall survival and recurrence-free
survival in limited resection group was evaluated to determine whether limited resection
is satisfactory in treating small, peripheral early-stage NSCLC.
Results
A total of twelve studies were met the inclusion criteria for the systematic review,
including a total of 2256 patients (868 patients underwent LR and 1388 patients underwent
lobectomy). The mean duration of the studies was 8.25 years. The tumor size was between
0.5 to 3 cm. Overall, limited resection was associated with OS and RFS of 41 – 100%
and 59.4–100%, respectively.
Conclusion
The current systematic review suggests that for selected patients limited resection
is feasible for selected patients with early stage NSCLC and tumors < 3 m cm and located
peripherally. From available data, the post-operative OS at 5-year interval and RFS
rates appear to be comparable to lobectomy. Further prospective RCTs are needed to
confirm these findings.
A246 Preservation of Functional Status post Manubrial Resection for Chest Wall Sarcoma:
A Single-Centre Retrospective Analysis
Shatila, Mohamed, Mr; Khor, Bo, Mr; El-Gamal, Islam, Mr; Khalil, Haythem, Mr; Patel,
Akshay, Mr; Kalkat, Maninder, Mr
Queen Elizabeth Hospital, Birmingham, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A246
Introduction
Approximately 30% of malignant, primary bone tumours are chondrosarcomas, which occur
on the anterior chest wall most frequently. Patients who are treated with adequate
surgical intervention tend to recover well and survival at 10 years is as high as
97%. In select cases, resection of the manubrium is warranted and aside from the aesthetic
outcome, the impact on chest wall mechanics, functional status, and preservation of
respiratory efficiency and loading of the chest wall are key post-operative aspects
which need to be considered when undertaking radical resections.
Methods
We collected demographic, operative and post-operative pathological data on all patients
as well as an objective assessment of functional status post-operatively using the
MRC and Karnofsky grading systems. Median follow-up was 1864 days (30–4984 days).
Results
Twelve patients underwent manubrial resection for chest wall sarcoma between 2008
and 2021. Median pre-operative ECOG status was 0 (0–3) and MRC score was 1. Post-operatively,
patients were mainly limited by pain at the operative site, however functional status
was preserved if not improved in most cases (post-op median MRC score was 0) (p = NS).
Median length of post-operative stay was 9 days (3–31). Fifty percent of all cases
were chondrosarcoma. Overall survival was significantly improved in the chondrosarcoma
cohort (p = 0.0043). Adjuvant therapy was administered to 25% of the cohort (n = 3),
and recurrence occurred in 1 patient at 12 months post-operatively.
Conclusions
Manubriosternal resection is the best treatment modality for anterior chest wall sarcomas.
It can be carried out safely with few post-operative complications. Overall survival
at the maximum follow-up of 13.6 years was around 80% for chondrosarcomas. The alteration
in chest wall geometry and respiratory mechanics did not result in a significant decline
in post-operative functional status in these patients.
A247 Uniportal Non-intubated SVATS Thymectomy Compared to Uniportal Intubated SVATS
Thymectomy: The Technical Feasibility, Enhanced Recovery and Safety
Bushra, Raisa
1, Mrs; Nizami, Maria2, Miss; Hogan, John1, Mr; Williams, Luke1, Mr; Peryt, Adam1,
Mr; Coonar, Aman1, Mr; Aresu, Giuseppe1, Mr
1Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK; 2Guy’s and St Thomas’
NHS Foundation Trust, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A247
Objectives
Subxiphoid video-assisted thoracoscopic surgery (SVATS) has been associated with less
pain and subsequent opioid requirements. Furthermore, a non-intubated approach reduces
sedatives and opioids required and may also enhance recovery. The current retrospective
comparative study is aimed to compare the technical feasibility, enhanced recovery,
safety, and adequacy of oncological resection in patients undergoing non-intubated
subxiphoid video-assisted thoracoscopic thymectomy and in patients who underwent a
traditional intubated subxiphoid resection.
Methods
We conducted a retrospective study of 42 patients who underwent Subxiphoid VATS thymectomy
from September 2016 until June 2021. Among them 21 carefully selected patients underwent
non-intubated SVATS thymectomy. Patients were selected for the study and were matched
with regards to age, gender, comorbidities, smoking history.
Results
A total of 42 patients were included in the analysis of which the mean age was 59.6 years,
and 52% were female. Mean age for the non-intubated group was 57.5 years and 54.5%
female. Among them 12 patients had myasthenia gravis. Major complications were bleeding,
mandating conversion, acute kidney injury, prolonged air leak and vocal cord palsy.
In total for Group 2, there were 3 cases converted to sternotomy, compared to Group
1. Subsequently, there were two admissions to the Intensive Care Unit for Group 2
and one admission due to AKI for Group 1. The median hospital length of stay for both
groups was 2 days. Complete resection was achieved in all cases in Group 1 whereas
in Group 2, 4 cases were reported with R1 resection margin.
Traits
SVATS non-intubated (Group 1)
SVATS intubated (Group 2)
Length of Hospital Stay (mean)
2
2
Conversion to sternotomy
1/21
3/21
ICU admission
1
2
Operating time (mean)
2 h 32 min
3 h 59 min
Resection Margin R0
100%
71.4% ( R1 = 4 patient)
Conclusion
Non intubated subxiphoid thymectomy is technically feasible, safe and associated with
adequate oncological resection.Reduced sedation and opioid requirement lower the risk
of post-operative respiratory failure and delirium thus accelerate enhance recovery.
However, larger studies are required to confirm this hypothesis.
A248 Introduction of Macmillan Community Thoracic Specialist Nurse
Stockdale, Stacey, Mrs; McNaught, Hayley, Mrs; Calvert, Rachel, Mrs; Connelly, Leanne,
Mrs
South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A248
The Thoracic Surgical service cares for around 800 patients/ year, serving a population
of 1.5million covering North Yorkshire, Teesside and County Durham who undergo thoracic
procedures for diagnostic, therapeutic or palliative intent for both benign and malignant
disease. The introduction of Community Thoracic Specialist Nurse who can visit the
patient at home 24–48 following discharge, allowing a nurse with specialist knowledge
in relation to thoracic surgery to review the patient, manage symptoms, provide reassurance
and support, whist facilitating earlier discharge from hospital and reducing readmissions.
We know that patients and their relatives have experienced heightened levels of anxiety
relating to attending hospital and having to undergo treatment for cancer, we believe
there is an increased need to protect patients requiring thoracic surgery.
We have shown a significant reduction in length of stay to average of 4.1 compared
to national average of 6.6 days (GIRFT data) and we believe over the coming year this
could be reduced further as LOS has increased by 1 day throughout COVID due to no
Day of Surgery admissions. Our initial data shows a reduction in readmissions to 11%
from 29 and 36% (VIOLET study VATS vs OPEN lobectomy). We identified appropriate patients
who required readmission, issues were recognised during visit, bloods and COVID swab
taken, we were able to readmit directly to our ward avoiding high-risk COVID areas
such as A&E, AAU and outlying hospitals. Patient experience feedback has been overwhelmingly
positive with 50% response rate. Patients have told us how valuable they feel this
service is in terms of reassurance and support.
Since introducing this service we have constantly adapted to change and surpassed
all of our initial expectations and achieved our initial goals in improving patient
experience, reducing length of stay and reducing readmission rates.
A249 Current UK Practice in the Management of Patients with Pulmonary Neuroendocrine
Tumours
Mehdi, Rana, Miss; Steyn, Richard, Mr; Kalkat, Maninder, Mr; Fallouh, Hazem, Mr; Naidu,
Babu, Mr; Bishay, Ehab, Mr; Shah, Tahir, Dr; Rogers, Vanessa, Ms
Queen Elizabeth Hospital Birmingham, Birmingham, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A249
Pulmonary neuroendocrine tumours [NETs] are increasing in incidence. There is growing
understanding of the multidisciplinary management of these patients. We wanted to
explore the current national management of pulmonary neuroendocrine tumours by means
of a survey to determine the scope of practice in relation to current guidance.
An online survey was created using SmartSurveyTM. The questionnaire was based on the
2015 European Neuroendocrine Tumour Society expert consensus for best practise for
typical and atypical pulmonary NETs and the updated 2021 Lung and Thymic Carcinoids:
ESMO Clinical Practise Guidelines for diagnosis, treatment and follow up. It was disseminated
to all UK Thoracic Surgery Centres. The results were analysed to understand scope
and variation of practise across the UK in patient management, surgical technique
and follow up.
Responses were received from 17 UK Thoracic Surgery units. All centres reported awareness
of guidelines; however, only 63% of respondents reported using them routinely in their
clinical practise. 74% of respondents reported access to a specialist Neuroendocrine
multidisciplinary team. Surgical resection techniques for typical and atypical peripheral
tumours varied between centres. 84% of respondents favoured anatomical resection for
peripheral carcinoid tumours, however 47% stated their strategy would change with
atypical versus typical carcinoid tumours. 95% of respondents reported following International
Association for the Study of Lung Cancer recommendations for lymph node dissection/sampling.
Follow up procedures varied greatly between centres, with regard to who conducted
follow up, the frequency and duration.
There is widespread awareness of the current guidelines with regard to the management
of Pulmonary Neuroendocrine tumours. Despite this knowledge, practice is varied. More
work is needed to promote joint management planning between the Lung and NET teams
and improve the use of accepted guidelines.
A250 Are Chest Drains Routinely Required After Thoracic Surgery?
Proli, Chiara, Miss; Abdul Khader, Ashiq, Dr; De Sousa, Paulo, Mr; Pons, Aina, Dr;
Alshammari, Abdullah, Dr; Palmares, Abigail, Ms; Booth, Sarah Ann, Mrs; Leung, Maria,
Mrs; Lim, Eric, Prof
Royal Brompton and Harefield Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A250
Background
A principal bottleneck for early discharge is the presence of a chest drain after
routine elective thoracic surgery. The aim of this study is to report the technique
and outcomes of on-table drain removal for selected thoracic surgical procedures to
facilitate day-case surgery.
Methods
A 5-year retrospective analysis of protocolised on-table drain removal for pleural
(pneumothorax and effusions), mediastinal, pericardial, and selected lung (wedge resection)
surgery, excluding lung volume reduction. Single port VATS was the standard approach
and drains removed at the end of the procedure on confirmation of air leak of < 20 ml/hour
by digital drain. Data on post-drain removal pneumothorax, effusion and need for further
intervention were obtained by formal radiology reporting of post-procedure chest films.
Results
Between 2016 and 2021, we operated on 617 patients, of which 107 (17%) patients had
drains removed on-table in theatre with a mean age (SD) of 58 (17) years of which
54 (51%) were male. The majority of the procedures were pulmonary wedge resections
in 43 patients (40%) and pleurodesis in 23 (22%).
Post-drain removal pneumothorax occurred in 22 patients (21%), pleural effusion in
6 (5.6%). Drain reinsertion was required in 1 patient (0.9%) after pleurodesis for
pneumothorax. The median (IQR) length of hospital stay was 1 day (1–2) and 14 patients
(13%) discharged on the day of surgery.
Conclusions
Routine chest drains are not required after thoracic surgery. On table chest drain
removal can be safely achieved in selected procedures paving the way for day case
thoracic surgery.
A251 Experiences of Healthcare Professionals in Surgical Oncology During the COVID-19
Pandemic: A Qualitative Study
Kapur, Alanah
1, Miss; Shah, Salonee
1, Miss; Bekker, Hilary1, Prof; Boele, Florien2, Dr; Young, Alistair2, Mr; Pompili,
Cecilia2, Dr
1University of Leeds, Leeds, UK; 2St James Hospital, Leeds, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A251
Objectives
COVID-19 has been a burden for healthcare systems globally. Within the UK, the NHS
faced new pressures, including burden on intensive care units, staff redeployment
and delays or cancellation of elective cancer procedures. This study explores the
experiences of healthcare professionals to investigate the impact of COVID-19 on decision-making
in surgical oncology.
Methods
In this service evaluation, participants with relevant professional experience were
recruited using purposive sampling. Semi-structured qualitative interviews were recorded
and transcribed verbatim. Thematic analysis was used.
Results
Thirteen participants were interviewed, and seven themes identified. The majority
described increased discussions regarding patient prioritisation during multi-disciplinary
team meetings. Concerns were expressed about telephone-based pre-operative assessments
with limited examination of patients prior to surgery. Participants experienced increased
workload and responsibilities throughout the pandemic, although this was not perceived
to influenced patient-centred decisions. Generally, participants experienced various
stresses which were not thought to hinder clinical performance.
Conclusion
Interviews with healthcare professionals highlighted that COVID-19 has influenced
clinical decisions in surgical oncology. Although changes to patient pathways were
highlighted, the delivery of care was not perceived to be affected. Future research
should explore the COVID-19 related changes remaining in surgical oncology and how
they affect the patients’ experience of care.
A252 5 Year Audit of Pericardial Effusion Management in a Tertiary Thoracic Unit
Eckersley, Martyn
1, Dr; Baranowski, Ralitsa2, Ms
1Glasgow Royal Infirmary, Glasgow, UK; 2St Bartholomew's Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A252
Objectives
We aimed to investigate management of chronic large pericardial effusions referred
to a tertiary thoracic centre over a five-year period and if these complied with the
ESC guidelines.
Methods
A retrospective audit looking at whether referrals in a five-year period between 2015
and 2020 was performed. Records were investigated by one of the authors, basic demographic
information and length of stay were recorded. Indications for intervention, previous
pericardiocentesis, whether the patient was in tamponade at time of referral and specific
operation that took place as well as final histology result were recorded.
Results
133 cases of pericardial effusion were referred to the thoracic surgery service. Of
those accepted (100) average age was 51, average length of stay 10.6 days (range 2–57).
Seven patients referred were in tamponade, six accepted under the care of the Thoracic
team, one to cardiology for temporising pericardiocentesis.
Most underwent Video Assisted Thorascopic Surgery (VATS) (51%), followed by anterior
minithoracotomy (38%). Most common indications for intervention were recurrence (30),
the need for a tissue diagnosis (13), and diagnosis of malignant effusions (18). Complications
experienced included re-accumulation, fast AF and post-operative nausea and vomiting.
33 referrals were not accepted. The most common reasons were not being fit for general
anaesthesia or in tamponade (48%). Second was patients redirected to cardiology for
consideration of percutaneous drainage first (33%).
Conclusions
Good compliance with ESC guidelines regarding management of chronic pericardial effusions
was demonstrated, although 25% of referrals were redirected to a different service. A
limitation of this audit is that the data is only from those referred to the thoracic
team. The introduction of a clear clinical pathway for the management of chronic pericardial
effusions to ensure patients get the necessary management promptly, per ESC guidelines,
is recommended.
A253 Is a 6-month Follow-up CT Scan After Lung Resection for Primary Lung Cancer Necessary?
Philip, Bejoy, Mr; Basak, Bappy, Dr; Tariq, Humaira, Dr; Shackcloth, Michael, Mr
Liverpool Heart and Chest Hospital, Liverpool, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A253
Objectives
Despite the lack of high-quality evidence, most patients following lung cancer resection
are followed up with CT scans. The interval of these CT scans varies between guidelines
and institutions. We sought to determine the value of performing a CT scan at 6-months.
Methods
The CT scan reports and clinical details of 132 patients who underwent lung resection
at our institution, between February and June 2018 were analysed.
Results
Out of 132 patients, 69 patients had a CT scan and 12 had X-rays at 6-months. 10 patients
had recurrence identified on CT scans while 49 patients had no recurrence, and 10
had indeterminate findings. 12 had no recurrence on a chest x-ray. Out of the 61 patients
with normal radiology at six months, only three had a recurrence on the CT scan at
one year. Out of 10 patients who had indeterminate findings on the 6-month scan 5
proved not to have recurrence, two had a recurrence and 1 had a 2nd lung primary.
Two died of unrelated causes. Recurrence of cancer identified on the 6-month CT scans
did not appear to be related to the tumour stage, which might due to the adjuvant
chemotherapy received by patients with higher tumour staging.
Conclusions
A CT scan at six months appears to be valuable at picking up recurrence, with few
indeterminate findings. The recurrence rate on the yearly Ct scan was low if the initial
CT or CXR at six months was normal, questioning the value of a scan at a year.
A254 Lung Cancer Resection in the Absence of Pre-operative Histology: The Accuracy
of Multidisciplinary Team Consensus
Whooley, Jack, Dr; Weedle, Rebecca, Dr; White, Alexandra, Dr; Breen, David, Dr; Soo,
Alan, Mr
University Hospital Galway, Galway, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A254
Objectives
Lung resection remains the gold-standard of treatment for non-small cell lung cancer
(NSCLC). British Thoracic Society (BTS) guidelines recommends the pursuit of pre-operative
histological diagnosis and staging where possible. In the absence of pre-operative
histology, surgical treatment can be offered in conjunction with multidisciplinary
team (MDT) and patient consensus. We aimed to perform a single-centre analysis of
the accuracy of the thoracic MDT in recommending surgical resection for those patients
with suspected NSCLC in the absence of pre-operative histological diagnosis over a
five-year period.
Methods
A retrospective review was performed of patients undergoing lung resection at the
recommendation of the thoracic MDT for suspected NSCLC in our unit between May 2016
and August 2021. Patients with confirmed histological diagnosis were excluded from
analysis.
Results
234 patients underwent lung resection without pre-operative histology in the five-year
period. 54.6% were female, mean age was 67.4 years. Overall, the positive predictive
value of the MDT team consensus for lung malignancy in the absence of pre-operative
histology was 88.9%. Of the 208 patients with confirmed malignancy on post-operative
histology, this consisted primarily of NSCLC (70%), metastatic disease (17%) and carcinoid
tumours (5%.) 26 patients had benign histology post-operatively, with the most common
benign histology consisting of benign hamartomas (19%), organizing pneumonia (15%),
benign scar tissue (15%) and granulomas (11%.)
Conclusion
In the absence of pre-operative histology, lung resection of suspected NSCLC is reasonable
if performed in conjunction with multidisciplinary team and patient consensus, in
keeping with the British Thoracic Society Guidelines.
A255 Pre-operative Prognostic Factors for 5-year survival Following Pulmonary Metastasectomy
from Colorectal Cancer. A Systematic Review and Meta-analysis
Gkikas, Andreas
1, Dr; Kakos, Christos2, Mr; Lampridis, Savvas3, Mr; Godolphin, Peter1, Dr; Patrini,
Davide4, Mr
1MRC Clinical Trials Unit, UCL, London, UK; 2Royal Victoria Hospital, Belfast Health
& Social Care Trust, Belfast, UK; 3Guy's and St Thomas' NHS Foundation Trust, London,
UK; 4University College London Hospitals (UCLH), London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A255
Objectives
We seek to identify pre-operative prognostic factors and measure their effect on 5-year
survival following Pulmonary Metastasectomy (PM) for Colorectal Cancer (CRC).
Methods
We systematically reviewed the databases of Cochrane Library, MEDLINE, Embase and
Google Scholar from January 2000-April 2021 to identify pre-operative factors that
have been investigated for their prognostic effect on survival following PM. Quality
assessment was performed using the QUIPS tool. The prognostic effect of each identified
factor on 5-year survival post PM was estimated using random-effects meta-analyses.
Results
We identified 115 eligible articles which included 13,294 patients who underwent PM
from CRC. The overall 5-year survival after resection of the lung metastasis was 54.1%.
