SCTSCONFERENCE NEWS · Heidi Caisley Advanced Clinical Practice Project Lead, Royal Sussex County Hospital, Brighton & Sussex University Hospitals NHS Trust, Brighton, UK ObjectiveF

Welcome to the 2019 SCTS Annual Meeting and Cardiothoracic Forum in London. This year’s programme covers the many different aspects of cardio-thoracic surgery, emphasising areas that are

important in your daily clinical work. As ever, we are hoping to create an interactive meeting with the exchange of knowledge and ideas, facilitating discussions and debates between delegates. With a wide range of educational formats presenting the latest and the best information on new technologies and techniques in cardio-thoracic surgery, the presentations will be of interest to surgeons, anaesthetists, nurses, surgical care

practitioners, physiotherapists, child governance leads, database managers and allied health professionals.

This year’s meeting will include presentations of the highest quality from surgical and masterclass presentations to the latest clinical updates and technical innovations. As ever, the meeting will also witness some outstanding debates presented by some of the foremost experts in their field. Away from the scientific programme, all delegates are reminded that this year’s SCTS Annual Dinner will be held on Monday 11 March at the UnderGlobe. Some spaces are still available, please ask at the registration desk for further details.

The organisers would like to extend their thanks to industry for their continued support of the meeting, and all the presenters who have taken the time to contribute to this year’s SCTS Conference News newspaper. It is a great pleasure to welcome you to London and the organisers are honoured and delighted with your presence at this meeting. We hope the information presented will be of great interest. London is one of the world’s great cities and we hope you enjoy the meeting and all this wonderful city has to offer…and remember to make in note in your diaries for next year’s meeting that will be held in Cardiff, 22-24 March 2020!

The impact of respiratory illness on the morbidity and mortality in non-small cell lung cancer: A single-centre retrospective analysisAkshay Patel Cardiothoracic SpR, Health

Education West Midlands, Thoracic Surgery

Research Fellow, Institute of Immunology and

Immunotherapy, University of Birmingham, UK

Lung cancer is the most prevalent malignancy worldwide1 and the commonest cause of cancer-related death within the UK2;

despite advances in cancer medicine, age-adjusted 1- and 5-year survival remain poor at 32.1% and 9.5% respectively3. An ageing population and resulting increased cancer rate, in parallel with advances in diagnostic and anti-cancer therapeutic strategies, are driving growing costs in the field of cancer medicine4. A breakdown of these expenditures reveals the high cost of inpatient care, highlighting the importance of reducing unplanned hospital admissions (UHAs) allied with preventative strategies in the outpatient setting5. UHAs in lung cancer need to be better characterised to determine whether there are preventable admissions.

Lung cancer patients often present with respiratory infection which remains an important cause of morbidity and mortality during the disease course and studies examining this are largely historical,

variable in sample size and may be difficult to extrapolate from given the changes in the epidemiology and treatment of lung cancer. We carried out an observational study, characterising the impact of respiratory infection in NSCLC by analysing the

Thoracic – Oncology Pathway St James Tuesday 12 March 11:30

Adult Cardiac – Mitral Surgery Westminster Monday 11 March 09:00

Cardiopulmonary exercise testing augments watchful waiting in asymptomatic severe primary mitral regurgitationJonathan Afoke, Prakash Punjabi

Hammersmith Hospital, London

The seminal work of Enriquez-Sarano published over 20 years ago established the guidelines for surgery for primary mitral regurgitation.

In spite of these guidelines, many patients undergo surgery late in their pathology due to late diagnosis, non-compliance with guidelines and insensitivity of current imaging; resulting in increased mortality and morbidity. There has been much debate between early surgery versus watchful waiting, with the thrust of modern academia turning towards the benefits of mitral valve repair and minimally invasive surgery.

Hammersmith Hospital is fortunate to host one of the nine specialist pulmonary hypertension centres in the UK. There is long standing collaboration due to the RIPCOM 1 study (Clinicaltrials.gov identifier NCT03155373) funded by the Rosetrees Trust and The Friends of Hammersmith Hospital, which seeks to establish cardiopulmonary exercise testing (CPEX) as a new indication for surgery for primary mitral regurgitation.

CPEX is an objective method of assessing cardiorespiratory function. Usually a subject (Figure 1) undergoes a set exercise protocol

to maximum limits whilst measuring the basic parameters of heart rate, ventilation, blood pressure, oxygen consumption (VO2) and carbon dioxide production (VCO2). From these fundamental values, one can calculate parameters such as peak VO2, anaerobic threshold (AT) and O2 pulse which

Prakash Punjabi

Annual Meeting and Cardiothoracic Forum 2019

In this issueHighlights of CERN at SCTS 2019 4

Nurse-led early extubation practice in post-cardiac surgery patients 8

Quadrangular fixation of pectus bars to prevent displacement in Nuss procedure 12

Insights from the REgistry for QUality assESsmenT (REQUEST) study 17

Opioids in Cardiothoracic Surgery 20

Quantifying aortic morphological variability in bicuspid aortic valve patients with and without coarctation 25

SCTS exhibition and floor plan 42

The official newspaper of the SCTS Annual Meeting and Cardiothoracic Forum 2019 10-12 March 2019

SCTSCONFERENCENEWS

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Welcome to London

2 10–12 March 2019 SCTS CONFERENCE NEWS

are surrogates for cardiac output in the absence of significant respiratory deficit, and ventilatory equivalent of carbon dioxide (Ve/VCO2) which can be caused by heart failure or pulmonary hypertension.

Between 2016 and 2018, 10 patients with asymptomatic severe primary MR were referred for a surgical consultation and the opinion of the mitral MDT was that they did not meet current guidelines for surgery. This cohort underwent six monthly clinical review and transthoracic echo, with yearly CPEX. At one-year follow-up, five patients met the indications for surgery (two for class I indications, three for class II indications). This group elegantly demonstrated a strong trend towards a lower peak VO2 and AT. However, the group that did not meet the indications for surgery had stable CPEX parameters.

This clinical vignette demonstrates the

potential of CPEX to augment watchful waiting in asymptomatic severe primary mitral regurgitation. The current class I guidelines for surgery are surrogates for myocardial dysfunction and CPEX has the ability to objectively demonstrate this. It is our hope for the future, that once the final

results of the RIPCOM 1 study are known, that CPEX can be used to monitor not only asymptomatic severe, but moderate-severe primary mitral regurgitation. In doing so, we may be able to demonstrate a truly objective and evidence based optimum timing for surgery.

proportion of UHAs from a single UK centre within this patient cohort. Our study cohort included all patients with known NSCLC who had a UHA to our centre; we retrospectively ascertained clinical and demographic data at admission and during their inpatient stay. The type of admission was categorised according to those who were admitted with a respiratory infection (RI) and all other admissions (AOA).

Over the 26 month study period, the UHA rate for patients with NSCLC was 75.2%; there were 455 separate patient UHAs from a total cohort of 605 patients. Of these, 164 UHAs were as a direct result of respiratory infection (36.0%). In-hospital mortality

(p<0.0001) and length of hospital stay (p=0.031) were significantly higher in the respiratory group. Factors related to in-hospital mortality were further explored by Multivariate analysis; patient age, PPSV23 status, RI admission, Tazocin administration on admission, tumour stages IIb, IIb, IVa and IVb and smoking status were all significant independent predictors of in-hospital mortality. Odds ratios of 0.160 (95% CI 0.077 – 0.366; p<0.0001) for positive PPSV23 status and 9.522 (95% CI 5.051 – 17.954; p<0.0001) for RI status indicate that for patients admitted to hospital with a respiratory infection without previous PPSV23 in the last five years, the odds of death were almost 60-fold higher. Pulmonary infection has

been highlighted as an important and significant cause of death in lung cancer. Advanced stage lung cancer in particular is difficult to treat and given the high prevalence of Stage III disease or higher in the respiratory cohort (71.3%, n=117), the control of infection may be an important clinical step in improving the prognosis of lung cancer.

Vigilance for infection, optimising vaccination, early diagnosis with adequate assessment and efforts to identify a culprit organism should be a priority in both the inpatient and outpatient setting in order to improve outcome in NSCLC and reduce the incidence of hospital admission; such interventions require prospective clinical trials.

REFERENCES:

1. Ferlay J, Shin H-R, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer. 2010 Dec 15;127(12):2893–917.2. Death registrations summary tables – England and Wales – Office for National Statistics [Inter-net]. [cited 2018 Jul 31]. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/deathregistrationssummarytablesenglandandwales-referencetables3. Lung cancer survival statistics [Internet]. Cancer Research UK. 2015 [cited 2018 Oct 29]. Avail-able from: https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/lung-cancer/survival

4. Cuppens K, Oyen C, Derweduwen A, Ottevaere A, Sermeus W, Vansteenkiste J. Characteristics

and outcome of unplanned hospital admissions in patients with lung cancer: a longitudinal tertiary

center study. Towards a strategy to reduce the burden. Support Care Cancer [Internet]. 2016 Jan

27 [cited 2018 May 14]; Available from: http://link.springer.com/10.1007/s00520-016-3087-4

5. Jönsson B, Hofmarcher T, Lindgren P, Wilking N. The cost and burden of cancer in the European

Union 1995–2014. Eur J Cancer. 2016 Oct;66:162–70.

6. Akinosoglou KS, Karkoulias K, Marangos M. Infectious complications in patients with lung can-

cer. Eur Rev Med Pharmacol Sci. 2013 Jan;17(1):8–18.

Can an in house CALS course increase survival rates in the post-operative Cardiac surgical patient?Heidi Caisley Advanced Clinical Practice

Project Lead, Royal Sussex County Hospital,

Brighton & Sussex University Hospitals NHS

Trust, Brighton, UK

Objective

Following the introduction of an in house one day CALS course at our centre in 2015, we aimed to compare

outcomes to assess the effectiveness of our teaching to the Multiprofesional team and the impact on survival rates for patients.

MethodsWe collected retrospective data over the three year period that we have been running in house CALS. This was then compared to the three year period 2012 to 2015 prior to the introduction of the course. This data was collected from our theatre and Cardiac ICU records as well as our clinical information system. During the period 2012-2017 a total of 145 patients were reopened. 130 of those made it back to theatre, 15 patients were re-opened outside of the theatre environment. The course provides direction re role allocation; utilises prompt cards and has developed a recognised escalation

process for calling in the surgical and theatre teams.

ResultsThe results from both timeframes were collected and compared. The results indicated that pre the CALS course 37% of patients survived a reopening. In contrast the survival rate increased to 71% following the introduction of the course. Once the CALS course had been adopted throughout the unit we demonstrated that 100% of patients were re-opened within five minutes and consistently followed the European CALS Protocol. Anecdotally staff also reported a positive impact on MDT working.

ConclusionWe demonstrate that adopting an in house CALS course, that runs three times a year have benefited our patients and centre significantly. Not only have patient outcomes improved but we would suggest that early recognition of the deteriorating patient results in effective MDT working. Moreover, we have demonstrated the effect of regular sessions and the benefits of running a formal course for staff and patients alike.

The Clinical Practice Leadership in Research (CPLR) programme: Increasing nursing research in cardiac care at St Bartholomew’s HospitalProfessor Julie Sanders Director Clinical

Research, Quality and Innovation, St

Bartholomew’s Hospital, Clinical Professor

Cardiovascular Nursing, William Harvey

Research Institute, QMUL.

SCTS Nursing and AHP Academic and

Research Lead. FNF and Council of Deans for

Health Scholar 2018 Council on Cardiovascular

Nursing and Allied Health Professionals

Treasurer 2018-

It is known that research active Trusts have improved patient outcomes1 but also that nursing research activity is substantially less than other

healthcare disciplines2. However, there is great potential for impact on healthcare delivery and patient outcome if nursing research is optimised3. Generally, research hasn’t always been recognised or valued in nursing clinical practice4 but clinical/ward managers are key to engaging nurses in research5. They have the necessary influence in the clinical area to operationalise research6, create supportive and sustainable research environments3, identify gaps for research7 and build an evidence-based culture6. Thus, we developed the Clinical Practice Leadership in Research (CPLR) programme specifically to develop, inspire and engage Band7

(B7) clinical/ward managers in research, in order to empower them to provide supportive research environments and opportunities for their nursing staff.

The CPLR programme, a 12-month programme funded by the Burdett



CT Forum (Nurse and AHP) – Quality and Safety Windsor Monday 11 March 15:30

Cardiopulmonary exercise testing augments watchful waiting in asymptomatic severe primary mitral regurgitation

The impact of respiratory illness on the morbidity and mortality in non-small cell lung cancer: A single-centre retrospective analysis

Research – CT Forum (Nurse and AHP Windsor Monday 11 March 14:10

Group planning the research engagement dashboard

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Figure 1. Richard Ross, Chairman of the Rosetrees Trust undergoing a

cardiopulmonary exercise test.

Figure 2. Comparative CPEX on a subject showing a peak VO2 of 94% predicted in 2017 compared to 82% predicted in 2018.


Nursing Trust, had four key components:nWS1 Knowledge/skill development: Four

masterclasses on key research areas (Searching, critiquing and applying the literature; Research ideas and project progression; Patient and Public Engagement; Writing for Publication) were delivered with follow-up workshops implementing into practice;

nWS2 Research exposure: Six conference places were funded to increase research exposure;

nWS3 Organisational culture: Two round table discussions occurred to seek solutions to organisational barriers to engaging in research and to develop a ward-level research dashboard to evaluate ongoing research engagement;

nWS4 Research leadership fellows (RLFs): Two, strategically placed research champions (RLFs), were appointed 1-day/week to bridge the gap between

research leaders and bedside nurses.Initial engagement was slow and questionnaire completion at the beginning

and end of the programme was poor (33.8%, 27.0%, respectively). Although statistically non-significant, interest,

awareness, motivation and engagement were found to increase over time. The RLFs, conference and organisational change components were particularly successful. Those attending conferences were inspired to submit abstracts to subsequent meetings. Each B7 has 0.5day/month rostered to research, research boards are present in each area and increased numbers of nurses are engaging in research opportunities. RLFs have also excelled in confidence, developing own and others’ leadership. Finally, a ward-based research engagement dashboard was developed by the B7s to evaluate ongoing research engagement in clinical practice at ward level.

Our work highlights the need for a dedicated programme if nursing motivation, engagement and research leadership in clinical practice is to increase. Even with a dedicated programme, engagement is slow and thus sustained programmes are required to make a

significant difference. This is essential if we are to increase evidence-based practice, research in practice, and build our clinical academic nursing workforce.

This work is being presented on Monday 11 March at 14.10 in the Windsor Room.

References

1. Ozdemir BA, Karthikesalingam A, Sinha S, Poloniecki JD, Hinchliffe RJ,

Thompson MM, Gower JD, Boaz A, Holt PJE. Research Activity and the As-

sociation with Mortality. Chalmers JD, ed. PLoS One 2015;10:e0118253.

2. James V, Clark JM. Benchmarking research development in nursing: Cur-

ran’s competitive advantage as a framework for excellence. J Res Nurs Sage

PublicationsSage UK: London, England; 2007;12:269–287.3. Gifford WA, Holyoke P, Squires JE, Angus D, Brosseau L, Egan M, Graham ID, Miller C, Wallin L. Managerial leadership for research use in nursing and allied health care professions: a narrative synthesis protocol. Syst Rev 2014;3:57.4. Pravikoff DS, Tanner AB, Pierce ST. Readiness of U.S. nurses for evidence-based practice. Am J Nurs 2005;105:40–51; quiz 52.

5. Sellars BB, Mayo A. Transforming care through leadership and research

alignment. Nurs Manage 2013;44:12–15.

6. Fitzsimons D, McCance T, Armstrong N. Vision, leadership and partnership:

How to enhance the nursing and midwifery contribution to research and de-

velopment. J Adv Nurs 2006;55:748–756.

7. Scala E, Price C, Day J. An Integrative Review of Engaging Clinical Nurses in

Nursing Research. J Nurs Scholarsh 2016;48:423–430.v

The Clinical Practice Leadership in Research (CPLR) programme: Increasing nursing research in cardiac care at St Bartholomew’s Hospital


The Cardiothoracic Interdisciplinary Research Network (CIRN)Mr Luke J. Rogers (ASSL), Mr Ricky Vaja (ASSL),

Professor Julie Sanders (SCTS Nursing & AHP Academic & Research Lead)

Professor Gavin Murphy (SSL) on behalf of CERN

We are delighted to report that there has been considerable development and engagement in the Cardiothoracic Interdisciplinary Research Network (CIRN), since it was successfully launched at this meeting last year. The Terms

of Reference1 has been agreed (included within the SCTS conference pack), corporate authorship has been adopted and support for the Associate Principle Investigator Scheme2 has been gained from the Royal College of Surgeons (RCS) and National Institute for Health Research (NIHR). This Associate PI scheme is a new initiative to increase the opportunity junior doctors, nurses and allied health professionals (NAHPs) have to be involved in high-quality research to improve care with the ultimate aim of ensuring the development of the PIs of the future through recognition and promotion of their role within NIHR portfolio trials. It is hoped all future NIHR portfolio trials will have an Associate PI at each site involved.

We have also had fantastic engagement with trainees NAHPs from 22 hospitals volunteering to actively represent their Trusts in the CIRN. There is still progress to be made as we are still looking for trainee and NAHP representation at the following sites:nAberdeen Royal InfirmarynRoyal Infirmary EdinburghnSheffield Teaching Hospitals NHS FT (Northern General)nBlackpool Teaching Hospitals NHS FTnUniversity Hospital of South Manchester NHS FT (Wythenshawe)nNottingham University Hospitals NHS TrustnRoyal Wolverhampton NHS TrustnUniversity Hospital of North Midlands NHS Trust (Royal Stoke)nUniversity Hospitals Coventry & Warwickshire NHS TrustnBasildon & Thurrock University Hospital NHS FTnSt Georges Healthcare NHS TrustnKings College Hospital NHS FTnRoyal Victoria Hospital; Belfast

nMater Misericordiae University Hospital; DublinCIRN offers a fantastic opportunity to be involved in multicentre, high-quality research that will shape the future of patient care in cardiothoracic surgery, so please do contact us to be involved!

Alongside these foundations the CIRN has focussed on providing the impetus for a clinical trial to reduce the incidence of surgical site infection (SSI) following cardiac surgery. This involves two ongoing projects that will outline the current evidence base and highlight any variation in practise that exists;1. A systematic review of evidence-based interventions to reduce SSI in

adult cardiac surgery – preliminary findings to be presented at the SCTS Conference. (Monday 11 13:40; Westminster Suite)

2. A national variation in practise audit of interventions implemented throughout Trusts in Great Britain & Ireland to reduce SSI in cardiac surgery – survey pilot to be launched at SCTS Conference. (Monday 11 09:00; Keats Room)

This work is being delivered in partnership with the National Cardiac Benchmarking Collaborative (NCBC) and Public Health England. These projects offer anyone whether you’ve aspirations of being the next PI or

are simply intrigued to find out a little more about cardiothoracic research the opportunity to get involved. Throughout the SCTS Conference there are a number of opportunities to hear more about the CIRN and we would encourage you to come and join us at the meeting listed below. We look forward to seeing you there!

For more information, or to become involved in the CIRN, please contact: Ricky Vaja ([email protected]) or Luke Rogers ([email protected]): Cardiothoracic surgeons (NTN’s, non-NTN’s, Fellows, Trust grades, Foundation Doctors, Core Trainees & students) Julie Sanders ([email protected]): Nurses and Allied Health Professionals.

References

1. Terms of Reference. Cardiothoracic Surgery Interdisciplinary Research Network (CIRN). Society for Cardiothoracic Surgery (SCTS) in Great Britain & Ireland. Dec 2018.2. Associate Principle Investigator Scheme. National Institute for Health Research. West Midlands Research Collaborative, Birming-ham Surgical Trials Consortium. Birmingham Clinical Trials Unit & West Midlands NIHR CRN. Version 1.4. Nov 2018.3. A Systematic Review & Meta-Analysis of Interventions to Prevent Surgical Site Infection (SSI) in Cardiac Surgery Protocol. 20th July 2018. https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=1042194. Variations of Practise in the Management of Surgical Site Infections in UK Cardiothoracic Surgery Centres Protocol. (Not yet published).

MERITS: Multicentre Evaluation of Renal Impairment in Thoracic Surgery (MERITS) – a SCTS STUDENTS supported projectVinci Naruka1, Sofía Villar2, Giuseppe Aresu1, Adam Peryt1,

Jon MacKay3, Aman Coonar1, MERITS Collaborators4,

SCTS Students4 1 TAISER group, Thoracic Surgery, Royal

Papworth Hospital, Cambridge; 2 Biostatistics Unit, University

of Cambridge; 3 Anaesthetics & ICU, Royal Papworth Hospital,

Cambridge; 4 Cambridge, Hull, Brompton & Harefield,

Edinburgh, Birmingham, Middlesbrough, Liverpool, Basildon,

Leeds, Cardiff

Improvements in thoracic surgery have led to a progressive reduction in mortality. This is despite an increase in age, co-morbidity and frailty of many

patients. Very low mortality rates limit its use as a quality measure since it may not discriminate well between units. Generally, we are looking for additional quality measures that are both meaningful and can

also be collected with ease.We proposed that renal impairment could

be such a measure. In the UK, acute kidney injury (AKI) is calculated using standard algorithms and allows comparisons between units. Following a single centre study, we designed a dataset which we considered to be robust, meaningful and practical to collect.

In order for this to be reflective of UK

practice, a power calculation found that we needed to collect data on a minimum of 2,520 patients and we reasoned that a large number of data collectors would be required.

Over the last five years, the student engagement wings of the RSM and SCTS have evolved into SCTS STUDENTS with increasing membership. The initial purpose of SCTS STUDENTS was to make Cardiothoracic Surgery more accessible to students. Using the platform to allow students to become involved in meaningful investigations was a logical extension.

Our aims were:1. Is this multi-centre study feasible with

current resources?2. To collect at least the minimum sample

size (n=2,520 at 1.5% margin error)

for statistical analysis to estimate a national rate

3. To determine incidence and baseline characteristics of AKI in multiple centres.

In particular, examine any significant variation in AKI rate rendering it useful as a comparative indicator.

The study launched in September 2018 and we report the study status as of 1st March 2019. The protocol and site support have been largely internet developed using secure and very economical resources.1. In five months, we have collected data on

4,911 patients from six centres and data collection has commenced in another six centres. We are pledged >6,000 patients.

2. The student-delivered data collection has been highly successful and the model is

being considered for other studies.3. We have identified in AKI rate between

centres from 3.4 to 17%. Length of stay is longer in patients with AKI and AKI is more frequent in open surgery than in VATS.

We will report our full results later in 2019. Our interim results reported at SCTS 2019 suggest that AKI is practical to collect with a wide variation between units. Since it is correlated with a meaningful outcome (length of stay) it may be a useful measure to improve quality. The involvement of students has enabled this big-data project and we would like to extend and propagate this model.

https://royalpapworth.nhs.uk/merits

Thoracic – Outcomes St James Tuesday 12 March 09:10

Research – CT Forum (Nurse and AHP Windsor Monday 11 March 14:10

Table 1. SCTS Annual Conference 2019 Cardiothoracic Interdisciplinary Research Network (CIRN) Presentations

Time & Date Topic Location

17:00 Sunday 10 March Trainees Meeting Wesley

09:00 Monday 11 March

CIRN Breakout (National Audit Launch)

Keats

13:40 Research Trainees Initiative Westminster

16:20 Role of Research Networking to Maintain Collaboration Before, During & After Research

Moore

09:00 Tuesday 12 March

Nursing & AHP CTS Forum Windsor

Ricky VajaLuke J. Rogers

Vinci NarukaAman Coonar

SCTS CONFERENCE NEWS 10–12 March 2019 5

There are currently surgical and benchtop (in vivo) air leak lung models – what are their limitations?Most benchtop models are limited to intraoperative breathing, and the lungs are treated as dead tissue. The entire postoperative phase is overlooked, which may represent a critical time in PAL development. Any leak testing is performed by inflating the lungs until the lungs leak or the ventilator reaches its maximum pressure. In vivo (animal) models, as well as clinical studies, lack the ability to accurately monitor and track leaks from specific location, so although the mechanics are physiologic, it is difficult to assess the outputs and control variables in such models.

What were the aims of this study described in the publication?First and foremost, we wanted to describe the model and provide data around the clinical approximation of its functionality. The invaluable input of our surgeon co-authors provided guidance with these efforts. We felt it essential to publish on the model itself, seeking review and critique of the concept and validation approach. Additionally, we began assessing how different breathing conditions (intraoperative through postoperative ventilation) may influence existing leaks. Towards this, we tracked known needle-prick leaks through different types of breathing and measured leak rate. Insights in this experiment were foundational to our next efforts.

What were the specific challenges of designing and developing ex vivo lung model that represented clinical scenarios?Important in all modelling efforts is recognizing that no model will be perfect (by definition, a model approximates reality). It was important for us to prioritize key features of the model, knowing that inclusion of some features would introduce some departure from clinical reality (e.g. using saline in the chamber to detect and isolate air leaks doesn’t match physiology). Additionally, lungs can be exceptionally fragile, so even tissue harvesting and shipment techniques required study. The model needed to accommodate lung perfusion, lung ventilation, organ preservation, leak visualization, leak capture/quantification, and ease of use considerations, all of which added to its

complexity. Paramount to overcoming these challenges was partnering with brilliant researchers and thoracic surgeons.

Why do you believe the ex vivo lung model is superior to current surgical and benchtop air leak lung models (ie. inducing negative pressure)?Certainly, the ability to simulate physiologic breathing – negative pressure – is a key attribute of the model, but I believe the main strength is having the capability to keep an appropriately-procured set of lungs alive and functioning in a physiologic manner (e.g. performing gas exchange and metabolism) for extended periods of time. Perioperative ventilation is one component of the complete system. The ability to use diseased human lungs presents a step-function increase in clinical relevance of the model which will advance our work even further.

In the study you decide to monitor air leak rates, physiologic ventilation and perfusion parameters. Are there any parameters you were unable or decided not to measure?Measuring perfusion distribution within the lungs would have been interesting, but this would have required placing the chamber within a CT machine, which was not feasible. To get as complete of a description of ventilation as possible, measuring alveolar pressures would have been insightful, but this is technically challenging. The beauty of the model is that when advances in imaging and pressure measurement are made, they can be deployed in our model without major redesigns.

Why did you decide to create (approximately) 250 cc/min air leak – is this the approximate air leak witnessed in clinical scenarios?Under the guidance of our thoracic surgeons, we sought to create a leak as reproducibly as possible and of qualitative significance which happened to be around 250 cc/min. Clinically, there is not robust association of an actual leak rate value with clinical significance, so we relied on the assessments of surgeons.

What were the key outcomes of the study?A critical outcome of the work was describing the model and showing

validation of important aspects of the model; essentially, it was crucial to build a strong base of the model before moving to studies. The most interesting finding was the role of pressure modality on leak progression. We found that the switch between positive pressure (intraoperative) to negative pressure (postoperative) substantially increased the magnitude of leak from the parenchymal defects. Because of the way we can control variables in the model and accurately quantify leaks, this provided new insights into the science behind air leaks.

What were the limitations of the study/ex vivo model?In this first set of experiments, we intentionally used healthy porcine lungs. Though this is different than what surgeons face, it provided a relatively consistent platform on which we could validate key model components and explore the effects of breathing modality. Additionally, we limited apposition (lung tissue sticking to other surfaces such as the chest wall or other lung tissue) to better isolate leak effects. Apposition is clinically meaningful, but it represents an event that is desired but not guaranteed – we wanted to know the extent of a variable like ventilation modality in the absence of cofounding variables.

In your opinion, what is the significance of this study and how can its outcomes/conclusions increase our understanding of the risk of air leaks and their subsequent treatment?I believe the study is significant primarily because it introduces a new model that more closely mimics clinically reality than previous efforts. From a high level, this provides a means to better understand the science behind air leaks. Specific to the ventilation modality versus air leak portion of the work, the findings help foster discussion with surgeons about how and when air leaks may occur. The work does not suggest changing ventilation protocols, but it hopefully brings awareness to the complexity of linking intraoperative air leaks to postoperative air leaks. I suspect that a proportion of leaks exist intraoperatively but do not manifest until the lungs experience negative pressure and a proportion of leaks originate during negative pressure. These findings point to the importance of device-tissue interactions and continuing to evaluate new device designs under both pressure modalities.

Using this study, what future work will you and your colleagues be focusing on?We are currently undertaking a number of experiments continuing the momentum from this initial work. Recently, we conducted a large study investigating staple line specific air leaks, and we performed some pilot work using cadaveric diseased human tissue. We are engaged in research discussions to begin testing living rejected donor lungs, which represents a significant advancement in the model. We are also studying more basic questions such as how

leak location may influence leak incidence and severity and to what extent the degree of negative pressure worsens existing leaks.

What evidence is there to suggest that ventilation modality – intraoperative positive pressure vs postoperative negative pressure – and stapler design may play a role in air leaks?Our first publication on the Physiologic Lung Model provides novel and convincing evidence that ventilation modality can influence air leaks – the ability to observe this highlights key features of our model. There are some publications that have qualitatively noted that negative pressure can worsen or increase the number of leaks in lung volume reduction procedures, and other publications have observed increased peripheral ventilation with physiologic breathing versus breathing with a ventilator – all data that helps support our observations. Outside of our recent publication, a study by Imhoff et al. tested two different stapling designs (uniform staple heights and graduate staple heights) and showed a difference, at least under positive pressure in a relatively simplistic model.

What were the aims of the second study?In a statistically powered way, we wanted to extend our previous work to more clinically relevant air leaks – those from staple lines – as well as further explore the role of stapler design under both breathing modalities.

What were the key outcomes of this study?In comparing the stapler designs, we saw a substantial increase in the incidence (those staple lines that leaked) and magnitude of air leaks in graduated staple lines compared to uniform staple lines. This was statistically significant in the postoperative breathing phase. Additionally, we saw a similar trend with regards to air leaks and breathing modality as in our first publication: negative pressure worsened the magnitude of staple line air leaks.

What did the outcomes reveal about the location of staples and air leaks?In nearly every staple line that leaked, we observed bubbling from the outermost row of staples (those furthest from the cut edge of the tissue). Many of the leaks appeared to be near the edges of the resection line which involved the thinnest tissue along the staple line; however, we also saw leaks in the thickest portion of the tissue which also included a mix of vessels and airways.

What did the outcomes reveal about the different staple designs (graduated vs uniform staples)?The observation that leaks occurred at the outermost row of staples suggest that these staples did not adequately compress the tissue in this region to prevent air escaping from the staple puncture sites. Staples must perform two functions – they must compress the tissue to prevent air moving inside the tissue and compress the

tissue to prevent air escaping out of the punctures created during placement of the staples. If the staples are too tall for a given tissue and are unable to sufficiently compress the tissue, leaking will occur. Interestingly, in the graduated staple design, the outermost row is the tallest staple across the three rows. We suspect that the uniform staple line provides better compression, especially in the outer row, while not over-compressing the inner row of staples. This is a similar observation and conclusion to what Imhoff et al. discussed when comparing uniform versus graduated staple lines.

What were the limitations of the study?In this work, we studied only healthy porcine lungs. This was essential to reduce the variability associated with diseased tissue and was part of a stepwise progression to better understand air leaks. We also only studied those lungs that didn’t present apposition during testing. Because apposition is a variable that may clinically influence results, we wanted to understand the effects of ventilation modality and stapler design paradigm absent of this variable.

In your opinion, what is the significance of this study and how can its outcomes/conclusions increase our understanding of the risk of air leaks and their subsequent treatment?This work helps build awareness that (absent apposition), physiologic breathing may substantially change the mechanics of lung ventilation and influence air leaks. What a surgeon observes intraoperatively may not reflect what manifests postoperatively. This work also continues to build on previous literature that graduated heights staples – particularly the outermost staple row – may not compress lung tissue as well as uniform height staples, thus leading to a greater number and more severe air leaks.

Using this study, what future work will you and your colleagues be focusing on?In our ongoing discussions with surgeons, we are actively pursuing the testing of human rejected donor lung tissue. This will enable us to compare our findings in porcine lungs to tissue that is as clinically relevant as possible. Surgeons seem very excited about this type of information and the prospect for continued testing in this model. We have also had discussions with surgeons about using the model to better define postoperative chest tube management strategies – this is important to helping improve patient care and is germane to our commitment to outcomes. Consistent with our spirit of innovation, we are also beginning to explore next generation stapling technologies to further improve device performance.

References

1. Stéphan F, Boucheseiche S, Hollande J, et al. Pulmonary complications following lung resection: a comprehensive analysis of incidence and pos-sible risk factors. Chest 2000;118:1263-702. Abolhoda A, Liu D, Brooks A, et al. Prolonged air leak following radical upper lobectomy: an analysis of incidence and possible risk factors. Chest 1998;113:1507-10

Increasing our understanding of post-operative prolonged air leaks

Clinical commentTo assess the importance and possible clinical implications of the second paper, SCTS Conference News spoke with Professor Eric Lim, Consultant Thoracic Surgeon at Royal Brompton Hospital and Professor of Thoracic Surgery at Imperial College London, UK.

In your experience, what are the risk factors associated with air leaks following thoracic surgery?The causes are multi-variable and include patient factors (e.g. emphysematous lungs increase air leaks), surgeon factors (technique of operating such as fissure last decrease air leak) and equipment (different stapling technology).

Do you believe that differences in stapler design (graduated vs uniform) and how each device exerts force on tissue during stapling contributes to air leaks?The data by Eckert et al to me are quite convincing in that the rate of air leak is higher with graduated staplers compared to uniform height stapler, a difference in favour of uniform staple height that persisted in a range of conditions using different tissue

thickness, different stapling heights and variations in mode of ventilation.

In your opinion, what are the key take home messages from this paper?I think that the work undertaken by Eckert et al, using a more appropriate physiological model provides new insights into the question. Traditionally surgery is performed with the lung collapsed and air leak is tested using positive ventilation that switches to negative pressure ventilation when the patient is extubated which becomes the predominant mode of ventilation in the succeeding post-operative days for the patient in hospital with the chest drain. The key messages from this paper is that air leak is lower in uniform height staplers regardless of tissue thickness or mode of ventilation.

