Nawwar Al-Attar

This study sought to compare the morbidity and mortality of redo aortic valve replacement (redo-AVR) versus valve-in-valve trans-catheter aortic valve implantation (valve-in-valve TAVI) for patients with a failing bioprosthetic valve. A multicentre UK retrospective study of redo-AVR or valve-in-valve TAVI for patients referred for redo aortic valve intervention due to a degenerated aortic bioprosthesis. Propensity score matching was performed for confounding factors. From July 2005 to April 2021, 911 patients underwent redo-AVR and 411 patients valve-in-valve TAVI. There were 125 pairs for analysis after propensity score matching. Mean age was 75.2±8.5 years. In-hospital mortality was 7.2% (n=9) for redo-AVR vs 0 for valve-in-valve TAVI, p=0.002. Surgical patients suffered more post-operative complications, including IABP support (p=0.02), early re-operation (p<0.001), arrhythmias (p<0.001), respiratory and neurological complications (p=0.02 and p=0.03) and multi-organ failure (p=0.01). The valve-in-valve TAVI group had a shorter intensive care unit and hospital stay (p <0.001 for both). However, moderate aortic regurgitation at discharge and higher post-procedural gradients were more common after valve-in-valve TAVI (p<0.001 for both). Survival probabilities in patients who were successfully discharged from hospital were similar after valve-in-valve TAVI and redo-AVR over the 6-year follow-up (log-rank p=0.26). In elderly patients with a degenerated aortic bioprosthesis, valve-in-valve trans-catheter aortic valve implantation provides better early outcomes, as opposed to redo surgical aortic valve replacement, although there was no difference in mid-term survival in patients successfully discharged from hospital.

OBJECTIVES: To evaluate the use of CABG utilising an isolated pedicled Right Internal Thoracic Artery (RITA) or Left Internal Thoracic Artery (LITA) or the Pure Internal Thoracic Artery (PITA) technique to treat anomalous aortic origin of coronary artery (AAOCA). METHODS: A retrospective review of all patients at our institution over an 8-year period (2013–2021) who underwent surgery for AAOCA was performed. Data assessed included patient demographics, initial presentation, morphology of coronary anomaly, surgical procedure, cross-clamp time, cardiopulmonary bypass time, and long-term outcome. RESULTS: A total of 14 patients underwent surgery, including 11 males (78.5%) with a median logistic EuroSCORE of 1.605 (IQR 1.34). The median age was 62.5 years (IQR 48.75). Presentation was angina (7 patients), acute coronary syndrome (5 patients), incidental findings in aortic valve pathology (2 patients). AAOCA morphology varied: RCA from left coronary sinus (6), RCA from left main stem (3), left coronary artery from the right coronary sinus (1), left main stem arising from right coronary sinus (2) and circumflex artery arising from the right coronary sinus (2). Overall, 7 patients had co-existing flow-limiting coronary artery disease. CABG was performed using either a pedicled skeletonized RITA, LITA or PITA technique. There was no perioperative mortality. Overall median follow-up time was 43 months. One patient presented with recurrent angina secondary to graft failure at 2 years and there were two non-cardiac-related deaths at 4 and 35 months. CONCLUSION: The use of internal thoracic artery grafts can provide a durable treatment option in patients with anomalous coronary arteries. The potential risk of graft failure in patients with no flow-limiting disease should be very carefully considered. However, a proposed benefit of this technique is the use of a pedicle flow to increase the long-term patency. More consistent results are obtained when ischaemia can be demonstrated preoperatively.

The coronavirus (COVID-19) pandemic disrupted all surgical specialties significantly and exerted additional pressures on the overburdened United Kingdom (UK) National Health Service. Healthcare professionals in the UK have had to adapt their practice. In particular, surgeons have faced organisational and technical challenges treating patients who carried higher risks, were more urgent and could not wait for prehabilitation or optimisation before their intervention. Furthermore, there were implications for blood transfusion with uncertain patterns of demand, reductions in donations and loss of crucial staff because of sickness and public health restrictions. Previous guidelines have attempted to address the control of bleeding and its consequences after cardiothoracic surgery, but there have been no targeted recommendations in light of the recent COVID-19 challenges. In this context, and with a focus on the perioperative period, an expert multidisciplinary Task Force reviewed the impact of bleeding in cardiothoracic surgery, explored different aspects of patient blood management with a focus on the use of haemostats as adjuncts to conventional surgical techniques and proposed best practice recommendations in the UK.

Andexanet alfa was employed to reverse the anticoagulant effect of direct oral anticoagulants in 3 patients who required emergent surgery for repair of type A aortic dissection. Its use was instrumental in securing haemostasis. However, we caution against the administration of Andexanet alfa prior to cardiopulmonary bypass as it can induce heparin resistance and complicate the perioperative monitoring of anticoagulation during cardiopulmonary bypass.