The risk of bias of the included studies was at least moderate in 93% (107/115). Seventy-seven
pre-operative factors had been investigated for their prognostic effect. Our analysis
showed that 11 factors had favorable and statistically significant prognostic effect
on 5-year survival post-PM. These included solitary metastasis, size < 2 cm, unilateral
location, N0 thoracic disease, no history of extra-thoracic or liver metastasis, normal
carcinoembryonic antigen levels both before PM and CRC excision, no neo-adjuvant chemotherapy
before PM, CRC T-stage < T4 and no p53 mutations on CRC. Disease free interval at
24 months did not appear to affect 5-year survival.
Conclusion
We identified 11 factors that had a strong prognostic effect on 5-year survival, including
single metastasis and unilateral disease. Despite the considerable risk of bias in
the literature, this study comprises the most rigorous summary of the current evidence
base. These findings can complement both clinical practice and the design of future
research on the field of PM.
A256 Performance of an Opt-out Integrated Pre-operative Tobacco Dependency Treatment
Service
Brunswicker, Annemarie, Dr; Meghani, Nevan, Dr; Hewitt, Kath, Ms; Singhania, Asmita,
Miss; Huddart, Helen, Ms; Ayrton, Laura, Ms; Evison, Matthew, Dr; Rammohan, Kandadai,
Mr
Wythenshawe Hospital, Manchester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A256
Objectives
Smoking tobacco is a significant risk factor for developing postoperative complications
and poorer long-term outcomes following thoracic surgery.
Current guidance is that the NHS should provide opt-out tobacco dependency treatment
services to smokers at any point of contact, but provision of such services is woefully
inadequate.
Assess the performance of a new opt-out tobacco dependency treatment service (The
CURE team) in a thoracic surgery service (service model = immediate ad-hoc review
by a specialist tobacco dependency practitioner for all active smokers attending thoracic
surgery outpatient clinics with direct supply of stop smoking pharmacotherapy).
Methods
Retrospective data collection from electronic patient records and prospective patient
questionnaires.
Consecutive new patients attending thoracic surgery outpatient clinics from June to
September 2021 were included.
Key performance indicators were screening of smoking status, opt-review by the CURE
team, uptake of specialist assessment, pharmacotherapy provision and quit rate.
Results
262 new patients attended the thoracic surgery service in the study period
40 (15.3%) were identified as active smokers
60% (24/40)completed specialist assessment with the CURE team in the opt-out model
79% (19/40) were prescribed pharmacotherapy Nicotine Replacement Therapy (NRT)
58% (14/24) quit smoking during the follow-up period
63% (25/40) of patients rated the opt-out service model as acceptable or very acceptable
in a 5 point Likert scale question
Conclusions
Our opt-out model ensured comprehensive screening, significant uptake of support and
treatment for tobacco dependency with high quit rates.
This service model provides a blueprint for the treatment of tobacco dependency in
all outpatient services requiring investment in these services
A257 COVID-19 Impact on Post-operative TNM Staging and Adjuvant Treatment for Primary
Lung Cancer
Williams, Jennifer, Miss; Allen, R., Dr; Combellack, T, Mr; Kornaszewska, M., Miss;
Pirtnieks, A., Mr; Valtzoglou, V., Mr
University Hospital of Wales, Cardiff, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A257
Objectives
Our aim was to review the impact of COVID-19 on our primary lung cancer patients.
Analysing if there was a delay in the referral pathway, acquiring PET imaging and
subsequently resulting in significant post-operative TNM upstaging. We also assessed
the impact COVID-19 had on those patients requiring adjuvant treatment, comparing
this to the nationally quoted 66%.
Methods
374 patients who underwent primary lung cancer resections between January 2019 and
September 2021 were identified from our PATS database. The retrospective data collected
included pre-operative TNM staging via CT-PET imaging. This was compared with the
post-operative surgical TNM stage. We also reviewed which patients had indications
for adjuvant treatment and if this was undertaken during the first wave of COVID-19.
We defined the first wave as March 2020 to September 2020, with 83 patients being
identified.
Results
During the first wave of COVID-19 our single centre reports there was an increase
in post-operative T and N upstaging; 7% and 4% respectively. The time in days between
PET imaging and surgery in 2019 was 58 days and insignificantly increased to 63 days
during the pandemic. The focus to maintain primary lung cancer resection in our single
centre meant our waiting list for primary resections was not impacted by COVID-19
when compared to 2019 and 2021.
We observed that in patients who had T3 disease and borderline patients for adjuvant
treatment during the first wave of COVID-19 were significantly less likely to receive
adjuvant treatment. The quoted survival benefit for adjuvant treatment during the
pandemic was 5%. During the first wave 19 patients underwent adjuvant treatment; 22%
compared to the nationally quoted 66%.
Conclusions
Referral into the lung cancer pathway was delayed during COVID-19 resulting in T and
N upstaging, rather than delay in MDT decision to offer surgical resection. Adjuvant
treatment was significantly reduced during the first wave of COVID-19.
A258 Outcomes and Characteristics of Patients with Second Primary Lung Cancer After
Radical Treatment
Nizami, Maria, Miss; Farinelli, Eleonora, Dr; Ugur, Tugba, Dr; Ashrafian, Leanne,
Miss; Pilling, John, Mr
Guy's Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A258
Objectives
Patients with non-small lung cancer (NSCLC) are at risk of developing a secondary
primary lung cancer (SPLC). However, the characteristics of these group of patients
at risk remain largely speculative. This study reviews our experience in the occurrence
and the overall survival of SPLC.
Methods
We retrospectively reviewed 1366 patients undergoing radical treatment of multiple
primary lung cancer from January 2010 to October 2021. Using criteria set out by Martini
and Melamed [1], we categorised as synchronous SPLC when it was diagnosed within 24 months
of the first primary lung cancer (FPLC) and after direct histological comparison of
the different tumours. Tumours occurring after the 24 month interval were categorised
as metachronous [1]. We compared the overall survival (OS) for each group.
Results
53 patients were identified with multiple or secondary primary lung cancer [median
age 69(50–4);45.2%male] (M:22,F:31). In total 31 were synchronous, 22 were treated
for metachronous tumours. The median interval between procedures for metachronous
tumours is 39.5 months (25-111 months). 7 patients had further surgery for a third
malignancy, 4 of which were synchronous and 3 metachronous (occurring at 45, 50 and
58 months after the second procedure). The primary lung cancer most commonly occurred
in the right upper lobe, with the commonest site of second primary in the right lower
lobe. The OS with synchronous SPLC was 82.1% at 1 year, 59.7% at 3 years and 50.6%
at 5 years. For metachronous SPLC was 100% at 1 year, 90.9% at 3 years and 76.2% at
5 years. There was no statistical significant difference in OS (p = 0.47) between
synchronous and metachronous disease (Fig. 1).
Conclusions
The occurrence of second primary lung cancer is not rare and a radical approach to
these lesions is justified by the results. Aggressive surgical intervention is a safe
and effective treatment for metachronous cancer and should highlighted within the
MDT setting.
A259 Impact of a Newly Established Robotic Program on the Practice of a Thoracic Surgery
Department Amid the Covid Pandemic
Kouritas, Vasileios, Mr; Saad, Haisam, Mr; Alqudah, Obada, Dr; Szafron, Bartlomiej,
Mr; Kadlec, Jakub, Mr; Bartosik, Waldemar, Mr; Hogan, John, Mr
Norfolk and Norwich University Hospital, Norwich, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A259
Introduction
Aim of this study was to evaluate the establishment of a new robotic program in Norfolk
and Norwich University Hospital (NNUH) amid the Covid era.
Patients and methods
A Da-Vinci X system was used to establish the program.
A retrospective analysis of all robotic cases was performed using the business intelligence
tool of the Trust (October 2020—October 2021) as service evaluation.
Data collected were age, gender, type of procedure, length of procedure, length of
stay (LOS) and in-hospital/30-day mortality.
Results
During the study period 80 patients were operated on. Mainly anatomical lung resections
were performed (29 lobectomies, 14 segmentectomies/bisegmentectomies) and resection
of anterior mediastinal masses/thymectomies (16 cases).
The robotic cases performed increased in numbers throughout the study period (figure).
In the lung resection group, there were 2 conversions (4.6%) and 1 (2.3%) death for
non-procedure related reason. The median LOS was 4 days (range 2–14) and the mean
operative time was 168 ± 52.3 min. There were no R1 resections. More segmentectomies
and bisegmentectomies were performed when compared to the rest of the activity.
Conclusion
Despite the Covid pandemic the establishment of a new robotic program was possible
in the Trust showing low mortality and comparable results with the rest of the activity
of the department.
A260 Short Acting Opioid Analgesia, Breaking Through Pain in Thoracic Surgery
Petrov, George, Mr; O'Dwyer, Marliza, Mrs; Ryan, Ronan John, Mr; Fitzmaurice, Gerard,
Mr
St James Hospital, Dublin, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A260
Objective
Assessment of adherence to updated enhanced recovery after thoracic surgery (ERATS)
analgesic protocol, incorporating elimination of Gabapentin and long-acting opioids,
and evaluation of patient-reported post-operative pain.
Methods
Retrospective analysis of two groups of thoracic patients undergoing lobectomy or
pleurectomy at distinct time points; August 2021 (Group A, n = 19) post-implementation and
May 2021 (Group B, n = 23) pre-implementation, of the updated ERATS analgesic protocol
in a single centre. This protocol focused on the elimination of regular prescribing
of controlled analgesia apart from short acting opioids with expansion of NSAID use.
We utilized the electronic patient record to evaluate adherence by analysing patient drug
charts and discharge prescriptions; reported pain was assessed at 6-week clinic review.
Results
The majority of surgeries were VATS (A = 89%, B = 70%). Adherence to the updated protocol
was 89.5%, with only 10.5% receiving long-acting opioids and/or Gabapentin, compared
to 82% in Group B prior to implementation. At the 6-week post-operative review, 21%
of Group A vs 13% of group B patients reported some ongoing pain.
Conclusion
The transition to the updated ERATS analgesic protocol in our unit has been successful,
with a significant reduction in long-acting opioid and elimination of Gabapentin analgesic
prescribing, minimizing patient exposure to their associated adverse effects and maintaining
good pain control.
A261 Surgery vs Oncological Treatment in High-risk Thoracic Patients: The Role of
a High-risk Multidisciplinary Team Meeting (HRMDT)
Talukder, Shagorika
1, Ms; Ramalingam, Aravindh2, Dr; Irvine, Michael2, Dr; Kadlec, Jakub2, Mr; Bartosik,
Waldemar2, Mr; Szafron, Bartlomiej2, Mr; Van Tornout, Filip2, Mr; Kouritas, Vasileios2,
Mr
1Royal Papworth Hospital, Cambridge, UK; 2Norfolk and Norwich University Hospitals,
Norwich, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A261
Introduction
Multidisciplinary team (MDT) meetings for lung cancer are routinely utilized for decision
making. There is little data on the implementation of high-risk MDTs (HRMDT) for patients
referred to thoracic surgery. Oncological treatment is usually perceived as the safer
alternative to a high-risk procedure. We aimed to compare outcomes between patients
accepted for operative or non-operative management following HRMDT discussion.
Methods
Data for primary lung cancer patients discussed at the department’s fortnightly thoracic
HRMDT between May 2019 and October 2021 were retrospectively analysed for baseline
demographics, type and stage of cancer, total length of stay (LOS), and overall survival.
Reasons for HRMDT discussion included poor lung function or cardiopulmonary exercise
tolerance, technical operative challenges, multiple or severe comorbidities, advanced
TNM staging, poor performance status and age > 80 years.
Results
115 primary lung cancer cases (mean 67 ± 10 years; 67 (58%) male) had HRMDT discussion,
mostly due to poor lung function tests (33%). 78 (68%) patients received operative
management. The gender, age and type of cancer were similar in the two groups. More
patients with stage 2 and 3 disease were operated than sent for oncological treatment
(59% vs 35%, p = 0.047). LOS for the surgical group was longer than the non-surgical
group (median 7 vs 1 day p < 0.01). Surgery performed was not predictive of death
by time (p = 0.629, CI 0.322—0.768). There were no in-hospital or 30-day deaths. Four
deaths in total were documented in the surgical group and 3 in the non-surgical one
(p = 0.432). Overall survival was similar between groups (Log-Rank = 0.236, p = 0.627).
Conclusion
Many patients, including those with progressed lung cancer, were ultimately offered
surgery, which may otherwise not have been an option. High-risk operated patients
showed similar longer-term survival as the non-operated group. Surgery may thus be
safe in appropriately selected patients.
A262 Robotic Surgery Reduces the Barrier to Widespread Practice of Segmentectomy
Sahdev, Nikhil
1, Dr; Lee, Michelle2, Miss; Waller, David2, Mr; Stamenkovic, Sasha2, Mr; Wilson,
Henrietta2, Miss; Baranowski, Ralitsa2, Miss; Lau, Kelvin2, Mr
1Royal Brompton and Harefield Hospital, London, UK; 2St Bartholomew's Hospital, London,
UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A262
Objectives
Segmentectomy offers an alternative to lobectomy but with parenchymal preservation
and comparable outcomes. However, segmentectomy is technically more challenging. We
report our experience of rapid adoption of segmentectomy through robotic surgery.
Methods
Single-institution retrospective audit of segmentectomies, from 2017–2021. Segmentectomies
were performed by thoracotomy, video-assisted thoracoscopy (VATS) and robot-assisted
thoracoscopy (RATS) by all 5 surgeons in one department. Data was analysed between
3 equal time periods (405 days), P1, P2, P3, representing different stages of implementation
of the segmentectomy.
Results
217 segmentectomies were performed for proven or suspected stage I lung cancer. Number
of segmentectomies increased by 348% (31(P1), 78(P2), 108(P3)); the ratio of lobectomy:
segmentectomy increased from 100:13(P1) to 100:55(P3). 182(83%) segmentectomies were
RATS, these increased 594% from 17(55%) (P1) to 101(95%) (P3). The median operative
time fell: from 210 min(P1), 180 min(P2) to 173 min(P3).
The complexity of the segmentectomies also increased: the proportion of atypical segmentectomies
increased sixfold (10%(P1) vs 65%(P3)).
Overall 30-day-mortality and 90-day-mortality was 1% and 3% respectively. Respiratory
complications occurred in 30 cases (14%), persistent air leak in 59 (27%) and other
complications in 15 (7%) cases. 11 cases (5%) returned to theatre and 13 (6%) required
re-admission. There was no difference in complication rates between the study periods.
Conclusions
The number, proportion, and complexity of segmentectomies performed increased rapidly
driven by the RATS approach. The complication and mortality rates remained similar
in all study periods and the procedural efficacy improved, despite increasing complexity
of the operations. Therefore, RATS provides a safe and effective method to enable
delivery of segmentectomy as standard of care.
A263 Animation Supported Consent for Lung Resection Procedures
Ike, David Ikenna1, Dr; Jackson-Wade, Rashaan1, Mr; Baranowski, Ralitsa1, Ms; Wilson,
Henrietta1, Ms; Wald, David1, Prof; Perikleous, Periklis.2
1St Bartholomew's Hospital, London, UK; 2Royal Brompton Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A263
Introduction
Patient understanding of Lung Resection Procedures is often incomplete before consent
to surgery. Innovative approaches are needed to improve the consent pathway and support
shared decision-making.
Methods
Video animations created by Explain my Procedure Ltd for evaluation pending subscription.
Baseline understanding of patient understanding of Lung Resection Procedures (Questionnaire)
n = 29
Links to multi-language videos sent to patients pre-admission
Patients provided with video books at pre-admission clinic and on admission to ward
Post-animation patient Understanding of Lung Resection Procedures (Questionnaire)
n = 30
Results
Figure 1 compares patient-reported understanding of the procedure, its benefits and
risks and alternatives to the procedure in the no animation group and the animation
group. There was a significant (P < 0.05) improvement in patient understanding in
all domains following introduction of the animation to aid consent.
Conclusion
Animation supported sample group showed a greater level of understanding in terms
of procedure, benefits, risks and alternatives.
Thoracic advanced nurse practitioners have found videos to be immensely useful especially
with non-native English speakers.
Patients who utilized the animations would recommend its use.
Explain my Procedure recommended for routine use before consent to thoracic surgery.
A264 Incidence and Resource Burden for the Management of CT Detected Ground Glass
Opacities at a Tertiary Lung Cancer Service in the UK
Ashraf, Muhammad Arsalan
1, Mr; Alshammari, Abdullah
1, Dr; De Sousa, Paulo1, Mr; Tincknell, Laura2, Dr; Naruka, Vinci1, Mr; Booth, Sarah1,
Mrs; Patel, Anant3, Dr; Proli, Chiara1, Miss; Docherty, Catherine3, Mrs; Lim, Eric1,
Prof
1Academic Division of Thoracic Surgery, The Royal Brompton Hospital, London, UK; 2Barking,
Havering and Redbridge University Hospitals NHS Trust, Romford, UK; 3Royal Free London
NHS Foundation Trust, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A264
Objectives
The increased use of computer tomography (CT) for lung cancer screening and evaluation
of other intrathoracic disease has led to greater awareness of ground glass opacity
(GGO) lesions. We aim to evaluate the incidence of GGOs identified on CT at a tertiary
lung cancer service in the UK to determine any trends and to quantify impact on time
and resources.
Methods
We retrospectively identified patients reported with GGOs and discussed during MDT
meetings held from 2017 to 2019 between the Royal Free and the Royal Brompton Hospitals.
Data were collected, their demographics were reported, and annual incidence as well
as further analyses on their management were calculated.
Results
3,731 patients were discussed at MDT meetings from 2017–2019. 53% were male, the mean
age (SD) of the cohort was 68 years and 12% (438 patients) had GGOs identified on
CT scans. GGO incidence showed an increasing trend between 2017 and 2019 at a frequency
of 100 (9%), 159 (12%), 179 (14%) respectively. These 438 were filtered using an exclusion
criterion to leave 274 individual patients. Of these, 148 (54%) were discharged from
the MDT, 24 (9%) were deceased in the follow up period, and 31 (11%) were lost to
follow-up; the rest remain under follow up. The median (IQR) follow-up time was 263 days
(61–734) and time between scans was 89 days (32–183). 19 (10%) patients had biopsy
proven pre-cancerous lesions or adenocarcinoma. 24 went on to have surgical intervention
in our study period.
Conclusion
Over the three-year period of our study, we report an increasing trend in the identification
and presentation of patients with GGOs in MDT. Combined with the extent of follow
up and the risk of representing cancerous lesions, this demonstrates a significant
burden in the present and future. We suggest an increased emphasis must be placed
on establishing more effective pathways than those currently stipulated by existing
national and international guidelines to better manage this burden.
A265 Covid-19 Shouldn't Impact the Thoracic Surgical Training
Mayooran, Nithiananthan1, Mr; Chubsey, Rachel
2, Ms; Kutywayo, Kudzayi2, Mr; Caruana, Edward2, Mr; Rathinam, Sridhar2, Mr
1Nottingham City Hospital, Nottingham, UK; 2Glenfield Hospital, Leicester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A265
Objectives
Covid-19 pandemic has changed our lives in many ways. Surgical elective operation
lists are reduced, which has had a direct impacted on surgical training. In our unit,
after careful planning and implementation of strict ‘super clean pathway’ has enabled
us to continue lung cancer operations till end of December 2020. This study is to
assess the impact of Covid-19 pandemic in training Opportunities.