In your opinion, what are the limitations of this paper?The paper clearly shows that the leak rates are lower with uniform height staplers, however the model is “mechanical” ex-vivo study. What we don’t know is if the difference in the air leak rate is clinically important as body heals in-vivo. Common sense tells us that the higher the leak rate, the longer the air leak. However, if the body may be able to compensate in vivo for any

small differences. In addition, decisions to remove drains are usually made on a daily basis, therefore any difference will have at leaks 24 hours to “compensate” before a clinical decision is made. Finally, it needs to be borne in mind that the work was undertaken by the manufacturers of uniform height staplers (I personally consider the data to be robust).

Will/have the outcomes and conclusions of this paper influence/d your clinical practice?It’s an important message, but would not make a difference to my clinical practice because a) I already use uniform height staplers and b) we don’t have any corresponding clinical data. If I was using graduated height stapler, In-vivo clinical data (ideally via a randomised trial) in support of uniform height staplers would be required to convince me to change if there is a difference of at least one day in length of drain or length of stay.

In your opinion, how can surgeons and staple manufacturers improve the design and functionality of staplers?For multi-port VATS, I believe that currently staple designs are perfectly adequate (many ports allow different angles for the staple pass, so you don’t really require exacting demands on the stapler design. The

real challenge is for single port VATS surgery where you only have one angle of approach through a port shared with the camera and two or more instruments. In this setting, further improvements to staple design would facilitate surgery and include thinner stapler jaw, shorter residual (unused) tip of the jaw, thinner stapler shaft, greater articulation, off sync (with the staple shaft) position of the anvil and greater closing pressure.

As a thoracic surgeon, do you have any tips or tricks for your surgical colleagues on how best to minimise the risk of post-operative air leaks?For lobectomy, it needs to be emphasised that the majority of (significant) air leaks is due to dissection of the fissure rather than differences in staple height. Fissure-last techniques produce the least air leak (none is the expectation). For wedge resections, air leak can be minimised by using the correct stapler thickness for the tissue and to avoid touching any lung (e.g. with graspers) that is not going to be resected.

Advances in staple technology, greater awareness of correct usage to eliminate air leak (as confirmed by digital drainage) moves us naturally towards day-case thoracic surgery (currently a third of my work) that will become the main modality for thoracic surgery as we continue to improve.

Post-operative prolonged air leaks (PALs) are the most prevalent postoperative complication with a reported occurrence of 18-26%1,2 and is the most important determinant of length of postoperative hospital stay1. Two recently published papers have provided valuable insights into our understanding of prolonged air

leaks and the variables that could influence their occurrence. The first paper, ‘A novel ex vivo model is described to advance the understanding of prolonged air leaks’ (Klassen et al. Transactions on Biomedical Engineering.00262-2018: 1-11), described how researchers successfully designed and validated a novel ex vivo lung model, the outcomes of which could help mitigate the risk of air leaks. The second paper, ‘Clinical quantification of air leaks in a physiologic lung model: effects of ventilation modality and staple design’ (Eckert et al. Medical Devices: Evidence and Research. 2018:11 433–442), identified breathing modality (intraoperative positive pressure vs postoperative negative pressure) and staple design as two important variables that may contribute to air leaks. SCTS Conference News talked to Chad Eckart (Ethicon Inc, Research and Development, Cincinnati, Ohio, USA), co-author of both papers, who discussed the aims, outcomes and possible clinical implications of the papers.


Traumatic ruptured descending thoracic aorta: Open or endovascular repair? A systematic review and meta-analysisAmer Harky1, David Bleetman2,

Shirish Ambekar2, Neil Roberts2,

Aung Oo2 1. Department of

Cardiothoracic Surgery, Liverpool

Heart and Chest Hospital, Liverpool,

UK; 2. Department of Cardiac surgery,

Barts Heart Centre, St Bartholomew’s

Hospital, London, UK

Traumatic rupture of thoracic aorta is a highly lethal condition, normally as a result of

massive deceleration at the aortic isthmus. It is estimated that up to 80% of such patients die at the scene of the accident, often from associated injuries to the head, abdomen, pelvis or extremities. In-hospital mortality rates reported to be 32% while one third of those patients die before surgical repair is even attempted.

Surgical techniques have evolved significantly since the very first repair in 1951 by Lam and Aram. In addition to high mortality rates, conventional early surgical intervention was associated with a paraplegia rate of 11-26%. This has now improved to approximately

2% with advancement in surgical practice. Despite this, the need for a less invasive method has been developed and the use of endovascular stent graft prostheses in the emergency setting was appealing. The key advantages of endovascular repair over surgical intervention includes shorter

operating times, lower overall early mortality rates (3-6%), minimal requirement for heparin and lower paraplegia rates. Endovascular stent grafting has been established as a safe approach; and in suitable cases, it provides better outcomes to open repair in treating descending thoracic and

abdominal aortic diseases, including ruptured cases.

As the literature is predominated by single centre cohort studies, and no prospective randomised trials have been undertaken; we performed a meta-analysis of existing studies to evaluate the clinical outcomes between open

and thoracic endovascular aortic repair in isolated traumatic ruptures of the thoracic aorta.

Our study was conducted through a comprehensive literature search among the four major electronic databases (PubMed, Embase, Scopus and Ovid) to identify all relevant articles until July 2018.

The results from such extensive search reported a total of 1,944 patients among 21 included studies in our study. Thoracic endovascular repair (TEVAR) was performed in 29% (n=566) and open repair in 71% (n=1,378) of the cases. Mean age was similar in both group of patients (42.1±13.8 yrs vs 44.1±13.6 yrs, p=0.49). There was no reported difference in the duration of intensive care and total hospital stay between TEVAR and open repair groups (13±6.8 vs 13.1±7.9 days, p=0.35 and 26.3±9.2 vs 28±10.8 days, p=0.62 respectively). Similarly, no statistically significant difference in postoperative paraplegia or stroke rate were noted (2% vs 1.4%, 95%

CI 1.19 [0.54, 2.60], p=0.67 and 0.3% vs 0.7%, 95% CI 0.5 [0.12, 2.14], p=0.35, figure 1).

It is important to note that a lower operative and one-year mortality rates were noted in TEVAR cohort (7.8% vs 20%, 95% CI 2.87 [1.87, 4.42], p<0.00001 and 95% CI 2.11 [0.99, 4.52], p=0.05). However, no difference in mortality rates were observed at five-year (23% vs 17%, 95% CI 0.07 [-0.07, 0.20], p=0.33). The only drawback of using TEVAR was a higher rate of re-intervention at one year in the endovascular group (0% vs 6%, 95% CI 0.17 [0.03, 0.96], p=0.04). Table 1 is summary of those findings.

Based on the findings above, we conclude that endovascular repair of traumatic ruptured thoracic aorta gives satisfactory perioperative outcomes and lower operative and one-year mortality rates; however, this comes at the expense of requirement for higher re-intervention rates at one year. Utilization of such techniques is favourable in specialized centres.

Staged Vs Simultaneous Coronary Artery Bypass Grafting Surgery and Carotid Endarterectomy – A Systematic Review and Meta-analysisAmer Harky1, Mark Field1, Francesco Torella2 1.

Department of Cardiothoracic Surgery, Liverpool Heart and

Chest Hospital, Liverpool, UK; 2. Department of Vascular

Surgery, Royal Liverpool Hospital, Liverpool, UK

Coronary artery disease is one of the leading causes of death globally. In selected cases, coronary intervention is required for symptomatic relief and/or prognosis.

Intervention can be performed either percutaneously or surgically. In cases of surgical revascularization, the co-existence of carotid artery disease adds an incremental risk of perioperative stroke proportional to its severity. The prevalence of severe carotid artery stenosis (>80%) among patients undergoing coronary artery bypass has been estimated to be between 6 and 14%.

Several approaches have been proposed to reduce the risk of stroke in patients with concomitant carotid stenosis; these include staged carotid endarterectomy (CEA) followed by coronary artery bypass graft (CABG), combined CEA and CABG, or staged carotid stenting (CAS) followed by CABG.

The benefits of CEA in managing both asymptomatic and symptomatic patients versus optimal medical management is well established. CAS was introduced as an alternative to CEA in patients that were considered not suitable for CEA, in as similar fashion to how TAVI was introduced for patients not suitable for aortic valve surgery. Randomised controlled trials have shown that both CEA and CAS have similar long-term outcomes with respect to stroke, myocardial infarction or death, although CAS appears to have an increased

risk of stroke in recently symptomatic patients.Patients referred for CABG who have concomitant

carotid artery disease represent a high-risk population; their management remaining controversial, due to the absence of randomised controlled trials. Our systematic review and meta-analysis aimed to compare the reported outcomes of staged CEA with CABG or simultaneous CABG and CEA in patients with concomitant coronary artery disease and asymptomatic unilateral carotid artery diseases (>80% stenosis). The primary outcome measure was postoperative stroke; the secondary outcome measures were acute myocardial infarction (AMI) and 30-day mortality rates.

We performed a comprehensive literature search in August 2018; we included randomised and non-randomised studies that compared reported perioperative clinical outcomes between staged and simultaneous CABG and CEA in the same paper. After applying such criteria, we identified a total of 67,953 patients across eleven articles. Our analysis showed neither a difference in the incidence of pre-operative AMI (43% vs 37%, OR 1.09, 95% CI (0.80 – 1.49), p=0.57) nor in pre-operative stroke rate (1.9% vs 1.6%, OR 0.97, 95% CI [0.77 – 1.21], p=0.76) between the staged and simultaneous CABG with CEA respectively. Notably, there were more patients with pre-operative unstable angina in the simultaneous CEA and CABG cohort (83% vs 67%, OR 0.39, 95% CI [0.22 – 0.70], p=0.001). Postoperatively, there was a higher incidence of stroke in the simultaneous CEA and CABG cohort (5.2% vs 3.3%, OR 0.69, 95% CI [0.58 –

0.83], p<0.0001, Figure 1).The incidence of AMI was higher in the staged

group (14% vs 11.5%, OR 2.95, 95% CI ]1.00 – 8.68], p=0.05, Figure 2). No difference in all-cause 30-day mortality was noted (5% in staged vs 4.3% in simultaneous cohort, OR 1.27, 95% CI [0.77 – 2.10], p=0.35).

In conclusion, within the limitations of the study, our analysis shows a potential benefit of staged over simultaneous CEA with CABG in preventing post-operative stroke at the expense of an increased risk of AMI. There is no demonstrable difference in perioperative mortality between the two treatment startegies.

Figure 1

Adult Cardiac – Thoraco-Abdominal Aortic Surgery Abbey Tuesday 12 March 14:10

Adult Cardiac – CABG: General Westminster Tuesday 12 March 11:40

Table 1. Summary of the postoperative findings.

Variable Open repair Endovascular repair

P value

Paraplegia (%) 26 (2.1) 6 (1.4) 0.67

Stroke (%) 4 (0.3) 3(0.7) 0.35

Intensive care stay (days) 13±6.8 13.1±7.9 0.35

Total hospital stay (days) 26±9.2 28±10.9 0.62

Vascular complications (%) 44 (4) 9 (3.5) 0.82

Cardiac Complications (%) 37 (3.3) 7 (2.5) 0.27

Renal failure (%) 53 (4.4) 20 (5.5) 0.51

Re-intervention prior to discharge (%) 6 (2.2) 8 (3) 0.76

Operative mortality rates (%) 102 (20) 35 (7.9) <0.00001

1-Year mortality rates (%) 22 (17) 12 (8.7) 0.05

5-Year mortality rates (%) 15 (24) 12 (17) 0.33

Re-intervention at one year (%) 0 (0) 8 (6.3) 0.04

Figure 2. Higher postoperative acute myocardial infarction rates in staged cohort

Figure 1. Higher postoperative stroke rates in simultaneous cohort

Amer Harky Aung Oo


Validation of Cardiac Surgical Score (CASUS) in post-operative cardiac patientsSarah Raut, Ananthakrishnan

Ananthasayanam, Ajith Vijayan, Mubarak

Chaudhry, Priyad Ariyaratnam, Mahmoud

Loubani 1 Hull and East Yorkshire Hospitals

NHS Trust; 2 Hull and East Yorkshire Hospital; 3

Hull and East Yorkshire hospital; 4 Hull And East

Yorkshire Hospital

Informed consent involves explaining the risk of a procedure to patients and their family. Quantification of a risk can be helpful for both the doctors,

patients and their family in deciding the best course of action.3 Cardiac surgery is no exception; with this in mind, various scoring systems have been developed to help clinicians describe risk to patients and family. European system for Cardiac Operative Risk Evaluation (EuroSCORE) is widely used pre-operatively to predict perioperative mortality in cardiac patients.5 Intensive care National Audit Research Centre (ICNARC), Acute Physiology and Chronic Health Evaluation (APACHE), Sequential Organ Failure Assessment (SOFA), Simplified Acute Physiology Score (SAPS) score are used in general intensive care setting to predict outcome. In 2005, Cardiac Surgery Score (CASUS) was developed for use in post-operative cardiac patients.1 The scoring system uses 10 variables that are routinely collected in intensive care. The variables are lactate, pressure adjusted heart rate, intraaortic balloon pump, ventricular assist device, patient intubation, creatinine renal support, neurological status, bilirubin and platelet.1 The scoring system was developed with an understanding of the acute, yet transient physiological impact of cardiac surgery and bypass.1 CASUS has previously been validated against APACHE II, SOFA and SAPS.2 The study found CASUS to be the most reliable mortality risk stratification for post cardiac surgery patients followed by SOFA, SAPS II and APACHE II.2

We did a study to validate CASUS against APACHE II and EuroSCORE on patients in our unit. 427 patients were included over a two-year period; 115 female patients and 312 male. We measured the scoring system’s ability to predict three outcomes; mortality, pulmonary complication and renal failure in the patients. Using our existing database, we identified factors that were associated with higher CASUS score.

ResultThe mean age of patients at the time of

surgery is 67.99±10.55. Mean cross clamp time was 64.54±32.145 with a mean cumulative bypass time of 100.89±48.822. (table 1)Average post operative stay was 10.24±11.827. (table 1) The mean logistic EuroSCORE was 7.88±10.49. (table 1)The mean additive CASUS score was 3.81±4.44 whilst the mean APACHE II was 3.49±6.67. (table 1) 17% of our patients had COPD, 3% had chronic renal failure. 5% were classified as having poor ejection fraction, 16% have peripheral vascular disease and 7% were classified a NYHA class 4. (table 1) The c-indices for EuroSCORE, CASUS and APACHE II were respectively 0.834, 0.904 and 0.721 for mortality, 0.775, 0.925 and 0.722 for renal failure. (Image 1, 3) The receiver operating characteristic (ROC) curve for pulmonary complication shows area under the curve of 0.726, 0.636, and 0.544 for CASUS, Logistic EuroSCORE and APACHE II respectively. (table 2) We consider and area under the curve of >0.7 to indicate a good scoring system and >0.8 to indicate a very good or strong scoring system. The significant predictors of a high CASUS Score from multivariate analysis were pre-operative AF (P=0.006), poor ejection fraction (P=0.000), longer bypass times (P=0.000) and urgent surgery (P=0.11). (table 2)

Conclusion:Our study shows that CASUS is the best predictor of mortality2,4, renal failure and pulmonary complication followed by EuroSCORE and APACHE II in post-operative cardiac patients. CASUS has shown to be a strong predictor for mortality and renal failure as well as a good predictor of pulmonary complication.

The accuracy of CASUS as a post-operative predictor may help in identifying patients that would need more aggressive intensive care therapy following cardiac surgery.3 This could have significant impact on a stretched out public healthcare system in terms of focusing resource allocation and better stratification of patients.3

References1. Cardiac-icu.org2. Doerr F, Badreldin A, Heldwein M, Bossert T, Richter M, Lehmann T, Bayer O, Hekmat K: A comparative study of our intensive care outcome prediction mod-el in cardiac surgery patients. Journal of cardiothoracic surgery 2011; 6:213. Pintor PP, Colangelo S, Bobbio M: Evolution of case-mix in heart surgery: from mortality risk to complication risk. European Journal of Cardiothoracic Surgery 2002, 22: 927-933

4. Badreldin A, Kroener A, Heldwein M, Doerr F, Vogt H, Ismail M. Bossert

T, Hekmat K.: Prognostic value of daily cardiac surgery score (CASUS) and

its derivatives in cardiac surgery patients. The thoracic and cardiovascular

surgeon 2010; 58:1-6

5. Nashef S, Roques F, Hammill B, Peterson E, Michel P, Grover F, Validation of

European System for Cardiac Operative Risk Evaluation (EuroSCORE) in North

American cardiac Surgery. European Journal of Cardiothoracic Surgery 2002;

22:101-105

Adult Cardiac – Miscellenous Rutherford Tuesday 12 March 15:50

A four-year retrospective study on nurse-led early extubation practice in post-cardiac surgery patientsJincy Abraham

Clinical Nurse

Manager

2, St James’s

Hospital, Dublin,

Ireland

The viability of early extubation within six hours after cardiac surgery has been demonstrated as a

benchmark of postoperative quality of care (Garg et al., 2014; Richey et al., 2018). Longer mechanical ventilation time increases complications such as ventilation-associated pneumonia and delirium (Burkhart e al., 2010; Brown, 2014; He et al., 2014). In November 2015 an audit was undertaken in Keith Shaw ICU (KSICU) of St. James’s

Hospital (Dublin) to look at current nurse-led extubation practices for cardiac surgery patients. Results revealed delays in commencement of weaning despite criteria being met and that certain criteria were contributing to unnecessary delays. The majority of our extubation times were between 6-10 hours. Opportunities for earlier extubation in these patients were identified and areas for improvement noted. These findings were discussed within the multi-disciplinary team (MDT) and a plan was implemented to improve extubation times.

A Quality Improvement Initiative was developed in consultation with the MDT with the following aims: (a) to commence weaning as soon as criteria for weaning were met, (b) to reduce ventilation time, (c) to monitor practices

and adherence to current SJH protocol. Four areas of focus were recognised; these include strengthening MDT engagement, reviewing of the weaning criteria, educating staff, and identifying/supporting change agents within the cardiothoracic ICU.

After consultation and review of international best practices, the nurse-led extubation policy and criteria were updated. The new criteria included: stable HR 60-110bpm, SBP >90 mmHg, minimal inotropic support 0.5 mcg/kg/min, no compromising arrhythmias, respiratory rate <35, pressure support <5 cmsH2O, oxygen saturation 95% on FiO2 <60%, chest drain loss <100 mls/hr, central temperature >36.0, and ABG consistent with pre-op baseline. A measurement was developed to

monitor progress. Inclusion and exclusion criteria (Ender etal., 2008) were used to identify cases to be included in the study. The inclusion criteria are: male patients, elective cases, coronary artery bypass grafts (CABG) and/or aortic valve replacement (AVR) only cases. The exclusion criteria are: patients older than 80 years of age, creatinine of greater than 150 umol/L, ejection fraction of less than 35%, and a re-do/re-operation.

After implementing the changes in 2016, the following improvements were noted: from a baseline of 3.9 hours mean time (baseline in 2015), the weaning time improved significantly to 2.6 hours (2016). Similarly, the total ventilation mean time which was initially 8.8 hours (2015) has decreased to just 5.2

hours (2016), indicating effective practice of early extubation. While it is noted that both the mean weaning time and ventilation time have increased in 2017 and 2018, which can be attributed to ever more complex patients being admitted to KSICU, there is, however, an increasing trend where more patients are extubated less than six hours post cardiac surgery – from just 27% in 2015 to a significant 63% in 2018. The change initiative which was commenced in 2016 has improved nurse-led extubation practices. However, to have a meaningful outcome, this change initiative should be a continuous process, requiring constant monitoring, and iterative learning with small changes being made along the way.

References:

Brown IV, C.H. (2014) ‘Delirium in the cardiac surgical intensive

care unit’. Current opinion in anaesthesiology, 27(2), p.117.

Burkhart, C.S., Dell-Kuster, S., Gamberini, M., Moeckli, A.,

Grapow, M., Filipovic, M., Seeberger, M.D., Monsch, A.U., Streb-

el, S.P. and Steiner, L.A. (2010) ‘Modifiable and nonmodifiable

risk factors for postoperative delirium after cardiac surgery with

cardiopulmonary bypass’. Journal of cardiothoracic and vascular

anesthesia, 24(4), pp. 555-559.

Ender, J., Borger, M.A., Scholz, M., Funkat, A.K., Anwar, N.,

Sommer, M., Mohr, F.W. and Fassl, J. (2008) ‘Cardiac Surgery

Fast-track Treatment in a Postanesthetic Care UnitSix-month

Results of the Leipzig Fast-track Concept’. The Journal of the

American Society of Anesthesiologists, 109(1), pp. 61-66.

Garg, R., Rao, S., John, C., Reddy, C., Hegde, R., Murthy, K. and

Prakash, P.V.S., (2014) ‘Extubation in the operating room after

cardiac surgery in children: a prospective observational study

with multidisciplinary coordinated approach’. Journal of cardio-

thoracic and vascular anesthesia, 28(3), pp. 479-487.

He, S., Chen, B., Li, W., Yan, J., Chen, L., Wang, X. and Xiao, Y.

(2014) ‘Ventilator-associated pneumonia after cardiac surgery:

a meta-analysis and systematic review’. The Journal of thoracic

and cardiovascular surgery, 148(6), pp. 3148-3155.

Richey, M., Mann, A., He, J., Daon, E., Wirtz, K., Dalton, A.

and Flynn, B.C. (2018) ‘Implementation of an early extubation

protocol in cardiac surgical patients decreased ventilator time

but not intensive care unit or hospital length of stay’. Journal

of cardiothoracic and vascular anesthesia, 32(2), pp. 739-744.

Cardiac – CT Forum (Nurse and AHP) Windsor Monday 11 March 09:40

Table 1: Summary of results

Mean Std. Deviation

Mean Age at Surgery 67.99 10.550

% Female Gender 27

% NYHA 4 7

% COPD 17

% Diabetes 26

% Chronic Renal Failure

3

% PVD 16

% AF 20

% Poor Ejection Fraction

5

Longest X-Clamp time (min)

64.54 32.145

Cumulative bypass time (mins)

100.89 48.822

% Urgent 33

% CABG 51

Post-operative stay (days)

10.24 11.827

Mean Logistic EuroSCORE

7.8844 10.49092

Mean additive Casus 3.81 4.440

Mean APACHE II 3.49 6.67

Table 2: Multivariate analysis for CASUS prediction model

Model correlation P

1 (Constant) -2.123 .035

Age at Surgery 1.379 .169

Gender bin -1.765 .079

CCS bin 1.857 .064

NYHA bin 1.509 .132

COPD bin .266 .790

DM bin -1.540 .124

CRF bin 5.976 .000

PVD bin -.364 .716

AF bin 2.791 .006

EF bin 4.425 .000

Longest X-Clamp time in minutes

-1.742 .083

Cumulative bypass time in minutes

7.677 .000

Urgent bin 2.548 .011

CABG .873 .383

Area Under the Curve (Mortality)

Test Result Variable(s) Area

Casus .904

Logistic EuroSCORE .834

Apache .721

Area Under the Curve (Pulmonary Complications)


Casus .726


Apache .544

Area Under the Curve (Renal Failure)


Casus .925


Apache .722

Image 1: ROC for mortality

Image 2: ROC for Pulmonary complications

Image 3: ROC for Renal Failure


An evidence-based review on the effects of laminar air flow ventilation on surgical site infection in clean surgeryMs Tracey Cox Cardiothoracic surgical care

practitioner University hospitals Coventry and

Warwickshire NHS Trust

This evidence-based review (EBR) was under taken as part of an MSc in wound healing and tissue repair. The need for identification

of surgical site infection (SSI) prevention strategies in cardiac surgery prompted the subject topic.

LAF was introduced into surgery with the design of the ‘Charnley Tent’ which was shown to reduce SSI following total joint arthroplasties. A subsequent, large randomised controlled trial in 1982 by Lidwell et al demonstrated a significant reduction in SSI with LAF use, and this popularised the use of LAF in orthopaedic theatres. However, this study has been criticised for the non-systematic use of perioperative antibiotic prophylactics, and although no further RCT’s have been performed, more recent studies have shown mixed results.

The literature review was undertaken using six relevant databases including Cochrane, Medline and CHINAL, looking at studies performed within the last ten years. Google scholar and the websites of surgical specialty groups and societies were also interrogated.

The aim of this EBR was to identify if laminar air flow (LAF) demonstrated any benefit in reducing SSI in clean surgery and specifically cardiac surgery. Due to the lack of existing evidence related to cardiac procedures, alternative surgical procedures had to be considered. Following exclusions using a pre-established criterion, eleven articles were reviewed, consisting of three systematic reviews

(SR) and nine cohort studies. The majority of the studies examined orthopaedic surgery where LAF ventilation is common place, only one SR and three cohort studies examined its effect in other surgeries.

Indications of researcher bias, selection bias and performance bias have been identified in a number of the studies reducing their validity. In addition, the evidence cannot be generalised because of a number of study limitations including a large amount of missing data and lack of attention to confounding factors such as, the administration of perioperative antibiotic prophylaxis.

The evidence presented suggests there is no benefit of using LAF in orthopaedic surgery; however, there could be some benefit in other types of surgery. As no studies included patients who had undergone cardiac surgery it is difficult to draw any conclusions in this field. However, benefits of LAF were shown in vascular surgery where implantation of prosthetic grafts were utilised. This beneficial effect

could be translated into cardiac surgery where prosthetic grafts and valves are implanted.

It is therefore evident that further studies into the effects of LAF in different types of surgery are needed to enable any firm conclusions to be drawn. However, such studies would be almost impossible as they would need to account for all patient, surgical and environmental confounding factors which affect SSI.

This EBR was therefore unable to provide clear recommendations for clinical practice as the existing evidence related to the benefits or harm of LAF in clean surgery was equivocal.

Airflow patterns

Caption

CT Forum (Nursing and AHP) – Quality and Safety Windsor Monday 11 March 16:40

Results of surgery of cardiac and pericadial hydatid disease in childrenSobhi Mleyhi, Jaleleddine Ziadi, Faker Ghédira, Raouf

Denguir. Cardiovascular surgery department, La Rabta

Hospital, Tunis, Tunisia.

The aim of this study is to analyze the results in the short and long-term cardiac and pericardial hydatidose surgery in children, in terms of morbidity, mortality and recurrence of hydatid.

Material-MethodsWe report a retrospective study including 12 children (four boys and eight girls) among 43 patients operated for cardiac and pericardial hydatid disease between 1988 and 2017. The average age was 11 years. Circumstances of discovery were essentially when explorations for another hydatid localization (lung, liver).

ResultsAll children underwent general anesthesia with invasive hemodynamic monitoring and intervention

under full cardiopulmonary bypass. The pre-operative assessment of the lesions found hydatid cyst in the

left ventricle in five cases, in the right ventricle in three cases, in the interventricular septum in two

cases (fig 1) and in the right atrium in one case.The surgical treatment was a puncture with

evacuation of contents of the cyst then sterilization by the injection of hypertonic saline serum (Figure 2).

Only one patient was dead by right ventricular failure during operation. In more than 50% of cases, inotrope drugs were necessary during the off by-pass. The immediate complications were essentially pleuropulmonary (25%). In the long term, there has been no recurrence of cardio-pericardial hydatid but three cases of bilateral pulmonary hydatidosis has occured and treated.

ConclusionThe cardio-pericardial hydatid localization in children is rare, its clinical manifestations are polymorphic. The anesthesia has no particular problems and the results of surgery are satisfactory. Moderate heart failure with respiratory complications represents the most postoperative risks.

Figure 2Figure 1

Video Presentation – SCTS: ‘Take on the experts live webinar stream Moore Tuesday 12 March 14:10

Long-term outcomes are poor in intravenous drug users following infective endocarditis even after surgerySam Straw

Leeds Teaching Hospitals NHS Trust, UK

Managing patients with infective endocarditis (IE) is challenging for cardiologists and cardiac surgeons and in

published series the surgical intervention rate averages around 50%. Previous studies of intravenous drug users (IVDU) with IE have been of variable quality. Many have contained a small sample size, have not included a control group, have not stated the surgical intervention rate and the follow-up period has been variable. None have reported detailed survival data, particularly the cause of death after treatment. We performed a novel analysis by comparing survival in our cohort depending on whether they were managed medically or required surgery to establish whether operating conferred long-term survival advantage. We also examined the survival of these patients with a comparison group of IVDUs who were admitted to hospital during the period with other infections and referred

to the IE team for opinion.We examined 105 episodes of IE

in 92 IVDU patients over an 11-year period. The commonest pathogens were Staphylococcus (60%) and Streptococcus spp. (30%). Left-sided structures (44 mitral, 38 aortic) were affected more commonly that right (38 tricuspid, 2 pulmonary). The surgical intervention rate was 47%. Heart failure was the primary indication for surgery in 33 episodes and the secondary indication in four (total 76%). Aortic root abscess was the indication in one (1%), embolization was the primary indication in 14 and secondary indication in 15 episodes (total 28%) and fungal infection occurred in one (1%). Bioprosthetic valve replacements (18 aortic and 10 mitral) for left-sided IE were used more commonly than mechanical devices (six aortic and eight mitral). Surgery for right-sided IE was uncommon, with eight bioprosthetic tricuspid valve replacements and one abandoned attempt at pulmonary valve replacement. Valve repair was undertaken in five cases. Recurrent endocarditis occurred in 15 patients. One

patient underwent repeat surgery and six patients were successfully managed with medical therapy. The remainder were too unwell to have further operation owing to either severe heart failure (three), sepsis (four) or stroke (one).

Survival at 30 days was 92% and 30-day surgical survival was 96%. Survival at 1, 3, 5 and 10 years was 74%, 63%, 58% and 44% and significantly reduced compared to the comparison IVDU group (p=0.0002). Mortality was higher in patients who required surgery compared to those who did not (HR 1.8, 0.95-1.3). There was no difference in mortality between those who received a bioprosthetic valve versus a mechanical valve (p=0.12). We examined the death certificates in 90% and found that the commonest cause of death was infection (66%) and this most frequently a further episode of IE (55%).

While early survival from IE was good, life-expectancy in subsequent years was poor. Although all patients operated on had Class 1 indications for surgery, it did not confer long-term survival advantage, owing

to continued infection risk. A particular problem is encountered when continued drug use results in a further episode of IE. If our findings are replicated it might lead to a reassessment of the indications and

timing of surgery for these patients. More needs to be done to reduce infection risk in IVDU after hospitalisation with IE and that perhaps is the key to improving their long-term survival.

Adult card – Valve General Abbey Tuesday 12 March 15:40


The Papworth haemostasis checklist results in significant reduction in re-exploration rate and blood transfusionJason Ali Papworth Hospital, Cambridge, UK

Bleeding is arguably one of the more preventable complications of cardiac surgery. Despite this, up to 8% of patients are reported to return to theatre for mediastinal bleeding. In the majority of cases, a surgical source of bleeding is identified.

We have demonstrated at our centre that patients re-explored for bleeding have prolonged ICU (2.9 vs. 1.1 days p<0.001) and hospital (10.2 vs. 9.3 days p=0.03) stays suffering increased morbidity including neurological, respiratory and renal complications. Survival was inferior at 30-days (88.8% vs. 95.3% p<0.001) and 1-year (78.3% vs. 93.3% p<0.001).

In an attempt to reduce the morbidity associated with re-exploration, we designed the Papworth haemostasis checklist with multidisciplinary collaboration. It contains two components: 1) a comprehensive series of surgical sites to be checked and 2) factors affecting coagulation status

such as ACT, calcium and hypothermia. The checklist is performed at a ‘time-out’ prior to sternal wire insertion.

2,824 patients have undergone surgery in the 18 months since implementation of the checklist. There has been a significant, and sustained, reduction in the re-exploration rate (2.27% vs. 3.47%, p=0.01) and proportion of patients bleeding >1 Litre in 12-hours (3.49 vs. 6.10%, p<0.001) compared with the year prior to implementation. This has been associated with a significant reduction in consumption of blood products. The cost saving attributed to the reduced blood product consumption per patient is £54.73, amounting to a total saving of £102,165 in the first year. We have also observed a reduced ICU and hospital length of stay since checklist implementation.

Although it can be argued that the Hawthorne effect is at play, and checklist fatigue is an issue, the results speak for themselves. The Papworth haemostasis checklist represents a simple intervention which is quick and easy to use but has had a substantial sustained impact on clinical outcomes. We would advocate implementation of a similar checklist in all cardiothoracic centres.

Comparison of outcomes following valve-in-valve TAVI versus surgical redo aortic valve replacement

Jason Ali Papworth Hospital, Cambridge, UK

The optimal management for patients developing non-endocarditic structural degeneration of bioprosthetic

aortic valves has become less clear with the development and evolution of transcatheter aortic valve implantation (TAVI). Patients requiring redo-SAVR tend to be elderly and suffer from multiple comorbidities. With the growing body of literature demonstrating the equivalence and even superiority of TAVI compared to SAVR in high and intermediate risk patients, valve-in-valve TAVI (ViV-TAVI) has become an increasingly attractive treatment option for the management of bioprosthetic valve structural degeneration.

Over the 10-year period of our study 92 patients underwent reintervention for bioprosthetic valve structural degeneration. Of these 53.2% underwent redo-SAVR and 46.8% underwent ViV-TAVI, with an increasing proportion undergoing ViV-TAVI over time. The median logistic EuroSCORE was higher for the redo-SAVR group but this did not reach statistical significance (24.7 vs 20.6 p=0.11). The majority of ViV-TAVI procedures were performed by the transfemoral route (86%).

Patients undergoing redo-SAVR had a higher incidence of permanent pacemaker implantation. Otherwise the incidence of complications was similar. The significant difference was in recovery times. Only one patient undergoing ViV-TAVI required ICU admission. The length of hospital stay was significantly prolonged for patients undergoing redo-SAVR – with a median stay almost 12 days longer. In-hospital mortality was not significantly elevated in the redo-SAVR group (6.1% vs 2.3% p=0.34). Overall 1-year and 3-year survival were similar between the groups

(89.7% and 84.3% respectively for redo-SAVR vs 86.5% and 82.2% for ViV-TAVI). Surprisingly, a cost analysis demonstrated that ViV-TAVI works out to be a lower cost compared with redo-SAVR (£19,204 vs £22,263), despite the significant cost of the prosthesis.

Our findings demonstrate that valve-in-valve TAVI can be accomplished with low morbidity, lower peri-procedural mortality and faster recovery when compared to redo-surgical aortic valve replacement and is potentially cost saving. ViV-TAVI may become the future standard of care.

