Research

Tian DH, Chakos A, Hirst L, Chung STW, Yan TD

Ann Cardiothorac Surg 2019 Sep;8(5):518-523

PMID: 31667148

Abstract

Background: Management of type A intramural hematoma (IMH) remains controversial, with opinions divided as to whether patients should be treated with early aggressive surgery or a more conservative approach. The present systematic review aims to evaluate the mortality and morbidities following surgery for type A IMH.

Methods: Electronic searches were performed on five databases from dates of inception to December 2018. All studies with surgical outcomes for type A intramural hematoma were identified by two independent researchers and relevant data extracted. Random-effects meta-analysis of proportions or meta-analysis of means were performed to aggregate the data. Survival data were pooled using reconstructed individual patient data derived from Kaplan-Meier curves.

Results: Fifteen studies with 744 patients were identified. Ten studies were from Asian countries (73% of patients). Overall mortality was 8.2% [95% confidence interval (CI): 4.6-13.9%]. Mortality from Asian centers was 5.3% (95% CI: 3.6-7.7%) and 18.9% (95% CI: 7.0-40.4%) in Western centers. Postoperative complications were poorly reported and hence not analyzable. Overall pooled survival of 343 patients from four studies at 1-, 2-, 3-, 5-, and 10-year was 91.8%, 90.2%, 89.2%, 87.7%, and 71.1%, respectively.

Conclusions: There is an acceptable level of risk of death after surgery for type A IMH, though significant variations exist between results from Asian and Western centers. More detailed studies are required to clarify the controversies surrounding management of type A IMH.

Zhu YY, Seco M, Harris SR, Koullouros M, Ramponi F, Wilson M, Bannon PG, Vallely MP

Heart Lung Circ 2019 May;28(5):807-813

PMID: 30126790

Abstract

BACKGROUND: Bilateral internal mammary artery (BIMA) grafts have demonstrated superior long-term outcomes compared with single internal mammary artery (SIMA) grafts. Despite this, BIMA remains widely underutilised due to perceived technical challenges and concerns regarding wound healing. We sought to examine the morbidity and mortality associated with BIMA use in a propensity-matched cohort of patients.

METHODS: From 2009 to 2016, 3,594 consecutive patients underwent coronary artery bypass surgery at three affiliated institutions. Thirty-day (30) mortality and morbidity data were collected prospectively. Propensity-score matched analyses were performed for BIMA versus SIMA use controlling for a number of preoperative characteristics.

RESULTS: Overall, 29% of procedures were performed off pump, with a greater proportion in the BIMA group (43% vs. 21%, p<0.001). In the propensity-score analysis consisting of 820 matched pairs, there were similar rates of 30-day mortality (1.3% BIMA vs. 0.9% SIMA, p=0.48) and deep sternal wound infection (1.1% BIMA vs. 0.9% SIMA, p=0.84). The rate of superficial sternal wound infection trended towards being higher in the BIMA group (2.6% vs. 1.3%, p=0.077). The rates of red blood cell transfusions (27.4% vs. 27%, p=0.217), other blood product transfusions (18% vs. 20%, p=0.217), and reoperation for bleeding (2.9% vs. 2.1%, p=0.349) were similar.

CONCLUSIONS: Bilateral internal mammary artery use was associated with similar rates of deep sternal wound infection compared to SIMA use, with a preponderance of superficial sternal wound infections that did not result in increased mortality or transfusion requirements. The use of BIMA should be more widely considered for coronary artery bypass surgery.

Cao JY, Wales KM, Zhao DF, Seco M, Celermajer DS, Bannon PG

Ann. Thorac. Surg. 2020 Mar;109(3):950-958

PMID: 31589849

Abstract

BACKGROUND: This systematic review and meta-analysis was undertaken to investigate the short- and long-term clinical outcomes of concurrent repair of mild or moderate tricuspid regurgitation (TR) during left-sided valve surgery.