Methods
A single thoracic surgical firm’s pre Covid-19 (January 2019 till December 2019) case
Loads of were analysed with cases performed during Covid 19 pandemic (Jan 2020 till
December 2020). The following variables are collected for each year; type of operation,
elective vs emergency, primary surgeon, operating surgeon, and percentage of the operation
performed by Trainee as a first operator. Correlation of data was performed to analyse
the influence on training opportunities.
Results
Pre- Covid 19 pandemic single surgeon performed a total of 328 major thoracic cases,
Out of these 99% of cases were performed by trainee as a first operator. During the
pandemic a total of 238 cases were performed. Which is almost 27.5% lesser activity
than 2019. In the beginning of 2020 (First Quarter) The monthly case numbers remained
the same. After April 2020, there is an expected gradual decrease in general case
load noted. Regardless of this, the trainees performed almost 90% of these cases as
first operator.
Conclusions
The Covid -19 Pandemic has had a considerable impact on Thoracic surgical activity
after March 2020 till date. But this hasn’t impact on training opportunities in our
unit. The trainees have had their fair share of operative training, Which maintained
a high morale among the trainees during this difficult time.
A266 Comparison of Efficacy of Intra-operative Regional Analgesia Techniques for Video
Assisted Thoracoscopic Surgery (VATS)
Shenoy, Ranjeetha
1, Dr; Kew, Ee Phui1, Mr; Basharat, Kamran2, Dr; Tan, Carol1, Ms
1St George's University Hospitals, London, UK; 2Kingston Hospital, Kingston upon Thames,
UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A266
Objectives
Poor pain control after thoracic surgery is associated with increased risk of respiratory
complications and chronic pain. Paravertebral catheter (PVC) placed under direct vision
has been found an effective analgesia, but poses a small risk of infection, hematoma,
and pleural leak. Alternative to the PVC are single injection paravertebral block
(PVB) and multi-level intercostal nerve block (INB). Our objective is to compare the
efficacy of the PVC, PVB and INB.
Methods
Retrospective study of elective patients undergoing VATS procedure between February
and April 2021. All patients received intra-operative PVB, INB or PVC, as well as
morphine patient-controlled analgesia (PCA) and regular oral analgesia. The outcomes
measured were PCA usage and duration, duration of chest drain, and length of hospital
stay (LOS).
Results
61 cases were included (see table). The mean PCA usage in 24 h was the lowest in PVB
compared to INB and PVC (21.53 mg vs. 28.16 mg vs. 27.63 mg respectively). The mean
PCA duration was also the lowest in PVB (1.1 days) compared to INB (1.37 days) and
PVC (1.4 days). The mean duration of chest drain and LOS were also shorter in PVB
with 2.3 and 3.5 days respectively (vs. INB 2.31 and 3.67 days; PVC 2.87 and 3.87 days).
Subgroup analysis of only lobectomy and wedge resection revealed that PVB had the
lowest PCA usage in 24 h (18.53 mg vs. INB 28.13 mg vs. PVC 26.6 mg), shortest PCA
duration (1 1.1 vs. INB 1.5 vs. PVC 1.36 days), shortest hospital stay (3.5 vs. INB
4.29 vs. PVC 3.91 days), and shortest chest drain duration (2.3 vs. INB 2.36 vs. PVC
3.91 days).
Surgical procedures (VATS)
Overall (N = 61)
Intercostal nerve block (N = 36)
Single injection paravertebral block (N = 10)
Paravertebral catheter (N = 15)
Lobectomy
25 (40.9%)
11 (30.5%)
9 (90%)
5 (33.3%)
Wedge resection
10 (16.3%)
3 (8.3%)
1 (10%)
6 (40%)
Pleural biopsy and pleurodesis
17 (27.8%)
17 (47%)
-
-
Bullectomy and pleurodesis
6 (9.8%)
2 (5.5%)
-
4 (26.6%)
Mediastinal mass excision
2 (3.2%)
2 (5.5%)
-
-
Pericardial window
1 (1.6%)
1 (2.7%)
-
-
Conclusions
PVB is associated with the least PCA usage and the shortest LOS. All of the outcomes
were statistically insignificant but data collection is on-going.
A267 Are we Really Justified in Redo Surgery for a Positive Resection Margin?
Lee, Michelle, Miss; Alvarado, Patricia, Dr; Nardini, Marco, Mr; Waller, David, Mr
Barts Thorax Centre, London, UK, St Bartholomew's Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A267
Objectives
To challenge the value of elective redo surgery for patients following an R1 resection
for lung cancer.
Methods
In a retrospective 5 year analysis of a prospectively collected institutional database
the perioperative course of 17 patients undergoing elective redo surgery for R1 disease
was analysed. The outcome of the primary operations (Group A) was compared (by age,
comorbidities and type of procedures) with the outcome of the second procedures (Group
B) in terms of in hospital complications (IHC) rate and length of hospital stay (LOS).
Results
The primary operation was lobectomy in 0/17 (0%), segmentectomy in 4/17 (24%) and
wedge resection in 15/17 (88%). The overall complication rate of Group A was 6% versus
58% of Group B. Only 1 patient (6%) had cancer detected in the second specimen. First
admissions ranged between 4(2–10) days, whereas second admissions ranged from 7(3–27)
days.
Redo Operation
n
R1 Indication
Residual Tumour
Complications
P Value
Parenchyma
Bronchus
Nodal
12/17 (71%)
Segmentectomy
1/17 (6%)
1/17 (6%)
0%
0%
0%
1/12 (8%) Prolonged Air Leak (PAL)
NS
Lobectomy
16/17 (94%)
12/17 (71%)
2/17 (12%)
2/17 (12%)
1/17 (6%)
PAL 5/12 (42%), Haemorrhage 3/12 (25%), Hospital-acquired Pneumonia (HAP) 2/12 (17%),
Sepsis 1/12 (8%)
NS
Pneumonectomy
0/17 (0%)
0%
0%
0%
0%
0%
NS
Conclusion
These results question the value of elective redo completion surgery for R1 disease
in view of higher IHC, LOS and absence of cancer in the ‘redo’ specimen. Further randomised
comparison with observation alone is suggested.
A268 A 15-year Experience of Colorectal Pulmonary Metastasectomy in a High-volume
Tertiary Referral Centre
Taylor, Marcus
1, Mr; Singhania, Asmita1, Ms; Biswas, Sayan1, Mr; Grant, Stuart2, Mr; Krysiak, Piotr1,
Mr; Fontaine, Eustace1, Mr; Granato, Felice1, Mr; Joshi, Vijay1, Mr; Rammohan, Kandadai1,
Mr
1Wythenshawe Hospital, Manchester, UK; 2Manchester University, Manchester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A268
Objectives
Results of the PulMiCC trial have challenged the role of pulmonary metastasectomy
as part of the management of metastatic colorectal cancer in contemporary practice.
We aimed to review our short and long-term outcomes for patients undergoing surgical
resection of pulmonary colorectal metastases.
Methods
A retrospective analysis of electronic patient record data was performed. All patients
undergoing lung resection for pathologically confirmed colorectal pulmonary metastatic
disease from November 2005 to May 2021 were included. In-hospital, 90-day, 1-year,
2-year, 5-year and 10-year mortality rates were analysed. Cox proportional hazards
regression analysis was used to identify factors associated with reduced overall survival.
Statistical analysis was undertaken using SPSS version 28.
Results
In total, 619 patients underwent surgery during the study period. Mean age was 66.0 years
(± 10.0) and 61.2% (n = 379) were male. Overall, 68.7% (n = 425) underwent open surgery.
There were 151 (24.4%) patients who had multiple metastases resected. Median follow-up
time was 45 months (IQR 23–87). In-hospital mortality was 0.3% (n = 2) and the median
post-operative length of stay was 4 days (IQR 3–5). 90-day and 1-year mortality rates
were 1.1% (n = 7/619) and 4.5% (n = 26/580), respectively. The 5-year and 10-year
mortality rates were 40.6% (n = 165/406) and 74.0% (n = 208/281), respectively. After
multivariable analysis, advanced age (HR 1.026, 95% CI 1.011–1.043, p < 0.001) and
resection of more than one metastasis (HR 1.524, 95% CI 1.108–2.097, p = 0.010) were
independently associated with reduced overall survival.
Conclusion
Although there is inherent selection bias associated with patients referred for surgical
management of colorectal cancer, our results demonstrate extremely low short-term
mortality and encouraging longer-term outcomes for these patients. Advanced age and
the presence of more than one metastasis at the time of surgery were associated with
worse prognosis.
A269 Outcomes After Lung Resection for Primary Lung Cancer in Octogenarians: Trends
Over Time
Taylor, Marcus
1, Mr; King, Jenny1, Dr; Sinnott, Nicola1, Dr; Crosbie, Phil2, Dr; Booton, Richard1,
Prof; Shackcloth, Michael3, Mr; Granato, Felice1, Mr; Grant, Stuart2, Mr; Fontaine,
Eustace1, Mr; Rammohan, Kandadai1, Mr
1Wythenshawe Hospital, Manchester, UK; 2Manchester University, Manchester, UK; 3Liverpool
Heart and Chest Hospital, Liverpool, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A269
Objectives
Despite octogenarians representing an ever-increasing proportion of patients with
lung cancer, there is a paucity of evidence describing outcomes after lung resection
for these patients. We aimed to evaluate outcomes for octogenarians after lung resection
over time.
Methods
A total of 5470 consecutive patients undergoing lung resection for primary lung cancer
in two UK centres were included. The cohort was divided into two groups (group 1:
2012–2015 and group 2: 2016–2019) to identify trends over time. Primary outcomes were
peri-operative, 90-day & 1-year mortality and post-operative complications. Univariable
analyses were used to compare outcomes between octogenarian and non-octogenarian patients.
Results
Overall, 9.4% (n = 513) of patients were aged 80 years or over. There was no significant
difference in the peri-operative and 90-day mortality rates for octogenarians between
groups 1 and 2, however the 1-year mortality rate for octogenarians was significantly
lower for group 2 compared to group 1 (2012–2015: 16.5% vs 2016–2019: 10.2%, p = 0.034).
There was also no significant difference in peri-operative, 90-day or 1-year mortality
between octogenarian and non-octogenarian patients in group 2, but not in group 1.
Conclusions
Mortality for octogenarians fell significantly over time in this study. Indeed, when
confined to the most recent time period, comparable rates of both 90-day and 1-year
mortality for octogenarian and non-octogenarian patients were seen. Whilst preventative
strategies to reduce the incidence of post-operative atrial fibrillation in octogenarians
should be considered, these findings demonstrate that following appropriate patient
selection, octogenarians can safely undergo lung resection for lung cancer.
A270 Outcomes After Lung Resection for Primary Lung Cancer in Never Smokers
Taylor, Marcus
1, Mr; Abah, Udo2, Ms; Smith, Matthew2, Mr; Grant, Stuart3, Mr; Shackcloth, Michael2,
Mr; Granato, Felice1, Mr; Crosbie, Philip3, Dr
1Wythenshawe Hospital, Manchester, UK; 2Liverpool Heart and Chest Hospital, Liverpool,
UK; 3Manchester University, Manchester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A270
Objectives
Chronic exposure to tobacco smoke is the main environmental risk factor for developing
lung cancer. However, an important proportion of patients diagnosed with lung cancer
have never smoked. We aimed to assess whether short and long-term outcomes after lung
resection were different between never smokers and ever smokers.
Methods
All consecutive patients undergoing lung resection for primary lung cancer between
2012 and 2018 in two UK centres were included. Patients with missing smoking status
data were excluded. Any patient with a history of smoking was defined as a smoker,
regardless of pack years. Primary outcomes were 90-day mortality, 1-year mortality
and overall survival. Statistical tests were used to compare short-term outcomes (chi-square
test) and overall survival (multivariable Cox regression analysis) between never and
ever smokers.
Results
Of the 4955 patients included in the study, 83.0% (n = 4115) were smokers and 17.0%
(n = 840) were never smokers. Smokers had significantly worse lung function, functional
status and comorbidity burden. Smokers were less likely to undergo VATS surgery but
were not more likely to have more advanced-stage disease. The rates of pulmonary complications
were significantly higher for smokers (lower respiratory tract infection: 11.7% vs
8.5%, p = 0.007; reintubation: 3.3% vs 1.4%, p = 0.004). The 90-day mortality rate
was not significantly higher for smokers (3.8% vs 3.0%, p = 0.227) but smokers had
significantly higher 1-year mortality (11.6% vs 7.7%, p = 0.001). Ever smoking was
associated with significantly reduced overall survival despite adjustment for stage
of disease (HR 1.302, 95% CI 1.112–1.525, p = 0.001).
Conclusions
Never smokers represented just under one-fifth of patients undergoing resection for
primary lung cancer. As expected never smokers had better lung function and less co-morbidities.
This study has demonstrated that never smokers have significantly better short and
mid-term.
A271 Impact of COVID-19 in Lung Cancer Service and Disease Progression – A Single
Centre Experience
Chan, Jeremy, Dr; Lallmahomed, Najeeba, Miss; Lhote, Francois, Mr
Morriston Hospital, Swansea, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A271
Introduction
The COVID-19 pandemic has a significant impact on lung cancer resection. Limited service
leads to delay in surgical treatment. Previous studies showed delay between diagnosis
and surgical resection may result in disease progression and dismal outcome. While
several articles summarise their experience on the impact of COVID-19 in lung cancer
resection, disease progression secondary to delay in surgery remains unknown. We aim
to share our experience.
Method
All patients underwent primary lung cancer resection from June 2020 to May 2021 were
included in this study. The date between diagnosis and surgical referral, MDT and
surgery date were evaluated. The tumour size and staging was compared between pre-operative
imaging and histological sample.
Results
A total of 61 patients were included in this study. The average date between diagnosis/thoracic
surgery clinic to surgery was 120 and 50 days, respectively. Upstaging in T and N
staging were seen in 27.87% (17/61) and 11.48% (7/61) of lung resection cases, respectively. No
differences were observed when compared between the pre and post-operative mean tumour
size (25.71 cm2 vs 28.66cm2, p = 0.37).
Conclusion
The COVID-19 pandemic leads to a significant delay in lung cancer resection and disease
progression was observed. Better resources allocation is required to improve the service
after the pandemic.
A272 The Impact of Intra-operative Conversion During Planned Video-assisted Thoracoscopic
Lobectomy for Primary Lung Cancer on Short and Long-term Outcome
Taylor, Marcus
1, Mr; Raj Krishna, Gokul1, Mr; Grant, Stuart2, Mr; Rammohan, Kandadai1, Mr; Fontaine,
Eustace1, Mr; Joshi, Vijay1, Mr; Granato, Felice1, Mr
1Wythenshawe Hospital, Manchester, UK; 2Manchester University, Manchester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A272
Objectives
Video-assisted thoracoscopic surgery (VATS) is recommended as the gold standard for
early-stage lung cancer surgery in the UK. There is variation in the causes and rates
of intra-operative conversion to open surgery. Our objective was to review the impact
of intra-operative conversion from a VATS approach on outcomes after resection for
primary lung cancer.
Methods
A total of 2622 consecutive patients undergoing anatomical pulmonary lobectomy for
primary non-small cell lung cancer between 2012 and 2019 in a single UK centre were
included. Primary outcomes were 90-day mortality and overall survival. Conversions
were classified as due to bleeding or non-bleeding reasons. Outcomes were compared
between groups using univariable analysis.
Results
Overall, 20.6% (n = 541) completed surgery via VATS and 79.4% (n = 2081) via thoracotomy.
A total of 631 patients were planned to undergo VATS surgery giving an overall conversion
rate of 14.3% (n = 90). Bleeding was the reason for conversion in 31.1% (n = 28/90)
of patients. The 90-day mortality rate after conversion was not significantly different
to the 90-day mortality rate for either planned open surgery (3.3% vs 3.4%, p = 0.987)
or surgery completed via VATS (3.3% vs 1.1%, p = 0.099). Whilst experiencing conversion
was associated with significantly reduced overall survival in comparison to completing
surgery via VATS (p < 0.001), there was no significant difference in overall survival
between patients experiencing intra-operative conversion and those undergoing planned
open surgery (p = 0.135).
Conclusion
In our experience, patients experiencing intra-operative conversion have similar short
and long-term outcomes to patients undergoing planned open surgery. Short and long-term
mortality was lower for patients who underwent pulmonary lobectomy for primary non-small
cell lung cancer via VATS compared to patients who had a thoracotomy.
A273 Single Centre Outcomes for Lobectomy vs Sub-lobar Resection in Primary Lung Cancer
Brazier, Andy1, Mr; Mahendran, Kajan1, Mr; Ahmed-Issap, Amber
2, Miss; Jain, Shubham1, Mr; Habib, Akolade1, Dr; Briant, Zachariah2, Mr; Menon, Sowmya2,
Miss; Srinivasan, Lakshmi1, Miss; Ghosh, Shilajit1, Mr; Abah, Udo1, Miss
1UHNM, Manchester, UK; 2Keele University, Newcastle, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A273
Objectives
Lobectomy is the gold standard treatment for early lung cancer. Sublobar resection
is a useful alternative in patients with limited lung function but has recently garnered
evidence for its role as definitive treatment; with fewer complications and comparable
survival. We designed a study to observe if our results matched current evidence.
Methods
We analysed all resection from 01/01/2012 to the 07/07/2021. Variables where extracted
from a prospectively filled database and missing data supplemented from records. Patients
were divided into three cohorts; lobectomies, segmentectomies and wedge resections.
Complications, length of stay and mortality figures were examined.
Results
1400 patients had histology confirming primary lung cancer. 861 (61.5%) received a
lobectomy, 255 (18.2%) segmentectomy and 284 (20.3%) wedge resections. Five-year survival
data was available for a 353, 73 and 139 patients respectively. There were fewer complications
and shorter hospital stays following sublobar resections. Five-year survival was higher
following segmentectomy compared to lobectomy. This was not true for wedge resections
(Table1).
Conclusions
Despite poorer pre-operative condition, patients who underwent sublobar resections
faired better in the short term than lobectomy patients. Where sublobar resection
is indicated, formal segmental resection should be performed to convey a five-year
survival benefit.
VARIABLE
LOBECTOMY
SEGMENTECTOMY
WEDGE
N
861
255
284
Age (mean)
69
71
71
Arrhythmia (%)
7.20
2.35
3.87
LRTI (%)
13.82
7.84
13.38
Prolonged air-leak (%)
14.75
13.73
13.03
Length of stay in days (mean/median)
8.63/5.3
7.33/5.94
6.82/5.07
HDU length of stay in days (mean/median)
2.73/1.2
1.49/1.03
1.41/0.97
30-day mortality (%)
2.67
1.96
1.41
5 year survival (%)
66.01
73.97
56.64
A274 Nutritional Status of Lung Cancer Patients Undergoing Lung Surgery
Simmonds, Shanique, Dr
Queen Elizabeth Hospital Birmingham, Birmingham, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A274
Objectives
The nutritional status of patients undergoing thoracic surgery is not well known and
has been generally neglected on a national scale. Therefore, the aim of this audit
was to assess the nutritional status in lung cancer patients pre-and -post lung cancer
surgery and identify strategies for nutritional optimisation in this patient group.
Methods
On the day of surgery, participants completed two questionnaires – the PG-SGA which
is a patient-reported nutritional assessment tool that has been validated in cancer
patients and the SARC-F which is used as a predictor of sarcopaenia. Four weeks postoperatively,
participants were contacted via telephone consult to once again complete both questionnaires.
Results
Preoperatively seven participants reported scores indicative of requiring nutritional
intervention on the PG-SGA assessment. This reduced to three participants postoperatively.