ICU and Blood Management – ICU / Anaesthesia Wesley Tuesday 12 March 10:10

Adult Cardiac – Mini AVR and TAVI Abbey Tuesday 12 March 11:30

Heart Failure and Transfer – Transplant Rutherford Tuesday 12 March 09:20

Pre (n=1944) Post (n=2824) P-value

Return to theatre 3.5% 2.1% <0.01

Bleeding >1 litre in 12 hours (%)

6.1% 3.5% <0.01

12-hour blood loss (ml) 415.26 342.47 <0.001

ICU length of stay (days) 2.89 2.60 0.04

Hospital length of stay (days)

10.12 9.16 <0.001

Mean cost of blood products per patient

£364.24 £309.51 <0.001

Redo SAVR (n = 49) ViV-TAVI (n = 43) P value

ICU length of stay (days; median (IQR)) 0.95 (0.85-1.33) 0 (0-0) <0.001

Blood transfusion (units; median (IQR)) 1 (0-3) 0 (0-0) <0.001

Complications (%)Return to theatre for bleedingPost-operative cardioversion

AKIPermanent Pacemaker within 3-months

CVAHospital length of stay (days; median

(IQR))

1 (2.0)1 (2.0)15 (30.6%)6 (12.2%)1 (2.0%)13.4 (9.1-23.9)

0 (0.0)0 (0.0)7 (16.3%)0 (0.0%)1 (2.3%)2 (1-3.5)

>0.99>0.99

0.130.03

>0.99<0.001

In-hospital mortality (%) 3 (6.1%) 1 (2.3%) 0.34

One-year survival (%) 89.7% 86.5% 0.79

Transfer of patients with refractory cardiogenic shock using veno-arterial extracorporeal membrane oxygenator support

Jason Ali Papworth Hospital, Cambridge, UK

Currently VA-ECMO availability is limited to a few specialist tertiary centres and not available to patients with

refractory cardiogenic shock in non-ECMO centres too unstable to transfer. There is a now a well-established service in UK for the retrieval and transfer of patients with severe respiratory failure who may require veno-venous-ECMO (VV-ECMO) support, with excellent outcomes reported. Since 2010 we have used our expertise to attend a limited number of patients referred with refractory cardiogenic shock, institute VA-ECMO in the referring hospital and subsequently transfer them. In addition, some patients have been transferred already on VA-ECMO support.

Over the nine-year period, 24 patients were transferred to our centre on VA-ECMO support. Of these, 10 were transferred having been initiated on VA-ECMO by the referring centre and 14 were instituted on VA-ECMO and transferred by our ECMO retrieval team. The mean age was 34.1 years with a range from 15 – 65 years. The distance travelled ranged

from 16 – 341 miles. Ten patients were transferred with central cannulation. The mean duration of support on VA-ECMO was six days, ranging from 1 – 24 days.

VA-ECMO support was successfully weaned, or the patient underwent a definitive surgical procedure in 15 (62.5%) patients. Five patients underwent cardiac transplantation and three pulmonary endarterectomy. Fourteen patients (58.3%) were discharged home. Overall 30-day survival for this patient cohort was 69.6%, with a one-year survival of 56.2%. For patients who were weaned from VA-ECMO or underwent definitive surgical management, the 30-day survival was 100% and one-year survival 86.2%.

Our experience demonstrates the feasibility and survival benefit of a salvage VA-ECMO retrieval service for a small number of selected patients with refractory cardiogenic shock who have no other treatment options. Patients can be safely transferred long distances, even with an open chest. We suggest that a system based on the model of nationally commissioned severe respiratory failure services could be commissioned to support the transfer of these patients.

Quadrangular fixation of pectus bars to prevent displacement in Nuss procedureJin Yong Jeong1, Gyeol Yoo2 1 Department

of Thoracic and Cardiovascular Surgery; 2

Department of Plastic and Reconstructive

Surgery, Incheon St. Mary’s Hospital, College of

Medicine, The Catholic University of Korea, Seoul,

Republic of Korea

Pectus excavatum is one of the most common congenital deformities of the chest wall and accounts for over 90% of

cases. Since 1998, the Nuss procedure has been used to correct pectus excavatum deformity as a minimally invasive surgery. Bar displacement is a major cause of initial failure of pectus excavatum repair after the Nuss procedure with 1.8% – 16.6% of displacement rate. Double pectus bars are sometimes inserted to correct pectus excavatum with long depression of anterior chest wall. We have used quadrangular fixation of the double pectus bars to prevent bar displacement and report comparative analysis between the result of the quadrangular fixation

procedure and of the classic double bar fixation procedure.

Eighty-six patients underwent double bar insertion in Nuss procedure from September 2011 to January 2016. Before July 2014, both lateral fixations were

made separately on each bar with fixators (Claw fixator, Primemed, Seoul, Korea) in 44patients (separate fixation; group A). After July 2014, upper and lower bars were bilaterally fixed by connecting each bar with the one-third tubular plates (One third plate, OT Medical Co., Seoul, Korea) to form quadrangular shape in 42 patients (quadrangular fixation; group B). The one-third tubular plate is cheap and easily available. Bar displacement index (BDI) was defined as the distance change of the bar position / initial distance of the bar position. In other words, BDI = [D0 – D3] / D0 x 100, where D0 was the distance of the bar position after surgery, D3 was the distance of the bar position at the following postoperative three months. We collected patient demographics, Haller index (HI), BDI, and re-operative rate and compared between groups.

The mean patient age was 17.2 years (range, 3~40 years) in group A, 17.8 years (rage, 4~30 years) in group B. There was no significant difference between the

preoperative and postoperative Haller indices of two groups (p>0.05). In group A, three patients underwent corrective surgery to correct the bar displacement (6.8% of reoperation rate) whereas there was no corrective surgery in group B. BDIs of the two groups were significantly different (group A, 13.11±15.66; group B, 5.38±2.86; p<0.01).

With these results, quadrangular fixation, which was performed with the upper and lower pectus bars bilaterally fixed by connecting each bars with the plates, showed that the bar displacement was prevented more effectively than the separate fixation method and that the re-operation rate could be minimized.

Thoracic – Chest wall surgery St James Monday 11 March 09:00

Jin Yong Jeong


One of the most crucial issue in Minimally Invasive Cardiac Surgery (MICS) is the venous drainage. An optimal drainage is required for full control of the MICS procedure, an empty heart allows surgeon

to work in better conditions improving the quality. A good flow provides reliable blood oxigenation and avoiding low flow situations is essential for best result.

The most critical point in Extra-Corporeal Circulation (ECC) is the venous Canula. Usually to improve drainage, vacuum or kinetic assistance is applied, but if depressurization is too high the atrium wall or the vessel wall can collapse around the canula occluding the canula holes (Figure1). This phenomenon results in reduced drainage.

Another negative effect with a standard canula is due to the canula concept. Paradoxically, since the drainage site is the tip of the canula placed in the atrium, blood coming from lower part of the body, the kidneys, and the visceral organs, must pass along the Inferior Vena Cava (IVC) between the venous wall and the canula before reaching the cannula orifices at the tip of the venous canula. A larger canula, which could be thought as problem solver can actually reduce flow as it partially occludes the IVC.

The solution is a truly innovative solution in cannula

technology provided by Smartcanula LLC, Lausanne, Switzerland. The Smart Canula is a device which can be considered a “hybrid” partially a cannula partially a stent. A mandrel is inserted inside the device, the stent section is elongated and its diameter is reduced. The Smart Canula is then positioned (over a guide wire) and the mandrel is removed. The Smartcanula gently expands to its full diameter inside the vena cava and shortens slightly.

Better drainage results from two factors, lumen optimization and flow path reduction. Blood drains directly into the Smart Canula along its full length. There is no more need to go up to

the atrium and go down inside the canula. The space between the canula and the vein is no longer a channel but the vena cava itself becomes the canula. Results is wider lumen, shorter path which means lower pressure drop.

In conclusion.nFluid dynamic benefits are translated in clinical benefit.nLess vacuum = less Gaseous Micro Emboli (GME).nBetter drainage = better flow.nMore laminar flow = less recirculation.nLower flow velocity = less hemolysis.nLess stasis around the canula = reduced chance of clotting.

When Engineering helps Surgery: Smart Canula for MICS

Figure 3: Venous blood is drained at all levels directly into the Smart Canula which is virtually wall-less and acts as a temporary caval stent

Figure 2: Venous blood to be drained at the cannula tip must travel between the vessel wall and the cannula body prior to being drained.

Figure1: Venous cannula orifice occlusion due to augmentation of venous drainage with a centrifugal pump

Thoracic – Peri-operative Strategies in Thoracic Surgery St James Tuesday 12 March 16:10

Hybrid theatre CT supports video assisted thorascopic surgery (iVATS) with pulmonary nodule isolation: Early experience of a novel techniqueBen Shanahan and Karen Redmond Mater

Misericordiae University Hospital, Dublin, Ireland

Lung cancer remains the leading cause of cancer death in both sexes in Ireland, accounting for 19% of cancer deaths in women

and 23% in men. There have been encouraging results from large scale UK (UKLS), European (NELSON) and US (NLST) studies proving a benefit to screening for at-risk populations. We anticipate that the burden of pulmonary nodule diagnoses will continue to increase, both due to the advent of screening programmes, and the

increase in incidental pulmonary nodule diagnoses in patients undergoing CT scans for other reasons.

The thoracic surgeon is increasingly being called upon to biopsy those lesions which are either too small, or too inaccessible for the interventional radiologist. Traditional surgical biopsy relies on visualisation, and in many cases palpation of the lesion prior to resection. With the trend toward ever more minimally invasive thoracic surgery, we anticipate a trend away from palpation via a large port site or mini-thoracotomy in order to facilitate biopsy.

To that end we believe that image guided VATS (iVATS) in the hybrid theatre is the procedure of choice for lesions that would otherwise be prone to sampling error, either due to their small size or their deep location.

Our technique utilises a fashioned intra-operatively placed radio-opaque surface lung marker (sLM) to guide localisation and resection. A baseline CT is performed and the sLM is then placed via two 5 mm ports. The target lesion location is then confirmed using intra-operative C arm CT, facilitating minimally invasive resection of the lesion. As the procedure is all performed in one

room, and the patient remains in the same position from the insertion of the sLM to the resection, the chances of sLM displacement are minimal.

Our series consists of six cases. In all cases there was no lesion located on initial thoracoscopic resection. In all patients a tissue diagnosis was obtained which guided further management, obviating the need for continued surveillance or open surgery. There were no postoperative complications. We believe our technique offers a truly minimally invasive option for the diagnosis of the small or inaccessible pulmonary nodule.

Should patients be denied thoracoabdominal/ descending thoracic aortic surgery on the basis of pulmonary function test alone?Rashmi Birla, Matthew Shaw,

Fiona Wells, Omar Nawaytou,

Vipin Mehta, Deborah Harrington,

Manoj Kuduvalli, Mark

Field Liverpool Heart and Chest

Hospital, Liverpool, UK

Risk stratification of patients undergoing thoraco abdominal aortic surgery is

paramount. Factors impacting the long-term survival include age older than 65 years, acute renal failure, dialysis, cerebrovascular accident, chronic obstructive pulmonary disease, peripheral vascular disease, and descending or thoracoabdominal

aorta (TAAA) surgery1. The burden of postoperative respiratory complications remains high and is known to significantly influence the risk of postoperative mortality2. This series also found that the presence of COPD and FEV1 less than 1.45 L significantly increased the risk of respiratory failure and consequently death. Other series however found that pre-existing renal insufficiency and extensive aneurysm are important predictors of respiratory complications3. We thus sought to determine whether or not pulmonary function tests should determine operability.

In order to assess the effect of preoperative pulmonary function testing (PFT) on respiratory outcomes following TAAA surgery, we collected the data on all 231 elective patients undergoing elective TAAA surgery between 1998 and 2017 in

our institution. These patients were further divided into two groups: group 1: FEV1 below 70% predicted (n=71) and group 2: FEV1 equal to or over 70% predicted (n=136). 24 patients did not have full records of the preoperative PFTs. Between group 1 and 2, there was no significant difference in the postoperative need for ventilation over 48 hours (p=0.17), tracheostomy (p=0.78), chest infection (p=0.61), composite of all these three measures (p=0.57) and mortality (p=0.98). More patients in group 1 needed full cardiopulmonary bypass but this difference was not statistically significant.

Preoperative% predicted FEV1 was not a strong predictor of postoperative adverse outcomes in patients undergoing TAAA surgery in the cohort of the patients operated. Whilst single lung ventilation

may not be sufficiently maintained in certain select group of patients with suboptimal PFTs, perhaps the use of full cardiopulmonary bypass may be considered to allow operability. Thorough preoperative evaluation of cardiopulmonary status, functional status, frailty, anaesthetic preassessment and multidisciplinary team discussion is important for identification of these patients.

References:

1. Long-term outcomes after thoracic aortic surgery: a population-based study. Higgins J1, Lee

MK2, Co C3, Janusz MT4. J Thorac Cardiovasc Surg. 2014 Jul;148(1):47-52.2. A prospective study of respiratory failure after high-risk surgery on the thoracoabdominal aorta. Lars G. Svensson, MD, PhD, Kenneth R. Hess, MS, Joseph S. Coselli, MD, Hazim J. Safi, MD, E.Stanley Crawford, MD. Presented at the Fifteenth Annual Meeting of the Southern Association for Vascular Surgery, Palm Springs, Calif. Jan. 23-26, 1991.3. Pulmonary complications after descending thoracic and thoracoabdominal aortic aneurysm repair: predictors, prevention, and treatment. Etz CD1, Di Luozzo G, Bello R, Luehr M, Khan MZ, Bodian CA, Griepp RB, Plestis KA. Ann Thorac Surg. 2007 Feb;8

Adult Cardiac – Thoraco-Abdominal Aortic Surgery Abbey Tuesday 12 March 13:40


Premature structural degeneration of the Trifecta aortic bioprosthesis in mid-term follow-up: A large single-centre experience

Dr Hassan Kattach and Mr Sunil Ohri

Southampton General Hospital, Southampton, UK

We conducted this retrospective analysis after observing a cluster of aortic bioprosthetic valve failures, most of which

were Trifecta bioprostheses, in Southampton General Hospital. The aim of the study was to assess if the cluster represents a significant failure of this valve model.

We analysed all bioprosthetic aortic valve replacement operations (isolated or with concomitant procedures) performed in our institution between 2011–2016 inclusive. Patient-related and valve-related risk factors

for early valve failure were analysed. In addition, a comparison of the performance of Trifecta with Perimount Magna Ease (PME) bioprostheses was performed.

During the study period, a total of 3313 aortic valve were implanted. Of these, 2807 were bioprosthetic valves (mean age 74.6±3.5 years, 62% men, mean follow-up 4.98±4.2 years) out of which 837 were Trifecta valves.

Seventeen (2.0%) of patients with Trifecta bioprosthesis suffered premature failure requiring re-intervention. Mean time to re-intervention was 4.1±1.8 years. Mean failed prosthesis size was 21.9±1.7 mm. At the time of failure, 11/17 (65%) of the failed

valves had moderate or severe prosthetic regurgitation and the average peak gradient was 65 ± 28 mmHg. One of the failed valves had severe patient-prosthesis mismatch on the pre-discharge echocardiogram. The valves were implanted by 10 different surgeons, and there was no predominance of one particular surgeon.

ConclusionThe Trifecta valve had a low – but higher than other models – incidence of structural valve failure (2.0%) over a follow-up period of five years. Multicentre studies/ registries are required to determine if these data are observed in other institutions.

Evaluation of surgery in the treatment of recurrent thymomaAndrea Bille1, Camilla Cavalli2, Leanne Harling3,4

1 Thoracic Surgery Department, Guy’s Hospital, London UK; 2 University of Milan,

Milan, Italy; 3 Thoracic Surgery Department, Barts Hospital, London, UK; 4 Department

of Surgery and Cancer, Imperial College London, London, UK

Recurrent thymoma is defined as the relapse of disease after prior complete pathological

resection1. Although this is uncommon, rates of up to 10-15% have been reported2. This article summarizes our 10-year experience of complete resection for thymoma, demonstrating disease recurrence in 5% with a median follow-up of seven years (range 1-25).

In accordance with previous reports, higher grade type B and C thymomas were significant risk factors for recurrence. Up to 80% of recurrent tumours occurred in the thoracic cavity with no evidence of distant metastases, suggesting that these tumours may be amenable to more aggressive local control. Re-do surgery is usually associated with increased operative risk often associated with the decreased physiological reserve with each subsequent procedure, however in our experience we believe it should be considered where possible. In our series we demonstrate a significant improvement in survival in those patients undergoing surgical resection with 5- and 10-year survival rates of 82% and 68% versus 43% and 25% in patients treated non-surgically.

Notably however, surgery should not be undertaken lightly and may require a combined surgical approach with radical resection to achieve complete tumour clearance. As such, we believe it is pertinent to consider such an approach only in those patients with good performance status, good cardiac function and younger age, who have the physiological reserve to cope with

these procedures. Despite these strict inclusion criteria we still observe a reasonably high morbidity rate of 30%, with a mortality rate of 13%.

Unfortunately, due to the complex nature of recurrence, complete resection was only obtainable in 50-60% of patients, and adjuvant radiotherapy may be necessary (reported in 10% of our patient cohort). However, we still believe that where possible de-bulking surgery has a role in these patients where it can be performed with an acceptable morbidity and mortality. Where complete resection was achieved, we demonstrated a 10-year survival rate of 80% at five years.

In conclusion, there has been a debate regarding the best treatment for recurrent thymoma. Given the small numbers of patients affected, prospective data collection through National and international registries is imperative. At present, we believe that surgery for recurrent thymoma is safe and feasible and may increase survival in selected surgical candidates as demonstrated within our own dataset. Most importantly, cases of recurrent thymoma should be discussed in a multidisciplinary setting in the presence of experienced surgeons and oncologists with particular care taken to assess operative risk and resectability before embarking on any intervention.

References

1. Detterbeck F. International thymic malignancies interest group:

a way forward. J Thorac Oncol. 2010;5(10 Suppl 4):S365–70.

2. Mizuno T, Okumura M, Asamura H, Japanese Association for Re-

search on Thymus, et al. Surgical management of recurrent thymic

epithelial tumors a retrospective analysis based on the Japanese

nationwide database. J Thorac Oncol. 2015;10(1):199–205. 3.

Awad WI, Symmans PJ, Duss

Adult Cardiac – BHVS Session: Aortic Valve Westminster Tuesday 12 March 09:40

Adult Cardiac – Mini Mitral and TMVR Westminster Monday 11 March 15:50

Thoracic – Thoracic Oncology St James Monday 11 March 15:30

Figure 1: Summary of the implanted aortic bioprostheses with the total incidence of valve re-intervention, re-operation for endocarditis and re-intervention for structural failure.

Valve type Total implants Total re-operations Re- operation for endocarditis

Re-operation for structural failure

Perimount 1030 8 8 (0.8%) 0

Perimount Magna Ease 449 6 6 (1.3%) 0

Trifecta 837 28 11 (1.3%) 17 (2.0%)

Soprano 46 2 1 (2.2%) 1 (2.2%)

Mitroflow/Crown 351 5 4 (1.1%) 1 (0.3%)

Others 94 3 2 (2.1%) 1 (1.1%)

Total 2807 52 32 (1.1%) 20 (0.7%)

Figure 2: Comparison between Perimount Magan Ease and Trifecta groups

Perimount Magna Ease Trifecta p value

Number 449 837

Mean prosthetic size 22.4 ± 2.0 22.4 ± 1.9 NS

Mean age 72 ± 10 75 ± 8 <0.001

Hypertension 279 (62%) 586 (70%) =0.005

Mean creatinine 96 ± 63 96 ± 47 NS

Diabetes mellitus 112 (25%) 176 (21%) NS

Re-intervention for structural failure 0 17 (2%) =0.001

Re-intervention for endocarditis 6 (1.3%) 11 (1.3%) NS

Mortality during the follow-up period 74 (16.5%) 151 (18.4%) NS

Severe patient prosthesis mismatch 0 1 NS

Technical challenges when surgically treating mitral annular calcification with trans-catheter valvesReuben Jeganathan Department of Cardiac Surgery,

Royal Victoria Hospital, Belfast

Mitral annular calcification (MAC) is increasingly encountered in the ageing population with coexisting mitral valve disease. Conventional

mitral valve replacement has been the standard practise but poses the potential risk of atrio-ventricular disruption and para-valvular leaks. A novel approach in the last few years has been to implant a trans-catheter valve in the mitral valve position in the presence of severe MAC. Data from the Trans-catheter Mitral Valve Implantation (TMVI) in MAC Global registry and more recently, the MITRAL Study (Mitral Implantation of Trans-catheter Valves) have reiterated that the “techniques still require further refinement”.

The aim of our study was to identify technical challenges when performing a TMVI in MAC during open-heart surgery. Over the last 2 years five patients underwent a TMVI in MAC with or without concomitant procedures. All patients had an Edwards Sapien 3 (Edwards Lifesciences) balloon expandable valve implanted on cardiopulmonary bypass. Following evaluation of these cases, we identified three technical considerations that must be addressed when performing a TMVI in MAC procedure. The first was para-valvular leaks and migration of the prosthesis. This can occur in all cases and can be prevented by 1) careful correlation of the cardiac gated CT/TOE sizing with the intra-operative balloon sizing and 2) stitching the atrial wall tissue onto the skirt of trans-catheter valve prosthesis (Figure 1).

The second technical consideration was the possibility of an annular-prosthesis mismatch. This should be identified pre-operatively from the

imaging modalities. This can be potentially resolved by implanting a complete annuloplasty ring (Size 30/32) above the annulus, thereby creating a neo-annulus for a valve in ring implantation (Figure 2). With a size 30 ring there is a possibility of a higher trans-valvular gradient across the prosthesis and if using a size 32 ring, ensure the balloon is over-inflated with an additional 2cc. The final technical consideration is left ventricular outflow tract obstruction. This can occur in every case, especially with a trans-septal and trans-apical approach. However, in the trans-atrial approach the anterior mitral valve leaflet should always be excised to prevent this

complication from occurring. If the LVOT diameter is small as seen from the pre-operative imaging, it will be important to angle the prosthesis towards the diaphragm and more atrialised during the implantation.

In summary, TMVI via a trans-atrial approach in MAC is able to deal with the technical challenges as mentioned with better procedural outcomes as compared to the trans-septal or trans-apical approach and possibly even conventional mitral valve replacement. However further studies and participating in global registries will better inform us of the role of TMVI in MAC.

Figure 2: Size 30 C-E Physio II ring implanted to facilitate deploying a size 29 Edwards Sapien 3 trans-catheter valve for a dilated calcified

annulus with concomitant tricuspid valve repair.

Figure 1: An Edwards Sapien 3 trans-catheter valve sewn in place utilising surrounding atrial wall tissue.


CT Forum (Nurse and AHP) – Research Windsor Monday 11 March 14:50

CT Forum (Nurse and AHP) – Thoracic Windsor Tuesday 12 March 16:20

Emergency care research: alternative informed consent models for STEMI patientsJoana Oliveira Clinical Research

Nurse (Cardiology), Royal Papworth

Hospital NHS Foundation Trust,

Cambridge, UK

Ethical dilemmas and discussions around informed consent are historical in human

research, especially in settings like emergency care. Considering the patients’ competing care needs in a stressful environment along with a limited therapeutic period, the requirement to receive written valid informed consent for a randomised control trial (RCT) at the time of enrolment is very challenging in these settings1. However, acutely ill patients are the ones with the greatest need to access innovative treatments2 and this can only be achieved through clinical research.

A lengthy informed consent process can expose patients presenting with an ST elevation myocardial infarction (STEMI) to a higher risk of harm. In this population, each additional hour it takes to initiate treatment from the onset of symptoms means

losing 1.6 lives per 1,000 patients treated3. For this reason, some authors argue that the requirement of receiving written valid informed consent at the time of enrolment could be a barrier as it could delay the start of treatment4. Yet, if the requirement to receive valid informed consent is removed from emergency care research, these populations can become even more vulnerable5. Therefore, special regulations for emergency care research have been encouraged and developed in the European Union and the United Kingdom. These are the cornerstones to help achieve a balance between respecting the patients’ will and the need to progress the medical care available to all of us.

Currently, some RCTs conducted during emergency situations may use alternative informed consent models if approved by an Independent Ethics Committee (IEC). Therefore, the RCTs may use verbal informed consent at the time of enrolment followed by written retrospective and prospective valid informed consent at a later time; or they may use deferred consent (e.g. no verbal or written consent at the time of enrolment) followed by written valid informed consent at a later time6,7. Independent of the type of alternative consent

model used, written valid informed consent must be sought from the patient or legal representative as soon as possible6,7.

Nonetheless, as simplistic and straight forward these special regulations may seem, the work and discussions conducted between the clinical research team and the IEC prior to a RCT protocol approval are lengthy and burdensome8. The research team must prove without a doubt that the life-threatening medical condition is so urgent that there is no possibility, within the therapeutic window, of providing written information to the patient or legal representative and seeking written valid informed consent prior to enrolment. In addition, the new intervention must be directly related to the participants’ medical condition, have potential to produce direct benefit for the participant whilst imposing minimal risk and burden when compared to the standard treatment6.

Although the alternative informed consent models currently available are extremely valuable to respect the patients’ will while supporting advances in emergency care, further research to explore the optimum consent model for emergency care research from both the patients’ and researchers’ perspective is required.

References

1. Schmidt TA, Salo D, Hughes JA, Abbott JT, Geiderman JM, Johnson CX, et al. Confronting the Ethical Challenges to Informed Consent in Emergency Medicine Research. Acad Emerg Med [Inter-net]. 2004 Oct;11(10):1082–9. Available from: http://doi.wiley.com/10.1197/j.aem.2004.05.0282. Halila R. Assessing the ethics of medical research in emergency settings: How do international regulations work in practice? Sci Eng Ethics [Internet]. 2007;13(3):305–13. Available from: http://gateway.proquest.com/openurl?ctx_ver=Z39.88-2004&res_id=xri:pqm&req_dat=xri:pqil:pq_clntid=47866&rft_val_fmt=ori/fmt:kev:mtx:journal&genre=article&issn=1353-3452&volume=13&issue=3&spage=3053. Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and ma-jor morbidity results from all randomised trials of more than 1000 patients. Lancet [Internet]. 1994 Feb;343(8893):311–22. Available from: http://linkinghub.elsevier.com/retrieve/pii/S01406736949116144. Kämäräinen A, Silfvast T, Saarinen S, Virta J, Virkkunen I. Conduct of emergency research in patients unable to give consent—Experiences and perceptions of patients, their consent providing next of kin, and treating physicians following a prehospital resuscitation trial. Resuscitation [Inter-net]. 2012 Jan;83(1):81–5. Available from: https://auth.elsevier.com/ShibAuth/institutionLogin?entityID=https://idp.eng.nhs.uk/openathens&appReturnURL=https%3A%2F%2Fwww.clinicalkey.com%2Fcontent%2FplayBy%2Fdoi%2F%3Fv%3D10.1016%2Fj.resuscitation.2011.07.0185. Adams JG, Wegener J. Acting without asking: An ethical analysis of the food and drug adminis-tration waiver of informed consent for emergency research. Ann Emerg Med. 1999;33(2):218–23.6. European Union. REGULATION (EU) No 536/2014 OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL. Off J Eur Union [Internet]. 2014;2014(April 2001):76. Available from: https://ec.europa.eu/health/sites/health/files/files/eudralex/vol-1/reg_2014_536/reg_2014_536_en.pdf7. European Medical Agency. Guideline for good clinical practice E6(R2). Eur Med Agency [Inter-net]. 2016;6(December 01):1–70. Available from: http://www.ema.europa.eu/docs/en_GB/docu-ment_library/Scientific_guideline/2009/09/WC500002874.pdf8. Flory JH, Mushlin AI, Goodman ZI. Proposals to Conduct Randomized Controlled Trials Without Informed Consent: a Narrative Review. J Gen Intern Med [Internet]. 2016;31(12):1511–8. Available from: http://dx.doi.org/10.1007/s11606-016-3780-5

Exploring the experience of the Frozen Elephant Trunk procedure at a single regional centreMr Alex Cale, Richard

Thomson, Maxine Read, Rona

Calanao, Tony Jessop, Mathew

Joseph Castle Hill Hospital, NHS

Trust Hospital, Cottingham, UK

The Thoraflex hybrid Frozen Elephant Trunk device allows for a one stage procedure

in the treatment of aortic arch and descending aortic disease. It is a complex procedure involving the replacement of the ascending aorta, the replacement of the arch of the aorta with re-implantation of the head

and neck vessels and the placement of a stent within the descending aorta to eliminate the false lumen of an aortic aneurysm. Our study seeks to describe our experience of this procedure in terms of both our patient outcomes and also the experience of our staff involved in the care of these patients. As background information it should be noted that we are a regional centre for cardiac

surgery serving a population of around 1.2 million people and we generally operate on around 700 to 800 cardiac patients each

year; opinion may be that more complex aortic cases should be directed toward centres with much higher case volumes.

In 2001, The Kennedy Review of children’s cardiac surgery at the Bristol Royal Infirmary concluded that surgery should be concentrated at a few major centres in order to ensure that surgeons had sufficient numbers (125 per year per surgeon) of these complex cases to achieve and maintain their competency. The purpose of this study was to understand our centre’s experience of the Thoraflex FET procedure and not to attempt to answer the question of whether a small regional centre should be attempting this complex

surgery. However, if competency at a task can be inferred from performance, then Ariyaratnam et al (2014) suggests that our mortality rates were comparable with other units. The question of who should be performing this surgery will obviously continue to be the subject of future debate and something we are just beginning to evaluate at our centre.

In our study we have reviewed our small experience of the FET procedure and present our figures for crude mortality, time spent in the operating theatre, length of ICU stay and length of hospital stay. Additionally we have conducted unstructured interviews with members of staff involved in the care

of these patients from theatres, ICU and the Ward and using the constant comparative method have drawn from them emergent themes for consideration.

We conclude that although we are a smaller regional centre, our results show that we are competent at providing our population with this complex procedure. More staff education is required to reduce staff anxiety and improve performance, along with the need to improve multi-disciplinary communication to ensure that there are no delays or omissions in the care of these patients. We will continue to evaluate our performance against other centres who also offer this procedure.

Intraoperative Transit-Time Flow Measurement and High Frequency Ultrasound Assessment in CAGB: Insights from the REgistry for QUality assESsmenT (REQUEST) studyDavid Taggart1, Daniel Thuijs2, A. Pieter Kappetein2, Tersesa

Kieser3, Daniel Wendt4, Gabriele Di Giammarco5, Gregory

Trachiotis6, John Puskas7, Stuart Head2 1 John Radcliffe

Hospital, Department of Cardiovascular Surgery, University of

Oxford, Oxford, UK; 2 Department of Cardiothoracic Surgery,

Erasmus MC, University Medical Centre, Rotterdam, The

Netherlands; 3 Division of Cardiac Surgery, Department of Cardiac

Sciences, Libin Cardiovascular Institute of Alberta, University of

Calgary; 4 Department of Thoracic and Cardiovascular Surgery,

West German Heart and Vascular Centre, University of Duisburg-

Essen, Duisburg; 5 Department of Cardiac Surgery, Università

degli Studi “G. D’Annunzio” Chieti-Pescara, Chieti, Italy; 6 Division

of Cardiothoracic Surgery, Veterans Affairs Medical Centre,

Washington, DC, USA; 7 Department of Cardiovascular Surgery,

Mount Sinai Saint Luke’s, New York, NY, USA

In the last decade there have been significant technological developments that have assisted cardiac surgeons in helping to validate intraoperative

bypass graft patency, such as transit-time flow measurement (TTFM) and epicardial and epiaortic high frequency ultrasound (HFUS) for patients undergoing coronary artery bypass grafting (CABG). However, so far, the evidence has been limited and mostly from single centres and case reports, despite intraoperative quality assessment of the aorta and grafts gaining IIa recommendation in the 2018 ESC/EACTS Guidelines on myocardial revascularization (Sousa-Uva M, et al 2018 ESC/EACTS Guidelines on myocardial revascularization. European Journal of Cardio-Thoracic Surgery. 2018:ezy289-ezy289).

As a result, Professor David P Taggart (Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, Oxford, UK), in conjunction with seven international cardiac centres, initiated the REgistry for QUality assESsmenT (REQUEST)

study in April 2015. This is the first international, high volume, multi-centre study examining the impact of TTFM and HFUS in patients undergoing CABG.

“Essentially, the REQUEST Registry was designed to reveal whether there was any change in the planned surgical strategy following assessment using TTFM and/or HFUS,” Professor Taggart explained. “For example, following intraoperative quality assessment if the bypass graft was shown to be suboptimal, information was collected on how a surgeon would change their surgical strategy. Data was also collected on the number and cause for surgical changes related to the aorta, conduits, coronary targets and completed grafts.”

TTFM and HFUSAll TTFM and HFUS procedures performed in the study used the MiraQ™ Medistim or VeriQ™C (Medistim ASA, Oslo, Norway) devices. These enable a surgeon to further assess the quality of both the conduit (before and after harvest), potential

coronary vessels for bypass grafting and to assess the blood flow in bypass grafts, and check for potential problems that can be detected and corrected prior to chest closure.

According to Medistim, the TTFM principle is based on transmitting two ultrasound beams covering the blood vessel in both the upstream and downstream direction. The blood volume flow is then derived from the difference in propagation time of the upstream and downstream beams. This measurement principle gives an accurate quantification of the real time volume flow with minimal interference with the blood vessel.

In addition, HFUS imaging generates images by transmitting ultrasound pulses and receiving echoes from the pulses as they travel through the body. The received echoes are used to create an image of the target area. The colour flow mode uses the doppler principle to detect and visualise blood flow. Pulsed wave doppler uses the same principle to measure blood flow velocity.

Experienced surgeons“As the study was seeking to identify changes to surgical strategy, another important element was that we only included very experienced cardiac surgeons,” Professor David Taggart explained. “Highly-skilled and experienced cardiac surgeons are far less likely to change course from their surgical strategy, compared to less experienced colleagues, therefore any change to surgical strategy following intraoperative quality assessment would demonstrate the efficacy of intraoperative TTFM and HFUS.”

Professor Taggart emphasised that TTFM and HFUS technology also requires specialist training to enable the user to correctly interpret data as well as circumventing the dangers of misinterpretation. Therefore, all surgeons and study participants received training to work with and to interpret intraoperative TTFM and HFUS results, and following their training were subsequently qualified in Good Clinical Practice qualifications in the use of intraoperative TTFM and HFUS.