This postmarket clinical study evaluated the safety and effectiveness of the novel adjunctive topical hemostat SURGICEL® Powder (SURGICEL®-P), a powdered form of oxidized regenerated cellulose. In a prospective, open-label, single-arm multicenter trial, adult surgical subjects with mild-to-moderate bleeding for which conventional hemostatic methods were impractical/ineffective were treated with SURGICEL®-P. Descriptive analyses included hemostatic success rate at 3, 5, and 10 min, rebleeding and thromboembolic events, SURGICEL®-P-related serious adverse events requiring surgical intervention, and SURGICEL®-P ease of use (questionnaire). In 8 centers, 103 subjects were enrolled with a median (range) age of 64.0 (33.0-88.0) years. Surgeries were open (53.4%) or laparoscopic/thoracoscopic (46.6%) and mostly urological (37.9%) and abdominal (32.0%) procedures. Bleeding sites included various tissue types, with a median (range) surface area of 4 (0.02-72.0) cm². Hemostatic success rates were 77.7%, 87.4%, and 92.2% at 3, 5, and 10 min, respectively. In 7 subjects (6.8%), investigators reverted to standard of care. No safety signals were identified. Two deaths occurred with causes unrelated to SURGICEL®-P. Investigators favorably evaluated the ease of use of the SURGICEL®-P device. SURGICEL®-P is safe and effective in controlling mild-to-moderate bleeding in a broad range of surgical procedures. The trial was registered at https://clinicaltrials.gov as NCT03762200.

Background. Topical hemostats reduce blood loss and optimize patient outcome and health care costs. The choice of agent depends on mode of action and surgical situation. This post-market clinical study evaluated the safety and effectiveness of Surgicel®-P, a powdered form of oxidized regenerated cellulose, designed to help control mild-to-moderate bleeding on broad or raw tissue surfaces.Methods. In a prospective, single-arm, multicenter trial, adult subjects with a target bleeding site (TBS) (mild-to-moderate bleeding for which conventional hemostatic methods were impractical or ineffective) were treated with Surgicel®-P. The primary endpoint was the proportion of subjects showing hemostasis at 5 minutes after application, without re-bleeding needing other hemostatic treatment. Secondary endpoints were these proportions at 3 and 10 minutes. The investigators’ ease-of-use evaluation of Surgicel®-P was recorded via questionnaire. Safety endpoints were the incidences of re-bleeding and thromboembolic events through day 30, and serious adverse events requiring surgical intervention through month 6 with a causal (including unlikely or at least possible) relationship to Surgicel®-P. Results. In 8 centers, 103 subjects were enrolled [median(range) age 64.0(33-88) years], of which 100 completed the study. Two deaths occurred, due to causes unrelated to Surgicel®-P. Surgeries were open (53.4%) or laparoscopic/thoracoscopic (46.6%), and mostly urological (37.9%) and abdominal (32.0%); TBSs included various tissue types, with mild (69.9%) or moderate (30.1%) bleeding over a median(range) surface area of 4(0.02–72.0) cm². The 5-minute hemostatic success rate (primary endpoint) was 87.4%; the 3- and 10-minute rates (secondary endpoints) were 77.7% and 92.2%, respectively. Subgroup analyses showed 3-, 5- and 10-minute rates of 84.7%, 93.1%, 95.8% for mild, versus 61.3%, 74.2%, 83.9% for moderate bleeding, and 80.0%, 90.9%, 96.4% for open versus 75.0%, 83.3%, 87.5% for laparoscopic/thoracoscopic procedures. Within 10 minutes, initial manual compression (27.5%) was progressively abandoned, and additional Surgicel®-P was applied to 17.4% of TBSs. Investigators reverted to suture, cautery or other topical hemostats in 6.8% of procedures. No safety signals were identified. Investigators favorably evaluated the ease of use of Surgicel®-P device. Conclusions. This post-market clinical study supports the safety and efficacy of Surgicel®-P in controlling mild-to-moderate surgical bleeding in a broad range of surgical procedures.Clinical Trial Registration number. NCT03762200, 03/12/2018

Introduction: Aortic valve replacement with the Trifecta aortic bioprosthesis has reported favourable haemodynamic performance. However, several reports of structural valve deterioration have raised concerns of design risks and its long-term durability. Purpose: We conducted this study to assess reintervention and outcomes in a large single-centre cohort of 944 patients receiving the Trifecta valve over a 10-year period. Methods: Consecutive patients undergoing aortic valve replacement with the Trifecta valve between October 2011 and October 2020 in our centre were included in this study. Perioperative patient and operative characteristics were prospectively recorded in an independent database. Reintervention was recorded as a surrogate for structural valve deterioration, and survival data was analysed. Results: A total of 944 patient (mean age 72.82 years ± 8.13, range 28–91, 58% male) underwent aortic valve replacement with the Trifecta valve in our centre between October 2011 and October 2020. At 10-years, 1.4% of patients required a redo operation for aortic valve replacement, giving an overall freedom reintervention of 98.6%, with a 99.3% and 99.4% freedom from reintervention due to structural valve deterioration and infection, respectively. The mean time to all-cause reintervention was 48.87 months, and the mean time to reintervention due to SVD was 68.87 months. Patients that did not require reintervention had a 97.74% freedom from mortality and those that underwent reintervention had a freedom from mortality of 84.62% with a median survival of 69-days. Conclusions: In a large single-centre cohort, the Trifecta aortic bioprosthesis was safe with a 1.4% all-cause reintervention rate and a 0.7% reintervention rate for structural valve deterioration at 10-years. Funding Acknowledgement: Type of funding sources: None.