Preoperatively, four participants achieved scores predictive of sarcopaenia, whereas
postoperatively this reduced to one participant.
Conclusions
There are a proportion of patients undergoing thoracic surgery for lung cancer that
may benefit from pre-operative nutritional support and/or physiotherapy input to optimise
them for surgery.
A275 Lobectomy After Prior Contralateral Lobectomy: High Risk, High Reward
Barrett, Sean, Mr; Kennedy, Fionnuala, Dr; McLoughlin, Joseph, Mr; Keane, Colm, Dr;
Ryan, Ronan, Mr; Young, Vincent, Mr; Fanning, Niall, Dr; Fitzmaurice, Gerard, Mr
St. James's Hospital, Dublin, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A275
Objectives
Lobectomy after previous contralateral lobectomy is a radical treatment option for
patients presenting with bilateral lung malignancies, intuitively representing increased
perioperative risk. Due to the rarity of cases, there is limited outcome data for
these patients. The aim of this study was to examine outcomes for this select patient
group and we hypothesised that mortality rates would be lower compared with patients
undergoing a pneumonectomy.
Methods
A retrospective review was performed on a prospectively collected clinical database
of all patients who underwent staged contralateral lobectomy for pulmonary malignancies
between January 2012 and June 2021. Sublobar resections and completion pneumonectomies
were excluded.
Results
31 patients met the inclusion criteria with a mean age of 65.6 years. Pulmonary function
tests pre-second lobectomy demonstrated a mean FEV1 of 75.4% and DLCO of 69.3%. 74%
(n = 23) of cases were performed via open thoracotomy. Contralateral double lumen
tubes were used for all patients with a permissive hypercapnic strategy employed in
one-third of cases. 78% of second lobectomies had Stage I/II disease. The ICU admission
rate was 29% (n = 9) and reintubation rate was 22.6% (n = 7). The 30- and 90-day mortality
was 6.4% (n = 2). The median hospital length of stay was 9 days.
Conclusions
The mortality rates for staged lobectomy were lower than those expected with pneumonectomy.
Although this group have a significant ICU admission rate of 29%, discharge to home
and rates of survival were excellent. Consequently, we suggest that staged lobectomy
is a suitable treatment strategy in carefully selected patients presenting with contralateral
malignancies and pursuit of extended ICU admissions is worthwhile.
Figure 1: Outcomes following Contralateral Staged Lobectomy.
A276 Factors linked to Outcome in Resected Pulmonary Typical Carcinoid Tumours
Patel, Akshay1, Mr; Perris, Rebecca1, Dr; Mangel, Tobin
2, Dr; Humphries, Sian1, Ms; Smith, Stacey1, Mrs; Shah, Tahir1, Dr; Hughes, Simon1,
Dr; Rogers, Vanessa1, Miss; Naidu, Babu1, Mr; Kalkat, Maninder1, Mr
1Queen Elizabeth Hospital, Birmingham, UK; 2St. George's Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A276
Objectives
Typical carcinoids account for the majority of lung carcinoids and have a better prognosis
and lower propensity for metastatic spread than atypical carcinoids. Surgical resection
with lymphadenectomy is the gold standard for patients with bronchial carcinoids.
Typical carcinoids are amenable to treatment with non-anatomical sublobar resection
with numerous groups having reported no significant difference in outcomes in patients
with wedge resection compared to those patients that underwent anatomical resection.
We explored the impact of pre-operative, operative and pathological factors on overall
and disease-free survival.
Methods
We performed a retrospective interrogation of data collected from 92 patients with
typical pulmonary carcinoid tumours who underwent surgical resection over a 25-year
period at our institute. All demographic, operative, post-operative pathological and
survival data was collected. Median follow-up was 1359 days (726–2265 days). Kaplan–Meier
and Multivariate Cox Proportional Hazards modelling were performed in R studio, Rv4.0.3.
Results
Forty-one of these tumours were endobronchial and 51 were in the lung parenchyma.
The majority were resected anatomically (n = 71), and through a VATS approach (n = 61).
Mortality and recurrence rates at 10 years were 16% (n = 15) and 14% (n = 13) respectively.
There was no significant difference between anatomically and non-anatomically resected
typical carcinoids (log-rank, p = 0.6; Fig. 1). Significant independent predictors
of overall survival were advanced age (HR 1.09, p = 0.004) and VATS approach (HR 0.31,
p = 0.048). Type 2 Diabetes was a negative prognostic factor for disease recurrence
in this cohort (HR18.9, p = 0.013).
Conclusions
Sublobar resection may be an appropriate surgical strategy in typical carcinoid tumours,
however, further work is needed to investigate the role of segmentectomy versus lobectomy
and indeed segmentectomy versus wedge resection.
A277 Surgery vs. Radiotherapy for The Treatment of Early-Stage Non-Small Cell Lung
Cancer: A Systematic Review/Meta-Analysis of Propensity Matched Studies
Barrett, Sean, Mr; Rice, Darragh, Dr; Higgins, Patrick, Mr; McLoughlin, Joseph, Mr;
Fleming, Christina, Ms; Eaton, Donna, Ms
Mater Misericordiae University Hospital, Dublin, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A277
Objectives
Lung cancer is the leading cause of cancer death worldwide. With the increasing popularity
of lung cancer screening, the incidence of early-stage lung cancers is on the rise.
The current gold standard for management of early disease is surgery. Advances in
radiotherapy techniques and recent literature demonstrating similar outcomes in certain
patient groups has led to an increase in the popularity of this treatment modality.
We performed a meta-analysis of propensity score matched studies to compare these
treatments.
Methods
The overall aim was to synthesis the best available evidence comparing surgery versus
radiotherapy for the treatment of early-stage non-small cell lung cancer with regard
to 5- and 3- year survival and recurrence rates. A comprehensive search of Pubmed,
Embase, Scopus, and Web of Science was performed up to April 2021. We included retrospective
propensity score matched studies for quantitative analysis. The study was performed
in line with PRISMA guidelines. Statistical analysis was performed using Revman software.
Results
22 studies were included in the meta-analysis. There were statistically significant
superior outcomes in the surgical group for 5-year overall survival [RR 1.47 (95%
CI 1.28–1.68) p < 0.001] and 3-year overall survival[RR 1.24 (95% CI 1.10–1.40) p < 0.001].
These findings persisted on subgroup analysis of lobectomy and sublobar resection
versus radiotherapy.
Conclusions
According to the best current evidence in the form of retrospective propensity matched
studies, surgical approaches remain the gold standard of treatment of early-stage
non-small cell lung cancer. Further evidence in the form of prospective randomised
controlled trials is needed to provide optimum evidence in the subject.
Figure 1: Table of Outcomes.
A278 The Current Under the Wave: Increase in Upstaging in Early-stage NSCLC in the
COVID Era
Lodhia, Joshil, Mr; Hussein, Nabil, Mr; Brunelli, Alex, Mr; Chaudhuri, Nilanjan, Mr;
Milton, Richard, Mr; Papagiannopoulos, Kostas, Mr; Teh, Elaine, Miss; Tcherveniakov,
Peter, Mr
St James University Hospital, Leeds, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A278
Objectives
The COVID pandemic has led to reduced access to outpatient surgical appointments and
operative capacity. The purpose of this study was to evaluate the delay from diagnosis
to treatment of early-stage non-small cell lung cancers (NSCLC) [Stage IA–IB] and
if this led to an increase in upstaging and in turn a need for adjuvant therapy.
Methods
Data of consecutive NSCLC lung resections between January 2019 to August 2021 were
retrospectively collected. The COVID period was identified as post January 2020. Patients
who required further surgical staging or those with secondary lung cancers were excluded.
Chi-square test was used for statistical analysis.
Results
The number of resections, following exclusion, were 195 [2019], 194 [2020] 144 [2021].
There was an increase in the referrals of early-stage lung cancers 67% [2019], 72%
[2020] and 81% [2021, p = 0.015]. The proportion of lobectomies performed were 75%
[2019], 66% [2020], 62% [2021, p = 0.068]. The proportion of sub-lobar resections
increased from 19% [2019] to 32% [2020] and 36% [2021, p = 0.004]. The proportion
of VATS procedures increased from 80% [2019] to 88% [2020] and 92% [2021, p = 0.023].
There was no delay in PET to surgical review [31 ± 17 vs 33 ± 19, p = 0.94], however,
a delay was observed between surgical review and surgery [21 ± 19 vs 29 ± 22, p < 0.0001].
There was an increase in upstaging between 2019 and the COVID period of both tumour
[35% vs 48%, respectively] and nodal [19% vs 28%, respectively] staging, p = 0.02
but no difference in R1 margins [5%, p = 0.99]. Overall, the percentage of patients
who were upstaged to require adjuvant chemotherapy increased from 18% [2019] to 25%
[2021, p = 0.01].
Conclusions
Despite the increased proportion of patients being referred with early-stage lung
cancers, this cohort has seen an increase in upstaging above the levels from the pre-COVID
era. This is, likely, a consequence of the delay from surgical outpatient assessment
to surgery, brought on by the COVID pandemic.
A279 Electromagnetic Navigational Bronchoscopy Marking Image Guided Robotic (iRATS)
S9 + 10 Segmentectomy—Movie
Lau, Kelvin, Mr; Perikleous, Periklis, Mr; Nardini, Marco, Mr; Stamenkovic, Steven,
Mr
St Bartholomew's Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A279
https://www.youtube.com/watch?v=ueh-bMqNUGA
A280 Pulmonary Metastasectomy Outcomes for Sarcoma: Should we Always Operate?
Hoppe, Solveig
1, Dr; Taberham, Rhona2, Miss; Stavroulias, Dionisios2, Mr
1St Mary's Hospital, Isle of Wight NHS Trust, Newport, UK; 2John Radcliffe Hospital,
Oxford University Hospitals NHS Foundation Trust, Oxford, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A280
Objectives
Pulmonary metastases are a frequent site of disease recurrence in patients with sarcoma.
Metastasectomy is a mainstay of treatment for these patients who otherwise have controlled
disease. We aimed to review the survival outcomes from sarcoma patients undergoing
pulmonary metastasectomy in our institution.
Methods
We retrospectively reviewed the outcomes of a single surgeon’s consecutive patients
who underwent their initial pulmonary metastasectomy for sarcoma between October 2013
and March 2020. Electronic patient records were interrogated for primary tumour characteristics,
number and location of metastases, methods of treatment and survival.
Results
A total of 46 patients were included, with a median age at diagnosis of 57.5 years
(range 13–80). All the primary tumours were treated surgically, of which 8 (17.4%)
patients had positive margins. The mean disease-free interval was 27.9 months. The
median number of thoracic metastases removed in a single operation was one (range
1 to 11), 28 patients underwent more than one operation for pulmonary metastases (median
2, range 1–6, IQR 1–3). Size of metastases resected ranged from 2 to 110 mm, with
the median size metastasis excised being 10 mm (IQR 6–19). 30-day mortality was 0%.
Median follow-up time from initial pulmonary metastasectomy was 33.5 months (range
4 to 89 months). 29 patients (63.0%) are still alive. Of the 17 patients (36.9%) who
died, the mean survival from pulmonary metastasectomy was 21.9 months. Actual 5-year
survival was 8 out of 14 patients (57.1%). 28 patients received chemotherapy, with
15 following metastasectomy.
Conclusion
Pulmonary metastasectomy, in our cohort of patients, was associated with no post-operative
mortality. As a low-risk procedure, it is an acceptable treatment option with survival
in selected metastatic cases reaching 5 years and beyond.
A281 Characteristics and Postoperative Trajectory of Patients Requiring ICU Admission
After Extended Pleurectomy and Decortication for Mesothelioma
Chandarana, Karishma, Dr; Koulouroudias, Marinos, Mr; Caruana, Edward, Mr; Dawson,
Alan, Mr; Nakas, Apostolos, Mr
Glenfield Hospital, Leicester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A281
Objectives
Radical surgery in the form of Extended Pleurectomy Decortication (EPD) presents a
major physiological stressor to patients undergoing treatment for malignant pleural
mesothelioma (MPM).
The interplay of a patient’s susceptibility to organ injury and the stress response
to surgery likely determine the occurrence of postoperative organ dysfunction and
need for intensive care.
Identification of factors associated with admission to ICU after EPD can help improve
perioperative decision-making and patient counselling.
We aim to identify and compare the differences in clinical, oncological and operative
characteristics of patients undergoing EPD that require ICU and those who are discharged
from recovery to level 2 care.
Methods
All patients who underwent EPD for MPM between January 2019 and September 2021 were
included in final analysis. Data was collected from operative databases, electronic
patient records and the national ICNARC dataset. Statistical analysis was performed
using RStudio.
Results
74 patients underwent EPD for MPM, with a total of 34 ICU admissions directly from
theatre or recovery (46%).
Patients admitted to ICU were more likely to be male (88.5% v. 72.5%, p = 0.041),
have advanced stage pT3/4 mesothelioma, (88.2%, v.70.0%, p = 0.057) and receive more
units of red cells intraoperatively (2.8 v. 1.2, p = 0.0001).
50% of patients admitted to ICU required advanced cardiovascular support, 18% advanced
respiratory support, and 3% continuous veno-venous hemofiltration (CVVH). Median length
of ITU stay was 3 days (range 1–30), with all patients successfully discharged to
a high dependency unit (HDU).
Conclusions
Overall, admission to ICU following EPD for MPM is common and associated with more
advanced disease stages and a higher requirement for intraoperative red cell transfusions.
Further understanding of factors predisposing to post- operative organ injury can
open new avenues for prehabilitation, risk stratification and improved resource allocation.
A282 Streamlining Pre-operative Investigations and Pathway for Patients Referred to
a Thoracic Surgery Service
Brahambhatt, Krupali
1, Mr; Mohammed, Rayhaan2, Mr; Rathinam, Sridhar3, Mr
1Northampton General Hospital NHS Trust, Northampton, UK; 2Glenfield Hospital, Leicester,
UK; 3University Hospitals of Leicester NHS Trust, Leicester, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A282
Objectives
To design a streamlined process map for pre-operative investigations in referrals
to our peripheral clinics. Aimed at enabling better patient experience, efficient
use of junior doctor time and cost saving. Our service covers 4 different peripheral
clinics. Access to investigations is often limited resulting in repeated and unnecessary
blood tests on admission. This has led to delayed operating lists, patient dissatisfaction,
negative impact on trust finances and increased junior doctor workload. Lung cancer
referrals are discussed at MDT meetings and planned for theatre and as such they should
have investigations in keeping with NICE guideline NG45 and Cancer 62-day pathway.
With the introduction of ERAS for lung surgery, pre-operative anemia and hypoalbuminemia
can be corrected 2 weeks prior to surgery.
Methods
We audited preoperative blood investigations taken in keeping with these guidelines
and the 62-day cancer pathway for lung cancer referrals. We looked at how many of
these were available on prior to admission and which blood tests are carried out on
admission. We designed a process map to be carried out at the peripheral clinics.
(Fig. 1.) This was implemented in 2 of our peripheral clinics. We then focussed on
colleague education on current guidelines especially junior staff.
Results
With this process map in place, we found an increase in number of investigations requested
at our peripheral clinics in keeping with guidelines. Less blood investigations were
requested on admission at our institution with an average cost reduction of £10 per
patient. With approximately 500 patients referred to our service this would ultimately
result in £5000 savings per annum.
Conclusion
Our process map is cost-effective, simple to implement and reduces unnecessary tests.
The results can be greatly improved by involvement of all our clinics.
A283 Smoker Thoracic Physiotherapy Requirements in Anatomical Lung Resections
Badran, Abdul1, Dr; Lee, Alexander
1, Dr; Elena, Maria2, Miss; Cooper, T1, Miss; Neilsen, Louisa1, Miss; Alzetani, Aiman1,
Mr
1University Hospital Southampton, Southampton, UK; 2University of Southampton, Southampton,
UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A283
Objective
Consideration of the effectiveness of thoracic physiotherapy interventions in anatomical
lung resections.
Method
Prospective cohort of 59 anatomical lung resections and assessment of the physiotherapy
interventions in a busy teaching hospital over a 3-month period.
Results
60 patients were included. Median age of 71 (36–83). The majority were female (64%
vs 36%) with 63% performance status 0. Most were resections for adenocarcinoma (63%)
and squamous cell carcinoma (19%). 88% were resected by VATS and 11% open. A minority
had no comorbidities (17%), with hypertension (32%) and COPD (23%) being most common.
The vast majority of patients 93% were seen on day 1 by physiotherapy. Barriers to
this were weekend working (75%). Average length of stay was 4 days for the cohort
(3.8 for VATS and 5.3 for Open). Advanced physiotherapy techniques were needed in
18% (n = 11), these were 30% (n = 3) current smokers and the rest ex vs 13% current
smokers (n = 6) and ex-smokers in 75% (n = 36) for those that didn’t need advance
techniques.
Conclusion
We found that elective thoracic patients are more likely to have a reduced LOS and
are less likely to require advanced respiratory techniques when reviewed D1PO. This
highlights a need for potential service developments within our weekend and Level
2/3 elective thoracic caseload to optimise all patients within service.
A284 Open Versus Video-Assisted Thoracoscopic Surgery (VATs) Versus Robotic Approaches
to Thymectomy – a Systematic Review and Bayesian Analysis
Smith, Harry; Chan, Jeremy, Dr
Morriston Hospital, Swansea, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A284
Introduction
Thymectomy has traditionally been performed via a median sternotomy approach. More
recently evidence has emerged showing that alternative techniques are adequate if
not superior to the median sternotomy; these include video-assisted thoracoscopic
surgery (VATS) and robotic surgery – collectively these techniques allow a less invasive,
or minimally invasive approach. Our study group aimed to examine the relationship
between the approach used for thymectomy and its effect on some defined post-operative
outcomes.
Methods
A systematic review was conducted adhering to PRISMA guidelines using PubMed, Embase,
Cochrane library and Web of Science databases. We included original research articles
comparing robotics to open thymectomy to VATs for thymoma, anterior mediastinal masses
or myasthenia gravis associated thymomas. Bayesian meta-analysis were performed for
mortality, length of stay, recurrence rates, 5-year disease-free survival and complication
rates.
Results
Our analysis showed no statistically significant differences between the 3 groups
on mortality (p = 0.61). Length of hospital stay favours VATs and robotic groups when
compare to open (p < 0.05) but no difference was noted between VATs and robotic arm.
No statistically significant differences were noted in 5-year disease free survival
between 3 groups.
Conclusion
We have shown a definite hierarchy in surgical approach to thymectomy from the available
original articles in the selected databases when it comes to length of hospital stay,
which favours VATs. However, in order to form concrete conclusions regarding, randomised
controlled studies of a large magnitude are needed.
A285 Decision-making, Education, and Staff Confidence Regarding Chest Drain Assessment
in the Thoracic Surgical Patient: A Service Evaluation
Gopalaswamy, Madhura, Dr; Calvert, Rachel, Mrs; Connelly, Leanne, Mrs; Dunning, Joel,
Mr; Waterhouse, Benjamin, Mr
South Tees NHS Foundation Trust, Middlesbrough, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A285
Objective
Chest drains are an important part of the post-operative management of thoracic surgical
patients. Timing the removal of a chest drain is important for several reasons.
Removal too soon can result in pneumothorax or pleural effusion necessitating drain
re-insertion.
Leaving a drain in longer than required can be a source of infection, cause discomfort
and pain, limit mobility, and delay discharge from hospital.