OutcomesBetween April 2015 and December 2017, more than 1,000 CABG patients were included in the study and the outcomes revealed that a ‘significant’ number of patients had one or more surgical changes made to their procedure strategy based on imaging and flow data.

“The key finding of the study is that without routine assessment in the operating room, most graft issues would have not been identified until several hours after the patient had left the operating room,” he explained. “Therefore, using TTFM and HFUS to help verify graft patency and to correct any intraoperative issues is of huge benefit to cardiac surgeons, and ultimately, to the outcomes of our patients.”

Although Professor Taggart acknowledged that one key limitation of

the study was that it was not a randomised clinical trial and did not compare CABG with TTFM and HFUS vs. CAGB without TTFM and HFUS, nevertheless the study was adequately designed to prospectively evaluate the impact of TTFM with HFUS on CAGB patients. A second limitation was the lack of long-term data as clinical results were limited to in-hospital outcomes.

“We know from the REQUEST study that both TTFM and/or HFUS aided experienced surgeons in recognising the need to change their surgical strategy in a significant

number of patients. In addition, the study resulted in low in-hospital mortality and major morbidity rates, which in my view clearly demonstrates that these two intraoperative assessment procedures improve the quality, safety and efficacy of CABG procedures,” Professor Taggart concluded. “Therefore, I believe routine use of intraoperative quality assessment with TTFM and HFUS should become a standard of care.”

The final results from the REQUEST study will be presented for the first time at the annual meeting of the American Association for Thoracic Surgery (AATS) in San Diego 4-7 May 2019.

The REQUEST Study was funded by Medistim ASA (Oslo, Norway). Professor Taggart would like to disclose he has received research funding, speaking and travelling honoraria from Medistim.

Adult Cardiac – Graft analysis Westminster Tuesday 12 March 14:30

Maxine Read


Coronary surgery in India and the promote patency trialKunal Sarkar Kolkata, India.

Co-Principal Inestigator Promote Patency Trial.

Past-President Indian Association of Thoracic and

Cardiovascular Surgery (IACTS)

India currently performs around 200,000 coronary artery bypass surgeries annually, which imply an average of 90 procedures per million population. (India’s population 1.2 billion). This is along with

another 40,000 valves and congenital surgeries. PCI has overtaken CABG in 2008, with the current ratio being 2.5:1. In spite of the challenge of PCI, CABG has a lot of headroom for growth, given the low level of prevalence. With the standard of living and other economic indices fast approaching those of the developed Asian nations, it is predicted that number of cardiac procedures should triple in the next three years. This will still be below that of Japan and South Korea (500/ million).

To put it in perspective the comparable rates in UK are 600/ million and USA 1000/ million. So, with an increasing access to healthcare the loss of market share will not deter the growth of numbers. After all we operate on patients and not percentages.

Indian surgeons have been staunch advocates of off pump CABG over the past decade and a half. This comes from the practice of reuse of stabilisers which helps to cut the disposables cost significantly. The average disposable ( and medicines) cost for a standard CABG works out to 500 pounds ! In the early 2000’s we assumed that the off pump rates were in excess of 75%. With the National Registry being initiated since 2013, the ground reality appears quite different. The data suggests an off pump rate of around 60%. The global concern about the outcomes and graft patency has had its effect, coupled with training issues.

In order to gauge the quality of revascularization that was being achieved in our surgical environment and also to add some much-needed angiographic data to the ongoing on pump off pump debate, we commenced on this project.

It is perhaps for the first time that six Indian centers have collaborated under monitored randomization and data collection systems to produce a RCT. Each participating surgeon had performed more than 2,000

Off Pump surgeries previously.“Promote Patency” looks at three-month

angiographic patency in randomized cohort of 300 patients with more than 80% angiography compliance rate. Graft patency analyzed according to conduit and territory grafted were comparable in the two groups. Initial analysis of mortality and MACE at one year will also be presented.

Initial results have previously been presented at AATS 2016 and we are awaiting publication soon.

With satisfactory experience levels Off pump CABG can deliver patency rates comparable to On Pump.

In the not too distant future, we expect to contribute not just to numbers but also to scientific evidence.

Adult Cardiac – Arterial and Off Pump CABG Westminster Tuesday 12 March 15:50

Comparison of TEVAR versus open repair of blunt traumatic descending aortic injury in polytraumatic patients involved in motor vehicle accidentsDr Yasser Elghoneimy and Mr Imthiaz

Manoly

King Fahd Hospital of the University, Dammam,

Kingdom of Saudi Arabia

Background

Thoracic endovascular aortic repair (TEVAR) is now widely accepted as the standard of care for the treatment of Traumatic aortic

injury (TAI) if there are no contraindications. Few retrospective studies have demonstrated better short-term results with TEVAR for selected patients with blunt traumatic aortic injuries.

ObjectivesTo compare the early outcomes of endovascular treatment of blunt traumatic descending aortic injury with open repair in polytraumatic patients involved in motor vehicle accidents (MVA). We report our initial experience in our Province after integration of endovascular repair using thoracic devices.

MethodsBetween February 2008 and April 2017, 71 patients with TAI due to MVA with multiple trauma, presented to our institution. After initial stabilization, all patients with descending aortic injuries were considered for thoracic endovascular aortic repair TEVAR) using a thoracic device, if there was no contraindication. The primary outcome measure was mortality and secondary outcome measures were stroke, paraplegia, intensive care unit (ICU), and length of hospital stay.

ResultsThe mean ages were 28 years in the OR and 33 years in the TEVAR with majority of them males in both the groups. The injury severity score (ISS) were 41 (OR) and 33 in the TEVAR group. Forty-one patients had OR and thirty patients had TEVAR. Initially all patients with BTAI were managed with open repair. In the

last four years, TEVAR was developed and attempted in all eligible patients without contraindications. The demographics, operative and postoperative details of all patients who had open repair or TEVAR are tabulated. Thirty-six patients in the OR group had emergency OR within a mean time of one hour on arrival while TEVAR group had slightly longer time to interval due to steep learning curve. The OR group had more blood transfusion requirements [24 (58.5) vs. 8

(27.5)], renal impairment [6 (14.6) vs. 1 (5.50] and wound infection [21 (51.2) vs. 3 (10.3)]. Three TEVAR patients suffered perioperative stroke compared to two patients in the OR group. There was no difference in the mean ICU or hospital length of stay between the two groups. There were four deaths in the OR group and none in the TEVAR group. However, the OR group had more complex and higher ISS. Mortality correlated with the ISS score and three deaths were not procedure related.

ConclusionIn our experience, the results of TEVAR did not differ from Open repair and had better early outcomes. The complexity of injury and technical challenges were more in the Open group. TEVAR group had lower renal failure, decreased need

of blood transfusion and lesser rate of wound infection. There is a significant gap in the long-term follow-up of this cohort. A protocol or guideline is definitely needed to manage such patients and a provision to long-term follow-up is warranted.

Adult Cardiac – Aortic Arch Surgery Abbey Tuesday 12 March 09:00

Table 1. Demographic comparison between Open repair and TEVAR cohort

Table 2. Operative and Post-Operative Comparison Between Randomized Cohorts*


Should type A aortic dissection be surgically repaired in octogenarians?

Mohamed Osman, Tinrui Toh, Shagorika Talukder,

Marius Berman, David Jenkins, Steven Tsui, Catherine

Sudarshan, Fouad Taghavi, Ravi De Silva, Samer

Nashef Royal Papworth Hospital, Cambridge, UK

As cardiac surgical results improve, older and sicker patients are being offered repair of type A aortic dissection. As in all cardiac surgery, age is a risk factor for

early outcome, but does it have an impact on long-term outlook?

We studied patients over the age of 80 who had emergency repair of type A aortic dissection at Royal Papworth over nearly a decade. We collected hospital data on baseline demographics, co-morbidity, functional status, surgical variables, perioperative mortality, complications, and length of stay. We used the NHS care record tracing service to collect 12-month survival data.

We found that 33 octogenarians who had repair of acute type A dissection. Mean age was 83 (range 81 to 89) and half were female. Most had hypertension (55%), and other comorbidities

such as a smoking history (45%), extracardiac arteriopathy (30%), pulmonary disease (18%), coronary artery disease (15%), myocardial infarction (9%), and atrial fibrillation (9%). A third had impaired left ventricular function and six patients were in cardiogenic shock. Mean logistic EuroSCORE was 42 (range 22 to 77).

The majority of patients had ascending aortic replacement, but five also had root replacement and two aortic arch replacement. Concomitant CABG was done in two patients. Deep Hypothermic circulatory arrest was used in only eight patients.

Gratifyingly in this high-risk group, hospital mortality was only 12%, mostly due to bleeding and cardiac failure but, among those who survived to hospital discharge, the overall survival rate was 85% at three months, 76% at 6-months and only 32% at 12-months (figure).

Repair of type A aortic dissection can be performed with acceptably good early survival in octogenarians but the longer term results are disappointing and call into question the net risk-benefit indication of the procedure.

Opioids in Cardiothoracic SurgeryPriyadharshanan Ariyaratnam

Department of Cardiothoracic Surgery,

Castle Hill Hospital, Cottingham, UK

There is an opioid epidemic in the West that is partly driven by a surge in opioid prescribing in discharge

medications following surgery. Although the short-term effects of opioids in combating acute pain are second -to-none, it is the long-term physiological and psychological effects that are the primary concern among patients, relatives and carers in the community.

The United States of America have led the way in evaluating predictors of opioid prescribing following surgery and implementing possible strategies to limit its prescription prevalence on discharge. The opioid prescription trends in Cardiothoracic surgery have not been evaluated however, either in the UK or abroad.

We, therefore, performed a retrospective study of data collected from 2008-2018 (Cardiac Surgery) and from 2013-2018 (Thoracic Surgery) at our institution. In total, 4481 patients had complete discharge data for evaluation in cardiac surgery and 2260 patients in thoracic surgery.

In Thoracic surgery, we found that between January 2013 and May 2018 in thoracic surgery, 52.9% (1196/2260) of patients were discharged on some form of morphine-based pain-relief following surgery. This consisted of 35.9% (811/2260) long-acting opioids such as Oxycodone Modified Release and 31.3% (708/2260) short-acting such as Oxynorm; many patients were discharged on a combination of both. We also found that the patients discharged with opioids rose significantly from 36.5% (122/334) to 60.4% (246/507) (p<0.0001) from 2013 to 2017 respectively.

We discovered that the significant predictors for discharge-on-opioids in thoracic surgical patients were a lower age at surgery (OR 1.01, p=0.001), female gender (OR 1.274, p=0.04), a higher BMI (OR 1.026, p=0.019), a sub-lobar lung resection compared to a full lobectomy (OR 1.495, p=0.011) and a thoracotomy compared to key-hole surgery (OR 1.148, p=0.021).

In Cardiac surgery, we found 19.6% (918/4841) of patients were discharged on an opioid. This consisted of 16.4% (795/4841) long-

acting formulations and 8.6% (417/4841) short-acting formulations with many taking a combination of both. We found there was a rise in patients discharged on opioids from 3.2% (17/528) to 40.6% (143/352) (p<0.0001) between 2009 and 2017. The mean logES did not change significantly in line with this between 2009 and 2017 (6.12 +/- 8.9 vs 6.99+/- 8.86, p=0.15).

In cardiac surgery (all of whom had a median sternotomy), the significant predictors were again a lower age at surgery (OR 1.04, p<0.0001) and a higher BMI (OR 1.03, p<0.0001). Additional predictors were Chronic Obstructive Pulmonary Disease (OR 1.259, p=0.025), longer X-clamp (OR 1.011, p<0.0001), bypass times (OR 1.04, p=0.031) and CABG surgery (OR 1.51, p<0.0001).

Patients who developed renal, neurological complications and gastro complications after cardiac surgery were less likely to be discharged on opioids (p<0.001).

Our prescribing of opioids in cardiothoracic surgery has become more liberal over the last few years despite the risk profile of our group not changing dramatically in line with this. Larger studies are needed and perhaps a nationwide and international audit, of opioid prescribing is warranted across different surgical specialities to find if this trend is occurring elsewhere and why this may be.

Aortic valve replacement: Does prosthesis size matter?Mohamed Osman, Walid Elmahdy,

Mohamed Farag, Haisam Saad,

Marius Berman Royal Papworth

Hospital, Cambridge, UK

Aortic valve replacement (AVR) is one of the most common cardiac

surgeries nowadays. Using small valves ≤ 21 mm is not uncommon. During the performance of AVR with both mechanical and bioprosthetic valves, implantation of small size prostheses has been an issue of continued debate.

Several studies have evaluated the effect of patient-prosthesis mismatch and post-operative valve gradient on patients’ outcome. However, it is still unclear if implanting small prostheses ≤ 21 mm may collectively contribute to worse outcome. In Royal Papworth Hospital, we studied the effect of valve size on the outcome in aortic valve replacement surgery retrospectively.

We collected the data from 2,646 patients who underwent primary isolated AVR operations in the last 10 years. Patients were stratified by prosthesis size into small AVR (≤2 mm, n=805) and standard AVR (≥ 23 mm, n=1,841) groups. The effect of prosthesis size on outcome was evaluated by univariate and multivariable regression analyses.

The total In-hospital

mortality was 0.8% (1.2% in small AVR group vs. 0.7 in standard AVR group; p=0.161).

Small prostheses were used more frequently in females and older patients, with more death events at a median follow-up of four years compared with standard prostheses. In univariate regression analysis, small prosthesis predicted mortality (Figure 1), but not after adjustment for other risk factors.

Independent predictors of mortality were advanced age, diabetes, raised serum creatinine and persistent atrial fibrillation before surgery.

Our study concluded that small aortic valve prosthesis solely increases medium-term mortality after isolated AVR. Interestingly, persistent atrial fibrillation independently predicts mortality after isolated AVR.

Adult Cardiac – Aortic Dissection Surgery Abbey Monday 11 March 09:10

ICU/Anaesthesia – ICU and Blood Management Wesley Tuesday 12 March 09:00

Adult Cardiac – BHVS Session Westminster Tuesday 12 March 09:00

Months 1 2 3 4 5 6 7 8 9 10 11 12

Survival (%) 87.5 84.8 84.8 78.8 75.6 71.9 62.9 57.2 57.2 42.9 32.2 32.2

Figure 1

Shagorika Talukder

Does the failure of minimal lymph node staging criteria leading to R0(un) status consistently result in poorer survival after surgery for lung cancer?Paulo De Sousa, Fatima Mansour, Monica

Barbosa, Sarah Booth, Henriette Klein,

Aleksander Mani, Maria Nizami, Charlotte

Von Crease, Dimitris Kyparissopoulos,

Edward Townsend, George Ladas, Karen

Redmond, Nikolaos Anastasiou, Jonathan

Finch, Madhan Kumar Kuppusamy, Nizar

Asadi, Emma Beddow, Nial McGonigle,

Vladimir Anikin, Sofina Begum, Simon

Jordan, Angeles Montero-Fernandez, Jan

Lukas Robertus, Alexandra Rice, Andrew

G Nicholson, Eric Lim Royal Brompton and

Harefield NHS Foundation Trust

In 2009 the IASLC TNM 7 staging manual proposed the “testing” of minimal criteria for lymph node staging to ascertain certainty status of

complete (R0) resection after lung cancer surgery, which was three mediastinal (including subcarinal) and three N1 stations / nodes. In 2016, the IASLC TNM 8 staging

manual formally introduced the new category of R0 (un) based on failure of compliance with the proposed extent of lymph node staging.

Edwards et al, on behalf of the IASLC staging committee reported that failure of compliance leading to R0 (un) status was associated with poorer survival. However, this finding has never been validated outside the IASLC staging database.

We audited over 2,500 patients and conducted a retrospective analysis of a prospectively collected database to independently evaluate the impact of R0 (un) status at patients undergoing surgery for primary lung cancer at the Royal Brompton and Harefield NHS Trust. We discovered that R0 (un) status (to the contrary) did not concur with the IASLC suggestion of poorer survival. The hazard ratio of survival was 0.95 (95%

CI 0.74 to 1.21; P=0.657) compared to a “certain” R0 status.

Our results question the clinical utility of R0 (un) assignment on lymph node dissection criteria and we await further large-scale cohorts ideally from institutions with data that was not been used as part of the TNM 7 derivation cohort to determine the “consistency” of the hazard ratio of R0 (un).



Rumors, truth and reality: Coronary endarterectomy in diffuse coronary artery diseaseRedoy Ranjan1, Asit Baran

Adhikary2 1 Assistant Professor;

2 Professor and Chief of Special

Unit; Department of Cardiothoracic

Surgery, Bangabandhu Sheikh

Mujib Medical University, Dhaka,

Bangladesh.

Ischaemic heart disease patients, who are referred for coronary artery bypass graft (CABG) surgery, are progressively getting more complex with multiple comorbidities, and subsequently,

this group of patients have diffused coronary artery disease, which has made complete surgical revascularization more difficult. In the late 1957, coronary endarterectomy was at first presented as a surgical option for myocardial revascularization by Bailey and colleague. Coronary Endarterectomy is the expulsion of the atheromatous plaque, and isolating

the outer media and adventitia layers of arterial wall. Initial results for coronary endarterectomy with CABG surgery was downhearted due to greater incidence of perioperative mortality and morbidity. Furthermore, the adverse effects are even more disastrous when endarterectomy is performed on a coronary artery that are highly pivotal to achieve optimum myocardial revascularisation especially left anterior descending (LAD) artery, where incomplete myocardial revascularisation may results in an awful clinical outcome. Inadequate myocardial revascularizations do not influence the early death rate, but rather the occurrence of restenosis which influences the long-term cardiac dysfunction.

The fundamental concept of coronary endarterec-tomy in complex coronary artery disease is to extract the total atheromatous plaque, and achieve a good distal run off in diseased coronary arteries. The principle indication for endarterectomy technique is

the presence of diffuse coronary artery disease with leaping lesion, that are not feasible to achieve distal bypass grafting. However, atherosclerotic plaques

in LAD artery is hard and fragile in contrast to right coronary or circumflex artery, thereby increasing the incidence of plaque disruption. Moreover, branches of LAD artery like diagonal and septal artery arises in two different planes and have the chance of shearing-off the branches during extraction of the atheromatous plaque in either direction.

We reviewed the outcome of 1,473 endarterect-omised coronary artery in 1189 patients with diffuse coronary artery disease (CAD) was reviewed, who have had experienced CE with OPCABG. Endarterectomy was performed in multi-segmental diffuse CAD, or when a calcified or extremely thick plaque making anastomosis troublesome. Approximately 75.0% coronary endarterectomy were performed in the left coronary territory and most commonly left anterior descending artery was endarterectomized (42.83%). An average of 1.2 coronary endarterectomies performed per patient. Post-operative ICU and 30-days mortality rate was 2.2%, and 0.6% respectively in CE group. Post-operative atrial fibrillation, acute MI, neurological complication, and blood transfusion were significantly higher in CE group. Following CE, Kaplan–Meier cumulative survival rate was 89.5%, and about 85% patients were free from angina at follow-up of five years.

Endarterectomy techniqueA conclusive decision to endarterectomise a vessel is made per-operatively, and coronary endarterectomies were performed manually by utilizing the closed methods by “slow sustain and continuous traction” of atheromatous plaque with the aid of delicate ring forceps, followed by reproduction of distal anastomosis with pre-planned graft. The arteriotomy incision was roughly 8-10 mm long, however that was extended for another 5 mm in few cases. Much consideration was provided to the entire expulsion of the distal segment, but complete proximal endarterectomy avoided due to the danger of competitive flow loss between the graft and the native artery. To ensure complete expulsion, the atheromatous plaque carefully inspected for a smooth distal tapper end. In addition, back flow of blood from the distal vessel following extraction of the atheroma is a consoling indication of adequate removal atheromatous plaque and that is special feature in OPCABG endarterectomy. In this study, longest atheroma (14 cm in size) was removed from RCA and also another 10 cm atheromatous plaque extracted from LAD during OPCABG.

Anticoagulation therapyIn early post-operative period, every patient received heparin infusion bridging to warfarin from the first post-operative day for next three to six months. Heparin was used (usually 5000IU subcutaneously eight-hourly) in the early postoperative period, usually three to four hours following surgery, followed by oral warfarin (5-10 mg) till third post-operative day. From the fourth post-operative day onwards, warfarin was used at a dose of 2.5 to 5 mg for next three to six months and dose was adjusted according to INR (targeted INR was 1.5-2.5). In our study, a combination of clopidogrel with aspirin (75 mg) also used to anticipate acute thrombosis at the graft and also in the endarterectomies native artery for life long from 1st post-operative day.

ConclusionCoronary endarterectomy with OPCABG accomplishes better surgical myocardial revascularization in patients; when there is no other alternative for total myocardial revascularization. However, surgical skill, patient’s selection criteria, and postoperative anticoagulation therapy are the key words for better outcome following endarterectomy with CABG surgery. Altogether, endarterectomy should not take the place of CABG procedure, but this technique is an adjunctive to CABG surgery in diffuse calcified coronary artery disease, and endarterectomy is not expedient for every IHD patient undergoing CABG.

Figure-2: 2a- Buch of collected atheroma; 2b- Closed technique atherectomy; 2c- Histopathological slide preparation



Extended myectomy for severe hypertrophic obstructive cardiomyopathyPer Wierup, Raphaelle A. Chemtob,

Harry Lever, Dermot Phelan, Milind

Desai, Zoran Popovic, Patrick Collier,

Maran Thamilarasan, Lars Svensson,

Marc Gillinov, Kevin Hodges, and

Nicholas Smedira Cleveland Clinic,

Cleveland, Ohio, USA

Introduction

Septal myectomy remains the gold standard for managing left ventricular outflow tract (LVOT)

obstruction in patients with hypertrophic cardiomyopathy (HOCM).1–4 Analysis of the National Inpatient Sample has associated this procedure with high mortality and occurrence of complete heart block requiring permanent pacemakers.5 Surgical repair with mitral valve interventions in combination with septal myectomy or as isolated procedures, remains controversial. Different techniques have been suggested to address the septum and/or the subvalvular apparatus providing relief of the LVOT.

MethodsWe report a case of a 32-year-old male with HOCM causing LVOT and mid-cavitary obstruction, who was referred for surgery at our institution. The patient presented with a history of syncope. Preoperative echocardiography confirmed a systolic anterior motion (SAM) related mitral regurgitation and a high resting gradient 72 mmHg, which increased during Valsalva to 115 mmHg.

ResultsThe patient underwent surgical repair with an extended septal myectomy. Standard sternotomy, cannulation, cardiopulmonary bypass and cross clamp was applied and the heart was arrested with long-acting antegrade cardioplegia. An extended septal myectomy was performed of the septal muscle from the right trigone to the left trigone, removing a total of 23 gram of myocardium mass. Following cardiopulmonary bypass, the maximum outflow gradient was 6 mmHg during Isoproterenol provocation with no indication of SAM.

DiscussionAt follow-up after one month postoperatively, the patient was asymptomatic and presented with a maximum gradient of 7 mmHg (no change during Valsalva) and with no indication of SAM. Surgical pathology was consistent with the histopathologic features of HOCM. Extended myectomy in this patient with HOCM provided relief of LVOT obstruction without the need for intervention of the mitral valve itself. Most patients with substantial hypertrophy can benefit from myectomy alone. In our series of 1.559 patients undergoing surgical repair for left ventricular outflow tract obstruction, 37% of patients underwent concomitant mitral valve repair.6 As the degree of hypertrophy decreases, mitral valve interventions become an increasingly important component of the procedure to avoid mitral valve replacement and reduce the likelihood

of generating a ventricular septal defect in cases of extensive myectomy. Septal myectomy can be performed safely with excellent outcomes and a mitral valve intervension is useful adjunct in patients with moderate hypertrophy.

References

1. Agarwal S, Tuzcu EM, Desai MY. Updated Meta-Analysis of Septal Alcohol Ablation Versus Myectomy for Hypertrophic Cardiomyopathy. JAC. 2010;55(8):823-834.2. Schinkel AFL, Michels M, Berg M. A Systematic Review and Meta-Analysis of Long-Term Outcomes After Septal Reduction Therapy in Patients With Hypertrophic Cardiomyopathy. 2015;3(11).

3. Smedira NG, Lytle BW, Lever HM, et al. Current Effectiveness and

Risks of Isolated Septal Myectomy for Hypertrophic Obstructive Car-

diomyopathy. Ann Thorac Surg. 2008;85(1):127-133.4. Valeti US, Nishimura RA, Holmes DR, et al. Comparison of Surgical Septal Myectomy and Alcohol Septal Ablation With Cardiac Magnetic Resonance Imaging in Patients With Hypertrophic Obstructive Cardio-myopathy. 2007;49(3).5. Panaich SS, Badheka AO, Chothani A, Mehta K. Results of Ven-tricular Septal Myectomy and Hypertrophic Cardiomyopathy ( from Nationwide Inpatient Sample. Am J Cardiol. 2014;114(9):1390-1395.6. Hodges K, Rivas CG, Aguilera J et al (in press). Surgical manage-ment of left ventricular outflow tract obstruction in a specialized hy-pertrophic obstructive cardiomyopathy center. J Thorac Cardiovasc Surg. doi101016/j.jtcvs201811148.

Robotic mitral valve surgery: Over a decade of experience

Per Wierup, Raphaelle A.

Chemtob, Paul Cremer, Rakesh

M. Suri, Serge Harb, Wael Jaber,

Miliand Desai, Lars Svensson,

Stephanie Mick, Marc Gillinov

Objectives

First introduced in the late 1990s, robotic mitral valve surgery (RMVS) is being

performed with increasing frequency. This procedure enables surgeons to work through ports and small incisions on the right chest and is the least invasive surgical approach to the mitral valve.1 Other reported advantages include shorter postoperative stay, reduced need for blood transfusions, quicker return to full activity and superior

cosmetics.2–4 Despite these advantages, and the efficacy and safety of the procedure, RMVS is not a standard of care for managing degenerative MV disease. We assessed trends and outcomes of RMVS at our institution during our 13-year experience that involved a specially trained team of surgeons, anesthesiologists, nurses, perfusionists and surgical assistants.

MethodsA retrospective review of patients undergoing robotic primary mitral valve surgery between December 2006 and January 2019 at the Cleveland Clinic.

ResultsIn late 2005, all team members underwent specialized training that included didactic sessions, “dry run” simulations, and travel to other institutions to observe robotic mitral valve surgery. Over the ensuing 13 years, the team performed 1717 robotic mitral valve operations. Mean patient age was 56 ±10 years, and the most common etiology for mitral valve disease was degenerative (96%). Mitral valve repair was performed in 1702 (99%) of patients, whereas 15 (1%) patients had replacement

of the mitral valve. Hospital death occurred in one patient (0.06%). A total of nine (0.5%) patients underwent reoperation due to repair failure and 34 patients (2.0%) underwent reoperation for bleeding. Over the course of the experience, perioperative stroke rates decreased from 1.7% in the first five years to 0.6% in the following and recent years.

ConclusionsWith a team-based approach, RMVS was associated with low short-term mortality and morbidity, as well as a high success rate of mitral valve repair. Our results emphasize the technical and process improvement undertaken during the course of this experience resulting in excellent outcome following RMVS.

References

1. Gillinov AM, Mihaljevic T, Javadikasgari H, et al. Early results of robotically assisted mitral valve surgery: Analy-sis of the first 1000 cases. J Thorac Cardiovasc Surg. 2018;155(1):82-91.e2.2. Mohr, F. W., Falk, V., Diegeler A., Wather T., Gummert J.F., Bucerius J., Jacobs S. AR. Computer-Enhanced “Robotic” Cardiac Surgery: Experience in 148 Patients. J Thorac Cardiovasc Surg. 2001;121:842-853.3. Chitwood Jr WR. Robotic mitral valve surgery: over-view, methodology, results, and perspective. Ann Cardio-thorac Surg. 2016;5(6):544-555.4. Mihaljevic T, Jarrett CM, Gillinov AM, et al. Robotic repair of posterior mitral valve prolapse versus conven-tional approaches : Potential realized. J Thorac Cardio-vasc Surg. 2011;141(1):72-80.e4.

Complex tricuspid valve repair: Beyond simple annuloplastyGiuseppe Rescigno Lancisi Hospital–Ospedali Riuniti di

Ancona, Ancona, Italy

Tricuspid regurgitation is most frequently a consequence of left-sided valve disease. Nevertheless, cases of isolated tricuspid valve regurgitation do occur. Most of the

cases of functional TR are managed by restrictive annuloplasty, generally performed with a prosthetic ring. However, this would not suffice for extreme annular dilatation and/or leaflet prolapse. Our Department has a very aggressive policy in aiming to achieve valve repair for tricuspid regurgitation and our goal is to be a reference centre for complex tricuspid valve repairs.

We reviewed our series of complex tricuspid valve repairs (TVr), performed from August 2012 to August 2018. During this time period, 418 TVr were performed overall; 29 were complex TVr. In eight

cases (27.5%) the operation consisted of an isolated TVr. Clinical data are summarised in the table 1.

The regurgitation was considered severe in 23 patients (79%) and moderate to severe in six patients (21%). In 19 patients (65%) a patch augmentation of one or more leaflets was necessary (18 Cormatrix and one bovine pericardium; See picture). In eight cases (27.5%) two or more Gore-tex neo-chords were used. In seven patients (24.1%) other techniques were

applied (commissure closure, edge to edge, chordal mobilisation). In all patients, a prosthetic ring was implanted to stabilise the repair.

Twenty-six patients had an uneventful course. There were two in-hospital deaths, not related to the TVr (1 intraoperative aortic dissection and one nonconvulsive status epilepticus), and one patient had a cardiac tamponade requiring re-exploration. Mean hospital stay was 13+10 days. All patients had a follow-up

appointment and echocardiogram at six weeks post surgery. Residual tricuspid regurgitation was absent or trace in 14 patients (51%), mild in 11 (40%) and moderate in three (9%) patients (see Graph). NYHA

Class was I in 22 patients and II in five patients.Our early results demonstrate that in complex

patients with extreme annular dilation, lack of tissue or leaflet prolapse, a complex TVr can achieve a competent tricuspid valve, thus avoiding tricuspid valve replacement and its attendant problems of heart block, anticoagulation and thrombosis. All patients had a symptomatic benefit. A longer follow-up is warranted to assess the stability of the repair.

Residual tricuspid regurgitation (%)

SCTS: Take on the experts – Video Presentation Moore Tuesday 12 March 14:00


Adult Cardiac – Tricuspid Surgery Abbey Monday 11 March 13:40

Table 1

Parameter Mean± SD or N

M/F 7/22

Age 64±16

LV Ejection fraction 49.7±7.0

NYHA Class (I/II/III/IV) 0/2/15/12

PAPs 45.7±13.7

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Quantifying aortic morphological variability in bicuspid aortic valve patients with and without coarctationFroso Sophocleous1, Benedetta Biffi2, Elena Giulia Milano2, Jan Bruse3,

Massimo Caputo4, Cha Rajakaruna4, Silvia Schievano2, Costanza Emanueli5,

Chiara Bucciarelli-Ducci4, Giovanni Biglino6 1, Bristol Medical School, University

of Bristol; 2, Institute of Cardiovascular Science, University College London; 3,

Vicomtech-IK4, Data Intelligence for Energy and Industrial Processes, Donostia/San

Sebastián, Spain; 4, Bristol Medical School, University of Bristol and Bristol Heart

Institute, University Hospitals Bristol, NHS Foundation Trust; 5, National Heart and

Lung Institute, Imperial College London; 6, Bristol Medical School, University of Bristol

and Cardiorespiratory Division, Great Ormond Street Hospital for Children, NHS

Whilst bicuspid aortic valve (BAV) is the most common congenital heart

disease, there are gaps in the understanding of the disease. BAV is usually associated with aortic wall abnormalities and co-existing with other congenital defects such as aortic coarctation (CoA). However, the clinical significance of CoA in BAV aortopathy and the impact of segmental aortic morphology are not fully exploited yet. A single-centre retrospective study was conducted1, aiming to explore aortic morphology and any potential effects on functionality within three sub-groups of a BAV population, i.e. patients with repaired CoA, unrepaired CoA and without CoA.

Patients with MRI data and native BAV diagnosis were studied (n=525); those with a 3D MRI dataset were included for shape analysis (n=108, 64% males, 38±16.5 years). MRI-derived 3D aortic reconstructions were analysed using a statistical shape modelling framework2. A mean aortic shape (‘template’) was computed for the whole population and for the three sub-groups separately. Shape deformations (‘shape modes’) were computed for the whole population and correlated with demographic, volumetric and functional data within the three sub-groups, as well as with 2D measurements (i.e. ascending and descending aortic diameters, aortic height and width, curvature,

and isthmus). Sub-group analysis, including derivation of shape deformations, was also performed specifically for repaired CoA.

A comparison of the three sub-groups (Fig.1) revealed that the presence of CoA was significantly associated with increased curvature (p<0.001) and normalised curvature (p<0.001), and decreased width (p=0.001) compared to the absence of CoA, suggesting a more angulated aorta. The sub-group with absence of CoA had the highest degree of proximal ascending aortic dilation (p<0.001), as confirmed visually by the computed 3D shape results and measured diameters. Unrepaired CoA was significantly associated with increased height-to-width ratio (p=0.005) and smaller isthmus (p=0.05) compared to the others, suggesting the presence of gothicity and confirming the presence CoA. This group also had higher left ventricular mass (p=0.04) and the smallest percentage of functionally normal aortic valves (i.e. no aortic regurgitation and stenosis) whereas the sub-group of repaired CoA had the highest percentage (23% vs. 52%, p=0.01). The three sub-groups showed significant differences for shape modes 1 (p=0.007), 2 (p=0.02), 3 (p<0.001), 4 (p=0.002), 6 (p=0.03) and 8 (p=0.02), see Fig.2. Sub-group analysis of patients with repaired CoA interestingly revealed that

mode 6, which displays dimensional changes and angulation, was significantly associated with left ventricular ejection fraction (p=0.01) and end-diastolic volume (p=0.02), and with the presence/absence of re-CoA (p=0.05).

Through this study, it has been demonstrated that

aortic coarctation is likely not a localized disease but rather a disease of the whole aorta resulting in an overall change in the aortic arch morphology, and that operated coarctation continues to be a disease of the aorta with repercussions on

ventricular function. The clinical impact of our approach has been demonstrated by its potential to characterise patient sub-groups unearthing nuanced differences in arch morphology that would otherwise not be captured by gross dimensional or functional data.