METHODS: Medline, PubMed, EMBASE, and Cochrane Libraries were searched, and 12 studies were identified, comprising 1373 patients who underwent TR repair during left-sided valve surgery and 1553 patients who did not. Of these studies, 6 were classified as having a low risk of bias (randomized controlled trials or propensity-matched studies), and 6 were considered as having a high risk of bias (nonmatched observational studies). The primary analysis included only studies with a low risk of bias (399 repair and 426 nonrepair).

RESULTS: Primary analysis of studies at low risk of bias demonstrated that the addition of TR repair compared with nonrepair was associated with reduced risks of cardiovascular mortality, all-cause mortality, and progression of TR over a median of 5.3 years of follow-up (cardiovascular mortality: relative risk [RR], 0.46; 95% confidence interval [CI], 0.28 to 0.75; P = .002; all-cause mortality: RR, 0.68; 95% CI, 0.49 to 0.96; P = .03; and TR progression: RR, 0.26; 95% CI, 0.12 to 0.56; P < .001). Cardiopulmonary bypass time was significantly shorter in the nonrepair group (mean weighted difference, 18 minutes; 95% CI, 6 to 30; P = .003), although the risk of perioperative mortality was comparable between the 2 groups (RR, 0.72; 95% CI, 0.27 to 1.97; P > .05).

CONCLUSIONS: Concurrent repair of mild or moderate TR during left-sided valve surgery is associated with improved long-term clinical outcomes without adversely affecting early survival. Should these results be validated by ongoing trials, there should be a revision of current guidelines to recommend a more aggressive approach toward TR repair.

Brieger DB, Ng ACC, Chow V, D’Souza M, Hyun K, Bannon PG, Kritharides L

Open Heart 2019;6(1):e000959

PMID: 31168375

Abstract

Objectives: To describe changes in mortality among patients undergoing coronary artery bypass grafting (CABG) in New South Wales (NSW) Australia from 2000 to 2013.

Methods: Patients undergoing CABG were identified from the NSW Admission Patient Data Collection (APDC) registry, linked to the NSW state-wide death registry database. Changes in all-cause mortality over time were observed following stratification of the study cohort into two year groups.

Results: We identified 54 767 patients undergoing CABG during the study period. The risk profile of patients increased over time with significant increases in age, comorbidities and concomitant valve surgery (all p < 0.0001). During a median follow-up period of 6 years, a total 12 161 (22.2%) of patients had died. Survival curves and adjusted analyses showed a steady fall in mortality rate: those operated on during 2012-2013 had 40 % lower mortality than those operated on during 2000-2001 (HR 0.61; 95% CI 0.53 to 0.69). This was contributed to both by a fall in mortality both in hospital (HR 0.48, 95% CI 0.37 to 0.62) and postdischarge (HR 0.73; 95% CI 0.61 to 0.86).

Conclusions: We report a consistent reduction in medium-term mortality among a large unselected cohort of NSW patients undergoing CABG between 2000 and 2013. This fall is attributable both to an improvement in outcomes in hospital and in the postdischarge period.

McBride KE, Solomon MJ, Steffens D, Bannon PG, Glozier N

ANZ J Surg 2019 06;89(6):630-631

PMID: 31179630

Abstract

Cao C, Huang J

J. Thorac. Cardiovasc. Surg. 2019 Apr;

PMID: 31043314

Abstract

Cao C, Cerfolio RJ, Louie BE, Melfi F, Veronesi G, Razzak R, Romano G, Novellis P, Shah S, Ranganath N, Park BJ

Ann. Thorac. Surg. 2019 Jun;

PMID: 31255610

Abstract

BACKGROUND: Intraoperative catastrophes during robotic anatomical pulmonary resections are potentially devastating events. The present study aimed to assess the incidence, management, and outcomes of these intraoperative catastrophes for patients with primary lung cancers.

METHODS: This was a retrospective, multi-institutional study that evaluated patients who underwent robotic anatomical pulmonary resections. Intraoperative catastrophes were defined as events necessitating emergency thoracotomy or requiring an additional unplanned major surgical procedure. Standardized data forms were collected from each institution, with questions on intraoperative management strategies of catastrophic events.