The aims:
To assess concordance between ward round and drain chart assessment of air leak
To look for any weekend effect: day of the week drains removed (to evaluate if non-thoracic
registrars are less comfortable making decisions to remove drains)
Assess whether staff feel they are confident assessing chest drains
Methods
The study looked at lung resections and was conducted retrospectively over a 6-month
period (October 2020- March 2021).
Metrics included variation in length of time with drain in situ by day of operation,
chest drain chart entries and compared it to the ward round documentation of the drain.
To support this work and as a baseline for further assessment after intervention,
a staff questionnaire was given to measure confidence assessing different chest drain
devices.
Results
86 lung resections were performed over the 6 months.
Chest drain charts reviewed for 73 patient-days.
17/73 (23.3%) were discordant with the ward round documentation of air leak.
Chest drains removed by day of the week: No significant variation.
Patients operated on Mon
Mean 3.65 d
Median 1 d
Patients operated on Fri
Mean 3.25 d
Median 1 d
Results from the staff questionnaires showed a mean confidence of 82% for underwater
seal and 48% for the flutter bag.
Conclusions
There was significant difference between chest drain chart entries and ward round
notes of air leak and poor staff confidence especially in assessing flutter bags.
We were pleased that despite preconceptions within the team we found no evidence of
a "weekend effect" when it comes to removal of drains.
A286 The Role of Blood Patch Pleurodesis in the Covid-19 Era: Lessons Learned
Mustaev, Muslim, Dr; Hurley, Patrick, Dr; Harrison-Phipps, Karen, Mrs
Guy's & St Thomas' NHS Foundation Trust, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A286
Objectives
During the Covid-19 pandemic, the efforts of the cardithoracic surgical units were
concentrated on reducing postoperative complications, including persistent air leak
(PAL). As management of PAL by Heimlich valve adds on to potential risk of spreading
the Covid-19 in the community, the objective of this study was to analyse the efficacy
of blood patch pleurodesis (BPP) in the postoperative patients.
Methods
From January through October 2021, ten patients, six males (mean age 64.7 ± 11.4 yrs)
and four females (mean age 66.3 ± 12.3 yrs) operated on for various indications (pneumothorax
(1 pt), empyema (1 pt), mediastinal lymph node dissection (1 pt) and lung cancer (7
pts)) were analysed. All patients developed PAL and underwent BPP using 50–60 mL of
autologous blood as sterile once-only procedure.
Results
The mean duration of PAL from the index operation to BPP procedure was 13.6 ± 12.3 days,
median was 11.5 days (range 2–45 days), the mean period post BPP to drain removal
was 5.8 ± 5.1 days, median was 4.5 days (range 1–19 days). Nine patients were discharged
home uneventfully, and one patient (10%) was discharged home with Heimlich valve which
was removed in 19 days. There were no immediate complications after BPP. None of the
patients developed fevers or empyema post procedure.
Conclusions
Our study confirms overall efficacy and safety of BPP in the postoperative patients
with PAL. BPP provides a satisfactory seal of PAL in majority of patients and may
serve as a valid alternative to Heimlich valve and chemical pleurodesis.
A287 Significantly Reduced Blood Loss From the First Case: Early Outcomes of a New
Robot-assisted Lobectomy Programme
Harrison, Oliver, Mr; Veres, Lukacs, Mr
University Hospital Southampton, Southampton, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A287
Objectives
To review the early outcomes of a newly established robot-assisted (RATS) lobectomy
programme and compare to an established video-assisted (VATS) lobectomy practice.
Methods
The case notes from all patients undergoing RATS lobectomy at our institution from
the first case performed in May 2021 to October 2021 were reviewed. Cases involving
intra-operative frozen section were excluded. A matched series of patients undergoing
VATS lobectomy between January 2020–December 2020 were identified and used as a comparison
group. All procedures were performed by the same surgeon. Outcomes included operative
time, blood loss, length of stay and complications defined as any adverse event delaying
discharge by 31 day. Statistical analysis was performed with SPSS (v26). Independent
samples t-tests and Mann–Whitney U tests were used to compare parametric and non-parametric
outcomes respectively. Data are presented as mean ± standard deviation (SD) or median ± interquartile
range (IQR) based on normality testing.
Results
Table 1 conveys the key study data. Twenty RATS lobectomy cases were performed during
the study period and were matched with 16 VATS lobectomy cases. There were no significant
differences in major surgical risk factors between the groups. Operative time was
significantly longer in the RATS group (95% CI 8 – 47 min; p = 0.008). There was a
weak trend towards decreasing operation time over the study period (r = -0.289; p = 0.216).
Intraoperative blood loss was significantly lower in the RATS versus VATS lobectomy
group (30 ml vs. 50 ml; p = 0.016). There were no conversions in the RATS lobectomy
group compared to 7/35 for the unselected lobectomy cases started VATS in 2020.
Conclusions
Evidence supporting the benefits of RATS over VATS is limited. We demonstrate a significant
reduction in intraoperative blood loss with a RATS approach, including cases performed
on the initial learning curve, when compared to an established VATS lobectomy.
Transplant and Failure
A288 AManagement of Bronchial Stenosis in Post Lung Transplantation—Initial Evaluation
of Biodegradable Stents
Cyclewala, Shabnam, Dr; Padukone, Ashok, Dr; Asadi, Nizar, Mr
Royal Brompton and Harefield Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A288
Introduction
Bronchial stenosis one of the most common airway complications post lung transplantation.
Methods
Retrospective analysis of prospectively collected data of patients who have undergone
lung transplantation. Data was gathered with regards to the type of interventions
used to treat the bronchial stenosis and the outcomes were compared, along with looking
at the efficacy of absorbable bio-degradable stents.
Results
A total of 524 lung transplantations were performed. 44 Patients developed bronchial
stenosis out of which 32 patients required interventions for the stenosis. The most
common site for stenosis was found to be bronchus intermedius (28 – 63%) followed
by left main bronchus (9 – 20%), right main bronchus (5 – 11%) and left upper lobe
bronchus (2%). The patients were treated with initially balloon dilatation (32—72%),
cryotherapy (15 -34%) and later endobronchial stents (9 – 18%). With metallic stents
(4), 3-have had bronchomalacia, 1 -re-stenting, and 2 had persistent stentosis post
removal. The biodegradable stents(5), which have been followed up from 4 to 10 months,
have had no reports of bronchomalacia and also decreased the need for intervention
to removal the stent.
Conclusions
Conventional stents carry a risk of complications. Biodegradable stents have been
newly introduced which hold strength initially and degrade over months. It also bypasses
the issue of stent removal and show improved FEV1. Follow-up and prospective studies
need to be undertaken to compare benefits and subsequent complications.
A289 VATS Right Lower Bilobectomy Post Bilateral Single Sequential Lung Transplantation
(BSSLTX) for Airway Stenosis—Movie
Mayer, Nora
1, Dr; Perikleous, Periklis1, Mr; Khoshbin, Espeed2, Mr; Asadi, Nizar1, Mr
1Royal Brompton and Harefield Hospitals, Part of Guy`s and St. Thomas NHS Foundation
Trust, Department of Thoracic Surgery, London, UK; 2Royal Brompton & Harefield Hospitals,
Part of Guy`s and St. Thomas NHS Foundation Trust, Heart&Lung Transplantation, London,
UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A289
https://www.youtube.com/watch?v=XJKXloQxPvA
A290 Cardiac Power Output Index as a Predictor of Severe Primary Graft Dysfunction
and Early Mortality in Cardiac Transplantation
Williams, Luke
1, Dr; Duval, Jean-Luc2, Dr; Lim, Sern3, Dr; Catarino, Pedro4, Mr; Berman, Marius2,
Mr
1NHS Blood and Transplant; 2Royal Papworth Hospita, Cambridge, UKl; 3University Hospitals
Birmingham, Birmingham, UK; 4Cedars Sinai, Los Angeles, USA
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A290
Objectives
Cardiac Power Output Index (CPOi) has been suggested as an easy to measure and useful
haemodynamic predictor of severe primary graft dysfunction (PGD) and early mortality
after cardiac transplantation. We sought to analyse the utility of the recently published
cut-offs for CPOi as a predictor of severe PGD and early mortality.
Methods
We retrospectively analysed 250 consecutive adult patients who underwent cardiac transplant
between January 2016 to August 2021 at our institution. We used electronic records
to calculate CPOi (CIx(MAP-CVP)/451) at admission to ICU (0 h) and 6 h post-operation.
We applied the previously determined cut-off of CPOi < 0.34W/m2 at 0 h and < 0.33W/m2
at 6 h to determine the sensitivity, specificity, negative and positive predictive
values as a determinant of the combined outcome of severe PGD or 30 day mortality.
Results
27 patients were excluded due to incomplete recording of data required to calculate
CPOi at one or both timepoints. 16 patients met the primary outcome (6 died, 10 developed
severe PGD) within 30 days of their transplant. 14 of these fell below the cut-offs
at both timepoints, two fell below the cut-off at one timepoint. A total of 139 patients
fell below the cutoffs at both time-points, 30 patients were above the cut-offs at
both time points and 54 patients were below the cut-off at one time-point only. The
sensitivity of CPOi below < 0.34W/m2 at 0 h and < 0.33W/m2 at 6 h was 100%, with
a specificity of 19.35%, a positive predictive value of 0.1 and a negative predictive
value of 1.
Conclusions
CPOi can accurately rule out severe PGD and 30-day mortality within 6 h of operation
and can help to predict those who will require early mechanical circulatory support,
potentially facilitating earlier intervention and improving outcomes in cardiac transplantation.
A291 'A Window of Opportunity to be Considered': Challenges in Lung Transplantation
in Patients with COVID-19 Lung Disease Bridged with ECMO Support
Graziano, Giovanni, Dr; Gallagher, Grainne, Dr; Hutchison, Susan, Ms; Pereira, Charlotte,
Ms; Soliman-Aboumarie, Hatem, Dr; Kaul, Sundeep, Dr; Khoshbin, Espeed, Mr
Royal Brompton and Harefield NHS Foundation Trust, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A291
Background
Lung transplant is a last resort for COVID-19 patients with end-stage lung disease.
Despite lack of data for long-term outcomes, multi-institutional case series show
that lung transplantation can be carried out successfully with encouraging early outcomes
(92% survival at 80 days, Bharat 2021). Extracorporeal membrane oxygenation (ECMO)
is a supportive measure for patients with irreversible lung disease following COVID-19
infection as a bridge to transplant.
Case
We report a long run of veno-venous (VV) ECMO for COVID-19 of 252 days. This is the
longest ever ECMO run documented in a COVID-19 patient. A 41 year-old man with a background
of hypercholesterolemia and type-2 diabetes mellitus presented with COVID-19 pneumonitis.
Despite optimal medical therapy and rest ventilation, his support escalated to peripheral
VV-ECMO, for which he was sedated for the first 60 days. He developed irreversible
lung injury with CT evidence of end-stage pulmonary fibrosis. He was referred for
consideration of lung transplantation, but was deemed unsuitable due to profound physical
deconditioning, manifested as severe central and peripheral muscle wasting, increasing
ventilator driving pressure, low tidal volumes (< 2 ml/Kg) and right heart failure.
Discussion
This case gives us the opportunity to learn about the challenges associated with the
use of ECMO as a bridge to transplant in the context of COVID-19. As illustrated,
the patient underwent prolonged sedation, which negatively impacted prognosis as it
delayed reconditioning with physiotherapy.
Conclusion
In addition to the International Society for Heart & Lung Transplantation (ISHLT)
criteria (table) we suggest a multifactorial strategy to improve muscle strength and
endurance. This includes optimising nutritional status, and implementing an early,
personalised, physiotherapy-led muscle strengthening program, using muscle function
tests (effort and non-effort related) to guide progress and inform decision-making.
A292 'Long-Term' Use of Impella—Safe to Do?
Ahmed, Hesham, Mr; Alayyar, Mohammed, Mr; Jothidasan, Anand, Mr; Husain, Mubassher,
Mr; Stock, Ulrich, Prof; Smail, Hassiba, Ms
Royal Brompton and Harefield Hospital as part of Guys and St Thomas Foundation Trust,
London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A292
Objectives
Impella CP, 5.0 and RP belong to the group of short-term mechanical circulatory support
(MCS) devices used for patients with severe heart failure and cardiogenic shock. The
Impella is designed for short- term support up to 10 days, but our patients frequently
require a longer duration of support. As our patients are often bridged to transplant
and the long waiting lists often result in long waiting times, we are frequently forced
to prolong the use of the Impella. Therefore, we aimed to assess the safety of prolonged
device duration past 10 days.
Methods
We present our single center data of 69 patients who underwent Impella placement between
May 2017 and May 2021. We divided the patients into two groups, Group A (39 patients)
with device duration < 10 days and Group B (30 patients) with device duration > 10 days
and compared the occurrence of complications and mortality in the two groups.
Results
Median device duration for Group A was 6.08 (± 2.2) and 21.6 (± 11.8) days in Group
B (p 0.001). Group A contained 6 Impella 5.0, 27 Impella CP and 6 Impella RP vs. Group
B with 18 Impella 5.0, 10 Impella CP and 2 Impella RP (p 0.001).
There were no significant differences between Group A and Group B regarding: haemolysis
52.4% vs. 42.6% (p 0.36), access site bleeding 24.3% vs. 30% (p 0.4), thrombocytopenia
27% vs. 23.3% (p 0.47), vascular complications 8.1% vs. 6.7% (p 0.6), device migration
5.6% vs. 6.7% (p 0.6), pump thrombosis 10.8% vs. 17.9% (p 0.3), device malfunction
0% vs. 3.3% (p 0.4), ventricular arrhythmias 29.7% vs. 23.3% (p 0.38), access site
infection 0% vs. 3.3% (p 0.44), sepsis 32.4% vs. 46.7% (p 0.17), ischemic cerebrovascular
accident (CVA) 0% vs. 3.3% and haemorrhagic CVA 0% vs 6.8%. (p 0.13).
There was no significant difference regarding pre-implant and pre-explant bilirubin
levels in both groups (p 0.35 and p 0.19) and creatinine levels (p 0.2 and 0.06).
The platelet count pre-implant showed no significant difference (p 0.07). However,
the pre-explant level was significantly lower in Group A (p 0.005).
The mortality rate on Impella in Group A and Group B was 28.2% and 13.3% (p 0.1),
respectively.
Conclusion
Prolonged device duration has no significant impact on the short-term outcome except
on platelet levels. In cases where longer MCS is mandatory careful monitoring might
allow longer Impella support.
A293 Primary Graft Dysfunction (PGD) After Lung Transplantation, Incidence and Outcomes;
a Single-centre Experience
McGinley, Jack
1, Mr; Hardman, Gillian2, Miss; Parry, Gareth2, Dr; Clark, Stephen2, Prof; Dark, John2,
Prof; Fisher, Andrew1, Prof; Booth, Karen2, Mrs
1Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, UK; 2Department
of Cardiothoracic Transplantation, Freeman Hospital, Newcastle-upon-Tyne, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A293
Objectives
Data for the diagnosis and grading of Primary Graft Dysfunction (PGD) following lung
transplantation are not routinely recorded in the UK Transplant Registry (UKTR).
This study aimed to examine the incidence and impact of PGD after lung transplantation
from a single UK transplant centre.
Methods
Data for adult first-time lung transplant recipients in our centre between 1 January
2010 and 31 December 2019 were reviewed. Diagnosis and grading of PGD was established
retrospectively by ISLHT criteria.
Unadjusted 90-day, 1-year and 5-year survival by PGD grade was assessed using Kaplan–Meier
survival analysis and log-rank tests. Univariable analysis of PGD grade 3 at 72 h
post-transplantation, was performed.
Results
A total of 424 recipients were identified, with PGD grading available for 401 (95%).
The incidence of PGD3 at 72 h was 16% (64 recipients). There was a significant difference
in survival at 90-days, 1-year (p = < 0.0001) and 5-years (p = 0.0002).
Recipients with PDG3 at 72 h had a statistically significant higher mean BMI (26 SD ± 4
versus 24 (± 4) p = 0.0009), more donors with a history of smoking (41 (64%) versus
141 (42%) p = 0.001) and a lower proportion of ‘off-pump’ procedures (23% versus 41%
p = 0.04).
Conclusions
These results indicate a comparable incidence of PGD3 to studies outside the UK, and
a significant impact on both short- and long-term survival for recipients with PGD3
at 72 h post-transplant.
A294 Awake Non-intubated Veno-arterial ECMO in Acute Decompensation of Chronic Heart
Failure
Mohite, Prashant
1, Mr; Umakumar, Kabeer2, Mr; Verzelloni Sef, Alessandra2, Dr; Sef, Davorin2, Mr;
Husain, Mubassher2, Mr; Farmidi, Abu2, Mr; Marczin, Nandor2, Dr; Stock, Ulrich2, Prof
1Golden Jubilee National Hospital, Glasgow, UK; 2Royal Brompton & Harefield NHS Foundation
Trust, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A294
Objectives
Acute decompensation in patients of chronic heart failure that cannot be managed with
inotropes and diuretics may require short-term mechanical circulatory assist. These
patients usually have a good lung function and may tolerate awake peripheral implantation
of the veno-arterial extracorporeal membrane oxygenation (VA ECMO) or sedation hold
and extubation if ventilated at the time of ECMO implantation. We share our experience
of keeping these patients awake during the ECMO support.
Methods
53 patients (21 females) with a mean age of 39 (16–63) years received VA ECMO for
acute decompensation in chronic advanced heart failure due to cardiomyopathy. We utilized
Cardiohelp (Getinge, Sweden) or CentriMag pump (Abbott, USA) and Medos HiLite oxygenator
(Inspiration, Germany) for ECMO support. Peripheral ECMO was implanted percutaneously
under local anaesthesia without sedation in 51 patients whereas 2 patients received
central ECMO via sternotomy. Patients on ventilator support at the time of ECMO implantation
were given an early trial of sedation wean and extubation. Awake patients underwent
active mobilisation and physiotherapy.
Results
The average duration of the ECMO support was 12.1 (2–32)days and awake duration on
the ECMO support was 7.5 (1–29)days. Eleven (20.7%) patients died on the ECMO support,
16 (30.1%) patients had myocardial recovery with successful ECMO explant, 20 (37.7%)
patients were bridged to the long-term ventricular assist device, 1 patient to short-term
VAD, and 5(9.4%) patients were bridged to the heart transplant. The average ITU stay
was 22.6 (3–114)days and the average hospital stay was 50.1 (3–250)days. 21 patients
died in the hospital with a discharge to home survival of 60.3%.
Conclusions
Chronic heart failure patients supported on the ECMO can be maintained awake and can
mobilise, eat and drink and undergo physiotherapy. Complications related to mechanical
ventilation, sedation, and immobilisation can be avoided.
A295 Redo-sternotomy in Heart transplantation – Outcomes from the Scottish National
Advanced Heart Failure Service
Avtaar Singh, Sanjeet Singh
1, Mr; Das De, Sudeep2, Mr; Curry, Philip2, Mr
1Aberdeen Royal Infirmary, Aberdeen, UK; 2Golden Jubilee National Hospital, Glasgow,
UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A295
Objectives
Heart transplant recipients with previous cardiac interventions often have poorer
outcomes postoperatively. This could be due to increased technical difficulty, subclinical
deconditioning, bleeding and infections. We analysed the results from the Scottish
National Advanced Heart Failure Service to ascertain if redo sternotomies have poorer
outcomes.