References

1. Sophocleous, F., et al., Aortic morphological variability in

patients with bicuspid aortic valve and aortic coarctation. Eur J

Cardiothorac Surg, 2018.

2. Bruse, J.L., et al., A statistical shape modelling framework to

extract 3D shape biomarkers from medical imaging data: as-

sessing arch morphology of repaired coarctation of the aorta.

BMC Med Imaging, 2016. 16(1): p. 40.

Does your psychological make-up affect your recovery from a heart operation? The HOPE StudyChristine Mills1, Kim Lee2, Sofia Villar2, Samer

Nashef3 Papworth Trials Unit Collaboration1, MRC

Biostatistics Unit2, Royal Papworth Hospital3

Every year, around 40,000 patients undergo open heart surgery in the UK. Over the last 20 years heart surgery has become much safer.

Risk factors can be divided into two groups: those that cannot be changed (age, gender, family history) and those that are changeable (smoking, obesity, psychological factors). Most research on cardiac surgery outcomes focuses on biological risk factors, but, in striving to offer the best care possible, we may need to adopt a more holistic approach.

Some small studies have shown that patient outlook can influence recovery and that patient with a more positive disposition report better outcomes after surgery, emphasizing the importance of mental wellbeing in relation to physical conditions requiring surgery. Much of the previous research however has focused on a narrow range of operations and relied on patient-reported primary outcomes, which could indeed be influenced by the patient’s own outlook.

The HOPE study set out to determine whether a patient’s outlook before cardiac surgery can influence hard outcomes such as recovery and length of hospital stay. In a single-centre prospective observational study, 279 elective cardiac surgery patients

agreed to participate. Patient outlook was assessed preoperatively with two standardised questionnaires: Life Orientation Test (LOT) to measure outlook over a longer duration and the Positive and Negative Affect Schedule (PANAS) to measure current attitude. LOT was used to classify patients into optimistic (76), neutral (69) and pessimistic (74) outlook groups while PANAS ‘positive’ and PANAS ‘negative’ were used as potential

predictor variables.The primary outcome was length of hospital

stay. Secondary outcomes included length of intensive care unit (ICU) stay, ward stay and risk-adjusted survival using a multivariate linear regression model. Pessimistic patients spent a day more in hospital compared with the ‘neutral’ group. For the secondary outcomes, PANAS positive was found to be a significant predictor of ICU stay: gaining one point on the PANAS positive reduced ICU length of stay for the patients in the neutral and pessimistic groups by -0.09 day (2 hrs 17 mins).

Research has demonstrated that in a mental health setting it is possible to improve a patient’s outlook by using mental imagery based training. In this training patients are asked to repeatedly select positive information over negative information for 10 minutes a day over a two week period, this helps train the brain to automatically focus more on positive information. This method of increasing resilience is unexamined in the cardiac surgery population. This message is empowering for the patient as ‘improving mood’ before surgery is more within their control than clinical risk factors such as those used within EuroSCORE. Based on the results of this study, development of psychosocial intervention to boost optimism to target this patient population could have the potential to provide significant public health benefits as well as a cost saving to the NHS.

Beating heart repair for anomalous origin of right coronary artery from left coronary sinusYoshito Inoue, Soshu

Kotani, Masatoshi

Ohno Hiratsuka City

Hospital, Hiratsuka, Japan

I am pleased to present a new surgical approach to anomalous origin of

the right coronary artery from left coronary sinus (ARCA), which causes myocardial ischemia and sudden death. Much efforts has been made to treat this anomaly, including CABG, unroofing and translocation, however these treatments have drawbacks such as insufficient revascularization, complexity of the procedure or risk of post-operative aortic insufficiency.

To eliminate the problems of existing treatments, we performed beating heart repair, which is a simple and safe procedure, involving minimal surgical steps; dissection of ARCA and anastomosis to correct

sinus using anastomosis assist device. This technique can eliminate the need to crossclamp and to open the aorta and manipulate the intercoronary commissure under cardioplegic arrest. It also facilitates optimal anastomosis without kinks, angulation, torsion and stretching of the translocated

coronary artery. The optimal distance and course of ARCA to the neo-ostium was easy to determine because of the beating heart condition; moreover, the quality of the anastomosis could be confirmed immediately after anastomosis by flow probe measurements.

Our successful experience showed that novel beating heart repair is a safe and effective procedure, which adds an ideal treatment option for ARCA.

Figure 1: Templates of the whole population and of the sub-groups.Froso Sophocleous

Figure 2: Modes of the whole population that were significantly associated for differences between the sub-groups; template-red, mode extremities-yellow.

Yoshito Inoue

Christine Mills

Congenital – Congenital Abstracts Rutherford Monday 11 March 14:00


Adult Cardic – Arterial and off pump CABG Westminster Tuesday 12 March 15:30


The effect of post-operative day zero physiotherapy mobilisation following lung resection in the adult population: A service evaluationZoe Marie Barrett-Brown Team Leader

Physiotherapist for Thoracic Surgery, Royal

Papworth Hospital NHS Foundation Trust,

Cambridge

Enhanced recovery programmes have been a vital component in thoracic

surgery to minimise the effect surgery has on patients’ recovery. Physiotherapy plays an important role to ensure patients return to a good level of fitness post-operatively and minimise the risk of post-

operative pulmonary complications.A service evaluation was conducted in an NHS

Hospital to explore the benefits of early Physiotherapy mobilisation on post-operative day 0 (the day of

their surgery) following lung resection surgery compared to the previous service of Physiotherapy

mobilisation on post-operative day one (the first day after their surgery). Outcome measures included incidences of post-operative pulmonary complications (using the Melbourne Group Scale), post-operative hospital length of stay and Physiotherapy treatment length.

To be included in the study each patient must meet the inclusion criteria and deemed safe by the Thoracic surgical team post-

operatively to participate in early mobilisation. Patients in the early mobilisation group were seen approximately four hours after their surgery had finished. The early mobilisation group were mobilised with the aim to walk 80-100 metres as independently as possible. The patients in the non-early mobilisation group were mobilised with the nursing staff if indicated on the day of their operative and reviewed by a Physiotherapist on the first day after their surgery. All patients in were given the standardised post-operative Physiotherapy advice (breathing exercises, supported coughing, circulatory and upper limb exercises).

The incidences of post-operative complications, post-operative hospital length of stay and number of Physiotherapy treatment sessions were recorded for each patient that participated. A total of 20 patients

were included during this data collection period (April – June 2018) and were compared to 20 patients in the non-early mobilisation group. All 20 patients in the early mobilisation group were mobilised but not all the patients reached the target distance of 80-100 metres.

Results showed that the post-operative pulmonary complications rates significantly reduced from 40% to 5% after early mobilisation the day of surgery and the hospital length of stay significantly reduced from 4.95 days to 3.4 days. However, there was no significant reduction in Physiotherapy treatment length.

Early Physiotherapy mobilisation the day of surgery can be an effective and encouraging treatment following lung resection. However, due to small numbers in this evaluation further data collection is required to higher the studies reliability and reduce its variability.

Can a nurse-led approach improve the recovery of patient’s after routine cardiac surgery?Stephen Maurice Royal Papworth Hospital, Cambridge, UK

The Royal Papworth Hospital has a 33 bed Critical Care Unit (CCU) and it was routine for cardiac surgical patients to be admitted to anywhere within these 33 beds. However, this made it difficult to manage their post-operative recovery affectively.

To try and solve this problem, the lead CCU doctors and a team of nurses suggested having a set area of 6-8 beds within the CCU to be set aside for these patients. These patients’ post-operative care would then be managed by a term of nurses, led by a Cardiac Recovery Practitioner, a Band 6 nurse.

A specific training programme, taught by consultant surgeons and anaesthetists, was under taken by these practitioners to enhance and improve their in-depth knowledge.

Guidelines were also drawn up to manage the post-operative recovery of these patients. If the patients’ recovery fell outside these guidelines, then the practitioners would contact the duty surgical registrar for further advice.

The programme has now been running for the last six years and our

findings show that pro-active treatment for these patients within the Cardiac Recovery Unit has led to quicker post-operative recovery and early discharge to the wards for this group of patients (Table 1).

It has also shown new ways of thinking when dealing with this group of patients as nurses must be constantly alert and adjust their strategies to the patients changing needs.

Quantification of collagen deposition in the ventricle of the Greenland Shark – the World’s oldest vertebrateTer-er Kusu-Orkar1, Peter Bernal 2, Peter

Bushnell 3, John Steffensen 4, Holly Shiels 5 1

Aintree Hospital; 2 Indiana University South Bend;

3 University of Massachusetts; 4 Department of

Biology, University of Copenhagen; 5 Faculty of

life sciences, University of Manchester

An exciting discovery in the Artic has the potential to change our perception of ageing, and age-related disease. The potential

500-year lifespan of the Greenland Shark (Somniosus Microcephalus) is not only breathtaking, but questions many theories of ageing and previous understanding of physiology.

I was particularly interested in the fibrosis of the ventricle as this is the most common chamber affected by, and studied in other models of, ageing. I was fortunate enough to be the first researcher to study and describe its tissue.

I will be taking us through my methods of collagen and elastin quantification in which I used picrosirus red and Millers elastin respectively.

The results I obtained through such stringent methods produced findings never described in the ageing process and

although these need to be further assessed, my research provides an initial platform from which other fibrosis studies on the Greenland shark can build upon.

It is important to remember this is an

initial assessment of this ageing model and therefore future studies will need to improve upon various aspects of my research in order to increase the reliability and validity of any results. Although some comparison can be

made with human tissue, this should be done carefully as there has been no direct comparison between both tissues as of yet. Perhaps the Greenland shark can demonstrate that age is nothing but a number.

Tricuspid ring annuloplasty for moderate tricuspid regurgitation at time of mitral valve surgeryHesham Ahmed1, Amr Allama2, Ahmed Dokhan2 1 Menoufia University; 2

Menoufia University Hospital, Al Minufya, Egypt

Objectives

To evaluate tricuspid valve (TV) ring annuloplasty for moderate functional tricuspid regurgitation

(FTR) in patients undergoing mitral valve (MV) surgery.

BackgroundTV ring annuloplasty during MV surgery for severe FTR is recommended but for moderate FTR is controversial.

Methods80 patients with moderate

FTR whom were listed for MV surgery classified into; group A, tricuspid valve annuloplasty (TVA) group included 34 patients who underwent MV surgery and TV annuloplasty and group B, tricuspid valve non repair (TRN), 46 patient who underwent MV surgery alone.

ResultsOne month follow-up. In group

A; no, mild and severe FTR was detected in (70.6%), (26.5%) and (2.9%) of patients respectively. While in group B; no, mild, moderate and severe FTR was detected in (26.1%), (58.7%), (13%) and (2.9%) of patients respectively (P = 0.001). Pulmonary artery pressure (PAP) in group A and group B was 27.2±5.1 mmHg and 31.7±6.8 mmHg respectively

(P = 0.001). Six month follow-up, in group A; no, mild and severe FTR were detected in (64.7%), (32.4%) and (2.9%) of patients respectively, while in group B; no, mild, moderate and severe FTR was detected in (32.6%), (50%), (15.2%) and (2.2%) of patients respectively (P = 0.01). PAP in group A and group B, was 27.6±5.1 and 32.2±7.1 mmHg

respectively (P = 0.003). PAP and RV size were increased risk of persistence and recurrence by OR=1.12 and 1.16; respectively (P <0.05).

ConclusionsIntervention for moderate FTR is recommended during MV surgery to avoid persistence or progression of the TR.


CT Forum (Nurse and AHP) – Cardiac Windsor Monday 11 March 09:50

Pat Magee – SCTS Students Pat Magee abstract presentations Moore Sunday 10 March 14:00

Adult Cardiac – Tricuspid Surgery Abbey Monday 11 March 13:30

Table 1

Number of patients

Mean LOS (hours)

Median LOS (hours)

< 24 hours (%)

24–48 hours (%)

48–72 hours (%)

> 72 hours (%)

Mortality (%)

2011 1274 32.7 21.8 72 16 3 8 0.31

2012 1499 40.1 22.4 65 21 4 10 0.47

2013 1356 35.8 22.6 64 24 3 9 0.22

2014 1285 36.0 22.4 69 20 4 7 0.23

2015 1246 31.6 22.0 72 19 3 6 0.16

2016 1216 32.1 22.4 66 23 5 6 0.08

2017 1070 34.3 23.0 59 28 4 9 0.19

2018 1066 34.5 22.5 64 23 5 8 0.56

Ter-Er Kusu-Orkar, final year medical student, Liverpool

Greenland Shark


Efficacy and Safety of non-vitamin K antagonist oral anticoagulants for patients with atrial fibrillation after cardiac surgery: A retrospective studyDr Rachel Currie, Dr Qian Chen, Mr Nasir Mehmood,

Mr Anthony McCourt, Mr Reuben Jeganathan

Royal Victoria Hospital, Belfast, UK

There is minimal data from clinical trials regarding the use of NOACs following bioprosthetic valve replacement and valve repair. However, the 2017 ESC/EACTS

guidelines for the management of valvular heart disease recommended that despite this, “NOACs can be used in patients who have atrial fibrillation (AF) associated with a bioprosthesis after the third postoperative month.” There is also minimal guidance for use of NOACs with concomitant anti-platelet therapy, in particular, in relation to high-risk patients such as those following coronary artery bypass grafting (CABG).

The primary study outcome was to evaluate safety and efficacy associated with use of NOACs in patients with AF following cardiac surgery by assessing rates of stroke, systemic embolism and major haemorrhage. Secondary outcomes included thromboembolic or bleeding complications that did not fall into the primary outcome group. NOACs were commenced as soon as clinically relevant post-op (most within one week). The study also examined the duration

of inpatient hospital stay compared with patients prescribed warfarin and the effects of concomitant aspirin on outcomes.

Data was collected on a total of 76 patients; 75% male and 25% female, age ranging from 51 to 84 years (mean age 72), with varying renal function, and comparable proportions of both patients with new onset AF and pre-existing. 36 patients (47%) had NOAC as a monotherapy, 40 (53%) had NOAC with aspirin. The majority of procedures were aortic valve replacements (51%), followed by CABG alone (38%) with smaller numbers of MVR, MV and TV repairs and one excision of atrial myxoma.

None of the 76 patients experienced a stroke or systemic embolic event at the time of study. Three (3.9%) of individuals satisfied the criteria of major haemorrhage with a haemoglobin drop of >20 g/l and received two units of blood however one individual did not show evidence of active bleeding. This individual was prescribed aspirin, the other two were not. There was variation in NOACs involved and surgical procedure undertaken. Looking at secondary outcomes, three (3.9%) individuals had minor bleeding, all with different NOACs and surgical procedures. Two were co-prescribed aspirin and one was not. One patient on apixaban without aspirin

sustained a femoral DVT however this patient also had metastatic cancer. The average reduction in the number of inpatient days for the NOACs compared to warfarin group was 1.5 days for CABG, 4.4 days for CABG + valve and 1.7 days for valve operations.

Previous pivotal trials showed the yearly incidence of stroke or systemic embolism with the use of NOACs to be 1.1% to 1.7%. Major bleeding occurred in 2.1%-3.6% patients in the same cohort. The incidence of non-major bleeding ranges from 11.8% to 14.0%.

To conclude, outcomes of our study show that the risk of complications for patients on NOACs commenced within the first three months of cardiac surgery is comparable to the large NOAC trials. Surprisingly the addition of aspirin did not increase the risk of complications. Patients prescribed a NOAC had a shorter postoperative inpatient stay than those prescribed warfarin. We suggest caution when prescribing NOACs and recommend that clear local hospital guidelines are created for their use.

Fibrinogen remains the most significant prognostic inflammatory index amongst five markers in operable primary lung cancerSofoklis Mitsos, S Lampridis, A

Antonopoulos, C Kakos, D Patrini, M

Hayward, D R Lawrence, N Panagiotopoulos,

RS George Thoracic Surgery Department,

University College London Hospital Foundation

NHS Trust, London, UK

Over the past decade, many studies have shown that cancer-related inflammation substantially contributes to the

tumor initiation and progression, cancer metastases, cancer response to therapy, and is related to a poor prognosis in many tumors. The inflammatory response indices fibrinogen, C-reactive protein (CRP), platelets, neutrophil-to-lymphocyte

ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been shown to have a significant impact on the prognosis of various types of cancers. However, the role of preoperative assessment of inflammatory markers as prognostic indicators in lung cancer remain to be established. Hyperfibrinogenemia in particular has been recognised as an independent risk factor for the outcome of primary lung cancer. Patients with lung cancer have remarkably different survival outcomes, even among cases with similar stage and histologic classifications. Numerous promising biomarkers have been evaluated as potential prognosis predictors. The aim of this study was

to evaluate the prognostic significance of plasma fibrinogen, CRP, platelets, NLR, and PLR in patients with resectable lung cancer.

We studied 360 patients who underwent resection for primary lung cancer between 2013 and 2017. Resection was defined as segmentectomy, lobectomy, bilobectomy or pneumonectomy and included systematic mediastinum lymph node dissection.

We showed that patients with NSCLC had significantly higher inflammatory indices values compared to patients with neuroendocrine tumours and the optimal cut-off level for fibrinogen, CRP, NLR and PLR were 4.0g/L, more than 10.0 mg/L,

2.0, and 120, respectively. There was no correlation between survival and platelets counts, however, logistics regression analysis showed significant correlations between survival and the other four indices. Multivariate Cox regression analysis confirmed fibrinogen of more than 4.0g/L to be significantly correlated to survival (hazard ratio = 0.561, 95%CI (0.351-0.896), p=0.016).

We have therefore demonstrated that pre-operative elevated fibrinogen, CRP, NLR, and PLR may be associated with increased mortality with fibrinogen being the only independent prognostic inflammatory factor in patients undergoing surgery for primary lung cancer.

Is obesity associated with poorer outcomes in patients undergoing minimally invasive mitral valve repair?Firas Aljanadi, Matthew Shaw, Ken Palmer, Omar Al-Rawi, Tim Ridgway, Bil

Kirmani, Paul Modi Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool

High body mass index (BMI) can make minimally invasive mitral valve surgery (MIMVS) technically challenging and some surgeons consider this as a contraindication to this technique. The aim of our study was to compare the

clinical outcomes of those undergoing MIMVS stratified by body mass index (BMI).

We included all patients (n=296) undergoing a right mini-thoracotomy approach for Mitral/Tricuspid valve repair ± Cryomaze ± Myxoma resection between March 2011 and September 2018. Data are presented as median (interquartile range) or percentages.

Patients with a BMI ≥30 kg/m2 (range 30-43.6) (group 1, n=41) were compared to those with BMI ˂30 kg/m2 (17.6-29.9) (group 2, n=255).

Comparing 18 pre-operative variables, the only significant difference between the two groups was a higher rate of myocardial infarction in group 1 (9.8% vs 2.0%, p=0.02). There was no significant difference

between the two groups in any intra-operative or post-operative outcomes (group 1 vs group 2, respectively): aortic cross clamp time: 122 (100-141) mins vs 125 (105-146) mins, p=0.72; cardiopulmonary bypass time: 196 (168-214) mins vs 185 (161-211) mins, p=0.46; mortality: 0% vs 0.3%, p>0.99; stroke: no incidence in either group; conversion to sternotomy: 0% vs 2.4%, p>0.99; re-exploration for bleeding : 2.4% vs 4.7%, p>0.99; ICU stay : 3 (2-4) days vs 3 (2-4) days, p=0.34; hospital length of stay: 6 (6-9) vs 6 (5-8) days, p=0.34; and no significant difference in blood products usage, post-operative atrial fibrillation, duration of post-operative ventilation and need for permanent pacemaker.

We concluded that high BMI (up to 44) is not associated with poorer outcomes in patients undergoing minimally invasive mitral valve repair and, in experienced hands, should not be considered a contraindication to this technique.


Thoracic – Pushing the boundaries St James Tuesday 12 March 14:10

Adult Cardiac – Mini Mitral and TMVR Westminster Monday 11 March 15:40

Incidence of outcomes between studies

Study Primary outcomes (%) Secondary outcomes (%)

Stroke or systemic embolism

Major haemorrhage

MI DVT/PE Non-major haemorrhage

ARISTOTLE3 (Apixaban) 1.27 2.13 0.53 0.04 14.03

RE-LY4 (Dabigatran) 1.11 3.11 0.72 0.15 13.16

ROCKET-AF5 (Rivaroxaban) 1.7 3.6 0.9 Not measured 11.8

Our results 0 3.9 0 1.3 3.9

Rachel Currie

Paul ModiFiras Aljanadi


The value of post ICU clinics in a cardiothoracic specialist hospital – are we missing vital concerns?Lisa Davey Golden Jubilee National Hospital, Clydebank, UK

In 2016, the InS:PIRE programme (Intensive Care Syndrome, Promoting Independence and Return to Employment) was scaled up to include a variety of hospitals including the Golden Jubilee National Hospital. InS:PIRE had been established at the

Glasgow Royal Infirmary in 2014 in a general Critical Care unit. As a specialist Cardiothoracic unit, it was hypothesised that it may not translate well within our client group and that we may not encounter similar issues as the fellow InS:PIRE teams. There was also concern of geographical spread and that patients may not return for programme dates as the participants could come from any part of Scotland. Expectations were that physical strength and wound care may be the major concerns.

Patients were selected from Ward Watcher initially dating back to a year post discharge. The search included patients who were ventilated over 72 hours. There were no restrictions placed on gender, age, geographical location or pre-existing health conditions. The participants and their carers would have access to medical and nursing staff, physiotherapy, dietetics, SALT, a clinical psychologist and a member of the third sector. Initially the Cohorts were invited back for 3-4 hours each week over a five-week programme, however we adapted this from Cohort 3 to be three weeks of attendance

from 10-4 with lunch provided and phone contact in weeks 2 and 4. Each week the participants had time to speak to all of the professionals and more importantly each other.

Initially the uptake was of small numbers in relation to the number of invites sent out, however this improved over the two years. Surprisingly the biggest challenge encountered by both patients and carers was psychological. Half of all who attended had experienced some form of delirium and almost all the couples reported ongoing issues with sleep, anxiety/depression or changes in personality. All groups felt they had little to no support in the community post discharge. Swallowing issues were also identified as an ongoing problem for some in each group, though this was not diagnosed during the admission. At each Cohort the Speech and Language nurse discovered silent aspirations in at least 1-3 people per group.

Whilst the InS:PIRE programme is aimed at returning people to employment, we have concentrated on returning people and their families to an improved quality of life. It can be easy to assume that people undergoing elective cardiac surgery would encounter few long-term complications. Our experience has been that Critical Care admissions whether elective or emergency can result in psychological issues to both patients and carers that can

continue long past Critical Care discharge. It has also highlighted that even short periods of intubation can affect patients swallowing more than we realised and in the absence of standardised SALT assessments on all intubated patients this can be ‘missed’ during the entire admission.

Aortic dissection – can medical students diagnose it?Alex Teasdale1, Tamara Ni Hici2, Jeremy

Chan2, Pankaj Kumar2 1 Swansea University; 2

Morriston Hospital, Swansea, UK

Aortic dissection, although relatively uncommon, is a major killer claiming the lives of 1,347 people in England and Wales in

2015 and possessing an overall mortality of 27%.1,2 It frequently presents acutely as a cataclysmic event in the emergency department, however, it was estimated that in 2010, only 1,242 of 3,906 recorded AD events in the UK were admitted to hospital.3,4 The outcome of type A aortic dissection is dependent on early diagnosis and treatment. To increase the chance of early diagnosis it is vital that important risk factors and ‘red flags’ are elucidated and relevant investigations are undertaken. We produced a study aiming to understand how medical students, about to become junior doctors, assess chest pain and

if they consider aortic dissection as a differential diagnosis.

We distributed a survey via SurveyMonkey, to students in their final two years of study across six medical schools (Cardiff, Exeter, Leeds, Manchester, Swansea and UEA) with a mix of graduate, undergraduate, problem-based-learning and case-based-learning courses. Participants worked through a basic, but true, scenario; ’a 42-year-old lady presents to the ED with chest pain’. From this they were asked how they might clerk the patient by giving relevant questions, clinical findings and investigations. This would lead them to suggest the differential diagnoses they felt were most important to consider. The process was then repeated, but they were given a more detailed case with aortic dissection ‘red flags’ (such as ‘tearing’ chest pain, right-left blood pressure differential and a history of hypertension).5

We had 113 participants accepted into

the study and found that students were able to ask relevant questions for aortic dissection, but that the risk factors and examination findings were poorly explored. Unsurprisingly myocardial infarction and pulmonary embolism were the most common differentials. However, less than a third of students included aortic dissection as an initial differential diagnosis, significantly fewer than other conditions with a lower mortality such as gastro-oesophageal reflux disease, pneumonia and musculoskeletal pain. Although, nearly three quarters of students were able to identify the dissection when given red flags, this still served to highlight that a despite its frighteningly high mortality rates, aortic dissection doesn’t get the same level of recognition as other conditions. This could mean that patients with an aortic dissection are more likely to be under-investigated, missed and put at high risk.

We believe the way aortic dissection is currently taught across medical schools

does not place enough emphasis on the severity of the condition and that further education is required to ensure it is being considered as a differential and avoid a missed diagnosis. The study also suggests students are only considering the most likely diagnosis and are not looking to rule out conditions with a higher mortality, however more research needs to be carried out to confirm this and to elucidate the best way of combating the problem.

References

1. Evangelista, Maldonado, Gruosso, et al. 2016. Insights from the Interna-tional Registry of Acute Aortic Dissection. Global cardiology science & practice; 1, e201608.2. Pullinger. Office for National Statistics. 2017. Reply to UK parliament written question 70896. Aortic dissection.3. Howard, Banerjee, Fairhead et al. 2013. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk fac-tor control: 10-year results from the Oxford Vascular Study. Circulation. 21:127(20):2031-7.4. Stephenson. UK parliament, 2017, Written questions 70895. Secretary of state for health’s answer to written question 70895: aortic dissection.5. Black, Manning. 2018. Clinical features and diagnosis of acute aortic dis-section. UpToDate. Retrieved February 17, 2019 from https://www.uptodate.com/contents/clinical-features-and-diagnosis-of-acute-aortic-dissection

The InS:PIRE team at the Golden Jubilee National Hospital


Pat Magee – SCTS Students – Pat Magee abstracts Moore Sunday 10 March 15:30

Effect of prosthesis type on survival in middle –aged patients undergoing aortic valve replacement: A systematic review and meta-analysis

Adult Cardiac – BHVS Session: Aortic valve Westminster Tuesday 12 March 09:50

Alex Teasdale

Charlotte Holmes ST1 cardiothoracic trainee at

the Freeman Hospital, Newcastle

Prosthesis choice in aortic valve replacement (AVR) depends on many factors including patient choice. Mechanical

valves (MV) are chosen for younger patients because of their durability whilst biological valves (BV) are chosen for older patients to avoid anticoagulation. The guidelines for prosthetic choice in patients between 55 and 70 aren’t backed by published reviews.

MethodsSix electronic databases were searched. Studies comparing outcomes after AVR with MV and BV in patients aged 55-70 years were included. Studies not in English, abstracts, case reports, reviews, non-human studies, and studies with incorrect age range or endpoints were excluded. The primary endpoint was survival. Secondary endpoints included: structural valve degeneration (SVD), reoperation, bleeding, thromboembolism and endocarditis.

ResultsThirteen studies were included. Nine found long-term survival comparable. Meta-analysis found no significant difference in overall survival. All studies investigating SVD found the rate to be significantly higher in BV. six studies found reoperation rates comparable. Nine studies found no significant difference in stroke rate. Eight found a significantly higher bleeding rate in MV. Five of seven studies found no significant difference in infection rate. Meta-analysis of secondary endpoints found no difference in overall complication rate.

ConclusionThere is no difference in survival or overall complication rates between BV and MV. Bleeding is a significant complication of MV. Reoperation for SVD is a significant complication of BV. Valve-in Valve Transcatheter implantation as an alternative to reoperation for SVD means the durability of BV may become more of an acceptable risk when trying to avoid anticoagulation related complications.

Charlotte Holmes


Initial experience with segmentectomy for lung cancer using robotic-assisted thoracic surgery and intravenous indocyanine green fluorescence

Styliani Maria Kolokotroni Thorax Centre, St

Bartholomew’s Hospital, Barts Health NHS Trust,

London

Lung segmentectomy has been recognised as a valid treatment option to achieve complete resection and preserve lung

function in early-stage lung cancer. However, segmentectomy can be technically more challenging than a lobectomy in terms of identifying the intersegmental plane. The aim of our study was to evaluate the efficacy of robotic-assisted thoracic surgery (RATS) in addressing the problem of identifying the intersegmental plane during complex anatomical segmentectomy for lung cancer.

Between May 2018 and January 2019, at the Thorax Centre in St Bartholomew’s Hospital thirteen robotic-assisted anatomical segmentectomies were performed. These procedures were performed for peripheral lung tumours using intravenous

indocyanine green (ICG). Five were located in the right lung (S1/2x2, S6x2, S7-10) and eight were left lung (S1-2, S1-3x4,

S4/5, S 7-8, S7-10) using the Da Vinci Xi robot with four ports. Preoperative positron emission tomography standard

uptake value ranged from 0.8 to 17.7 and all lesions were potentially malignant. One case was confirmed as primary lung

cancer preoperatively, and two cases were confirmed as lung cancers intraoperatively by frozen section. ICG (Verdye 5 mg/ml) was injected in a peripheral vein, after the target segmental artery, bronchus and vein had been divided. Using near infrared (NIR) thoracoscopy, the non-targeted perfused segments fluoresced green and the isolated segment remained uncoloured thus clearly identifying the intersegmental plane.

Anatomical segmentectomy was successfully completed in all thirteen patients. Eight were male and five were female, with a median age of 75 years (range 35-84). There was no conversion to VATS or thoracotomy, with a median operating time of 160 minutes (range 122-228). ICG provided excellent demarcation of the intersegmental plane with sufficient duration to facilitate the transection of the segment using robotic endostaplers in twelve patients (92.3%). There were no intraoperative complications and no complications related to the use of ICG. Lung cancer was confirmed in twelve patients with no R1 resection. In one patient, histology revealed non-necrotising interstitial granuloma. Median chest drain duration and hospital stay were two days (range 1-10) and four days (range 3-18), respectively. Two patients developed persistent air leak and there was no perioperative mortality.

The use of RATS with ICG and NIR thoracoscopy is safe, effective and facilitates anatomical segmentectomy by clearly identifying the intersegmental plane.

Left RATS upper lobe trisegmentectomy…

…Post ICG

…Pre ICG

…Stapling tri-segment


Impact of moderate impairment of left ventricular function on short- and long-term outcome after isolated mitral valve surgery for degenerative diseaseVito D Bruno Translational Health Science, University of

Bristol, Bristol Heart Institute, Bristol, UK

The latest ESC/EACTS Guidelines for the management of valvular heart disease recommend mitral valve (MV) surgery for patient with asymptomatic primary

MV regurgitation and left ventricular (LV) function <60% (Class of recommendation I, level of evidence B)1. In the presence of symptoms and a severely impaired LV the recommendations for surgery are less robust and limited only to those who are refractory to medical treatment (Class IIa, Level of evidence C)1. The indications for surgery are even less clearly defined for patients with a moderately impaired LVEF. Therefore MV surgery in reduced left ventricular ejection fraction (LVEF) is still a grey area even because previous research have shown an higher operative mortality2 and worst long-term survival rates2.

With our study we aimed to investigate the impact of moderate impairment of the LVEF (between 30 and 50%) on the short- and long-term outcome after surgery for isolated degenerative mitral valve disease, to better clarify the impact of this surgery on this type of patients. From our internal cardiac surgery database, we selected the patients who underwent isolated mitral valve surgery for primary degenerative disease, and we divided them in two groups based on their LVEF: normal LVEF (group NLV, LVEF > 50%) vs moderate impairment of the LVEF (group RLV, LVEF between 30 and 50%). We evaluated in-hospital mortality, stroke, need for dialysis (NfD), reoperation for bleeding (RfB), length of stay (LoS) and 10-year survival.

Our dataset included 475 patients (mean age 67.3±12 years, female gender 34.1%) with 392 patients (79.7%) in the NLV group and the

remaining 83 patients in the RLV group. In-hospital mortality was 3.8% (2.3% and 10.8% for NLV vs RLV respectively; p = 0.001). Postoperative rates of stroke, NfD, and RfB were 1% vs 2.4%, 0.5% vs 1.2%, and 4.1% vs 3.6% all NLV vs RLV respectively. LoS was 10.7±10.3 days (10.3±10 vs 12.4±11.8 days, NLV vs RLV respectively (p = 0.09). 5 and 10-year survival rates were 85.1% vs 73.1% and 76.4% vs 47.3%, NLV vs RLV respectively (Figure) and were significantly in favour of NLV (p = 0.003).

Our study shows that even a moderate impairment of the LVEF has a negative impact on in-hospital outcomes and long-term survival rates after isolated MV surgery for degenerative disease. Further studies are needed to better identify the patients who would benefit the most from a prompt MV intervention in the presence of reduced LVEF, but these results support an early referral for surgical treatment of severe degenerative mitral valve disease, before the deterioration of LVEF begins.1. 2017 ESC / EACTS Guidelines for the manage-ment of valvular heart disease The Task Force for the Management of Valvular Heart Disease of the Euro-pean Society of Cardiology ( ESC ) and the European. 2017;(December):2739-2786. doi:10.1093/eurheartj/ehx391.2. Haan CK, Cabral CI, Conetta DA, Coombs LP, Edwards FH. Selecting patients with mitral regurgitation and left ventricular dysfunction for isolated mitral valve surgery. Ann Thorac Surg. 2004;78(3):820-825. doi:10.1016/j.athoracsur.2004.04.003.

Early health outcomes and 10-years survival following isolated mitral valve surgery for infective endocarditisVito D Bruno Translational Health

Science, University of Bristol, Bristol

Heart Institute, Bristol, UK

Mitral valve (MV) infections accounts for 35-50% of native infective endocarditis

(IE)1. The mortality rates for medically treated IE can range from 60-90%2 and an effective surgical treatment can greatly reduce the mortality, but the best surgical treatment for MV IE is still debated.