RESULTS: Overall, 1,810 patients underwent robotic anatomical pulmonary resections, including 1,566 (86.5%) lobectomies. Thirty-five patients (1.9%) experienced an intraoperative catastrophe. These patients were found to have significantly higher clinical TNM stage (p=0.031) and lower FEV1 (81% vs 90%, p=0.004). A higher proportion of patients who had a catastrophic event underwent preoperative radiotherapy (8.6% vs 2.3%, p=0.048), and the surgical procedures performed differed significantly compared to non-catastrophic patients. Patients in the catastrophic group had higher perioperative mortality (5.7% vs 0.5%, p=0.018), longer operative duration (195 min vs 170 min, p = 0.020), and higher estimated blood loss (225 ml vs 50 ml, p<0.001). The most common catastrophic event was intraoperative hemorrhage from the pulmonary artery, followed by injury to the airway, pulmonary vein, and the liver. Detailed management strategies were discussed.

CONCLUSIONS: The incidence of catastrophic events during robotic anatomical pulmonary resections was low, and the most common complication was pulmonary arterial injury. Awareness of potential intraoperative catastrophes and their management strategies are critical to improving clinical outcomes.

Edelman JJ, Kitahara H, Thourani VH

J. Thorac. Cardiovasc. Surg. 2019 Jul;

PMID: 31277811

Abstract

McBride KE, Steffens D, Solomon MJ, Anderson T, Young J, Leslie S, Thanigasalam R, Bannon PG

Aust Health Rev 2019 Jul;

PMID: 31306613

Abstract

Within Australia, robotic-assisted surgery (RAS) has largely been undertaken within the private sector, and predominately based within urology. This is rapidly developing, with RAS becoming increasingly prevalent across surgical specialties and within public hospitals. At this point in time there is a need to consider how this generation of the technology can be appropriately and safely introduced into the public health system given its prohibitive costs and lack of high-level long-term evidence.This paper describes a unique approach used to govern the establishment of a new RAS program within a large public tertiary referral hospital in Australia. This included the creation of a comprehensive governance framework that covered research, training and operational components, with research being the ultimate gatekeeper to accessing the technology.Taking this novel approach, both benefits and challenges were encountered. Although initially there was a trade-off of activity to enable time for the research program to be developed, it was found the model strengthened patient safety in introducing the technology, fostered a breadth of surgical speciality involvement, ensured uniformity of data collection and, in the longer term, will enable a significant contribution to be made to the evidence regarding the appropriateness of RAS being used across several surgical specialties.There is potential for this comprehensive governance framework to be transferred to other public hospitals commencing or with existing RAS programs and to be applied to the introduction of other new and expensive surgical technology.RAS is rapidly evolving and becoming increasingly prevalent across surgical specialities in major public hospitals. Consequently, it is important that this new technology is safely and appropriately implemented into the public health system.This article describes the benefits and implementation challenges of a novel RAS approach, including a comprehensive governance framework that covered research, training and operational components, with research being the ultimate gatekeeper to accessing the technology.This comprehensive governance framework can be transferred to other public hospitals introducing, or already using, new and expensive surgical technology.

Edelman JJ, Khan JM, Rogers T, Shults C, Satler LF, Ben-Dor II, Waksman R, Thourani VH

Innovations (Phila) 2019 Aug;14(4):299-310

PMID: 31328655

Abstract

An increasing number of surgically implanted bioprostheses will require re-intervention for structural valve deterioration. Valve-in-valve transcatheter aortic valve replacement (ViV TAVR) has become an alternative to reoperative surgery, currently approved for high-risk and inoperable patients. Challenges to the technique include higher rates of prosthesis-patient mismatch and coronary obstruction, compared to native valve TAVR. Herein, we review results of ViV TAVR and novel techniques to overcome the aforementioned challenges.