Methods
103 adults underwent heart transplantation in our institution between January 2011–January
2020. Recipients were divided into 2 groups: Virgin chest (first sternotomy group;
n = 72(69.9%) and those with at least 1 prior sternotomy (redo sternotomy group; n = 31(30.1%).
Univariable analysis was performed using student’s T test and Chi-squared test. A
time to event analysis was used to depict long-term outcomes between the groups. Outcomes
of interest were post-operative ECMO, Length of Hospital stay, 30-day survival and
1-year survival.
Results
Description
Virgin Chest (n = 72)
Redo-Sternotomy (n = 31)
p-value
Recipient Age(years)
46.3 ± 12.2
44.8 ± 11.8
0.570
Preoperative Inotropes(%)
38(52.8)
18(58)
0.621
Preoperative IABP(%)
27(37.5)
7(22.6)
0.216
Height(cm)
172 ± 10.1
174 ± 8.2
0.376
Weight(kg)
76.9 ± 12.2
77.5 ± 11.7
0.828
Female(%)
23(31.9)
5(19.2)
0.076
Ischaemic Aetiology(%)
14(19.4)
11(35.5)
0.070
Donor Age(years)
43.3 ± 11.6
37.4 ± 11.5
0.067
Total Ischaemic Time(mins)
188.9 ± 64
194.1 ± 60.5
0.764
Cold Ischaemic Time(mins)
101.4 ± 45.8
117.0 ± 45.9
0.244
Post-operative ECMO
20(27.7)
10(32.2)
0.644
Bypass Time (mins)
226.8 ± 69.8
253.0 ± 105.1
0.299
30-day Mortality
6(8.3)
5(16.1)
0.101
1-Year Survival
61(84.7)
23(74.2)
0.162
Post-operative length of stay(days)
37.6 ± 22.7
33.4 ± 17.8
0.383
There was a trend towards higher number of patients with ischaemic aetiology and mortality
within the first 30 days in the redo sternotomy cohort. There was also a trend towards
a younger donor age for these recipients, which may partly explain the equivocal findings.
The Kaplan–Meier curve shows a steep drop within the first year in the redo sternotomy
group but no differences were noted at up to 10 years follow-up (Log Rank p = 0.974).
Conclusion
There was no statistically significant increase in post-operative length of stay,
mortality or post-operative ECMO rates in the redo sternotomy cohort in our study.
This could be due to the preference towards younger donors in this cohort.
A296 Direct Procurement of Thoracic Organs Along With Abdominal Normothermic Regional
Perfusion in Donation After Circulatory Death
Husain, Mubassher, Mr; Jothidasan, Anand, Mr; Zeschky, Charlotte, Miss; Padukone,
Ashok, Mr; Ahmed, Hesham, Mr; Khoshbin, Espeed, Mr; Stock, Ulrich, Prof
Royal Brompton and Harefield Hospital as part of Guys and St Thomas Foundation Trust,
London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A296
Objective
Direct procurement of thoracic organs as compared to using thoraco-abdominal normothermic
regional perfusion (NRP), a modified form of extracorporeal membrane oxygenation (ECMO)
is the preferred method for thoracic organ procurement in donors after circulatory
death (DCD). The use of abdominal NRP alone has proven to significantly improve outcomes
from liver transplantation. We have developed a technique for thoracic organ isolation
during abdominal NRP that allows successful co-procurement of thoracic and abdominal
organs.
Method
In order to achieve successful thoracic isolation both the brain perfusion and abdominal
volume loss must be prevented. After certification of circulatory death and a period
of standoff the thoraco-abdominal incision is performed. Blood is collected either
from the donor right atrium or a side-arm of the abdominal NRP circuit to prime the
organ care system (OCS) before correct identification and isolation of vascular structures
in a systematic way. 1. The left pleura is opened, and the left lung retracted to
allow identification and clamping of the descending thoracic aorta above the diaphragm.
2. The ascending aorta is clamped, and the aortic arch vented cranial to the clamp.
Abdominal NRP can then commence. 3. The inferior vena-cava is clamped within the pericardium.
4. The SVC and the azygous vein are tied off. 5. The heart is vented on the left and
right side before induction of cardioplegia (Diagram 1). Diagram 2 illustrates complete
vascular isolation of the thoracic cavity enabling explanation of the heart and lung
after delivery of selective antegrade pneumoplegia while abdominal organs continue
to be perfused for 2-h before the start of abdominal procurement.
Results
Between 2019–21 we successfully performed seven such procurements. Three heart and
lungs, three lungs and one heart procurement alone. All organs were successfully implanted
with successful immediate outcome in all thoracic and abdominal recipients.
Conclusion
Direct procurement of thoracic organs is a feasible option during abdominal NRP. This
will potentially expand the thoracic organ donor pool and improve outcome of liver
transplantation.
A297 Prehabilitation in Lung Transplant Candidates- In Person or Virtual, Group or
Individual?
Holden, Nina, Miss; Winters, Julie, Miss
Mater Misericordiae University Hospital, Dublin, Ireland
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A297
The objective was to develop a prehabilitation programme to optimise exercise capacity
and overall muscle strength in lung transplant candidates.
A virtual pulmonary rehabilitation programme (VPR) was designed. The programme consisted
of an eight week virtual exercise class and pre and post programme face to face assessment
of the following:
Six-minute walk test (6MWT)
Grip strength
Subsequently, a physiotherapist attended pre transplant clinic once per week. Participants
were referred to provide the following-
Exercise testing and advice
Review of oxygen
Referral to pulmonary rehabilitation locally
Participants were followed up six monthly or via virtual clinic if required sooner.
During the 10 weeks of VPR, 50% participants were admitted to hospital. Half of participants
required an increase in oxygen. One participant passed away. Of eighty potential attendances,
19% of these were missed. Four of the remaining five participants improved 6MWT distance
and grip strength.
Analysis of outpatient clinic activity and data is underway.
Lung transplant candidates have complex needs. Virtual intervention provides opportunity
to access specialist input without travelling. Challenges include remote monitoring
and access to technology. In person contact facilitates real time assessment and tailoring
of interventions. It is resource intensive from a staffing and space perspective.
A298 Post-transplant Outcomes after Bridge to Candidacy and Heart Transplantation
with the CentriMag Short-term Ventricular Assist Device
Sef, Davorin1, Mr; Verzelloni Sef, Alessandra1, Dr; Jothidasan, Anand
1, Dr; Mohite, Prashant2, Mr; Raj, Binu1, Mr; De Robertis, Fabio1, Mr; Stock, Ulrich1,
Prof
1Harefield Hospital, Uxbridge, UK, Royal Brompton and Harefield Hospitals, London,
UK; 2Golden Jubilee National Hospital, Glasgow, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A298
Objectives
The role of short-term mechanical circulatory support (MCS) as a bridge to transplant
(BTT) or candidacy (BTC) remains unestablished. The CentriMag™ short-term ventricular
assist device (VAD) can be used as either BTT or BTC in patients with decompensated
end-stage heart failure when there is a contraindication for the use of a long-term
device or urgent heart transplantation (HTx). We have analyzed outcomes of patients
that were bridged to either transplant or candidacy with the CentriMag™ device.
Methods
In this retrospective study, we describe our 15-year single-centre experience of all
patients successfully bridged to candidacy or HTx with the CentriMag™ device due to
decompensated end-stage heart failure.
Results
A total of 29 patients (37.2 ± 13.8 years) underwent implantation of the CentriMag™
device as a BTT (18 patients, 62%) or BTC (11 patients, 38%). The device was used
for the left ventricular in 9 (31%), right ventricular in 6 (21%) and biventricular
support in 14 patients (48%). Preoperatively, 4 patients (17%) were mechanically ventilated,
4 (14%) had uncertain neurological status, 9 (31%) had intra-aortic balloon pump,
26 (90%) had moderate/severe right ventricular failure, 14 (48%) had renal failure,
5 (17%) had multi-organ failure, and 6 (21%) had previous sternotomy at the time of
the device implantation. 30-day mortality after implantation of the CentriMag was
7%. Mean duration of support was 38 ± 44 days. We had no device failure. Post-transplant
30-day and 1-year survival were 90% and 83%, respectively.
Conclusions
The CentriMag™ device can be effective in rescuing critically ill patients that are
considered unsuitable for long-term VAD or HTx. It can be used as either BTT or BTC
with satisfactory posttransplant outcomes.
Table 1. Post-transplant outcomes and complications.
30-day survival
26 (90)
1-year survival
24 (83)
Stroke
0 (0)
Renal failure
8 (28)
Acute rejection
4 (14)
Mechanical circulatory support
7 (24)
Sepsis
5 (17)
Bleeding
6 (21)
Arrhythmia requiring pacemaker
0 (0)
Data are presented as n(%).
A299 An Assessment of Risk Scores on the Survival of Post-cardiotomy Extra-Corporeal
Life Support (ECLS) Patients
Volpi, Sara, Miss; Oyebanji, Oluwatobiloba, Miss; Makariou, Nicole, Miss; Hamid, Umar,
Mr; Awad, Wael, Mr
St Bartholomew's Hospital, London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A299
Objectives
Post-cardiotomy cardiogenic shock (PCCS) is associated with poor outcomes. A number
of multivariable risk models have been developed to predict mortality following ECLS,
but the relative utility of these models in PCCS is unknown. We assess the predictive
value of 4 risk scores on mortality following PCCS.
Methods
Patients receiving post-cardiotomy ECLS at our centre between January 2015 and April
2021 were retrospectively risk-stratified using four commonly used scoring systems:
SAVE-score, ACEF-II, EuroSCORE II, and PC-ECMO. Area under the receiver-operating
curve (AUROC) was calculated for each risk model.
Results
112 patients underwent ECLS during this period, 46 (41.1%) patients for PCCS. The
median age of the PCCS cohort was 55 (19–79) years, 28/46 (60.9%) were male; 26/46
(56%) had pre-operative LV impairment; 52% were elective procedures. In-hospital mortality
was 34/46 (74%). AUROC for SAVE-score was 0.7 (95% CI 0.511–0.889), predicted mortality
was 63%, ACEF-II was 0.62 (95% CI 0.41–0.82), predicted mortality was 7.5%, the EuroSCORE
II was 0.53 (95% CI 0.313–0.745), predicted mortality was 16.7%, and PC-ECMO was 0.51
(95% CI 0.315–0.710), predicted mortality was 71%.
Conclusions
SAVE-score appears to be the better risk model in predicting mortality in PCCS patients
receiving ECLS in our patients. Larger studies to validate these models may guide
patient selection for PC-ECLS.
Figure 1: ROC for risk models used to calculate predicted mortality post ECLS.
A300 Selective Pneumoplegia Delivery System for Procurement in Donors After Circulatory
Death
Husain, Mubassher, Mr; Jothidasan, Anand, Mr; Zeschky, Charlotte, Miss; Padukone,
Ashok, Mr; Khoshbin, Espeed, Mr; Smail, Hassiba, Ms; Stock, Ulrich, Prof
Royal Brompton and Harefield Hospital as part of Guys and St Thomas Foundation Trust,
London, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A300
Objectives
Donation after circulatory death (DCD Maastricht III) increases the donor pool, but
the induction of organ preservation solutions necessitates a staged approach. As the
heart has a low ischemic tolerance it is vital in a DCD retrieval to reanimate the
heart quickly without waiting for pneumoplegia to finish. We have devised a selective
pneumoplegia delivery system to aid independent lung procurement from the heart to
reduce ischemic times.
Methods
The figure shows the parts of the customized pneumoplegia delivery system and its
use. It consists of two self-inflated soft balloon retrograde cardioplegia cannulae
connected with a ¼ inch y-connector and ¼ inch silicone tubes. During cardioplegia
the pulmonary artery is transacted, the cannulae inserted into the right and left
pulmonary arteries to deliver simultaneous selective antegrade pneumoplegia. After
cardioplegia, the heart procurement and its reanimation on the organ care system can
commence as the pneumoplegia is running. The self-inflated balloons of the cannulae
do not require manual fixation, saving time as there are several litres of pneumoplegia.
The same cannulae may be used to deliver the retrograde pneumoplegia.
Results
Between 2019–2021 we performed four such procurements, with good immediate outcomes
in two of the lung transplant recipients. One lung was declined on basis of poor results
of ex-vivo lung perfusion. The fourth was successfully procured but later declined
on history of donor drowning.
Conclusion
Our customized system allows simultaneous delivery of selective antegrade and retrograde
pneumoplegia during and after cardiectomy in a DCD heart and lung retrieval. This
may reduce ischaemia of the lungs and improve organ utilisation. More studies are
required to assess the potential benefit of our pneumoplegia delivery system.
A301 Impact of Prolonged Total Ischemic Time on the Outcomes of Lung Transplantation
Ahmed, Hesham, Mr; Umakumar, Kabeer, Mr; Smail, Hassiba, Ms; De Robertis, Fabio, Mr;
Khoshbin, Espeed, Mr; Stock, Ulrich, Prof
Harefield Hospital, Uxbridge, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A301
Objective
According to the international society of heart and lung transplantation guidelines
recommended total lung ischemic time for transplantation is less than 6 h. Utilising
lungs with longer period of ischaemia however may allow expansion of donor pool and
potentially increase transplant numbers. We studied the effect of moderately prolonged
ischemic time (> 8 h) on outcome of our lung transplant recipients.
Methods
158 patients who underwent bilateral sequential lung transplantation between 2013
and 2017 were studied. Patients with pre-operative extracorporeal membrane oxygenation (ECMO),
ex-vivo perfusion, mechanical ventilation and single lung transplantations were excluded.
Patients were divided into group A (n = 81) with ischemic time < 8 h for both lungs,
group B (n = 36) > 8 h and group C (n = 41) with one lung < 8 and the second lung > 8 h.
Results
There was no significant difference in age, gender, preoperative echo findings and
diagnosis between groups. Postoperative need for ECMO was 8.6%, 11.1%, 4.9% respectively,
p = 0.59. Duration of ventilation (62, 64, 39 h, p = 0.6) and acute rejections (1.2%,
2.8%, 12.2%, p = 0.018). Reintubation rate (18.5%, 30.6%, 22%, p = 0.35) and length
of ITU stay (12.36, 19.36, 16.07 days, p = 0.10). 1, 3- and 5-year survival was 73.3%,
73.7%, 69%, p = 0.97.
Conclusions
Prolonged lung allograft total ischemic time above 8 h does not impair short- and
medium-term outcomes of transplantation however may improve organ utilisation.
A302 Median Sternotomy vs Clamshell for Sequential Bilateral Lung Transplantation:
The Impact of Surgical Approach on Post-operative Lung Function
Chilvers, Nicholas
1, Mr; McPherson, Iain1, Mr; Grayling, Michael2, Dr; Freystaetter, Kathrin1, Ms; Ozalp,
Faruk1, Mr; Fisher, Andrew1, Prof; Parry, Gareth1, Dr; Clark, Stephen1, Prof; Dark,
John2, Prof
1The Freeman Hospital, Newcastle, UK; 2Newcastle University, Newcastle, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A302
Objectives
The clamshell incision remains the standard approach for bilateral lung transplantation,
however, this comes at the cost of high rates of chronic pain and wound complications.
Sternotomy offers fewer complications, superior wound healing, good short-term outcomes
and preserved chest wall mechanics. We sought to examine the impact of operative approach
on post-operative lung function.
Methods
Adult patients undergoing bilateral lung transplantation from 1995 to 2019 were identified
retrospectively using local transplant databases. Data collected included baseline
demographics, ischaemic times, ICU stay, length of stay, survival and post-operative
lung function at 1 month, 3 months, 6 months and 12 months.
Results
656 patients (177 sternotomy, 448 clamshell, 31 anterolateral thoracotomies) underwent
bilateral lung transplant. Sternotomy patients tended to be older (51.1 vs 38.8 years)
and less likely to have infective pathology. Post-operative FEV1 was significantly
better at 1 and 6 months (p = 0.0105, p = 0.0028) and FVC at 1, 6 and 12 months (p = 0.0345,
p = 0.0200, p = 0.0156). There was no difference in ICU stay or 30-day survival.
Conclusions
We have described the largest cohort of bilateral lung transplants via median sternotomy
in the literature and shown superior lung function compared to the clamshell incision.
The importance of this needs to be investigated further, however previous research
has shown a correlation between post-operative lung function and 3-year survival.
Lung function test
Time post op
Clamshell (n = 448)
Sternotomy (n = 177)
FEV1
1 month
64.5 (18.7)
70.3 (18.8)
3 months
74.2 (21.1)
74.6 (23.3)
6 months
80.9 (21.9)
78.3 (25.6)
12 months
82.7 (23.5)
81.3 (23.9)
FVC
1 month
60.6 (16.6)
66.3 (14.8)
3 months
71.4 (18.2)
74.0 (19.4)
6 months
79.6 (19.1)
79.9 (20.9)
12 months
83.4 (20.3)
85.9 (20.0)
A303 The Sternotomy Approach to Bilateral Lung Transplantation does not Mandate the
use of Cardiopulmonary Bypass
Chilvers, Nicholas
1, Mr; McPherson, Iain1, Mr; Freystaetter, Kathrin1, Ms; Senbaklavaci, Omer1, Mr;
Fisher, Andrew1, Prof; Parry, Gareth1, Dr; Clark, Stephen1, Prof; Dark, John2, Prof
1The Freeman Hospital, Newcastle, UK; 2Newcastle University, Newcastle, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A303
Objectives
Bilateral lung transplantation via sternotomy offers many benefits over the standard
clamshell incision. However, many consider cardiopulmonary bypass to be mandatory.
We have one of the largest experiences of this approach and have more recently employed
ECMO or off-pump techniques. We sought to assess our outcomes in these patients.
Methods
Adult patients undergoing bilateral lung transplantation from 1995 to 2019 were identified
retrospectively using local transplant databases. Data collected included baseline
demographics, mode of circulatory support, ischaemic times, ICU stay, length of stay,
post-operative lung function and survival.
Results
177 patients underwent double lung transplant via sternotomy (147 cardiopulmonary
bypass, 18 ECMO, 12 off-pump). In the ECMO group, median ICU stay and length of stay
were 4.5 days and 31 days respectively and in the off-pump group, 8 days and 34 days
respectively. 30-day survival was 100% in both groups.
Conclusions
We have the largest cohort of bilateral lung transplants via median sternotomy in
the literature and the only group to describe the off-pump sternotomy approach. ECMO
or off-pump techniques in this situation are both safe and feasible, with some minor
modifications including the use of a cardiac stabiliser device, and have excellent
outcomes. Furthermore, it has advantages over the anterolateral thoracotomy approach
as it offers easy access to the aorta and right atrium should unplanned mechanical
circulatory support be required. In summary, the sternotomy approach to bilateral
lung transplantation does not mandate cardiopulmonary bypass.
A304 Comparison of Early Postoperative Outcomes in DBD and DCD Lung Transplants: A
Single-centre Experience
Sef, Davorin1, Mr; Verzelloni Sef, Alessandra2, Dr; Jothidasan, Anand
3, Dr; Raj, Binu2, Mr; Trkulja, Vladimir4, Prof; De Robertis, Fabio2, Mr; Stock, Ulrich2,
Prof
1St. Bartholomew's Hospital, London, UK, Barts Health NHS Trust, London, UK; 2Harefield
Hospital, Royal Brompton and Harefield Hospitals, London, UK; 3Harefield Hospital,
Uxbridge, UK; 4Medical School, University of Zagreb, Croatia, EU
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A304
Objectives
Utilization of donation after circulatory death (DCD) donors can decrease donor shortage
in lung transplantation (LTx). There is increasing evidence that early clinical outcomes
following DCD LTx are satisfactory and could be comparable with the results from brain
dead (DBD) donors. We aimed to compare the early postoperative outcomes of LTx from
DBD and DCD donors.