MV repair is currently considered the preferred treatment for

mitral regurgitation and in case of IE has the

advantages to avoid prosthetic devices. Previous studies have shown its feasibility in this setting with good short and long-term results1,3. A very recent meta-analysis suggested that MV repair has

a superior post-operative outcome

compared to MV replacement2 and

similar conclusion were reached

with a

large population-based study4. With our study, we aimed to investigate the short- and long-term results of both techniques in the surgical treatment of isolated MV-IE at our institution over a period of 15 years.

We retrospectively analysed our database and identified 128 patients (mean age 63.3±15 years) who underwent an isolated mitral valve procedure for infective endocarditis: 36 of those patients were treated with a MV repair while the remaining 92 received a mitral valve replacement (31 with biological prostheses and 61 with mechanical prostheses).

The two groups were similar in terms of pre-operative and operative characteristics and had similar surgical times but had dissimilar in-hospital outcomes: in-hospital mortality was 0% in the repair group vs 3.3% in the replacement group. A higher incidence of re-sternotomy for bleeding was also found in the replacement group (2.8% vs 6.5%) and the post-operative length of stay was longer in the replacement group (10.8 ± 7.8 days vs 15.3 ± 13.9 days, p=0.07), while the rates of postoperative stroke and dialysis were similar. Over the long-term follow-up, there was a better survival rates in the repair group compared to the replacement

group with a survival rates at 10 years of 81.5% for the MV

repair group vs 59.6% for the MV replacement group (21.9% for biological and 67.9% for mechanical prostheses).

Our study, although limited by its retrospective nature and the small number of patients, confirms that MV repair can be safely performed in the context of isolated mitral valve IE providing excellent short-term outcomes as well as very good long-term survival rates. When replacing the valve, biological prostheses have a worst long-term survival rate compared to mechanical ones, although this result might be related to the younger population receiving the latter. Although MV repair in an infected mitral valve can be technical demanding and might be difficult to be widely extrapolated, it should be taken into consideration as a valid and effective alternative to valve replacement in patient with isolated IE.

References

1. Doukas G, Oc M, Alexiou C, Sosnowski AW, Samani NJ,

Spyt TJ. Mitral valve repair for active culture positive infec-

tive endocarditis. Heart. 2006;92(3):361-363. doi:10.1136/

hrt.2004.059063.

2. Liu JZ, Li XF, Miao Q, Zhang CJ. Surgical treatment of ac-

tive native mitral infective endocarditis: A meta-analysis of

current evidence. J Chinese Med Assoc. 2018;81(2):147-154.

doi:10.1016/j.jcma.2017.08.017.

3. Rostagno C, Carone E, Stefàno PL. Role of mitral valve repair

in active infective endocarditis: Long-term results. J Cardiothorac

Surg. 2017;12(1):10-15. doi:10.1186/s13019-017-0604-6.

4. Toyoda N, Itagaki S, Egorova NN, et al. Real-world outcomes

of surgery for native mitral valve endocarditis. J Thorac Car-

diovasc Surg. 2017;154(6):1906-1912.e9. doi:10.1016/j.

jtcvs.2017.07.077.


Adult Cardiac – Valve: General Abbey Tuesday 12 March 15:30


Spontaneous breathing thoracic surgical procedures: early experienceStamatia Pispirigkou Department of Thoracic Surgery,

Glenfield Hospital, Leicester, UK

Introduction and methods

Video Assisted Thoracoscopic Surgery (VATS) has been an important minimally invasive tool in the hands of experienced surgeons. On a natural progress, anaesthetic support

has evolved and become equally less invasive. General anaesthesia with single-lung ventilation is considered mandatory for such procedures however associated with complications and challenges particularly in patients with compromised lung function. Thoracoscopic surgery without tracheal intubation is an emerging treatment modality for a wide variety of thoracic procedures. By surgically induced open pneumothorax, the operated lung collapses progressively while the dependent lung is responsible for sufficiency of respiratory function, including oxygenation and ventilation. Spontaneously Breathing Thoracic Surgery (SBTS) offers an option in this cohort of patients.

We have introduced SBTS in our institution since

March 2018. 26 patients (18 male and nine female) with a mean age of 41 years underwent thoracic procedures under spontaneous breathing between March and November last year. Procedures (utilised by two single-port and 24 double-port techniques) included 18 VATS bullaectomies / pleurectomies, while eight patients underwent various different procedures (one EBV removal, three lung biopsies, one LVRS, one anterior chest wall abscess, one re-exploration for haemothorax and one mediastinal biopsy). We used I-gel for the majority of our patients and ETT for two out of 26 only. ASA grades were I (11/26), II (9/26), III (4/26) and IV (2/26). Paravertebral block was also applied to the majority of patients, using anatomical landmarks with single shot injections of 20 ml of Levobubivacaine 0.25% at two levels. Additional intraoperative analgesia was administered (3/26 patients received only Morphine 10 mg, 10/26 received Morphine 10 mg + Paracetamol 1 gr, 9/26 received Morphine 10 mg + Paracetamol 1 gr + NSAID 30 mg of Ketorlac, 3/26 patients received Morphine 10 mg + NSAID 30 mg of Ketorlac while one patient received Paracetamol 1 gr + NSAID 30 mg of Ketorlac).

Results and conclusionsOnly one patient needed a re-operation for air leak, four patients developed minor complications and only one out of 26 experienced more than average for the group postoperative pain. The average hospital stay was 4.846 days while the average recovery time was 79.92 minutes. The average time between the end of the surgical procedure and the transfer to recovery / LMA removal was significantly reduced in comparison to the conventional extubation procedures (5–10 min).

Mean operative time was 101.3 minutes. Mean values of oxygen saturation, peak end-tidal carbon dioxide tension and respiratory rate were 97%, 6.1 KPa and 15 cycles/min respectively. The average pain score in the recovery was 3.9, with an average use of 5.2 mg of morphine PCA in that period. All patients had at least two blood gas analyses with an average PaCo2 of 6.4 KPa.

Our initial experience in Glenfield Hospital has shown Spontaneously Breathing Thoracic Surgical procedures are safe. Our results are consistent with the literature data and the parameters studied are suggestive of improved final outcome.

Experimental study on myocardial protection and aquaporin 7Masahiro Fujii Nippon Medical School

Chiba Hokusoh Hospital, Chiba, Japan.

Background

Aquaporins (AQPs) are membrane water proteins through which water permeates the

lipid bilayer and play a vital role in maintenance of water homeostasis. Thirteen aquaporin isoforms have been identified in mammals. In the heart there are two isoforms. One is AQP 1, aquaporin that selectively transfer water, the other is AQP 7, aquaglyceroporin that transfer glycerol and water. Recently it has been demonstrated that AQP 7 acted as a glycerol facilitator in cardiomyocytes and glycerol was one of the substrates for cardiac energy production. AQP 7 knock-out (KO) mice got obese with increases of fat weight after 12 weeks and also showed insulin resistance in accordance with obesity. Glycerol and ATP content in the myocyte were significantly reduced in AQP 7 KO mice compared to wild type mice. Although AQP 7 gene has been demonstrated the down-regulation in obese patients, it remains uncertain that hyperkalemic cardioplegia, still gold standard for myocardial protection during cardiac surgery, induces the protective effect in the heart lacking AQP 7.

ObjectivesThe purpose of this study was to investigate the cardioprotective effect provided by St Thomas’ Hospital 2 solution (STH2) in isolated AQP 7 KO murine hearts.

MethodsAQP 7-deficient mice (male, C57/BL6), which frozen sperm was provided from RIKEN BRC, were generated and maintained. Isolated hearts from AQP 7 KO mice were aerobically Langendorff-perfused with bicarbonate buffer and pre-ischemic data were measured. Hearts were randomly allocated to each of two groups: the group 1 was the control with 25 minutes of normothermic global ischemia (GI). The group 2 was the STH2 group with five

minutes of STH2 infusion before 20 minutes of GI. Those were followed by 60 minutes of reperfusion. The recovery of function was measured throughout reperfusion and creatinine kinase and troponin T were measured as myocardial injury. The values for heart water content were determined by drying with a microwave oven as myocardial edema.

ResultsRecovery of left ventricular developed pressure (LVDP) in hearts in the control group with time had a slow gradual recovery to a low plateau level. In contrast, hearts in the STH2 recovered rapidly to a significantly higher plateau level 30 minutes after reperfusion. Recovery of left ventricular end-diastolic pressure (LVEDP) mirrored that of LVDP. Myocardial injury in the STH2 group was significantly reduced compared to the control group regarding both Creatinine kinase (IU per gram wet weight) and Troponin T (ng per gram wet weight). There was no significant difference in water content between the two groups.

ConclusionsThis is the first study to investigate a protective efficacy of STH2 in an experimental

preparation of isolated AQP 7 KO murine hearts. We demonstrated the myocardial protection afforded by STH2 even through AQP 7 was absent.

Ten seconds huddle: A new quality improvement measure in thoracic surgeryKakos Christos; Sacramento Jocel; O’Brien Paula; Panagiotopoulos Nikolaos; Lawrence David; Patrini Davide;

Hayward Martin; George Robert University College London Hospitals NHS Foundation Trust, London, UK

Despite the abundance of different safety measures and mechanisms within the NHS, human errors due to lack of effective communication have a significant impact

on the delivery of care. Following a similar human error, which compromised the quality of care delivered, the Thoracic Surgical Unit of University College London Hospitals NHS Foundation Trust took the initiative to propose a new safety mechanism to minimize the burden of human factors in the daily clinical practice.

Therefore, as a quality improvement project we introduced a 10-second per patient post-round huddle (PRH), during which the daily plan for each patient after the ward-round is re-iterated. The primary aim of the project was to eliminate within-staff communication errors. The secondary aims were to examine the integration of PRH by the team members and to boost confidence of each individual to discuss their opinions and raise concerns.

In order to achieve the set targets, a questionnaire (Image 1) was handed out to 26 members of staff in a very busy London Thoracic Surgical Unit before the implementation of PRH to assess the staff’s grasping of the management plan after the ward rounds and their level of confidence to vocalize their concerns regarding the plans. A repeat questionnaire was completed four weeks after the introduction of PRH aiming to re-assess staff’s confidence, and the impact of introducing PRH on the prevention of untoward events, effects on work load, and time management.

Analysis of the answers of the pre-introduction questionnaire revealed that 71% (15 out of 26) of staff were moderately confident regarding the management plan after the ward round as compared to five members of staff (24%) who were absolutely confident. After the introduction of PRH the absolute confidence level has increased three-fold (p<0.001). Similarly, staff’s confidence raising concerns after the introduction of the PRH has significantly increased by more than 3-folds (24% versus 79%, p<0.0001). 68% of the respondents believed that it was time effective. Overall, 100% of the team members were positive about the introduction of PRH, with 63% identifying a positive impact on the management of patients and the prevention of untoward events.

In conclusion, our survey clearly demonstrated that the implementation of PRH was crucial in increasing the confidence of the team members as reemphasizing the ward round plans allowed them to capture every detail regarding patient management. Apart from that, it enabled the staff

to gain confidence to speak up and raise concerns in relation to the management of the patients. The initial concerns that it could pose a burden to the daily routine and further increase the heavy workload, were diminished once we reviewed the replies from the second questionnaire supporting that the majority of the staff were satisfied with the extra time spent for the PRH. It was ultimately accepted by all members of staff. There was indisputable evidence of elimination of within-staff communication errors distinctly validated by the positive influence in the management of patients.


ICU/Anaesthesia – Renal and myocardial protection Wesley Tuesday 12 March 11:40

Thoracic – Miscellaneous Moore Tuesday 12 March 09:50

Kakos Christos

Masahiro Fujii


FEV1/ DLCO vs ERAS: Can Pulmonary Function Tests predict enhanced recovery outcomes?Written by Alexander Hannah, with contributions by

Rohith Govindraj. Study Co-Authors Iain McPherson

and Morag McLellan Golden Jubilee National Hospital in

Glasgow, United Kingdom

Enhanced recovery after surgery (ERAS) practices aim to improve surgical and patient-centred outcomes, utilising a variety of methods which encompass the

entirety of a patient’s surgical journey. Adoption of ERAS practices in Thoracic surgery across UK has resulted in shorter hospital stays and reduced incidence of post-operative complications. A variety of pre-operative factors put patients at a higher risk of complications which in turn limits the benefit achieved by the ERAS practices. Predictive Post- operative (PPO) FEV1 and DLCO are widely used to assess the patient’s risk for undergoing major lung resection surgery. Our aim was to assess the relationship relationship between PPO FEV1/DLCO and success in achieving ERAS goals.

At our based in Glasgow, United Kingdom, we studied 384 patients undergoing lung resection over

a one-year period between July 2017 and June 2018. Data gathered included PPO FEV1/ DLCO, duration of chest drain and length of hospital stay, noting if patients were discharged within ERAS targets. Multivariate binary logistic regression modelling was used to analyse the relationship between pulmonary function tests and post-operative outcomes.

The results showed that PPO FEV1 and PPO DLCO were significant predictors of length of hospital stay, with higher PPO FEV1 and PPO DLCO relating to increased likelihood of discharge within ERAS targets for both the VATS and the thoracotomy groups. These findings illustrate that patients with superior pre-operative pulmonary function test results are more

likely to meet their ERAS goals. Higher PPO FEV1 values were also shown to reduce the risk of drain requirement for a period longer than 72 hours in both groups, which is of significant benefit in efficient patient recovery.

In summary, our data illustrates that a higher PPO FEV1 and PPO DLCO are associated with reduced rates of failure to meet ERAS targets. The currently available pulmonary rehabilitation programs have limited applications in the pre-operative phase of the patient journey, and are mostly used in lung volume reduction procedures. The potential extension of these rehabilitation programs to patients undergoing lung resections may help them to achieve better ERAS results, however, there is a limited time window for this to be completed within. The 62 day cancer pathway, in which a patient needs to be staged, fitness checked and treated, leaves a small window of opportunity to improve their lung capacity. Therefore, pulmonary rehabilitation should be initiated at the very start of the patient journey in order to help an enhance the recovery of those who undergo major lung resections.

Alexander Hannah, Iain McPherson, Morag McLellan, Rohith Govindraj



Adult cardiac – Thoraco-Abdominal aortic surgery Abbey Tuesday 12 March 13:50

Outcomes of emergency re-sternotomy on the intensive care unit following cardiac surgeryAhmed M A Shafi and Wael I Awad Department of Cardiothoracic Surgery, St.

Bartholomew’s Hospital, London, UK

Early following cardiac surgery, patients are at increased risk of complications which can lead to clinical haemodynamic instability and cardiac arrest. The specific causes of cardiac arrest, such as tamponade, hypovolaemia, myocardial ischaemia,

tension pneumothorax, or pacing failure are all potentially reversible. The key to the successful resuscitation of cardiac arrest in these patients, usually on the ITU, is the need to perform emergency resternotomy early, especially in the context of tamponade or haemorrhage, where external chest compressions may be ineffective.

The aim of this study was to investigate outcomes of patientsthat required emergency resternotomy carried out on the ITU following adult cardiac surgery from March 2015 until September 2018 at our tertiary centre, one of the largest in the UK.

During this period a total of 6,570 cardiac operations were performed with only 49 patients undergoing an emergency resternotomy on the intensive care unit, representing 0.75% of the total cases.

Fifteen patients underwent CABG, 13 underwent CABG plus valve operation, seven had a valve operation and 14 patients had other procedures. 31 of the 49 (63.3%) patients had undergone elective surgery. 57% of the emergency resternotomies were undertaken within 24 hours of arrival to the intensive care. The most common indication for resternotomy was a cardiac arrest seen in 29 (59.2%) patients and in this group of patients, there was a 69% mortality. Findings during resternotomy were often acute cardiac tamponade or active bleeding. Survival decreased the greater the duration from arrival on ITU to the resternotomy (54% survival at <6 hours, 33% survival between 6-24 hours and 17% survival from 24-48 hours). Overall 34.7% (17 out of 49) patients left hospital alive post resternotomy and at 1 month only 30.6% (15/49) patients were still alive.

Despite the low incidence of resternotomy on the intensive care unit, these patients have poor outcomes. As many patients may potentially be saved by prompt treatment, ITU staff must be well versed in managing cardiac arrests. Practising protocol-based arrest management has been shown to halve the time to chest reopening and reduce complications in the conduct of the resternotomy after cardiac surgery. Identifying patient’s

haemodynamically deteriorating on the ITU prior to a cardiac arrest may allow earlier intervention and possibly improve outcomes.

Incidence of spinal cord ischaemia in contemporary open thoracoabdominal aortic repair Five-year systematic review toward a meta-analysis.Urszula Simoniuk 1, Simin Li 2, Josephina Hausnschild 2, Konstantin Von Aspern 3, Fabio

Abbondanza 3, David Petroff 2, Michael A Borger3, Aung Oo 4, Christian D Etz 5 1 Bart’s

Hospital /Leipzig University; 2 Leipzig University; 3 Herzzentrum Leipzig; 4 Bart’s Hospital London

Trust; 5 Leipzig University, Herzzentrum Leipzig

Specialised aortic and endovascular teams are dedicating efforts to improving the mortality and morbidity

of thoracoabdominal aortic aneurysm (TAAA). Rapidly developing technology and strategies include staged procedures, motor evoked potentials monitoring, careful perioperative blood pressure control and cerebrospinal fluid drainage (CSFD). It is thus particularly important to assess advances and estimate the contemporary prevalence of spinal cord ischaemia (SCI) and other complications in TAAA repair, but numbers vary wildly in the literature.

ObjectiveIt is difficult to estimate the contemporary prevalence of spinal cord ischaemia (SCI) associated with thoracoabdominal aortic aneurysm (TAAA) surgery since numbers vary wildly in the literature. The present

review examines data from recently published studies reporting on mortality and comorbidity categorised by the Crawford Classification.

MethodsPubMed, Ovid Medline, and Cochrane library were searched for eligible studies published between January 2012 and 2017 containing the keywords: aortic repair, open TAAA, spinal cord protection. The papers were evaluated for consistency in defining outcomes and for completeness in reporting major contributors to variance in SCI prevalence.

ResultsOut of 36 full-text articles assessed for eligibility 11 were included in qualitative synthesis. In total, we inspected 6,772 patients who underwent open TAAA. Only 4,316 patient (five studies) provided

sufficient data for detail analysis of SCI, mortality and morbidity breakdown depending from Crawford classification.

ConclusionsMany papers do not provide a breakdown

of SCI and other major outcomes by Crawford type and urgency status. Omitting such papers from a meta-analysis would lead to uncontrolled bias and one cannot expect to obtain enough data by requesting it from the authors. A meta-

analysis will thus require sophisticated mathematical modelling and several sensitivity and sub-group analyses for verification. Uniform and high-quality reporting standards are urgently required in the field of TAAA repair.


Evaluating the effects of supracoronary ascending aorta replacement with the ross procedure on subsequent aortic root dilatation and aortic valve regurgitation Rachel Steedman1, Asif Hasan2 1 University of

Glasgow; 2 Freeman Hospital

I am currently a fourth-year medical student at the University of Glasgow. In October 2018, I undertook a research project for five weeks with the Freeman

Hospital in Newcastle with the Adult Congenital Heart Disease department. Work was produced looking at the Ross procedure with ascending aorta replacement in comparison to the Ross procedure alone. In the future, we hope to re-audit and look in more detail at the outcomes that were found with the current research.

ObjectivesThe purpose of the study was to find

out if patients undergoing the Ross procedure with supracoronary ascending aorta replacement with a Vascutek graft

will have better post-operative outcomes regarding aortic insufficiency and aortic root dilatation as well as the need for reinterventionwith the neo-aortic root/valve in comparison to patients solely undergoing the Ross procedure.

MethodsA retrospective case review of 202 patients undergoing the Ross procedure (group A) or Ross with Vascutek graft (group B) between 1997 to 2018 was carried out. Data was analyzed from the Ross database which included demographic information, intraoperative data and echocardiogram data. Sixty-three patients were excluded due to online records being unavailable for analysis,

follow-up elsewhere or patients deceased.

ResultsFifty-five patients were children and 147 adults. The primary anatomical diagnosis that was most common was aortic stenosis and isolated aortic valve disease and at the time of operation, the most common finding for valve morphology was a bicuspid valve. Main findings include more re-interventions in group A post procedure, higher severity of regurgitation post-procedure for group B in comparison to A however greater severity of regurgitation and stenosis/dilatation at the patient’s most recent echo for group A. Group A patients also had a worsening group percentage change for severity of regurgitation and stenosis between echoes.

ConclusionThe study shows positive outcomes for the Ross procedure with Vascutek graft due to reduction in post-operation complications. However, in future it would be of benefit to analyse results separately for adults and children due to the differential anatomy and to re-evaluate the service with the addition of the patient’s written notes for extra information. Statistical analysis will also be done in future with this extra information to see if there are positive significant changes regarding post-operative outcomes between the patients who had the Ross procedure and those who had the Ross with supracoronary ascending aorta replacement.

Prosthesis-patient mismatch increases early and late mortality in low risk isolated aortic valve replacement: Time for small aortic annulus multidisciplinary teamWalid Elmahdy Senior Cardiothoracic Fellow, Papworth Hospital, UK

The concept of prosthesis-patient mismatch (PPM) was first described by Rahimtoola in 1978 as follows: “when the effective prosthetic valve

area, after insertion into the patient, is less than that of a normal human valve.” The validated criterion to identify PPM is the effective orifice area of the prosthesis indexed to the patient’s body surface area (EOAi).There remains considerable debate regarding the association between PPM and mortality. However, a large body of literature reported such an association especially with concomitant bypass grafting. Despite a lack of consensus on the issue, surgeons and valve companies remain concerned about the concept of PPM.

In Papworth hospital, we studied the effect of PPM on postoperative and late all-cause mortality after isolated primary AVR in a relatively low risk group of patients ≤80 years of age with preserved left

ventricular function. Between 2008 and 2018, we operated on 1707 consecutive patients fulfilling the criteria, with mean age 69 (+/- 8) years, 45% females, 95% aortic stenosis, 60% hypertension, 18% diabetes, 17% COPD, 5% PVD, 2% CVA, 4% MI, EuroSCORE 5.4 (+/-1.9) and Logistic EuroSCORE 5.1 (+/- 3.5). Biological valves were implanted in 84% of patients, of

whom 30% received a size 19 or 21 valve. Overall in-hospital mortality was 0.8%.

Taking a cut-off point of EOAi of 0.85 cm2/m2, PPM was present in 96 patients (5.6%). PPM occurred more frequently in females and older patients. In the PPM group, 67.4% received 19 or 21 size valves compared to 27.7% of No-PPM patients. The effect of PPM on mortality was evaluated with univariate and multivariate regression analyses. Despite the low overall In-hospital mortality, PPM patients had a significant increase in mortality 4/96 (4.2%) compared to No-PPM group 9/1611 (0.6%) (P=0.005).

Ten-year all-cause mortality was 290/1707 (17%). The survival curves separated early and the difference increased significantly for PPM in out to 10 years, with more than two fold increase in relative mortality in the PPM group (37.5%) compared to the No-PPM group (15.8%) (P <0.001). PPM was highly predictive of mortality (median 4 years [IQR 2-7]; HR: 1.79, 95% CI: 1.27–2.55, P=0.002) [Figure 1], and remained strongly and independently predictive after adjustment for other risk factors (HR: 1.56, 95% CI: 1.09–2.24, P=0.015).

We conclude that PPM increases in-hospital mortality and is an independent predictor of late all-cause mortality after primary isolated AVR operations. In the current era with increasing implantation of stented biological valves, there’s a rising demand for a well-structured system to preoperatively detect small aortic annulus through imaging, predict PPM from EOA reference tables, discuss in “small aortic annulus multidisciplinary team (MDT)” meetings to explore available options to prevent PPM. These include newer-generation valve designs, mechanical valves with lower target INR, aortic root enlargement, sutureless valves, stentless valves and TAVI, all potentially offering larger EOA.

Predicting surgical site infection with the new Barts Surgical Infection Risk (B-SIR) toolRosalie Magboo Senior Sister, ACCU,

Barts Heart Centre, St Bartholomew’s

Hospital, London, UK

Surgical site infections (SSI) are serious complication after any surgical procedure. They account

for 20% of all the healthcare-associated infections and are considered the second most frequent type of hospital-acquired infection (HAI) in Europe and the United States.1,2 SSI affects approximately 3.6% of the patients following cardiac surgery.3 Although SSIs are among the most preventable HAIs, they represent a significant burden in terms of morbidity, mortality and additional costs to health care system.

Risk assessment has been recommended to be useful in identifying at risk populations who may benefit from targeted interventions to reduce this possible

complication of cardiac surgery. Several SSI risk stratification tools exist, such as the National Nosocomial Infection Score (NNIS), Australian Clinical Risk Index (ACRI) and Brompton and Harefield Infection Score (BHIS), but they have several limitations. For example, the NNIS risk index was traditionally used to provide procedure-specific risk-stratified SSI rates to hospitals. It categorises patients according to their infections in terms of American Association of Anaesthesiologists (ASA) score, wound type and duration of surgery. Most of the patients who undergo cardiac surgery, however, have ASA scores greater than three and clean wounds; hence, this index only dichotomised these patients on the basis of the procedure duration.4 New methods of predicting and stratifying SSI risks in cardiac populations were then developed including ACRI and BHIS. They both have good predictive power in comparison with the NNIS

risk index.5,6 Both these tools, however, were developed in post coronary artery bypass graft (CABG) patients and it is unclear whether they can be applied to another patients’ group. Further, it has been recognised that risk profile assessment may vary according to each institution’s patient populations.7 These led to an interest in the development and validation of a new risk tool to improve on existing tools.

The development of the B-SIR tool was conducted at Barts Heart Centre using prospectively collected existing local data obtained from the National Institute of Cardiovascular Outcomes Research (NICOR), Intensive Care National Audit and Research Centre (ICNARC) and Public Health of England. From the study, six independent predictors of SSI were identified in our patients’ cohort, including: gender, increased body

mass index, diabetes, peripheral vascular disease, left ventricular ejection fraction <45% and operation type. We also found that the B-SIR tool improves the predictive power for the risk of SSI in the study sample. Figure 1 shows that the area under the Receiver Operating Characteristics (ROC) of the B-SIR

tool is greater in comparison with the existing validated tools indicating that it has a higher discriminatory ability in detecting the risk of SSI after cardiac surgery. Although this finding will need to be tested in other patient populations, it has broken new ground in terms of developing a scoring system that

is more sensitive and specific than those currently available.

References:

1. Surgical site infections: prevention and treatment | Guidance and guidelines | NICE. [cited 2018 Nov 29]; Available from: https://www.nice.org.uk/guidance/cg742. WHO | Global guidelines on the prevention of surgical site infection. WHO. 2016;3. Figuerola-Tejerina A, Rodríguez-Caravaca G, Bustamante-Munguira J, et al. Epidemiological Surveillance of Surgical Site Infection and its Risk Factors in Cardiac Surgery: A Prospective Cohort Study. Rev Española Cardiol (English Ed [Internet]. 2016 Sep 1 [cited 2018 Nov 29];69(9):842–8. Available from: https://linkinghub.elsevier.com/retrieve/pii/S18855857160012864. Roy MC, Herwaldt LA, Embrey R, et al. Does the Centers for Disease Control’s NNIS system risk index stratify patients under-going cardiothoracic operations by their risk of surgical-site in-fection? Infect Control Hosp Epidemiol [Internet]. 2000 Mar [cited 2018 Nov 7];21(3):186–90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/107389875. Friedman ND, Bull AL, Russo PL, et al. An alternative scoring system to predict risk for surgical site infection complicating cor-onary artery bypass graft surgery. Infect Control Hosp Epidemiol [Internet]. 2007 Oct [cited 2018 Nov 7];28(10):1162–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/178286936. Raja SG, Rochon M, Jarman JWE. Brompton Harefield Infection Score (BHIS): Development and validation of a stratification tool for predicting risk of surgical site infection after coronary artery bypass grafting. Int J Surg [Internet]. 2015 Apr [cited 2018 Nov 7];16(Pt A):69–73. Available from: http://www.ncbi.nlm.nih.gov/pubmed/257016167. Crabtree TD, Codd JE, Fraser VJ, et al. Multivariate analysis of risk factors for deep and superficial sternal infection after coronary artery bypass grafting at a tertiary care medical center. Semin Thorac Cardiovasc Surg [Internet]. 2004 [cited 2018 Nov 7];16(1):53–61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15366688

Figure 1

Congenital – Congenital Abstracts Rutherford Monday 11 March 14:20


CT Forum (Nurse and AHP) – Quality and Safety Windsor Monday 11 March 16:10

P=0.002

Fig. 1 Comparison of the predictive

power of B-SIR model and the NNIS, ACRI and BHIS models in

predicting surgical site infection (SSI) on the

sample population after cardiac surgery


The versality of the robot to get to the difficult spots of the chestSasha Stamenkovic Consultant Thoracic

Surgeon, Director of Robotic Surgery, Barts

Thorax Centre, St Bartholomew’s Hospital,

London, UK

This seemed to be a case akin to that 80’s advert of something reaching those parts that no other product

can reach. The patient was a well bank manager who had a small lung mass found on CT coronary angiogram wrapped around her left lower lobe pulmonary artery. She had self-referred out of region after an inconclusive endobronchial ultrasound and being told that hat she would need a lung resection possibly a pneumonectomy due to its position.

She came to Barts Thorax Centre for the possibility of a robotic solution. The video shows that the robot (da

Vinci Xi, Intuitive, Sunnyvale, California) gave the

best magnified vision and articulation resulting in the lesion being found wedged between the artery in front, the bronchus behind, and the lung around. Careful teasing of the tissue planes with a precise two-

handed articulated approach (Bipolar fenestrated left, Cadiere

right, 30 degree down camera) allowed the lesion to be gradually

freed from its surrounding tissues, using bipolar diathermy and being able to see the instrument tips at all times.

The mass was found to be a very abnormal looking bumpy

lymph node not involving

lung at all with a clear capsule but embedded

into the parenchyma. It is clearly a very delicate matter operating behind a pulmonary artery, which is cells-thick. The magnification and the gain on the robotic console set at fine meant that within a 5x5 cm visual field we had the best possible conditions to get this mass out without harm to the patient. She left hospital Day 2 but decided to stay and sight-see in London with her husband.

The pathologists had a hard time with this also and eventually had to settle on calling it exactly what it looks like in the video- a very abnormal lymph node. Follow-up CT has not shown any cause for concern. Needless to say the patient is delighted that she has had a tiny-hole operation and did not need any lung removed.

Robotic resection of the chest wall and lung inside-out allows patient her dream holiday

Sasha Stamenkovic Consultant Thoracic Surgeon, Director of

Robotic Surgery, Barts Thorax Centre, St Bartholomew’s Hospital,

London, UK

When a patient has a lung tumour invading two or three ribs only, then the resulting en-bloc lung and chest wall resection could come out using a minimally-

invasive approach from the inside-out. The author had already resected a third right rib for a metastatic cholangiocarcinoma using a robotic technique (da Vinci Si, Intuitive, Sunnyvale, California) in Newcastle and the bone scalpel (Misonix, Farmingdale, NY, USA), meaning no axillary or breast trauma would be caused.

Extrapolating this to the lung cancer patient in Barts Thorax Centre, an Xi-robotic stapled division of the lung well-medially to the cancer was performed to allow better vision. Then the hook monopolar diathermy was used to score and dissect out the peripheral margins of the chest wall resection. Once the bone has been mobilised, the bone scalpel was deployed to slice through the ribs laterally and medially. The scalpel is water-cooled and oscillates at a speed that only allows bone cutting, slicing through like a butter knife, with the intercostal bundle unaffected. The lung was anatomically resected with a totally-endoscopic robotic technique en-bloc and was removed in a bag through a slightly enlarged incision.

The chest wall did not need reconstruction as the scapula provided that protection, but a mesh could have easily have been clipped into place if the defect was more lateral. The patient went on a holiday for three weeks to Malaysia after being discharged on day three and is currently undergoing chemo-therapy.

Chest wall invasion of lung tumour

Chest wall after removal of ribs

Video Presentation – Video Displays Exhibition Hall Monday 11 March



Fissure being dissected to excavate mass behind PA to lower lobe

Right instrument scoops behind PA branch to lower lobe, and dissecting it off the bronchus while left retracts

Physicians’ assistants (anaesthesia) join cardiothoracic national organ retrieval serviceLorraine Fingleton Trainee Physicians’ Assistant in

Anaesthesia & Donor Care Physiologist, Papworth Hospital

NHS Foundation Trust, Cambridge, UK

Productivity within Royal Papworth Hospital has been steadily increasing throughout the years with the development of new and innovative procedures. Unsurprisingly the

demand for anaesthetic resources has also increased, not only for general anaesthesia but also regional anaesthesia and sedation. With the role of Physicians’ Assistant- Anaesthesia (PAA) well established in general surgery, Royal Papworth Hospital commissioned a pilot initiative designed to assess if the role of PAA could be successfully expanded to reinforce the current medical anaesthetic team and complement the specialist areas of cardiothoracic surgery and cardiothoracic organ retrieval in a cost-efficient manner.

The successful candidates for this pilot program had extensive experience as either a Senior Band 6 Anaesthetic Nurse or Operating Department Practitioner. They each enrolled in to the full-time, Physicians’ Assistant (Anaesthesia) Postgraduate Diploma course in Birmingham University. This course involved 24 months of distance learning covering modules such as applied physics, anatomy and physiology, fundamentals of general anaesthesia and advanced practice. Weekly tutorials delivered by

Consultant and fellow Anaesthetists supported the University modules, whilst teaching on the specialist topics of cardiothoracic surgery and cardiothoracic organ retrieval was supplemented by the surgical team. The PAA-DCP students attended 30 hours per week of clinical placement between Royal Papworth Hospital and a local General Department Hospital to develop their skills and knowledge (table 1) in addition to regular shadowing of Donor Retrievals

and Scouts. Further skills such as Transoesophageal Echocardiography & bronchoscopy were also achieved during the training period.

Having successfully passed their University examinations alongside additional local competencies designed for the specialist areas, the trainee PAAs currently await University exam board ratification to confirm their status as qualified PAAs’. They work a 60:40 role split encompassing their anaesthetic duties

in theatres, interventional cardiology and anaesthetic pre-operative assessment clinic, alongside cardio-thoracic organ retrieval. Within the anaesthetic team, the PAAs will work in either a 2:1 model with two PAAs in adjacent rooms supervised by one Anaesthetic Consultant, or a 1:1 model where a PAA works directly alongside the Consultant, depending on patient acuity. The specialist training surrounding cardiothoracic organ retrieval has also allowed the PAAs to successfully integrate into the Transplant team as Donor Care Physiologists (DCPs) supporting the National Organ Retrieval Service. Their role as a DCP allows them to work as independent practitioners undertaking invasive and complex investigations of potential organ donors, enhancing donor optimisation and providing donor care support during organ retrieval in trusts around the country.