Methods
All consecutive LTxs performed between April 2017 and March 2019 at our centre were
included. Donor characteristics and recipient preoperative, intraoperative and early
postoperative characteristics were analyzed and compared between DBD and DCD LTx.
Redo LTx and single LTx were excluded.
Results
Out of 105 patients, 25 (24%) were DCD LTx. Donors’ and preoperative recipients’ characteristics
were comparable between both subgroups. There were no statistically significant differences
between the two subgroups in terms of donor demographics and preoperative recipient
characteristics, except for higher incidence of female gender, aspiration and inotropic
support requirement in the DBD donors. Intraoperatively, mechanical circulatory support
(MCS) was more common in DCD LTx (56% vs. 36%). MCS duration (332 vs. 166 min, p = 0.046),
and first (p = 0.003) and second lung (p = 0.010) ischemia time were longer in the
DCD group. Postoperatively, DCD recipients more commonly required ECMO (32% vs. 8%, p = 0.004).
Postoperatively, patients from DCD group had significantly higher incidence of stented
chest (p = 0.008), drainage (p = 0.001) and peak lactate level (p = 0.023).
Conclusions
DCD donation has increased our lung transplant activity by almost 25% and early postoperative
outcomes are in general comparable with those achieved after DBD LTx. However, we
have observed a higher need for both intraoperative and postoperative MCS in DCD LTx
which could influence clinical outcomes, although further studies are required.
Tbl 1. Early postoperative outcomes.
Early postoperative outcomes
DBD
DCD
P
Mechanical ventilation (hours)
32.8 (19.3–56.8; 2–992)
42.5 (26.8–69.0; 6.5–640)
0.122
Tracheostomy
28 (35.0)
11 (44.0)
0.420
ECMO [VA/VV]
6 (7.5) [4/2]
8 (32.0) [7/1]
0.004
Drainage 24 h (mL)
1062 (806–1319; 400–5800)
1625 (1037–3275; 400–5900)
0.001
Delayed chest closure
8 (10.0)
8 (32.0)
0.012
Renal replacement therapy
21 (26.2)
13 (52.0)
0.019
Sepsis
11 (13.8)
6 (24.0)
0.241
Peak lactates 24 h (mmol/L)
4.9 (3.3–6.3; 1.5–14.4)
6.6 (3.9–10.6; 2.3–17.0)
0.023
Hospital length of stay (days)
28 (21–52; 2–163)
34 (18–52; 6–105)
0.772
Data are count (%) or median (quartiles; range).
A305 Eradication of Aspergillus Fumigatus Following Cardiothoracic Transplantation:
A Complex Case – The MDT Solution
Asemota, Nicole, Dr; Sitaranjan, Daniel, Mr; Osman, Mohamed, Mr; Kaul, Pradeep, Mr
Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A305
Objectives
We present a case of a 48-year-old female who, in fewer than 10 years, underwent aortic
valve surgery and then subsequent cardiac & renal transplantation. Her progress was
complicated with a mycotic aortic aneurysm and sternal osteomyelitis. Despite posing
such a complex surgical challenge, fungal eradication was achieved.
Methods
She initially presented with severe aortic and tricuspid regurgitation secondary to
infective endocarditis with renal infarction. She had a known muscular VSD. She underwent
a Konno procedure with aortic valve replacement, tricuspid annuloplasty and VSD closure.
She suffered with ongoing heart and renal failure eventually requiring listing for
transplant.
She underwent redo-sternotomy and heart & kidney transplant making an excellent recovery.
She developed a wound infection, growing aspergillus fumigatus which remained resistant
to antifungal therapy and debridement. An interval CT scan also revealed an ascending
aortic mycotic aneurysm.
She underwent ascending aortic mycotic aneurysm excision and replacement with a homograft.
Our plastic surgical colleagues then performed a musculocutaneous free flap with vastus
lateralis to close the sternal defect.
Results
She has no further clinical or microbiological evidence of A.fumigatus. She has a
great quality of life with excellent allograft function. She continues to be followed
up by the cardiac and renal transplant and plastic surgery teams, with close microbiology
and radiology input.
Conclusion
This case provides evidence that invasive A.fumigatus infection can be eliminated
with combined surgical, topical and systemic drug treatment even in an immunocompromised
patient. Furthermore, it highlights the importance of a multi-disciplinary team approach
in decision making and treatment.
Informed consent to publish had been obtained.
A306 Donor Cause of Death in Heart Transplantation and Its Effect on Post-Transplant
Survival
Surendran, Arthika
1, Dr; Mascaro, Jorge2, Mr
1Queen Elizabeth Hospital, Birmingham, UK
Journal of Cardiothoracic Surgery 2023, 18(Supp 1):A306
Objectives
There are no concrete analyses in the UK that assess the effect of donor cause of
death (CoD) on survival in heart transplantation (HTx). We sought to evaluate whether
the various CoDs cause significant short- and long-term survival differences in HTX
recipients.
Methods
We evaluated the registry for all adult HTX recipients at ***** Hospital from 2011
to 2021 and their adult donors. Recipients were stratified based on CoD into road
traffic accidents (RTA), intracranial haemorrhage (ICH), Hypoxic brain damage (HBD)
or other. Kaplan–Meier (KM) curves depicted the 24-h, 30-day, 1-year, and 5-year survival
of the CoD groups with the remaining study population (RSP). Further, Cox proportional
hazards survival models were used to estimate the effect of CoD adjusting for recipient
and donor age and gender.
Results
267 HTX donors were identified, of which, 26.2% died from RTA and 42.6% died from
ICH. For RTA, KM analyses showed a significant (P < 0.05) inverse association in mortality
at all time intervals as compared to RSP for RTA. In contrast, ICH showed a significant
positive association at all time intervals as compared to RSP for ICH. In adjusted
models omitting donor age and gender, RTA and ICH were significant, but when those
variables were included, donor death by RTA or ICH were not significant.
Conclusion
Donor cause of death, specifically RTA increasing survival and ICH decreasing survival,
showed to be a significant predictor of short- and long-term mortality in heart transplant
recipients. However, when donor age and gender were accounted for, there was no significance:
for RTA, it was most likely the robust health status of the donor that accounted for
the protective effect while for ICH, it was the frailty.
Author Index
A
Abah, U
312, 333, 396, 398, 401
Abba, P
217
Abbas, M
360
Abbas, S
86, 168
Abbasciano, R
127, 151, 161
Abdelbar, A
107
Abdelhadi, A
330
Abdelrahman, A
177
Abdul Hakeem, M
27, 28, 56
Abdul Khader, A
120, 274, 370
Abdullahi, Y
63
Abousteit, A
213
Acharya, A
298
Acharya, M
64
Ackah, J
375
Adams, B
29
Adebayo, A
191, 203
Adikoesoema, Mohamad S
69
Afoke, J
108, 179
Agrawal, S
355
Ahearn, U
261
Ahern, S
181
Ahmadi, F
291
Ahmadi, N
280, 291
Ahmed, A
124, 276, 311
Ahmed, E
25
Ahmed, H
400, 428, 433, 439
Ahmed, I
96, 236, 288, 289, 290
Ahmed, U
126
Ahmed-Issap, A
312, 333, 401
Akbarzad-Yousefi, A
275
Akberali, U
66
Akhtar, R
14
Akowuah, E
127, 167, 175, 187
Aktuerk, D
142
Al Attar, N
161
Aladaileh, M
327, 328, 329, 442
Alam, R
147, 161
Alayyar, M
428
Ali, J
131
Aljanadi, F
43, 314
Alkalbani, R
161
Allam, M
175
Allen, C
344
Allen, J
427
Allen, R
379
Almeida, Ana B
303, 305
Alphonso, N
211, 212
Alqudah, O
219, 382
Alshammari, A
326, 338, 340, 342, 370, 388, 413
AlShiekh, M
84
Alvarado, P
392
Alvarez Gallesio, J
338, 340, 342
Alwis, S
11, 306
Alzetani, A
243, 267, 315, 400, 415
Amin, F
180
Amoros Rivera, C
442
Amos-Hirst, R
209
Andrews, D
212
Angelini, G
25, 67, 76, 77, 79, 85, 102, 104, 127, 135, 138, 143, 144
Annamaneni, R
348
Ansaripour, A
161
Antolin, R
256
Anzaar, Ahamed A
161
Apicella, G
86, 168
Arcegono, T
256, 258
Aresu, G
280, 291, 346, 363
Argyle, R
177
Argyriou, A
161
Ariyaratnam, P
355
Arjomandi Rad, A
179
Arnold, P
225
Aroori, S
153
Asadi, N
306, 309, 422, 423
Asemota, N
444
Asemota, O
291
Ashraf, Muhammad A
30, 388
Ashraf, S
87
Ashrafian, L
380
Ashry, A
225
Asimakopoulos, G
6, 7, 40, 46
Asonitis, A
46
Asopa, S
281
Athanasiou, T
7, 8, 9, 63, 110, 120, 149, 194
Athansiou, T
11
Attia, R
130
Aujla, H
191
Austin, C
208, 223, 224, 226
Avci Demir, F
169
Avlonitis, V
100, 161
Avtaar S
432
Avtaar Singh, S
294
Aw, TC
332
Awad, W
31, 137, 201, 436
Ayrton, L
378
B
Bader, V
214, 215
Badran, A
106, 109, 243, 300, 344, 400, 415
Badran, D
106, 109, 300, 344
Baghai, M
125, 169, 171
Bagona, L
245
Bahrami, T
72, 84
Baig, K
30
Bakir, A
267
Bakr, L
123
Ball, P
174
Balmforth, D
45, 83, 142
Bannister, C
250
Baquedano, M
223
Baranowski, R
336, 359, 372, 386, 387
Bardolia, C
183
Barnard, J
105
Barnard, S
354
Barrett, S
221, 403, 407
Bartley, T
238, 239
Bartosik, W
219, 382, 385
Bartram, J
64
Barve, R
276
Basak, B
373
Basharat, K
391
Basilio, K
256
Batchelor, T
375
Bate, C
238
Baxter, J
235, 241
Beattie, G
140
Beaumont, E
119
Begum, S
326, 332
Bekker, H
371
Benedetto, U
25, 67, 79, 102, 104, 135, 138, 143, 144
Bennett, J
23
Bennett, S
183
Bentham, J
217
Berman, M
235, 241, 424, 427
Betts, K
211, 212
Bhag, G
213
Bhagra, S
427
Bharucha, T
267
Bhaskaran, Anusuya P
277
Bhaskaran, Arya P
277
Bhaskaran, India P
277
Bhatti, F
87
Bhudia, S
69, 72, 84, 161
Bibleraaj, B
239
Bingley, P
151
Birdi, I
86, 168
Birdsall, D
306
Bishay, E
365
Biswas, S
393
Blair, Joyce B
256
Bleetman, D
125, 169, 171
Bleibleh, S
126
Blythe, A
318
Boateng, M
118
Boele, F
134, 371
Bola, H
108
Bone, G
315
Booth, K
161, 273, 429
Booth, S
274, 370, 388, 413
Booton, R
394
Borger, M
50
Bose, A
48
Botha, P
209, 268
Boulemden, A
86, 168
Boyle, M
207, 225
Brahambhatt, K
414
Braidley, P
176
Braithwaite, S
19
Brazier, A
312, 333, 401
Breen, D
374
Brennan, M
265
Briant, Z
401
Briffa, N
167
Brizard, C
212
Brown, C
306
Brown, D
229
Brown, J
161
Brown, L
216
Brown, R
244, 247, 248, 252, 257, 265, 317, 327, 328, 329, 442
Brumpton, M
183
Brunelli, A
409
Bruno, Vito D
10, 66, 85, 173
Brunswicker, A
378
Buchan, K
294
Buderi, S
326, 332, 338, 340, 342
Bueser, T
119
Butler, C
164
Butt, S
92
C
Cabolis, K
145
Cacciottolo, P
427
Cahill, J
234
Calvert, R
349, 364, 417
Cannoletta, M
46
Capoccia, M
51
Caputo, M
25, 222, 223
Carroll, B
351
Cartwright, N
167
Caruana, E
302, 353, 389, 412
Caruso, V
149
Casey, A
96
Cassidy, R
318
Casula, R
194
Catarino, P
424
Chacko, J
108, 125, 179
Chadwick, A
251
Chambault, Aimee-L
216
Chambers, J
167
Chan, C
298
Chan, J
5, 60, 67, 76, 77, 87, 89, 102, 116, 117, 121, 143, 161, 397, 416
Chan,Shie W
196
Chandarana, K
262, 302, 353, 412
Chaney, U
229
Chaubey, S
64, 108
Chaudhry, M
55
Chaudhuri, N
409
Chauhan, I
46
Chavan, H
326
Chawla, A
34
Cheng, T
276
Cheng, Yeu Wah M
276
Chidambaram, S
298
Chilvers, N
395, 440, 441
Chivasso, P
10
Chiwera, L
236
Christodoulidou, M
12
Chrysikopoulou, M
55
Chubsey, R
339, 389
Cianci, V
87, 89
Clapon, I
250
Clare, C
68
Clark, S
114, 115, 275, 429, 440, 441
Clayton, T
119
Coats, L
205
Cocomello, L
144, 223
Codispoti, M
112
Cole, A
368
Colombino, Anna M
258, 336
Comanici, M
120, 130
Combellack, T
313, 319, 325, 334, 379
Conneely, J
327
Connelly, L
349, 364, 417
Connolly, K
245
Coonar, A
280, 291, 346, 363
Cooper, T
243, 415
Coppola, G
72
Cormack, S
73
Cormican, L
257
Crosbie, P
394, 396
Crucean, A
268
Crush, J
157
Curry, P
137, 432
Cyclewala, S
422
Cypel, M
366
D
D'Alessio, A
19, 263, 264
Daley, M
212
Dalrymple-Hay, M
98, 128
Daly-Devereux, M
345
Danaher, D
240
Dandekar, U
161
Danton, M
215
Dark, J
275, 440, 441
Darling, G
366
Darzi, A
298
Das De, S
432
Dawson, A
99, 412
Day, J
24
De Costa, J
238
De Franco, V
154
De Garate, E
85
De Paulis, R
50
De Perrot, M
366
De Rita, F
205, 218
De Robertis, F
72, 84, 435, 443
De Silva, R
82, 280
De Sousa, P
274, 370, 388, 413
Dean, A
187
Dearling, J
161
Debnath, P
284
Deehan, B
161
Deglurkar, I
52, 103
Derobertis, F
69
Derobrtis, F
439
Deshpande, R
92, 125, 169, 171
Desouza, Abigail-S
315
Devbhandari, M
313, 325, 413
Dhannapuneni, R
213, 225
Dhuga, Y
288, 290
Di Tommaso, E
10, 66, 85, 135, 138, 161
Diamond, O
318
Dilworth, Joseph M
296
Dimagli, A
67, 76, 77, 79, 102, 104, 135, 138, 143, 144
Divya, A
82
Dixit, P
108
Dixon, L
66, 79, 85, 135, 138, 144, 161
Djordjevic, J
263, 264
Docherty, C
388
Dodd, M
119
Doddakula, K
296
Doherty, P
187
Dominic, C
284
Donahoe, L
366
Dong, T
67, 76, 77, 104, 143
Doonan, R
23
Doshi, H
137
Downes, A
351
Drury, N
209
Dubecz, A
303, 305
Duckett, S
183
Duncan, A
57
Dunn, N
238
Dunning, J
239, 270, 349, 395, 417
Dutta, S
111
Duval, J
157, 424
E
Eagle-Hemming, B
191, 203
Eaglestone, E
263, 264
Earnshaw, C
330, 390
Eaton, D
247, 252, 257, 317, 327, 328, 329, 407, 442
Eckersley, M
142, 372
Edwards, J
355
Efthymiou, C
97
Elango, M
75
El-Dean, Z
151
Elena, M
415
Elfadil, A
46
El-Gamal, I
361
Elhassan, H
107
El-Hilly, A
30
Elliot, J
327
Elmahdy, W
51
El-Shafei, H
70
Elshafie, G
80
ElSherbini, A
208
Elsiddig, M
118
Elston, V
330
Endean, A
222
Enemosah, I
153
Eranki, A
21, 22, 158
Eskandari, M
169
Evans, N
131, 336
Evans, P
149
Evison, M
378
F
Fabroa, S
245
Fairhurst, C
187
Fallouh, H
365
Fang, Chen C
112, 304, 352
Fanning, N
403
Farinelli, E
380
Farmidi, A
72, 431
Ferguson, J
395
Ferrett, J
245
Field, M
5, 12, 14, 23, 24, 27, 28, 56, 261
Fisher, A
429, 440, 441
Fisher, R
14
Fisichella, S
8
Fitzmaurice, G
384, 403
Fitzpatrick, T
257
Fleck, R
94, 221
Fleet, B
270, 286, 293
Fleming, C
407
Folaranmi, O
175
Fontaine, E
393, 394, 399
Francis, J
219
Frattolin, J
9
Fredericks, S
228
Freystaetter, K
129, 395, 440, 441
Friedrich, O
217
Fudulu, D
67, 76, 77, 79, 102, 135, 143, 144
Fuentes-Warr, J
219
G
G Malvindi, P
37
Gadallah, B
442
Gaer, J
84
Gallagher, D
257
Gallagher, G
425
Gallesi, Jose A
326
Gama de Abreu, M
303
Gamal, M
212
Ganesananthan, S
184
Gannon, R
236
Garg, S
69, 72, 249
Garner, M
398
Gatta, F
35
Gemelli, M
10, 67, 79
Generali, T
205
George, J
59, 60
George, S
66, 173
Ghazarians, N
282
Ghosh, S
126, 312, 333, 401
Gibb, M
262
Giblin, S
253
Gkikas, A
376
Gnanalingham, S
271
Godolphin, P
376
Goodwin, A
129, 175
Gopalaswamy, M
349, 417
Goulden, C
276
Gradinariu, G
70, 137, 161
Graham, T
126
Granato, F
311, 393, 394, 396, 399
Grandjean, J
68, 132
Grant, S
197, 393, 394, 396, 398, 399
Grayling, M
440
Graziano, G
425
Green, J
161
Gregg, A
174
Guerrero, R
207, 213, 225
Guida, G
79, 85
Guida, M
85
Guo, A
17
Gurney, S
330
H
Habib, A
312, 333, 401
Hadjinikolaou, L
39
Hafiz, I
100
Hagmeijer, R
68
Halfwerk, F
68, 132, 192
Hambly, J
142
Hamid, U
31, 436
Hamilton, R
202, 297
Hammad, W
324
Hanna, G
347
Hanna, L
298
Haq, I
40, 53
Haq, M
284
Haqzad, Y
55
Hardman, G
429
Harfield, J
16, 128
Hargrave, J
358, 359
Harky, A
161, 213, 216, 276, 284
Harraz, A
194
Harrington, B
161, 273
Harrington, D
27, 28, 56, 261
Harris, W
25
Harrison, O
420
Harrison-Phipps, K
419
Hartley, J
280
Hartley, P
6
Hasan, A
205
Hasan, R
161
Hashmi, F
311, 360
Hashmi, Syed F
292
Haworth, K
164
Hawwash, N
292
Haycox, A
24
Hayes, T
197
Hayre, S
118
Healy, D
345, 351
Heatlie, G
183
Hernandez, L
304, 352
Hewitt, K
231, 238, 378
Higgins, P
407
Hildick-Smith, D
182
Hill, J
318
Hinde, S
187
Hing Chi, Kristie Hing C
169
Hoffman, R
326, 332, 338, 340, 342
Hogan, J
219, 363, 382
Holden, N
434
Holland, L
147, 182
Holmes, C
129, 354, 395
Hoppe, S
411
Horsfall, G
161
Hossack, M
14
Huddart, H
378
Hughes, S
307, 405
Humphries, S
405
Hunt, I
320, 322, 331
Hunter, S
159, 160
Hurley, P
419
Husain, M
428, 431, 433, 438
Husemann, Z
233
Hussain, A
64, 92
Hussein, N
409
Hutchison, S
425
Hutton, S
236
Hyde, J
147
I
Ike, D
83, 387
Imran Hamid, U
174
Inman, C
231
Internullo, E
375, 390
Iqbal, A
126
Iqbal, Y
92, 126
Irvine, M
385
Iyer, A
111
J
Jaber, O
209, 217
Jackson-Wade, R
387
Jacob, A
201
Jahangiri, M
99
Jain, S
312, 333, 401
Jakub, M
86
Jansen, K
205
Jansen, M
132
Jarral, O
8, 30, 83
Jarvis, M
55
Jawarchan, A
161, 249
Jeganathan, R
174
Jenkins, D
427
Jin, Xu Y
180
Jingco, F
258
Joel-David, L
191, 203
John, A
52
Johns, J
134
Johnson, T
66
Jones, C
207
Jones, M
43, 161, 208, 314
Jones, Mary E
244
Jones, N
280, 291
Jones, T
209, 268
Jordan, S
326, 332, 338, 340
Jos, H
31
Joseph, B
84
Joseph, D
292
Joshi, V
393, 399
Jothidasan, A
428, 433, 435, 438, 443
Justo, R
211
K
Kabir, S
208
Kadlec, J
219, 382, 385
Kakos, C
376
Kalkat, M
234, 307, 361, 365, 405
Kamalanathan, K
330, 390
Kandasamy, K
222
Kaniu, D
326
Kapur, A
371
Kar, A
368
Karia, C
348
Karsan, R
140
Karthikeyan, S
52, 103
Karunanantham, J
131
Karuppannan, M
48, 177
Kassai, I
209, 217
Kaul, P
241, 427, 444
Kaul, S
425
Keane, C
403
Kearns, D
19
Keiralla, A
19
Kellner, P
303
Kelly, M
247, 317
Kemp, B
19
Kenawy, A
27, 28, 56
Kendall, S
167, 175
Kennedy, F
403
Kenyon, L
234
Keshavjee, S
366
Kesieme, E
215
Kew, Ee P
320, 321, 391
Khalil, H
361
Khan, H
64, 92, 125, 169, 171
Khan, J
112
Khan, M
400
Khan, N
94, 209, 221, 268
Khan, T
51, 53
Kho, J
161, 180
Khodaghalian, B
207
Khor, B
307, 361
Khoshbin, E
84, 309, 423, 425, 433, 438, 439
King, E
319
King, J
394
Kinsella, A
242, 255
Klaassen, R
192
Knight, B
215
Knowles, A
177
Kogkas, A
347
Komber, M
355
Kornaszewska, M
313, 319, 325, 334, 379
Korre, S
348
Koskolou, S
325
Kothari, N
216
Kotta, Prasanti A
75
Koulouroudias, M
412
Kouritas, V
219, 382, 385
Krasopoulos, G
19, 190, 263, 264
Kreaden, U
357
Krishnadas, R
375
Krishnamoorthy, B
292
Krysiak, P
393
Kubiak, K
348
Kuduvalli, M
12, 23, 27, 28, 56, 261
Kumar, N
201
Kumar, P
59, 60, 87, 89, 161
Kumar, T
191
Kumar, U
202, 297
Kuo, J
16
Kutty, R
213, 225
Kutywayo, K
348, 389
Kwok, Chun S
183
Kydd, A
427
L
Lai, F
65, 78, 127, 191, 203
Lallmahomed, N
397
Lampridis, S
376
Langanay, T
50
Large, S
131, 427
Laskar, N
167
Laskawski, G
177
Lau, K
386, 410
Laufer, G
50
Law, Jacie J
346
Lawler, Z
442
Lawlor, D
223
Layson, R
69
Layton, G
39, 151, 161
Lee, A
415
Lee, G
211
Lee, M
336, 358, 359, 386, 392
Leone, F
80
Leung, K
125, 169, 171
Leung, Kristie Hing C
171
Leung, M
370, 413
Levine, A
239
Lewis, C
427
Lhote, F
397
Lim, E
274, 332, 370, 388, 413
Lim, K
41
Lim, Ru j
69
Lim, S
424
Limbachia, D
161
Linehan, K
95
Liu, G
108, 179
Lodhia, J
409
Longbone, T
134
Loo, Peh S
354
Lopez-Marco, A
29, 45
Lotto, A
213, 225
Loubani, M
35, 55, 80
Low, Mei K
151
Lukban-Bunalade, R
245
Luthra, S
37, 42
Lynch, W
192
M
Madine, J
14
Magboo, R
236, 256
Magpantay, A
251
Mahendran, K
312, 333, 401
Mahmood, Z
70, 163
Mahoud, L
161
Makam, R
161
Makariou, N
436
Malvindi, P
42
Mangel, T
29, 45, 321, 405
Manoharan, G
174
Manoj, S
351
Mansour, S
124
Mantio, K
312, 333
Marathe, S
211, 212
Marczin, N
69, 120, 431
Mariani, S
68
Mariscalco, G
39
Markides, C
194
Marsico, R
39, 151
Martinez, L
427
Martin-Ucar, A
352
Martorella, G
228
Mascaro, J
445
Masood, S
245
Masraf, H
37
Massey, J
159, 160, 176
Mastracci, T
29
Mayer, N
306, 309, 423
Mayooran, N
86, 389
McGinley, J
429
McGuinness, J
221
Mcgurk, C
30
McInerney, N
327
McInerney, P
153
McKeon, E
242, 248
McLean, A
215
McLoughlin, J
403, 407
McManus, B
111
McManus, K
318
McNaught, H
364
McNeilly, G
229
McPherson, I
205, 440, 441
Meghani, N
378
Mehat, N
190
Mehdi, R
365
Mehta, D
5
Mellor, S
216
Menon, S
401
Mensah, K
46
Messer, S
427
Metwalli, A
11, 57, 180, 245, 249
Meuris, B
50
Miksza, J
65, 78
Miller, D
191
Milton, R
409
Missouris, C
180
Mitchell, A
187
Mitchell, N
187
Mittal, A
64, 92
Moawad, K
161
Moawad, N
16, 98, 128
Modi, A
147, 161, 281
Modi, S
288, 290
Mohamadzade, N
173
Mohamed Ahmed, E
10
Mohamed, W
124
Mohammed, A
73
Mohammed, R
414
Mohite, P
137, 431, 435
Monaghan, M
169
Montaque, M
173
Montgomery, L
314
Moore Jr, J
8, 9
Morais, C
161, 236, 245, 249
Morcos, K
137
Moreira, L
190
Morosin, M
6
Mouyer, Z
122
Mozalbat, D
11, 321
Mughal, A
268
Mujtaba, Syed S
114, 115
Mulryan, K
310
Muneer, A
12
Murphy, G
39, 65, 78, 127, 145, 161, 189, 191, 203
Murray, S
119
Musab, M
313, 319
Mussa, S
222
Mustaev, M
419
Mustafa, A
118
Muston, B
17
Mylonas, G
347
N
Naase, H
149
Naidu, B
234, 365, 405
Naik, S
86, 168
Nair, J
263, 264
Nakas, A
262, 302, 353, 412
Nanjaiah, P
183
Narang, K
280, 291
Narayan, P
143
Narayana, A
182
Nardini, M
358, 410
Naruka, V
29, 108, 179, 388
Nassar, M
205
Nawaytou, O
27, 28, 56, 261
Nawaz, H
284
Neilsen, L
415
Ng Yin Ling, C
125, 169, 171
Ngaage, D
187
Nguyen, B
161
Nichols, S
187
Nicou, N
168
NiDhonnchu, T
181
Nielsen, L
243
Nienabar, C
11
Nimako, K
368
Nithiananthan, M
339
Nizami, M
363, 380
Nkolimbo, C
245
Nolke, L
94
Noonan, P
214, 215
Norkunas, M
332, 338, 340
Normahani, P
298
Ntouskou, M
12
Nunes, Joao P
235
Nwaejike, N
105, 161
Nwakwu, C
109
O
O’Mahony, S
327
O'Brien, L
327
O'Dwyer, M
384
Oezalp, F
40
Ohri, S
37, 42, 109, 250
Okorocha, C
42
Olivar, M
70
Olsen, K
216
Oo, A
24, 29, 45, 119
Oo, S
116, 121
Ooues, G
222
O'Regan, D
8
O'Rourke, S
41
Osman, M
241, 427, 444
Othman, A
27, 28, 56, 261
Owen, R
281
Owens, C
174
Owens, G
119
Oyebanji, O
436
Oyebanji, T
43, 137
Ozalp, F
440
P
P V S, P
232
Padukone, A
422, 433, 438
Pagliarulo, V
218
Pai, V
427
Pal, S
171
Palima, J
118
Palmares, A
274, 370, 413
Panahi, P
73, 152, 153, 285
Papagiannopoulos, K
409
Papalois, V
75
Parameshwar, J
427
Parry, G
275, 429, 440, 441
Patel, A
307, 361, 388, 405, 413
Patel, N
302
Patel, R
238
Paterson, S
287
Pathak, S
65, 127
Patrini, D
376
Patsalides, Michalis A
287
Paul, I
395
Pelella, G
209, 217
Peng, E
214, 215
Pengelly, S
283
Pepper, J
7, 46
Pereira, C
425
Perikleous, P
309, 336, 387, 410, 423
Perris, R
405
Peryt, A
280, 291, 363
Peters, M
236
Petrie, M
65
Petrou, M
46, 84, 161, 180, 249
Petrov, G
384
Pettit, S
235, 427
Philip, B
161, 373
Phillips, D
137
Pierre, A
366
Pilling, J
380
Pinto, A
344
Pirola, Selene
8
Pirtnieks, A
313, 319, 325, 334, 379
Platt, M
222
Plonek, T
132
Plunkett, D
240
Podd, S
98, 128
Pompili, C
134, 371
Pons, A
274, 326, 370, 413
Poon, S
59, 60, 87, 89
Popescu, F
56
Power, H
19
Price, N
34
Proli, C
274, 370, 388, 413
Punjabi, P
63, 108, 179
Purmessur, R
291
PVS, Prakash
3
Q
Qsous, G
351
Quarto, C
57, 199, 249
Quigley, R
235, 241
Qureshi, S
86, 168
R
Rafiq, M
427
Rai, K
45
Raj Krishna, G
105, 399
Raj, B
435, 443
Raja, M
288, 289, 290
Raja, S
7, 40, 53, 69, 72, 84, 120, 123, 130, 165, 236, 249
Rajakaruna, C
10, 25, 161
Rajamani, S
3, 232
Rajamiyer, V
197
Rajan, L
255
Ramalingam, A
385
Ramaraju, S
40, 53
Rammohan, K
378, 393, 394, 398, 399
Ramzi, J
127
Rao, A
28
Rao, J
355
Rathinam, S
99, 302, 339, 348, 353, 389, 414
Rathod, V
108
Raubenheimer, H
413
Ravendren, A
276
Ravishankar, R
63
Redmond, K
247, 252, 257, 310, 316, 317, 357
Redondo, A
224, 226
Reilly, S
190
Rescigno, G
118
Reynolds, A
273, 281
Rice, D
94, 221, 345, 407
Richards, T
12
Ridley, P
183
Ripoll, B
55
Rizzello, A
127
Rizzo, V
34, 100, 110, 120, 161
Roberts, N
83
Robinson, P
190
Robson, J
222
Rochon, M
161, 236, 245, 249, 306
Rodrigues, G
442
Rogers, L
98, 128, 161
Rogers, V
365, 405
Roman, M
78, 127, 191
Rooney, S
238
Rose, D
48
Rosendahl, U
7, 46
Rowe, H
109
Rowe, M
24
Rowe, S
351
Rubino, A
235
Ryan, R
384, 403
S
Saad, H
219, 382
Sabeshan, P
108
Sabetai, M
30, 34, 110
Sadia Aftab, S
137
Sadler, C
238
Saftic, I
375
Sahai, P
17
Sahdev, N
165, 386
Sajic, M
145
Salem, A
24, 155
Salih, C
208
Sallam, M
34
Salmasi, M Y
7, 8, 9, 11, 40, 57, 63, 120, 130
Salmasi, Mohammad Y
30, 194, 199
Salmasi, Y
6, 53
Samaddar, A
213
Samaraweera, D
157
Sanders, J
119, 228
Sandhu, M
135, 138, 144
Santhirakumaran, G
322, 331
Santhosh, G
3
Saravanan, P
177
Sarvananthan, S
42
Sasidharan, S
8, 9
Sayeed, R
161, 190
Scarrott, H
164
Schweigert, M
303, 305
Seale, A
268
Sebastian, L
256
Sef, D
431, 435, 443
Selvaraj, S
3, 232
Senage, T
50
Senbaklavaci, O
441
Seraj, Shaikh S
152, 285
Sereda, V
70
Shaarawy, E
332
Shackcloth, M
373, 394, 396, 398
Shah, B
167
Shah, M
322
Shah, O
106, 300
Shah, P
164
Shah, S
371
Shah, T
307, 365, 405
Shahansha, S
3
Shanahan, B
247, 357
Shanmugananthan, S
155
Shannon, J
57
Sharkey, A
159, 160, 176
Sharma, S
58, 59, 60, 89
Shatila, M
361
Shaw, M
12, 23, 24, 27
Shehata, M
34, 100, 110
Sheikh, A
137
Sheikh, S
189
Shenoy, R
391
Sheridan, N
244, 257
Sherif, M
51, 95
Shetty, G
211
Shetty, V
3, 232
Shinn, O
250
Shipolini, A
45
Shirke, M
284
Shoeib, M
163
Siepe, M
50
Simmonds, S
402
Simoniuk, U
12, 29
Singh, H
238
Singh, S
332
Singhania, A
161, 378, 393
Sinha, S
10, 16, 25, 67, 76, 77, 79, 102, 104, 135, 138, 143, 222, 223
Sinnott, N
394
Sinobas, A
272
Sitaranjan, D
444
Skulbedova, N
263, 264
Slim, N
194
Smail, H
84, 428, 438, 439
Smelt, J
321, 331, 368
Smith, B
215
Smith, E
328
Smith, H
5, 416
Smith, M
396, 398
Smith, S
405
Sobhun, G
70
Socci, L
355
Soh, Karen Chien L
346
Soliman, N
197
Soliman-Aboumarie, H
425
Somasundram, K
332
Soo, A
74, 374
Sorathia, N
216
Sorensen, J
357
Sounderajah, V
298
Spear, M
287
Speggiorin, S
208
Spence, A
312, 333
Spence, M
174
Spieth, P
303
Spinthakis, N
98
Spyridopoulos, I
73
Srinivasan, L
312, 333, 401
Sriskandarajah, S
56
Stamenkovic, S
357, 386, 410
Stavroulias, D
411
Stefano, P
50
Stein, H
305
Sterne, J
104
Steyn, R
365
Stickley, J
268
Stock, U
9, 84, 199, 428, 431, 433, 435, 438, 439, 443
Stockdale, S
364
Streets, E
233
Strickland, J
314
Struzik, E
223
Suhail, S
60
Sunny, J
225, 284
Surendran, A
445
Suseeladevi, A
223
Sutherland, F
70
Syed Aidil H
52, 103
Syed Nong C
52, 103
Szafranek, A
86, 168
Szafron, B
219, 382, 385
T
Taberham, R
411
Tafuro, J
183
Taghavi, J
157
Tahhan, G
334
Takyi, C
175
Talukder, S
385, 427
Tan, C
99, 321, 331, 391
Tandon, E
286, 293
Tariq, H
373
Taylor, M
105, 360, 393, 394, 396, 398, 399
Tcherveniakov, P
409
Teh, E
409
Tenconi, S
355
Thammandra, V
186
The RAV Group
35
Thekumkattil T, T
232
Theodore, S
164
Theologu, T
12
Thomas, A
216
Thomson, G C
3
Tincknell, L
388
Toale, C
316
Toerien, L
327, 329, 345
Toh, S
276
Tolan, M
351
Tomkova, K
145
Torella, F
14
Trevarthen, T
201
Trivedi, U
182
Trkulja, V
443
Tseng, Yuan-T
199
Tsin Yan, Grace T
275
Tsitsias, T
366
Tsui, S
427
Ttofi, I
19
Tuff, C
229
Turner, M
222
Turton, M
263, 264
Tyson, N
86, 99
U
Uberoi, R
19
Ugur, T
380
Umakumar, K
431, 439
Unsworth-White, J
16, 152
Uppal, R
45
Uy, C
256
Uzzaman, M
92
V
Vaja, R
161
Valesco-Sanchez, D
217
Valtzoglou, V
313, 319, 325, 334, 379
van Delden, R
192
van Doorn, C
209, 217
Van Tornout, F
385
Varghese, D
137
Veeralakshmanan, P
152, 285
Velissaris, T
106
Veltink, P
192
Venkateswaran, R
105
Venu, G
232
Venugopal, P
211, 212
Verdichizzo, D
19
Veres, L
420
Verzelloni Sef, A
431, 435, 443
Villaquiran, C
16
Villaquiran, J
16
Viola, C
390
Viola, N
267
Virdi, A
427
Visan, A
205
Vlastos, D
46, 413
Vohra, H
25, 102, 104, 116, 272
Volpi, S
436
W
Waddell, T
366
Wadey, K
117
Wald, D
387
Wali, A
16, 161
Walker, A
48, 282, 286, 293
Wallace, W
298
Waller, D
336, 358, 359, 386, 392
Wang, L
218
Wang, Y
254
Waterhouse, B
349, 395, 417
Watson, J
187
Weaver, H
353
Webb, S
131
Webb, V
259
Weedle, R
74, 345, 374
Wells, F
280
Wendler, O
64, 125, 169, 171
West, D
375
Whitaker, D
125, 171
White, A
74, 374
White, R
175
Whittaker, G
347
Whooley, J
74, 374
Wicks, W
31
Wilkinson, G
238
Williams, J
313, 319, 325, 379
Williams, L
363, 424
Wilson, H
386, 387
Wilson, I
161
Wilson, K
161
Wilson-Smith, A
17
Winters, J
434
Witzigmann, H
305
Wong, Qing N
294
Woo, E
315, 344
Woolley, R
209
Wozniak, M
127, 145, 189, 191, 203
Wright, L
302
Wynne, R
228
X
Xu, Xiao Yun
8
Y
Y Oo, A
12
Yao, L
153
Yap, T
100
Yasufuku, K
366
Yates, M
45
Yeung, J
366
Youhana, A
87
Young, A
371
Young, V
403
Yousef, O
272
Z
Zacharias, J
107, 177
Zaidi, A
87
Zakkar, M
39, 151, 161
Zargaran, D
30
Zeschky, C
433, 438
Zibdeh, O
165
Zientara, A
57, 199
Zlocha, V
124
Zouki, J
211