The aim of creating a unique group of highly trained staff to complement both the anaesthetic and donor retrieval teams has been successful. The combined PAA-DCP presence within this trust has already created increased availability for both anaesthetic and donor care physiologist cover, and therefore provides a valuable service improvement. The trust endeavours to provide ongoing support for the development of the roles to create a strong, reliable PAA and DCP team whilst continuing to provide the most beneficial and efficient service for our patients.

Table 1: Total number of invasive lines inserted by one PAA- DCP student during training


Has TAVI influenced the choice of prosthesis in SAVR?Saleem Jahangeer Aortic Surgery

Fellow, St Bartholomew’s Hospital,

London, UK

TAVI is currently an established intervention for aortic valve disease.

The recent technical and technological refinements in the field of TAVI have seen an increase in the number of valve-in-valve TAVI (ViV TAVI) being successfully performed. This has led to a new emerging paradigm; should younger patients be offered a biological valve with a subsequent ViV TAVI to avoid both anticoagulation and re-operation?

Our aim was to determine whether TAVI has influenced the choice of surgical prosthesis in patients undergoing surgical AVR. St Bartholomew’s Hospital is both a high volume surgical AVR centre and TAVI implanters in the U.K. We are currently the highest TAVI implanters in the country, with over 390 procedures performed last year alone.

From 2004 to 2018, all patients undergoing

surgical aortic valve replacements were reviewed. We also looked at the number of TAVI performed at our institution over the same time period. The average age at implantation of both biological and mechanical prosthesis were reviewed and compared between the pre TAVI (2004 – 2010) and TAVI era.

A total of 8069 aortic valve replacements were

performed. 69.4% (n=5620) had a biological valve implanted. The mean age of patients receiving a biological valve remained above 70 years in both the pre-TAVI and TAVI era (Figure 1). Moreover, the ratio of biological to mechanical prosthesis has not increased over the studied time period (Figure 2). While there have been major improvements in TAVI

procedures and outcomes, there are still technical limitations with regards to ViV TAVI. We do not currently advocate choosing a biological prothesis in younger patients with a subsequent ViV TAVI strategy. Despite the popularity and availability of TAVI at our institution, this has not influenced the choice of SAVR prosthesis.

Lower mortality and complication rate in off pump vs on pump CABG over a five-year period at Kings College Hospital LondonAneel Zaheer, Muhammad Nadeem Anjum, Donald

Whitaker, Ranjit Deshpande, Lindsay John, Alia

Noorani, Olaf Wendler, Max Baghai Kings College

Hospital – London

Objective

In our study we compare clinical outcomes of patients undergoing coronary revascularisation using an ‘on pump’ versus an ‘off pump’ technique at

Kings college hospital. Out of the six surgeons whose data we have looked into, two surgeons are specialised in performing off pump CABG via both a median sternotomy and an endoscopic assisted mini-thoracotomy. Our objective is to compare the incidence of postoperative stroke, renal failure, rate of coronary revascularisation and mortality in the two groups having CABG at our institute.

MethodsWe collected data for 2,221 patients undergoing coronary revascularization for last five years using our PATs database system looking

at incidence of postoperative stroke, renal failure and in hospital mortality in both on pump and off pump CABG. We also looked at the need for revascularization, either as percutaneous coronary intervention or redo surgical revascularization for the patients in both the on pump and off pump groups.

Almost a quarter of our surgical revascularization was performed using

an off-pump technique, both for single as well as multivessel coronary artery diseases. This has been fairly consistent in our practice for the last five years.

ResultsA total of 2221 patients were included, of which 522 had off-pump and 1699 underwent on-pump CABG. The off-pump group had a higher mean log euroscore of 4.58 vs 3.54 in the on-pump group. This was mainly due to higher proportion of patients with previous stroke and renal failure in the off-pump group. Our results showed that the incidence of new stroke in off pump group was 0.9% versus 1.4% in on pump group of patients. The incidence of new renal failure was also less in the off-pump group (0.7%) versus the on-pump group (2.9%). Mortality was also low in Off pump CABG group as compared to on pump CABG group. We also compared the revascularization rate in both groups for the last four years which showed that less pts in off pump group had revascularization as compared to pts in on pump group following CABG.

ConclusionOur review of our five-year data showed that despite of a higher risk cohort of patients in the off-pump group, they appear to have better survival outcomes with less incidence of new stroke, renal failure and lower revascularization rate as compared to the on-pump group.

Determining the clinical significance of an international expert consensus for multiple rib fracture taxonomy

Figure 1: Average age of implantation of surgical valves Figure 2: Ratio of biological to mechanical valves implanted.

On- vs Off-Pump Procedures[2013/18, five-year]

Caption

Adult cardiac – Mini AVR and TAVI Abbey Tuesday 12 March 12:00

Adult Cardiac – Arterial and off-pump CAGB Westminster Tuesday 12 March 15:30

Thoracic – Chest wall surgery St James Monday 1 March 09:10

Peter Clarke

University of Sheffield, Sheffield, UK

In 2006, the thoracic surgeons in Sheffield commenced a programme of Surgical Stabilisation of Rib Fractures

(SSRF) using plate and screw fixation, presenting initial results at the SCTS Annual Meeting 2009. Having collected and presented prospective data to many educational meetings, in 20015 the Sheffield Multiple Rib Fractures Study (SMuRFS) was created, giving opportunities to full time intercalated BMedSci medical students for different year-long research projects. The work presented this year is from the fourth such project

At the 2019 SCTS annual meeting work entitled “Determining the clinical significance of an international expert consensus for multiple rib fracture taxonomy” will be presented by Peter Clarke.

The project started by gaining an international consensus for multiple rib fracture definitions to increase

standardisation within clinical practice and research fields. The Delphi consensus survey was carried out on behalf of the Chest Wall Injury Society (CWIS). CWIS aims to optimise both the operative and non-operative care of the patients with chest wall injury and consists of members from many disciplines from around the world.

The international Delphi consensus process, which involved 113 surgeons from 18 countries worldwide, proposed 14 definitions. Nine recommendations were made with five definitions requiring further investigation. Whilst there may be broad applicability both clinically and in research, validation using a clinical database had not yet been performed. The present study aimed to validate the CWIS taxonomy against retrospective radiological scoring data and patient outcomes.

A continuous retrospective cohort of MRF patients were identified. CT scans were assessed in details for 539 patients and every fracture (n=3,944) coded according to all the different

the consensus criteria. Cases were also matched to Hospital Episode Statistics (HES) data. The available data was then analysed for each consensus definition in turn to identify any clinical significances.

Four consensus definitions and three no-consensus proposals were associated significantly with clinical outcomes. Clinical outcome assessment proved inconclusive for five agreed definitions and frequencies were too low to allow for statistical testing of one no-consensus definition. These require further investigation for the agreement of consensus to be possible.

We demonstrated that the rib fracture taxonomy agreed by the CWIS international consensus does demonstrate clinical relevance and recommendations can be made for seven definitions based on the clinical outcomes observed. We hope that the consensus definitions will gain wider acceptance within the field in order to improve communication both clinically and in future research.


LVRS: Improvement in lung function and mortality significantly reduced in recent practiceBrianda Ripoll1, Abraham Nash1, Giuseppe

Aresu1, Adam Peryt1, Jasvir Parmar2, Ravi

Mahadeva3, Aman Coonar1 1 TAISER group,

Thoracic Surgery, Royal Papworth Hospital; 2

Chest medicine & Transplant, Royal Papworth

Hospital: 3 Cambridge COPD centre

There remains debate as to the optimal treatment for patients with emphysema. For example, standard management of

emphysema entails smoking cessation, pharmacological treatment with bronchodilators and anti-inflammatory drugs, treatment of exacerbations, supplemental oxygen and rehabilitation. In some patients with emphysema medical therapy is has been shown to be inferior to lung volume reduction surgery.

The NETT study reported a mortality of 7.9% at 90 days and from that data we estimated a19% mortality at one year.

Our LVRS programme has been in two main phases. Between 1998-2007 procedures were mostly open and sometimes bilateral. Between 2008-2018

the programme has been based on staged unilateral VATS, enhanced recovery and from 2015 selection has been by MDT with pre-optimisation. VATS techniques and technology have improved.

We were interested in evaluating our performance.

Retrospective review was performed on 209 cases that underwent surgery since 1998.

Primary outcomes analyzed were 30-day, 90-day and one-year mortality rates.

Secondary outcomes (pulmonary

function, BODE, 6MW, MMRC, CAT and St.George’s Respiratory Questionnaire) were analyzed for pre and post LVRS change in mean. Analysis was done with SPSS.

Compared to the period of 1998-2007, there has been an improvement in the death rate in the period of 2008-2018 of 3.6% at 30 days, 7.2% at 90 days, and 9.1% at 1-year mortality (p<0.05). Our more recent performance is also superior to the NETT investigation.

Compared to baseline,%FEV1 increased (29.0 ± 10.5 vs 35.8 ± 14.2, respectively; p<0.05) while residual volume (mls) significantly decreased (211.6 ± 45.8 vs 173.6 ± 49.0, respectively; p<0.01) at 3 months post-LVRS. On six minute walk testing, values increased from baseline to post-LVRS in metres (297.2 ± 98.2 vs 323.4 ± 105.8, respectively; p<0.05), while BODE decreased (5.6 ± 2.0 vs 2.9 ± 3.8, respectively; p<0.05)

In summary, in an emphysema population, many with marked frailty, we have demonstrated an improvement in

objective patient related outcomes.We have also shown that MDT selection

and staged unilateral VATS LVRS with

intensive peri-operative management in an experienced centre is relatively safe and effective.

Recovery from intensive care unit-acquired weakness following aortic valve surgeryAshley Thomas Charge

Nurse in Adult Critical

Care and PhD Student, St

Bartholomew’s Hospital, Barts

NHS Trust, London, UK

Critical illness survival rates over the past 20 years have

dramatically increased leading to a paradigm shift, where the new focus is on recovering from the injurious effects caused by Intensive Care Unit Acquired Weakness (ICUAW). ICUAW is a multifactorial catabolic process associated with increased patient mortality and morbidity, with patients undergoing elective cardiac surgery losing significant muscle mass (9.6% in the wasters group). Despite the new focus, there remains little evidence on the effects of ICUAW on recovery (including functional ability and health-related quality of life (HRQoL)) after cardiac surgery.

Our aim for project VARIANCE is to investigate determinants of recovery from ICUAW and to discover its effects on physical function, strength, and HRQoL post aortic valve replacement (AVR).

Over the last decade, common imaging technologies such as ultrasound (US) have become an emerging interest in understanding the underlying mechanisms of muscle atrophy within the critically ill patient. The US of the Rectus femoris (RFcsa) is an effort-independent and radiation-free method of measuring the quadriceps muscle and therefore quantifying muscle loss in ICUAW. In our project we have utilised this technology and combined it with assessments of functional ability (Hand and Knee

dynamometry, spirometry, fat-free mass index and short physical performance battery) and HRQoL (EQ5D-5L, HADS and Reintegration to Normal Living Index questionnaires) to build a holistic view of the patient recovering from cardiac surgery and potentially ICUAW. Additionally, the RFcsa images will undergo histogram analysis to investigate pixel intensity, enhancing our data (Figure 1).

We will also be collecting muscle biopsies, blood and urine to better understand mediators of muscle

homeostasis and genomic profiles. The collaborative data should allow us to split the patients into those that have recovered well and those who have recovered poorly; understanding potential up-regulated molecules and predisposing factors in the development and recovery of ICUAW. Most of the data will be collected pre-operatively, on day 7 or hospital discharge and during the 6-week follow-up clinic.

Participant recruitment began on the 11th of February 2019. However, in the first year, we have

refined our ultrasound technique and methodology, ensuring it is reproducible and accurate. We have concluded that 70% from the anterior superior iliac spine to the superior patellar border is optimal for probe placement and therefore RFcsa quantification (Table 1).

As a first-year nursing PhD student, I have experienced challenges while setting up project VARIANCE including; the transition from clinical practice to research, becoming an autonomous worker, effective time management and academic expectations. I have been taught invaluable techniques and strategies to help me overcome these challenges however, such as prioritising tasks based on their urgency, importance and significance to the PhD. Furthermore, I feel privileged to be one of the few allied health professionals undertaking a research project as part of a PhD programme.

Our research aims to identify determinants of recovery from ICUAW using a subclinical cardiac surgical model. Exciting times lay ahead for us, as we embark on the research, assessing muscle loss, physical function and HRQoL post AVR.

References

1. Bloch SA, Donaldson AV, Lewis A, Banya WA, Polkey MI, Griffiths MJ, et al. MiR-181a: a potential biomarker of acute muscle wasting following elective high-risk cardiothoracic surgery. Crit Care. 2015;19:147.2. Bloch SA, Lee JY, Wort SJ, Polkey MI, Kemp PR, Griffiths MJ. Sustained elevation of circulating growth and differentiation factor-15 and a dynamic imbalance in mediators of muscle homeostasis are associated with the development of acute muscle wasting following cardiac surgery. Crit Care Med. 2013;41(4):982-9.3. Bloch SA, Lee JY, Syburra T, Rosendahl U, Griffiths MJ, Kemp PR, et al. Increased expression of GDF-15 may mediate ICU-acquired weakness by down-regulating muscle microRNAs. Thorax. 2015;70(3):219-28.4. Sanders, J, Keogh BE, Van der Meulen, J et al. The development of a postoperative morbidity score to assess total morbidity burden after cardiac surgery. J Clin Epidemiology, 2012;65:423-335. Seymour JM, Ward K, Sidhu PS, Puthucheary Z, Steier J, Jolley CJ, et al. Ultrasound measure-ment of rectus femoris cross-sectional area and the relationship with quadriceps strength in COPD. Thorax. 2009;64(5):418-23.

Dedicated wound and drain clinic improves patient experience and relieves cardiothoracic wards from significant service disruptionAmy Bradburn [United Kingdom], Sarah

Mattinson, Sion Barnard, Faruk Ozalp, Ali

Kindawi Newcastle upon Tyne Hospitals1

Objectives

An audit highlighted a high number of discharged cardiothoracic surgical patients attending the ward for wound or

drain care. This caused significant service disruption and often long waiting times.

A weekly clinic was set-up to address this and investigated with an audit of its performance, together with feedback from patients and staff.

MethodsProspective data was collected regarding Clinic activity including caseload and types of tasks performed. The amount of chest drains which were removed, potentially savings days of hospital beds

was calculated. Additionally, patient (21) and staff (40) feedback was sought via questionnaires.

ResultsWard attendances reduced to occasional episodes for urgent problems and patients’ convenience only. The Clinic was used by 191 patients with 376 attendances. Thirty-eight ambulatory chest drains were removed from 3-47 days post-

discharge, potentially saving 451 days of hospital beds.

Patient and staff feedback was overwhelmingly positive. A high percentage of patients (95.2%) stated they had a very good or good Clinic experience. Additionally, 100% of staff stating that the Clinic is necessary.

Although, many staff (52.5%) expressed their feeling that further improvement might be possible.

ConclusionnService disruption on the cardiothoracic

wards was minimised.nHospital stay could be reduced.nOverwhelmingly positive feedback by

patients and the healthcare team.nFurther fine tuning may be required to

improve the Clinic.nA dedicated multi-professional approach

helped establish what has become a fundamental part of our care.

Caption

Thoracic – Emphysema St James Monday 11 March 14:00



Brianda Ripoll Aman Coonar

Figure 1: Comparison of Healthy volunteer (HV) and patient (ICUAW) in B-mode ultrasound and rectus femoris (RF) echogenicity.

(VL, vastus lateralis; VI, Vastus intermedius; VM, vastus medialis). Dashed blue line traces the RF outline.

Values given by mean [standard deviation] n=10. (ASIS, anterior superior iliac spine; SPB, superior patellar border; U/A, unable to achieve.

Table 1: Rectus femoris cross sectional area (RFcsa) at progressive distances from 50% – 90% in healthy volunteers measured by ultrasound.

Distance ASIS to SPB (%) 50 60 66 70 80 90

RFcsa (left) U/A 4.63 [1.00] 3.92 [1.37] 3.47 [1.22] 0.97 [0.43x] U/A

RFcsa (right) U/A 3.62 [0.60] 2.96 [0.85] 3.56 [1.61] 1.16 [0.64] U/A

Accessible views (left and right) (L) 0/10(R) 0/10

(L) 4/10(R) 3/10

(L) 6/10(R) 4/10

(L) 9 /10(R) 8/10

(L) 9/10(R) 9/10

(L) 0/10(R) 0/10


Severe acute kidney injury after cardiac transplantation is a marker of poor early outcome and impacts on late renal function – a UK cohort studyHaemofiltration after lung transplantation is a marker of poor early outcomes but has no deleterious long-term renal effect – a UK cohort study

Lu Wang ST2 ACF Cardiothoracic Surgery,

Freeman Hospital, Newcastle, UK

The first successful heart transplant in the UK was performed in 1979, and first successful pulmonary transplant followed 7 years later.

The UK Transplant Registry has collected very complete records for cardiothoracic transplant recipients since 1995, on about 7,000 adult patients now.

From the start, renal function has been a concern, because of the nephrotoxic effects of the Calcineurin antagonist group of drugs that are fundamental to controlling rejection. However, in addition, many patients, particularly those receiving lung transplants, have a period of early instability related to primary graft dysfunction, when haemofiltration is an essential part of treatment. It is well established that the need for haemofiltration for acute kidney injury (AKI) post general cardiac surgery, even if there is a rapid recovery afterwards, is a marker for reduced late renal function – the acute injury carries a long-term burden.

With haemofiltration being used frequently after transplant surgery, we sought to determine if it was also a predictor of later problems in this set of patients, something not previously investigated.

From April 1995 to March 2017, 3,365 adults underwent heart transplant and 2929 underwent lung transplant in the UK. Their age, gender, pre-op heart/lung pathology, and diabetes mellitus (DM), survival status, peri-op renal function and post-op haemofiltration of these patients were retrieved from the UK Transplant Registry. Serum creatinine of these patients was measured immediately pre-op, three-month post-op, and annually afterwards in the follow-up clinics. We used multivariable Cox regression to study the risk factors associated with mortality and development of stage 4/5 chronic kidney disease (eGFR < 30).

26.0% of the heart recipients and 16.6% of the lung recipients developed post-op haemofiltration dependent AKI. Their one-year survival and five-year survival were strikingly worse than that of the non-haemofiltration group (Figures 1 and 2). This is because of the link between early graft dysfunction, a life-threatening complication, and the need for renal replacement therapy. Interestingly, long-term renal function of the haemofiltration

group in the heart transplant cohort declined faster than that of the non-haemofiltration group, but a similar phenomenon was not observed in the lung transplant cohort.

Through these two studies, we confirmed that post-transplant haemofiltration is a significant risk factor for post-transplant mortality, early after transplant. For heart recipients, as predicted in the studies in non-transplant patients, post-op haemofiltration has

an adverse impact on the long-term deterioration of renal function. Therefore, the heart transplant recipients required post-transplant haemofiltration will benefit from more frequent monitoring of renal function, more cautious use of nephrotoxic medications, and earlier referral to nephrologists. However, for the lung transplant recipients, post-transplant haemofiltration does not accelerate long-term renal function deterioration. We speculated that in this cohort,

closely screened for renal dysfunction, AKI is often associated with primary lung graft dysfunction, best treated by haemofiltration to avoid fluid overload. Hence, haemofiltration was started at an earlier stage than would be dictated by renal status alone. In conclusion, post-transplant AKI requiring haemofiltration predicts poor short-term outcomes and has slightly different impacts on long-term renal function in the heart and lung transplant recipients.

Initial experience with a commercially available artificial chordae pre-measured loops (Chord-X system by CryoLife)David Rose Department of Cardiac Surgery,

Lancashire Cardiac Centre, Blackpool Victoria

Hospital, Blackpool, UK

In the last decades, several methods for mitral valve repair have been developed, to make the surgical feasibility easier and improve the long-

term follow-up. Various techniques of chordae implantation and measurement have been described over the years; it is recognised that intraoperative creation of chordal loops can be tedious and adds to operative time.

A new device of pre-measured loops has been introduced by Cryo-Life and consists in artificial chordae prostheses ready for mitral chordal implant. We describe our

initial experience with this new deviceThe pre measured loops device was

used in 30 symptomatic patient with severe mitral regurgitation from November 2016 to December 2017. The mean age (years) is 67,2±10,1;21 patients were male(70%); four patients had coronary artery disease (13,3%); 12 patients with arterial hypertension (40%); four patients with pulmonary hypertension (13,3%); one patients had Dibetes (3,3%); 18 patients were in sinus rhytm (60%); six patients had tricuspid valve regurgitation (20%); Three patients had aortic valve regurgitation (10%); one patient was on dialysis (3,3%); two patients had previos TIA (6,6%). Access was obtained through median sternotomy in 17 patients (56,6%) and minimally

invasive in 13 patients (43,3%).The prolapse was localized in the

following segments: P2 in 18 cases (60%), A2 in four cases (13,3%), P2/P3 in three cases (10%), P3 segment in two cases (6,6%), A2/P2 in 2 cases (6,6%), A2/A3 in one case (3,3%)

Every patients received three loops of pre-measured chordae (six single chordae) distributed to the posterior leaflet in 23 cases (76,6%), to the anterior leaflet in four cases (13,3%) and to both in three cases (10%). The pre-measured loops device comes in to four different sizes; size 12 was used in eight cases (26,6%), size 16 in 13 cases (43,3%), size 20 in 6 cases (20%), size 24 in four cases (13,3%)

Mean CPB time/aortic cross clamp time

was 136,5 ± 26,17/98,3 ± 22,66 for isolated mitral valve repair and 168,5 ± 56,7/123,7 ± 43,3 for combined procedure. All patients had mild or less regurgitation at the end of the procedure on TOE. At 4-6 months follow-up post-operative echocardiogram showed No mitral regurgitation in 10 patients (33,3%), trivial or mild in 19 patients (63,3%) and moderate in one patient (3,3%)

In patients with fibroelastic deficiency and mitral regurgitation the Chord-X system gives very good early results from our early experience. We have found this system produces good early results for both leaflet repairs. It saves time, allow reproducible results and simplify the procedure.

Nebulised 7% hypertonic saline as a mucolytic in cardiothoracic patientsNamita Thomas and Philippa Oram University Hospital

North Midlands NHS Foundation Trust

One of the big challenges faced by patients post cardiothoracic surgery is airway clearance. Pain combined with reduced forced vital capacity, post anaesthetic

effect and thickening of secretions makes it difficult for patients to mobilise and expectorate their sputum, thereby predisposing them to lower respiratory tract infections. Commonly used treatment strategies to overcome this are normal (0.9%) saline nebulisers humidified oxygen, appropriate analgesia and early mobilisation. Patients who show clinical evidence of post-operative pulmonary complications are started on oral mucolytics like carbocysteine and active physiotherapy airway clearance techniques like intermittent positive pressure breathing.

Faced with this problem on our unit, we decided to trial hypertonic saline – HTS (7%) nebulisers, which are commonly used as mucolytics in Cystic Fibrosis (CF) and other respiratory patients. Studies in CF patients have shown HTS to osmotically restore the liquid layer lining the airways. It has also shown

to improve the rheological properties of the mucus and stimulate cough thereby enhancing clearance. Evidence suggests that 7% HTS has stronger effect on MC compared to 3% and 0.9% saline. HTS is known to have a short onset of action of 15 to 30 minutes but the effect is known to be sustained with repeated doses. This means that airway clearance techniques can be administered almost instantly. HTS is known to cause increased airway reactivity characterised by bronchoconstriction in specific patient groups, especially those with COPD, Asthma and CF. Since the current patient population undergoing cardiothoracic surgery can have other pre-existing comorbidities including diagnosed or undiagnosed lung diseases, we thought it would be safer to conduct a short study to assess the incidence of adverse reaction to the first dose of HTS in this patient group.

We included consecutive patients (n=96) admitted to

our cardiothoracic unit over 12 months who were identified as having thick secretions that they were unable to clear easily. The first dose of nebulised 7%

HTS was administered by a physiotherapist or a senior cardiothoracic nurse. The patients

were monitored pre, during and post nebulised therapy for signs of airway

hyperreactivity and bronchoconstriction. We measured patient oxygen saturations, respiratory rate (RR) and signs of increased work of breathing. We noted the auscultation findings and patients’ subjective feedback. We did not conduct spirometry studies on our patient population as we thought that post-surgical pain and poor chest wall compliance could provide unreliable and false results.

Although 58.3% patients included in our study had pre-existing diagnosed respiratory conditions, all the patients tolerated the 7% nebulised HTS solution well. No incidence of airway hyperreactivity or bronchoconstriction that required termination of therapy was observed.

We concluded that nebulised 7% HTS was well tolerated by post-operative cardiothoracic patients.

None of the patients showed adverse respiratory events following the first dose and continued

to receive HTS therapy. Patients also reported subjective ease with sputum clearance following nebulised HTS. We recommend further studies to probe into the efficacy of HTS in sputum clearance in this group.

Figure 2. Kaplan-Meier survival curve of lung transplant recipients

Figure 1. Kaplan-Meier survival curve of heart transplant recipients

Phillipa Oram (left) and

Namita Thomas

Transplant – Lung Transplant Rutherford Tuesday 12 March 11:20

Adult cardiac – Mitral Surgery Westminster Monday 11 March 09:40


Chord-X system


Caption

Thoracic – Minimally Invasive surgery Moore Tuesday 12 March 11:30

Quality outcome measures for single port VATS resection of non-small cell lung cancerHarvey George1, Hannah Gleeson1, Emily Hocknell1, Jagan Rao2, Laura

Socci2, Sara Tenconi2, David Hopkinson2, John Edwards2 1 University of

Sheffield; 2 Northern General Hospital

Intuitively, there is no less invasive intercostal approach to lung resection than SP-VATS. We hypothesise that there may be beneficial differences to this surgical technique, which are not seen with multi-port VATS or robot assisted thoracoscopic surgery.

In 2013, we saw dramatic changes in Sheffield with the initiation of the Single-Port VATS programme, coupled with Enhanced Recovery After Surgery, for Lung Cancer resections. Whilst over the years we have analysed our results through the SCTS Thoracic Surgery Register and now the Lung Cancer Clinical Outcomes Project, in 2017 we initiated the first of (to date) three intercalated BMedSci medical student full time research projects to examine our SP-VATS programme in detail. This has included a three-pronged approach. We have coupled departmental prospective registry data with Hospital Episode Statistics (HES) data; initiated a prospective quality of life study for all primary lung cancer resections by whatever route; analysed in detail the histopathology, oncology and follow-up records of over 2,000 lung

cancer resection patients.In common with many units, we have seen our VATS resection rate

rise from 21% (all Multi- Port) VATS in 2012 to over 70% (all SP-VATS) by 2015-16, but we believe that our SP-VATS programme is the amongst the most energetic in the UK. We have found that SP-VATS has at least equivalent safety, shorter length of stay and potentially better survival than thoracotomy in multivariate analysis. There is no difference in oncological efficacy on analysing resection margin status. The Quality of Life study is on-going but shows an association with better early outcomes, compared to thoracotomy. The endpoints for this part of the study mirror those in on-going clinical trials, potentially allowing statistical comparison in the future.

Detailed analysis of the histopathological reports of this cohort is allowing assessment of the surgical approach against the IASLC Lung Cancer Staging Database, to which we will contribute.

We have demonstrated that it is possible for a unit to adopt the practice and, with focused training. We are analysing aspects related to the learning curve of SP-VATS surgery, in addition to the quality of surgery outcomes. It is important to analyse all these issues, which are central considerations for the introduction of this technique into other units.

Sinus venosus atrial septal defect repair with minimally invasive cardiac surgeryMiss Charlene Tennyson

Blackpool Victoria Hospital,

Blackpool, UK

Sinus venosus atrial septal defects (SVASD) account for between 4-11%

of all atrial septal defects. They occur when there is a malformation of the interatrial wall separating the vena cava from the right sided pulmonary veins. Typically, SVASD are located next to the superior vena cava (90%) where they are commonly associated with partial anomalous pulmonary venous drainage of the right superior pulmonary vein. This defect can lead to left to right shunting with associated symptoms of breathlessness on exertion, tachyarrhthmias, pulmonary hypertension and evidence of right ventricular dysfunction.

In this case example, a 72-year-old female presented for repair of a sinus venosus ASD. A transthoracic echocardiogram (TTE) was performed and showed a dilated right heart with a large left to right shunt. Her right ventricular systolic pressure was 40 mmHg.

Operative Approach?In terms of operative approach for ASD repairs, the median sternotomy with central cardiopulmonary bypass (CPB) is the most common incision performed.

It is associated with low surgical risk and excellent long-term outcomes. In recent years, however, innovations in CPB technology alongside a new repertoire of port-access surgical instruments has allowed surgeons to develop the field of minimally invasive surgery. These techniques have been applied successfully and safely in patients with atrial septal defects. In this case example, three port incisions were made, two 5 mm ports in the 3rd and 6th intercostal spaces and a larger 6 cm subareolar incision. Peripheral cannulation was performed via the right common femoral artery and right common femoral and internal jugular veins. On establishing CPB she was cooled to 32°C and the aortic EndoClampÆ was deployed to give 900 mls of cardioplegia. Dependent on individual

case anatomy, there are multiple approaches to the repair of a sinus venosus ASD. In this case, the patient had a double patch repair using bovine pericardium. The first patch was used to baffle the superior pulmonary vein into the left atrium and the second patch to close the right atrium.

Benefits to patientIn minimally invasive access surgery both bypass and cross clamp times can be longer in comparison with a median sternotomy approach (bypass time 171 minutes, EndoClampÆ time 60 minutes in this example). However, the advantages include less postoperative bleeding, shorter hospital stay, excellent cosmetic results, less wound infections and

reduced levels of postoperative pain. This patient was discharged home on day 4 with little evidence on examination to suggest that she had undergone heart surgery. Her follow-up ECG showed no evidence of sinoatrial node dysfunction and the TTE demonstrated a satisfactory repair. Furthermore, there was no evidence of superior vena cava or pulmonary venous obstruction which are known complications associated with SVASD repair.

Benefits to traineeThrough careful preoperative planning with the aid echo and CT imaging you can appreciate the rigorous selection criteria which must be met before accepting a patient for minimally invasive repair. Minimally invasive repair of SVASD is a safe and successful procedure in carefully selected patients

As a trainee, my exposure to minimally invasive surgery has allowed me to discover an entirely unique way of operating. The use of 3D cameras provides a fantastic surgical view of pathology which is often not appreciated via conventional sternotomy for intra-atrial procedures. In addition, this has benefits for the entire theatre team who can become more involved in the procedure as they can directly visualise on-screen each stage of the operation.

Furthermore, utilising patient approved video recording provides an excellent platform for surgical training, an opportunity where trainees can review each surgical decision in retrospect with their trainers.

Cross-sectional aortic area / patient height ratio in thoracic aortic aneurysms: An additional predictor of complicationsMetesh Acharya, Oswaldo Valencia,

Maite Tome, Robert Morgan, Marjan

Jahangiri St. George’s Hospital, London

Current interventional guidelines published by the European Society of Cardiology in 2014 and

American Heart Association in 2016 recommend prophylactic aortic root or ascending aortic replacement at aortic diameters of 4.5–5.5 cm in non-aortopathy populations. However, 40% of type A aortic dissection occur at aortic diameters <5 cm, at which size 15% of patients with Marfan syndrome will have undergone dissection or rupture.

Looking beyond absolute aortic diameter as a surrogate marker for aortic complication risk, Svensson and colleagues proposed the aortic cross-sectional area/patient height ratio, which demonstrates significant prognostic value at the aortic root and ascending aortic level. Indexed aortic area (IAA) >10 cm2/m is associated with an increased risk of aortic complications.

We firstly analysed the IAA between the aortic root and mid-ascending aorta in 66 patients with acute type A aortic dissection and 187 patients with thoracic aortic aneurysms between 2010-2016 at St. George’s Hospital, London. All dissections occurred at mean diameters of 4.46 cm. In the aneurysm group, 56.7% of patients had an abnormal IAA at the mid-ascending aorta, and 39.6% at the mid-sinus of Valsalva. 49.1% of thoracic aneurysms measuring 4.5-5.0 cm had an IAA >10 cm2/m, rising to 98.5% at diameters of 5.0-5.5 cm. Out of the entire cohort of 200 aortic segments with an abnormal IAA exceeding 10 cm2/m, 139 aortic segments (69.5%) with diameters <5.5 cm would not fulfil the current criteria for aortic surgical intervention, despite being subject to increased risks of complications.

Next, we assessed the predictability of adverse aortic events using IAA.

Using backward multi-step multivariate logistic regression analysis, IAA at the sino-tubular junction was proven as a predictor of acute type A aortic dissection. A cut-off value for the indexed aortic area at the sino-tubular junction of 9.26 cm2/m was identified, translating into a relative risk of acute type A aortic dissection of 1.92.

Finally, we studied the influence of the IAA on the natural history of thoracic aortic aneurysms in 399 patients with non-intervened thoracic aortic aneurysms at a median follow-up of 3.5 years. 45 (11.3%) patients developed an abnormally-raised IAA between the aortic root and mid-ascending aorta, even over this relatively short duration. 8/11 (72.7%) patients and 20/22 (90.9%) patients who presented with acute type A and B dissections, respectively, had aortic diameters <5.5 cm between the aortic root and proximal descending aorta. The annual growth rates in aortic diameter and IAA in non-intervened thoracic aortic aneurysms were greatest at the most proximal (mid-sinus, 0.14 cm/year, 0.52 cm2/m/year) and distal thoracic aortic segments (proximal descending, 0.15 cm/year, 0.42 cm2/m/year), and least at the mid-ascending aorta (0.09 cm/year, 0.31 cm2/m/year).

Our findings shed new light on the relationship between IAA and aortic diameter, and support the notion that aortic dissection may occur at smaller diameters than are currently indicated for aortic replacement. Further prospective studies are required to elucidate the role of the IAA in pre-operative risk evaluation, and as a criterion for aortic surgical intervention.


Adult Cardiac – Aortic Dissection Abbey Monday 11 March 09:20

Postoperative image of patient – demonstrating scars from minimal access surgery

CT scan showing Sinus Venosus ASD

Metesh Acharya


Impact of diabetes on long-term outcomes following coronary artery bypass surgeryUmar Imran Hamid, Georgios Sotiropoulos, Adelina Dan,

Manuela Pizzuti, Giuseppe Siniscalchi, Wael Awad St


The prevalence of diabetes in patients presenting for coronary artery bypass graft surgery (CABG) continues to rise. EuroScore II adds weight to the operative mortality of

insulin-dependent diabetic patients undergoing cardiac surgery. The aim of this study was to evaluate the impact of diabetes on long-term survival in patients undergoing CABG, at a single cardiac centre.

We analysed prospectively collected data from all patients who underwent isolated first time CABG in our centre over a two-year period, between January 2006 and December 2007. Patient characteristics and post-operative survival (in-hospital and late) were compared between four patient groups: non-diabetic (ND), diabetic on diet control (DD), diabetic on oral medications (OD) and diabetic on insulin (ID). All-cause mortality following CABG was ascertained from the

NHS Spine Portal. Kaplan-Meier curves were used to calculate short term and long-term survival.

During this two-year period, a total of 1,095 patients underwent isolated first time CABG. 459 (41.9%) patients were non diabetic (mean age 68.2± 9 years; 79% males; 37% had impaired LV function) and 636 (58.1%) patients had diabetes (mean age 66±9 years; 77% males; 41% had impaired LV function). 94 (14.8%) of the 636 diabetic patients were DD, 331 (52%) were OD and 211 (33.2%) were ID. In-hospital mortality was 5/458 (1%) in the non-diabetic and 5/636 (0.8%) in the diabetic patients (DD: 1/94 (1%); OD: 0/331 (0%); ID: 4/211 (2%) p= 0.74).

Median follow-up was 336 months and was complete. Five-year survival in the ND group was 390/458 (85.1%) and in the patients with diabetes was 521/636 (81.9%), p= <0.0001 ; 92.5% in DD, 85.2% in the OD and 72.03% in the ID, p= 0.0007 ) and at 10 years was 305/458 (66.6%) in the ND group and 377/636 (59.3%) in the patients with diabetes, p= 0.01 ; 63.8% in DD, 66.2% in the OD and 46.4% in

the ID, p=0.008). There were no significant differences in the survival at 5 and 10 years between the ND and non-insulin dependent diabetic patients (p= 0.9 at 5 years and p= 0.9 at 10 years) (figure 1), but there was a statistical difference in the survival at both 5 and 10 years between the non-diabetic and the insulin dependent patients (p= 0.0001 at five years and p= < 0.0001 at 10 years) (Figure 2).

ConclusionInsulin dependent diabetic patients experience worse early and long-term survival following CABG. Non-insulin dependent diabetic patients appear to have similar long-term survival to non-diabetic patients.

Impact of left ventricular impairment on long-term survival following coronary artery bypass surgeryUmar Imran Hamid, Georgios Sotiropoulos, Adelina Dan,

Manuela Pizzuti, Giuseppe Siniscalchi, Wael Awad St


An important proportion of patients undergoing cardiac surgery have left ventricular (LV) systolic dysfunction. The EuroScore predicts operative mortality with

increasing weight for greater degrees of LV systolic dysfunction. The aim of this study was to evaluate the long-term survival of patients with good, moderately impaired and poor LV function undergoing coronary artery bypass surgery (CABG) at a single tertiary cardiac centre.

We retrospectively analysed prospectively collected data from all patients undergoing isolated first time coronary artery bypass surgery in our centre over a 13 month period Jan 2006 – Jan 2007. All-cause mortality was ascertained from the NHS Spine Portal.

Demographic data and post-operative outcomes (in-hospital and late) in patients with good (LVEF >50%), moderately impaired (LVEF 30-50%) and poor (LVEF <30%) LV function were collected and the groups were compared.

During this period a total of 672 patients underwent isolated first time CABG. The mean age of patients was 67.6 ± 9.2years (range 26-88 years),524 (80%) were male. 391(58.2%) patients had good (mean age 67.4±9.4years), 230 (34.2%) had moderately impaired (mean age 67.7±9.1 years) and 51(7.6%) had poor (mean age 70.1±8.9 years), LV function. The overall in-hospital mortality was 1.49% (10/672); 0.51% (2/391) in patients with good LV function, 1.3% (3/230) in patients with moderately impaired LV function and 9.8% (5/51) in patients with poor LV function, p <0.0001. At 5 years, actuarial survival in patients with good LV function was 86.4% (338/391), with moderately

impaired LV was 85.7% (197/230) and with poor LV was 60.8% (31/51); p <0.0001. At 10 years, actuarial survival in patients with good LV function was 69.8% (273/391), with moderate LV function was 60.9% (140/230) and with poor LV function was 31.4% (16/51); p <0.0001 (Figure 1).

ConclusionsPatients with impaired LV function undergoing CABG have higher operative mortality, as predicted by EuroScore II. Those with moderately impaired LV function have similar five year but worse 10 year survival compared to those with good LV function, and those with poor LV function have markedly worse mid- and long-term survival. Further studies comparing alternative treatment options in patients with poor LV function should be considered to optimise management of this high risk group.

Evaluation of preoperative assessment of patients referred for thoracic surgery at Southampton General HospitalRomaana Kanamia Southampton General

Hospital, Southampton, UK

The pre-operative assessment of patients referred for thoracic surgery at Southampton General hospital has been developed as a

methodological process, formally known as the ‘One Stop’. This consists of a meeting between the patient and the practitioners that carry out this service: a specialist cardiac nurse, an anaesthetist and a surgeon, over the course of a single appointment.

The aim of the One Stop service is to

ease the process by which the patient is assessed to establish whether they are in an appropriate state for surgery, informed of what their specific procedure entails and given the opportunity to ask questions. From June 2018 to February 2019 the efficacy of this service was measured by providing twenty-five patients who underwent the One Stop with questionnaires, in order to identify their level of satisfaction with the process. This data was compared to the results obtained in the same manner from 25 patients who also underwent this assessment from

referring centres. These candidates were required to make multiple appointments for the same information to be collated and to be briefed on their procedure. Additionally, staff satisfaction was measured by providing the nurses, anaesthetists and surgeons (eight members from the One stop team) with questionnaires.

All One Stop participants expressed that they found the service to be very convenient as only a single journey was required and the transition between each health care professional was ideal. All questions were answered by the appropriate specialists.

The One Stop multidisciplinary team all found that the service facilitated good communication between specialists and patients and enabled their families and the staff to collectively support them. However, it was identified that due to time constraints staff were often pressured and rushed to brief patients, affecting the quality of the process.

Twenty-three patients from the referring centres highlighted issues with regards to travel; for some transport had to be arranged for each trip which was inconvenient and/or incurred expense.

Additionally, a proportion of patients found multiple journeys difficult due to ill health. Four patients felt that separate appointments resulted in some misunderstanding and confusion, as they were not able to verify information they had received from a previous practitioner at following appointments.

To conclude, the One Stop service is highly favoured by patients and staff for its convenience. However, the process could be further improved by increasing the duration of each appointment to provide the best outcome.

The very small, elusive lung lesions: navigation bronchoscopy as an adjunct to finding, reaching and treating inaccessible lesionsRalitsa Baranowski, Kelvin Lau

St Bartholomew’s Hospital, London, UK

Increasingly surgeons are asked to remove smaller and smaller nodules, ground glass opacities and multiple nodules. Many of these are not palable

and identifying these lesions can be a challenge. At present there is no reliable localisation method. Conventional methods of hook wire and surface dye marking

suffer from dislodgement and spill over.Resection of multiple lung nodules is also

limited by the loss of lung parenchyma, and resection of small deep lesions can result in disproportionate loss of parenchyma for the size for nodule. Strategies to deal with the very small cancers especially in medically inoperable patients are needed.

Recent innovation in bronchoscopic techniques allow almost all parts of the lungs to be reached endoscopically.

Electromagnetic navigation bronchoscopy (ENB) is a technique designed to reach and biopsy peripheral lung lesions.

Using ENB we were able to reach, mark and treated these difficult to find lesions. Our early experience of surface marking for localization was disappointing, with 41% localisation failure rate. We developed a juxta-lesion marking method with ENB placed fiducial and localisation with fluoroscopy. This proved to be a reliable

and easy to use method which also gives information on the depth of lesion to ensure it is resected – something surface marking does not provide.

In addition, eight patients underwent a novel procedure of endobronchial microwave ablation where ENB was used to deliver microwave ablation to small, deep nodules which would otherwise require significant loss of lung parenchyma for resection. All procedures were completed

successfully with no complications.Navigation bronchoscopy is a useful

adjunct for the localization and treatment of the very small and inaccessible lung lesions. Image-guided VATS (iVATS) is more reliable than surface marking strategies, and deep, inaccessible lesions can be treated with bronchoscopic ablation as part of a hybrid strategy for parenchymal sparing radical treatment including metastasectomy.

Figure 1: Long-term survival of different groups based on LV function.




Posters Exhibition Hall Monday 11 March


EQ-5D-5L for cardiothoracic patients in critical care receiving rehabilitationTanya Usher CEL & Clinical Lead BHC/Cardio-Respiratory

Therapy Team, Barts Health NHS Trust, London, UK

The self-reported EQ-5D-5L questionnaire is a popular Quality of Life (QoL) measure in the inpatient environment and is easy to complete. It has been used within the critical

care environment1 and been linked with economic considerations of intervention2.

AHPs into Action (2017) states AHPs should evaluate improve and evidence the impact of their contribution. In this day and age of challenging NHS funding, therapists must be able to prove their worth to commissioners, and demonstrate a positive impact of interventions both from a clinical and economical perspective. The aim of this study was to assess the outcomes using the EQ-5D-5L for post-critical care patients in order to implement a functional assessment for patients after critical care in accordance with NICE CG83 guidelines.

Patients who received rehabilitation on critical care for over 48 hours and subsequently discharged home were included. Assessments were completed at discharge, six-weeks and three-months follow-up via telephone call. Those repatriated to a local hospital or following an integrated care pathway were excluded.

Fourteen patients were included in the study. There was a generalised trend of improvement in QoL and overall perception of individual health states with time. At discharge, all functional and non-functional domains highlighted perceptions spanning from ‘No Problems’ or ‘Slight Problems’ to ‘Severe’ and ‘Extreme Problems’. Subsequently, at six-weeks follow-up, extreme problems were not expressed, with the least favoured response being ‘Slight problems’ in the EQ-5D Domain ‘Usual Activities’. After three-

months, the Domain ‘Usual activities’ again demonstrated the least favourable results with ‘Moderate Problems’. At this point, all physical and non-physical domains had respondents that felt they had ‘No Problems’. Thus, ‘Usual Activities’ may represent an area of focus for future rehabilitation needs.

Limitations included: a small sample size; and a reduced data collection period meaning linear data could not be collated. However, the EQ-5D-5L is easy to complete and implement with appropriate organisation of follow-up assessments. Established critical care follow-up clinics could facilitate 6-week and three-month data collection by sending EQ-5D-5L questionnaires with the appointment letter to minimise the time taken to make phone calls to the discharged patients and therefore clinician time. Furthermore, domains requiring further rehabilitation focus could be identified, this study revealed ‘usual activities’ to have

the least favourable perceptions at each time-frame. Attention on rehabilitation

goals related to usual activities could therefore be the focus of the

rehabilitation team covering this patient population in the future.

Further data collection is required to generate linear relationships between results. Once established this also could be extrapolated to

consider Quality Adjusted Life Years and cost-benefit analysis,

to help prove the worth of therapy input in this financially challenging era

of budget constraints in both economical and clinically therapeutic terms.

References

1. Fuke, R., Hifumi, T., Kondo, Y., Hatakeyama, J., Takei, T., Yamakawa, K., Inoue, S. and Nishida, O., 2018. Early rehabilitation to prevent postintensive care syndrome in patients with critical illness: a systematic review and meta-analysis. BMJ open, 8(5), p.e019998.

2. Lansink-Hartgring, A.O., van den Hengel, B., van der Bij, W., Erasmus, M.E., Mariani, M.A.,

Rienstra, M., Cernak, V., Vermeulen, K.M., van den Bergh, W.M. and Dutch Extracorporeal Life

Support Study Group, 2016. Hospital costs of extracorporeal life support therapy. Critical care

medicine, 44(4), pp.717-723.3. Enderby P, & John A. (2015). Therapy outcome measures for rehabilitation professionals, Third Edition. Guilford: J&R Press.

The very small, elusive lung lesions: navigation bronchoscopy as an adjunct to finding, reaching and treating inaccessible lesionsRalitsa Baranowski, Kelvin Lau

St Bartholomew’s Hospital, London, UK

Increasingly surgeons are asked to remove smaller and smaller nodules, ground glass opacities and multiple nodules. Many of these are not

palable and identifying these lesions can be a challenge. At present there is no reliable localisation method. Conventional methods of hook wire and surface dye marking suffer from dislodgement and spill over.

Resection of multiple lung nodules is also limited by the loss of lung parenchyma, and resection of small deep lesions can result in disproportionate loss of parenchyma for the size for nodule. Strategies to deal with the very small cancers especially in medically inoperable patients are needed.

Recent innovation in bronchoscopic techniques allow almost all parts of the lungs to be reached endoscopically. Electromagnetic navigation bronchoscopy (ENB) is a technique designed to reach and

biopsy peripheral lung lesions.Using ENB we were able to reach, mark

and treated these difficult to find lesions. Our early experience of surface marking for localization was disappointing, with

41% localisation failure rate. We developed a juxta-lesion marking method with ENB placed fiducial and localisation with fluoroscopy. This proved to be a reliable and easy to use method which also gives

information on the depth of lesion to ensure it is resected – something surface marking does not provide.

In addition, eight patients underwent a novel procedure of endobronchial microwave ablation where ENB was used to deliver microwave ablation to small, deep nodules which would otherwise require significant loss of lung parenchyma for resection. All procedures were completed successfully with no complications.

Navigation bronchoscopy is a useful adjunct for the localization and treatment of the very small and inaccessible lung lesions. Image-guided VATS (iVATS) is more reliable than surface marking strategies, and deep, inaccessible lesions can be treated with bronchoscopic ablation as part of a hybrid strategy for parenchymal sparing radical treatment including metastasectomy.


Posters Exhibition Hall Monday 11 March

Poor preoperative quality of life is associated with prolonged hospital stay after anatomic lung resections for lung cancerCecilia Pompili1, Nilanjan Chaudhuri2, Manos Kefaloyannis2, Richard Milton2,

Kostas Papaggiannopoulos2, Peter Tcherveniakov2, Galina Velikova1, Alex

Brunelli 2 1 University of Leeds; 2 Leeds Teaching Hospital Trust

The Patient Centred Outcomes Research Group (PICOR) is part of the University of Leeds. We are based at St James’s Institute of Oncology, Leeds, and undertake applied research aimed at improving cancer patients’ quality of life. The group focuses

on the development and assessment of online PROMS systems to allow patients to self-report adverse events and symptoms where data is available in electronic patient records to assist patient care.

Patient Reported Quality of life is becoming one of the main outcomes in clinical research.

However, the growing interest in the assessment of quality of life in cancer patients has also raised the question of its impact on patient care and clinical outcomes and generated research streams to look at ways of incorporating this in every day clinical practice. The LILAC study supported by Yorkshire cancer Research, will soon release the first results on QoL trajectories of VATS and SABR treatments.

The Patient-reported outcomes field has been only recently implemented in the lung cancer surgical setting. Our published survey among European Thoracic surgeons, revealed a lack of standardised PROMS collection among this community with 88% of all surgeons currently not incorporating these outcomes into their clinical practices.

Several studies have shown that objective parameters, traditionally used to stratify the surgical risk (age, FEV1, DLCO, VO2max etc.) are not associated with patient reported residual quality of life. In this regard, the perioperative changes of quality of life in high-risk surgical candidates has

been shown to be similar to the one in their lower risk counterparts.This study has combined the expertise of the PICOR group in

implementing quality of life research in clinical practice with the high-volume thoracic surgery Unit in Leeds.

With limited data on this topic, this study was carried out as a pilot and feasibility study aiming to inform whether quality of life (QOL) scales are associated with postoperative length of stay (LOS) following anatomic lung resections for lung cancer.

We have carried out this study on a sample of consecutive patients

submitted to anatomic lung resections performed in our Institution and who were able to complete the preoperative quality of life questionnaire.

Three hundred and thirty consecutive patients were enrolled. QOL was assessed in by the self-administration of the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire. The individual QOL scales were tested for possible association with prolonged hospital stay which has been defined more than seven days (upper quartile) along with other objective baseline and surgical parameters using univariable and multivariable analyses.

We found that 22% patients remained in hospital longer than 7 days after surgery. Some scales of quality of life (General health (GHS), Physical Function (PF), Role Functioning (RF), fatigue(FA) and pain(PA)) were significantly worse in patients with prolonged stay. Role Functioning has been then found an independent factor significantly associated with prolonged stay after adjusting the analysis for other potential confounders (BMI, FEV1, DLCO, history of stroke or diabetes).

This study found that the Preoperative patient-reported Role Functioning was associated with prolonged postoperative hospital stay. Role functioning is an important part of health-related quality of life. In fact, comprises the ability of the individual to fulfil responsibilities typical for a specific age and social setting. Its assessment is quite complex due to the plurality of roles different persons define as relevant and due to the natural fluctuation of such roles over time. The importance of the effect of the treatment on this aspect of QOL should be accounted when approaching patient’s ability to make their decision to surgery.

Baseline QOL status should be taken into consideration to implement psycho-social supportive programmes in the context of enhanced recovery after surgery.

Cecilia Pompili1

Thoracic – Thoracic Oncology St James Monday 11 March 16:00


Are the outcomes from Valve Sparing Root Replacement more favourable than the Bentall procedure in proximal aneurysms? a meta-analysisIacovos Theodoulou1, M. Yousuf

Salmasi2, Priyanka Iyer1, Mohaimen

Al-Zubaidi2, Danial Naqvi2,

Mohammed Snober2, Aung Oo3,

Thanos Athanasiou2 1 King College

London; 2 Imperial College London; 3 St

Bartholemew’s Hospital

Background

The debate surrounding the optimum choice of surgical approach in patients with aortic root pathology is

ongoing and despite mounting evidence favouring the preservation of the aortic valve, rates of valve-sparing root replacement (VSRR) continue to remain stubbornly lower than Bentall. Valvular preservation in VSRR is certainly more challenging and reports of most large series emerge only from specialist centres. However, the benefits in preserving the native valve are often underestimated. Averting the risks of both thromboembolism and anticoagulation associated with mechanical valves, and the risks of structural valve degeneration associated with bioprosthetic valves, may deem VSRR more favourable in many patient groups.

There are many studies comparing outcomes in aortic root procedures, however heterogeneity in patient groups (Marfans, bicuspid pathology, acute dissection) and operative techniques (mechanical vs. bio-Bentall, Yacoub vs. David) are present. Whilst there have been several reviews on this topic, our group set out to conduct the largest meta-analysis in the field with multiple subgroup and meta regression analyses to account for heterogeneity

Main findingsInitial search yielded 9,517 titles. Thirty-four studies were finally included for meta-analysis, comprising 7,313 patients (2,944 valve sparing and 4,369 Bentall).

Operative mortality was found to be significantly lower in the VSRR group (OR 0.51, 95% CI 0.37 – 0.70, p<0.001). Five-year survival was also more favourable in the VSRR group (OR 1.93 95% CI 1.15 – 3.23, p<0.05). Significantly lower rates of heart block and cerebro-thromboembolism were also found after VSRR.

There was no significant difference in rates of reoperation between groups at long-term follow-up (OR 1.32, 95% CI 0.75 – 2.33, p=0.336). Meta-regression of patient factors (age, gender, AR severity, valve morphology) and

operative covariates yielded no influence on the main outcomes.

DiscussionOur present analysis found that VSRR results in significantly lower operative mortality and higher five-year survival compared to Bentall. This was observed despite longer cross clamp and bypass times required in the VSRR group (which

reflects the technical demand of the procedure) and upon subgroup analysis of studies focusing on acute dissection, highlighting the efficacy of VSRR in the emergency setting. Although there was moderate heterogeneity present in these analyses, meta-regression analysis found that important and relevant covariates were found to have no significant influence on the positive

survival profile affected by VSRR compared to Bentall.

Also, no difference was observed in reoperation rates between VSRR and Bentall groups. Despite the expected heterogeneity present within our selection of retrospective studies, meta-regression found that neither age, bicuspid valve pathology, the use of biological valve conduits nor the severity

of pre-operative AR, had any significant influence on the reoperation outcome reported.

The main limitation levelled against studies comparing VSRR with Bentall: are patients from one group comparable with the other group? It may be argued that the patient substrate is the main influence for a poorer outcome in the Bentall group, where valve morphology is either non-favourable for repair or irrelevant if the decision for native valve sacrifice has already been made by the surgeon.

However, there is limited evidence to suggest that irreparable valves that are replaced have poorer outcomes compared to reparable valves that are replaced: i.e. once the decision to sacrifice the native valve is made,

comparing prosthesis performance with the performance of native valve repair in another patient is a valid comparison.

Nevertheless, robust data from prospective randomised studies are lacking. Such studies are required to inform guidelines and consensus statements. Future studies would also need to control for valve reparability and non-biased selection of valve morphology per treatment group. This review, and indeed the incorporated retrospective studies, work on the notion that the outcomes of the two procedures should be compared, and help to inform the cardiothoracic community that the efforts to pursue VSRR as a first-line option for patients with root aneurysms are worth pursuing.

Adult Cardiac – Aortic Root Abbey Monday 11 March 16:20

Figures: Meta analyses a) Operative mortality, b) thromboembolic events, c) five-year survival, d) reoperation

a c

d

b

Robotic assisted thoracic surgery – establishing a programme and lessons learnedGJ Fitzmaurice, J Asante-Siaw, M Shackcloth, S

Woolley Department of Thoracic Surgery, The Liverpool

Heart & Chest Hospital, UK

Robotic assisted thoracic surgery (RATS) is a developing minimally invasive technique with increasing adoption in thoracic units throughout the British Isles. The advantages over VATS, and

indeed thoracotomy, include decreased blood loss, reduced impairment in pulmonary function, and shorter hospital stays. As a new technique representing the pinnacle of modern thoracic surgical practice, our institution (the largest single site specialist heart and chest hospital in the UK) developed a strategy to establish and implement a RATS program. Consequently, as Mr Fitzmaurice discussed, “the aim of our study was to evaluate our experience of introducing RATS surgery with multiple surgeons involved in a large thoracic unit”.

A retrospective review of a prospectively collected database of all RATS cases completed since the establishment of the program in December 2017 was conducted. This database included information on operative procedure, duration of operation, blood loss, chest drain duration, and length of stay. Individual patient electronic records were reviewed for data regarding final pathological stage.

There were 50 RATS cases completed over the first 10 months of the program (December 2017 to October 2018 – 33 lobectomies, 12 resections of mediastinal masses, and five other procedures [wedge resections,

mediastinal lymph node sampling, and bullectomy / pleurectomy]). Cases were undertaken on an all-comers basis. Amongst the lobectomy group, the blood loss was predominantly < 10 mls (< 10 mls – 900 mls) with a mean chest drain duration of two days (0 – 10 days). Final histopathology was predominantly NSCLC, ranging from pT1aN0 to pT2/3N0 with two cases of occult N2 disease. The median length of stay was three days (1–9 days). Amongst the mediastinal group, the mean chest drain duration was < 1 day (0–1 day) and median length of stay was 1 day (1–4 days). Overall operative times were expectedly longer and there were no conversions to VATS or open. Pain has been reduced for most patients.

These results demonstrated the safe establishment of a RATS program for three thoracic surgeons at a high volume thoracic unit. The operative times are longer than VATS and there is an expected learning curve, however patients are doing well. Mr Woolley concluded that “overall, our results would support the introduction of a team-based robotic assisted thoracic surgical program”.

Thoracic – Minimally Invasive Surgery Moore Tuesday 12 March 11:40


To multi-modality and beyond: a new model for risk rupture prediction in ascending aortic aneurysmsYousuf Salmasi, Omar Jarral, Selene Pirola, Thanos

Athanasiou

Disclosure: This work is supported by the NIHR Imperial College BRC

Guidelines for the management of proximal thoracic aortic aneurysms (TAA) are limited to size criteria only, and our understanding of which aneurysms are more vulnerable to

suffer from acute dissection/rupture is very limited.What are the better diagnostic methods we can

use to answer this important question? Most clinical studies tend to be anecdotal, poorly controlled and lack the scientific backing to make ground-breaking conclusions that may change clinical practice.

BiomechanicsThe aorta is a strong elastic structure that acts as an important biological conduit, withstanding the cycles of systolic and diastolic pressures, via complex flow patterns. Biomechanically, the aortic tissue fails when the haemodynamic forces exceed the strength of the aortic wall, leading to the clinical manifestations of aortic dissection. Studies have only just started to analyse these complex patterns by coupling in-vivo measurements of blood flow patterns gathered from 4D flow MRI, with aortic tissue mechanical properties from explanted aneurysms (subjected to tensile strength and failure testing).

Vascular biologyAs well as biomechanics, we have had a considerable rise in our understanding of syndromic and non-syndromic genetic mutations associated with hereditary causes of TAA disease. These studies have been coupled with histological analysis that have identified intracellular and matrix proteins associated with genetic defects associated with TAA and aortic dissection. Whilst we understand that gene-expression and aortic phenotype can adapt in response to shear flow in the aortic lumen, studies have not associated aortic biomechanics adequately with these intra- and extra-cellular pathways, nor have we used these mechanisms to create prognostic indicators for TAA behaviour.

Our projectThe work being undertaken at Imperial College is unique as it addresses this multi-dimensional problem with a multi-modal model.

We are recruiting patients undergoing proximal TAA

surgical replacement (root or 2 ascending) and subject them to the following:

Pre-operative 4D flow MRI scan. Using computational fluid dynamics and direct measurements from 4D flow images, patient-specific blood-flow profiles are generatednPre-operative blood for targeted genomic testing

metabolomics. As well as identify commonly associated genes with TAA, we hope to identify metabolic phenotypes that can potentially act as biomarkers of vulnerable TAAs

nExplanted aneurysm from theatre. This is subjected to regional tensile strength and failure testing. This is coupled with the aforementioned haemodynamic parameters to generate a finite element model to simulate aortic wall biomechanics and predict aortic wall rupture.

nAneurysm tissue is also analysed histologically using computational pathology methods

Our group is at present the only group in the UK to be carrying out a project on the thoracic aorta of this nature, bringing together advanced imaging technology with tissue biomechanics, genomics, metabolomics and computational modelling.

The research teamResearch of this type requires infrastructure, and this is what we have spent the last 12 months achieving. The team comprises several senior professors in clinical and scientific fields, as well as clinical researchers, nurses and fellows. In collaborating with Imperial College Chemical Engineering, Bioengineering, Clinical Genetics and Genomics (Brompton), the National Phenome Centre and Cardiac Histopathology, we have created an efficient workflow where patient recruitment, specimen collection, laboratory processing and data analysis are entirely streamlined. Moreover, there are four cardiac centres and more than 10 surgeons around London involved in the project, which

ensures adequate patient recruitment and aortic tissue acquisition: a factor which has not been present in other international studies of a similar nature.

Preliminary results and future implicationsTo date, we have recruited more than half the patient target (35/60) and initial results highlight the followingnAnatomical areas in the aorta of elevated WSS

correlate with reduced aortic wall strength and aortic medial degeneration (histology)

nGenetic mutations are associated with levels of higher WSS in the aortic root

We expect to demonstrate a significant association between blood flow and aortic wall biomechanics in the coming months, thus generating a risk rupture prediction algorithm aimed at risk-stratifying patients with TAA disease. Our project’s central focus is to transform the MDT process for patients at risk of type A dissection. With the current preliminary results, we

expect this work to provide clinicians with an improved risk stratification system and a stronger evidence base for clinical decision making. Current aortic guidelines are inadequate at providing the high level of clinical acumen that surgeons desire, and patients need. Relying solely on aneurysm size will soon become a thing of the past following the introduction of novel technologies and biomarkers in the clinical setting, which is a central goal of this project.

Acknowledgements: Surgeons: Prof A Oo & Prof R Uppal (Barts), Prof J Pepper, Mr U Rosendahl & Mr G Asimakopoulos (Brompton), Mr S Raja & Mr F De Robertis (Harefield)Prof Y Xu (Chemical Engineering), Prof J Moore Jr (Bioengineering), Dr D Morris-Rosendahl (Clinical Genetics and Genomics), Dr J-L Robertus (Cardiac Histopathology), Dr D O’Regan (Cardiac MRI), Dr Matthew Lewis (Metabolomics)

Are UK emergency departments diagnosing and referring acute aortic dissection correctly? results of a UK national surveyPhilip Hartley1, M. Yousuf Salmasi1, Omar

Jarral1, Kamran Baig2, Roberto Casula1,

George Asimakopoulos3, Aung Oo4, John

Pepper3, Thanos Athanasiou1 1 Imperial

College London; 2 St Thomas’s Hospital; 3 Royal

Brompton Hospital; 4 St Bartholemew’s Hospital

Background:

According to the global burden of disease project, death from thoracic aortic aneurysms is on the rise. This is mainly from its

life-threatening complication, type A aortic dissection (TAAD). Following a dissection, patients have approximately a 1-2% mortality per hour in the first 48 hours. Expediated transfer to a cardiothoracic centre for urgent surgery is therefore critical in the management of these patients.

However, TAAD can be a diagnostic conundrum for the following reasons:nPatients have variable signs

and symptomsncan mimic other common emergency

conditions (e.g. stroke, myocardial infarction – MI)

nup to 30% of TAAD can present with ST elevation and troponin positivity

The risk of misdiagnosing TAAD has been reported in the literature and can often be associated with worsened

outcome, especially in cases of thrombolysis administration.

In an era of increased public engagement and outcome reporting healthcare, the role of emergency departments (EDs) in their role of timely diagnosis initial management of TAAD is ever more important. The aim of this research was to assess the variability in practice amongst ED clinicians in TAAD management across the UK and whether predictors of misdiagnosis exist within these departments.

Methods:Between April 2018 and October 2018 an online research survey was distributed to Emergency Department Consultants across the UK. The survey included a mixture of clinical questions assessing the way in which ED physicians would treat patients with symptoms, or investigation results which may, or may not, be consistent with TAAD, as well as factorial questions about their department.

Results:Responses from 129 ED Consultants responded from 54 different NHS Trusts were gathered.

A fifth of responses were received from tertiary centres. The majority of ED consultants (97.4%) considered ST elevation in the setting of chest pain as sufficient for diagnosing STEMI. Furthermore, committing to STEMI by the administration of thrombolysis (prior to further investigation) was agreed by 54% of consultants. The response however changed with the addition of unilateral pulse deficit in the patient signs (89.6% would not give thrombolysis) and signs of a cerebro-vascular accident (92.0%).

Most ED consultants responded that D-dimer measurement was not useful if the troponin was elevated in chest pain (50.8%). In the same setting, 31.8% of respondents would never request a CT chest.

More than 70% described that an algorithm for TAAD diagnosis and management did not exist in the ED. More than half (55.8%) had no named cardiothoracic consultant for referral and 71.3% claimed no information on contact numbers for tertiary referral. Using logistic regression, we found that all these

factors had a significant impact on the likelihood for clinicians send patients to the CT scanner or considering d-dimer as a useful tool.

ConclusionHow much are EDs Thinking Aorta? This survey has highlighted that a large gap remains in the infrastructure of UK emergency departments in their ability to appropriately diagnose and manage TAAD.

TAAD presenting with ST changes is significantly more likely to be incorrectly managed as ACS than dissection presenting with features of CVA or unilateral pulse deficit. Additionally patients presenting with elevated cardiac enzymes, in the context of aortic dissection, are at significant risk of not receiving the imaging required to make the diagnosis. These results indicate aortic dissection presenting with features of ACS are at particularly high risk of inappropriate ACS management and/or insufficient investigation to make the diagnosis of TAAD.

Further education with AD risk detection scores, “triple rule-out” methods and an improved index of suspicion is needed. In cases of diagnostic uncertainty, d-dimer and echocardiography should be encouraged.

Multi-modal assessment of TAA Wall shear stress (clockwise top left): wall shear stress mapping using CFD, velocity profiles from MRI, explanted aneurysm tissue, tensile strength testing, histology (stained for elastin)

Left to right: Yousuf Salmasi (ST4, research fellow), Omar Jarral (ST7, post-doc), Selene

Pirola (bioengineer)

Adult Cardiac – Aortic Root Abbey Monday 11 March 15:40

Adult Cardiac – Aortic Dissection Abbey Monday 11 March 09:00

Yousuf SalmasiPhil Hartley


CardiacFloor plan

Company Stand NumberAbbott 9Abiomed 9cACSA 51aADMEDUS 44Aortic Dissection Awareness 38Aquilant Ltd 42Arthrex 36AtriCure 23,24,25B Braun 50

Baxter 18 &19BD 20BHIS Bra 12BVM Medical 13Cardiac Services 17Cardio Solutions 1 & 2Cryolife 34 & 35Dendrite 33Edwards Lifesciences Ltd 31Emmat Medical 8

Equip Med 9bFannin UK 14Getinge 10Heart Valve Voice 11Hemosonics 5Intuitive Surgical 48Johnson Johnson 6Leicester University 51Lemonchase 45LivaNova 30

Lynton Lasers Ltd 22Medela 16Medistim 32Medtronic 28 & 29MedXpert 9aNordic Pharma 43PHARMAPAL 39Pierson Surgical 4Pulmonx UK Ltd 27Q Close 37

R&D Surgical Ltd 26Sigmacon UK Ltd 40Smith & Nephew 15Takeda 21Terumo 49Urethrotech 7Wisepress Britten

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W H I T T L E F L E M M I N G

51a

45

78

1211

13

9c

9b

W H I T4

6

F L E M

31

30

9

5

9a 10

51

404243

36

28/29

373839

34/353332

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18/19202122

441/2

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SCTSCONFERENCE NEWS · Heidi Caisley Advanced Clinical Practice Project Lead, Royal Sussex County Hospital, Brighton & Sussex University Hospitals NHS Trust, Brighton, UK ObjectiveF