Cardiothoracic surgery is facing a multitude of challenges in leadership and training on the global scale, these being a complex and aging patient population, shortage of cardiac surgeons, diminishing student interest and trainee enthusiasm, increasingly challenging training obstacles and work-life imbalances, suboptimal job prospects, reports of discrimination and bullying and lack of diversity as well as gap between innovation and technology, clinical application, and training of future surgeons. The survival of cardiac surgery hinges on the leadership attracting and retaining young surgeons into the specialty. Mentoring, leading through example, recognizing the work-life imbalances, adapting to diverse and modern training models and embracing diversity with respect to gender and race, will ultimately be required to create and cultivate a nurturing environment of training and preparing future leaders. The vision for training future generations of cardiothoracic surgeons must rely heavily on strengthening the unity of the heart team. In doing so we can provide the best possible care for our patients and a most fulfilling career for the future generation of cardiac surgeons.
Background: Partial anomalous pulmonary venous connection (PAPVC) occurs when at least one pulmonary vein drains into the right atrium or its tributaries rather than the left atrium, most commonly connecting with the superior vena cava (SVC). The Warden procedure involves transecting the SVC proximal to the uppermost connection of the pulmonary vein followed by proximal SVC reattachment to the right atrial appendage. However, descending thoracic aortic homograft replacement for SVC translocation has recently been introduced as a modified technique. Aims: This commentary aims to discuss the recent study by Said and colleagues who reported their experiences with 6 PAPVC cases undergoing a modified Warden procedure using thoracic aortic homograft SVC translocation. Methods: A comprehensive literature search was performed using multiple electronic databases in order to collate the relevant research evidence. Results: The Warden procedure is associated with a 10% incidence of SVC obstruction with many requiring reintervention. Meanwhile, using the aortic homograft for SVC translocation, Said et al. observed no SVC obstructions. In addition, this modified technique does not require anticoagulation and has demonstrated an improvement in long-term SVC patency. Nevertheless, it can be considered an expensive procedure. Moreover, since the thoracic aortic homograft utilised is biological tissue, only long-term follow-up will determine whether calcification and graft degeneration is an issue. Conclusion: It can be concluded that the modified Warden procedure is a safe and effective method to reconstruct the systemic venous drainage into the right atrium when a direct anastomosis under tension might be prone to re-stenosis.
Background: Type A aortic dissection (TAAD) involves a tear in the intimal layer of the thoracic aorta proximal to the left subclavian artery, and hence, carries a high risk of mortality and morbidity and requires urgent intervention. This dissection can extend into the main coronary arteries. Coronary artery involvement in TAAD can either be due to retrograde extension of the dissection flap into the coronaries or compression and/or blockage of these vessels by the dissection flap, possibly causing myocardial ischaemia. Due to the emergent nature of TAAD, coronary involvement is often missed during diagnosis, thereby delaying the required intervention. Aims: The main scope of this review is to summarise the literature on the incidence, mechanism, diagnosis, and treatment of coronary artery involvement in TAAD. Methods: A comprehensive literature search was performed using multiple electronic databases, including PubMed, Ovid, Scopus and Embase, to identify and extract relevant studies. Results: Incidence of coronary artery involvement in TAAD was seldom reported in the literature, however, some studies have described patients diagnosed either preoperatively, intraoperatively following aortic clamping, or even during autopsy. Among the few studies that reported on this matter, the treatment choice for coronary involvement in TAAD was varied, with the majority revascularizing the coronary arteries using coronary artery bypass grafting or direct local repair of the vessels. It is well-established that coronary artery involvement in TAAD adds to the already high mortality and morbidity associated with this disease. Lastly, the right main coronary artery was often more implicated than the left. Conclusion: This review reiterates the significance of an accurate diagnosis and timely and effective interventions to improve prognosis. Finally, further large cohort studies and longer trials are needed to reach a definitive consensus on the best approach for coronary involvement in TAAD.
Background While open surgical repair continues to be the mainstay option for aortic arch reconstruction, the associated mortality, morbidity, and high turn-down rates have led to a need for the development of minimally invasive options for aortic arch repair. Though RELAY™ Branched (Terumo Aortic, Inchinnan, UK) represents a promising option for complex endovascular aortic arch repair, neurological complications remain a pertinent risk. Herein we seek to present multi-centre data from Europe documenting the neurological outcomes associated with RELAY™ Branched. Methods Prospective data collected between January 2019 and January 2022 associated with patients treated with RELAY™ single-, double-, and triple-branched endoprostheses from centres across Europe was retrospectively analysed with descriptive and distributive analysis. Follow up data from 30 days and 6-, 12-, and 24 months postoperatively was included. Patients follow up was evaluated for the onset of disabling stroke (DS) and non-disabling stroke (NDS). Results Technical success was achieved in 147 (99.3%) cases. Over 24 months period, in total, 6 (4.1%) patients suffered DS and 8 (5.4%) patients suffered NDS after undergoing aortic arch repair with RELAY™. All patients that developed postoperative DS had been treated with the double-branched RELAY™ endoprosthesis. Discussion The data presented herein demonstrates that RELAY™ Branched is associated with favourable neurological outcomes and excellent technical success rates. Key design features of the endoprosthesis and good perioperative management can contribute greatly to mitigating neurological complications following endovascular aortic arch repair.
Background: There is emerging evidence to support pre-emptive thoracic endovascular aortic repair (TEVAR) intervention for uncomplicated type B aortic dissection (unTBAD). Pre-emptive intervention would be particularly beneficial in patients that have a higher baseline risk of progressing to complicated TBAD (coTBAD). There remains debate on the optimal clinical, laboratory, morphological and radiological parameters which would identify the highest-risk patients that would benefit most from pre-emptive TEVAR. Aim: This review summarises evidence on the clinical, laboratory, and morphological parameters that increase the risk profiles of unTBAD patients. Methods: A comprehensive literature search was carried out on multiple electronic databases including PubMed, EMBASE, Ovid and Scopus in order to collate all research evidence on the the clinical, laboratory, and morphological parameters that increase the risk profiles of unTBAD patients Results: At present, there are no clear clinical guidelines using risk-stratification to inform the selection of unTBAD patients for TEVAR. However, there are noticeable literature trends that can assist with the identification of the most at-risk unTBAD patients. Patients are at particular risk when they have refractory pain and/or hypertension, elevated C-reactive protein (CRP), larger aortic diameter and larger entry tears. These risks should be considered alongside factors that increase the procedural risk of TEVAR to create a well-balanced approach. Advances in biomarkers and imaging are likely to identify more pertinent parameters in future to optimise the development of balanced, risk-stratified treatment protocols. Conclusion: There are a variety of risk profiling parameters that can be used to identify the high-risk unTBAD patient, with novel biomarkers and imaging parameter emerging. Longer-term evidence verifying these parameters would be ideal. Further randomized controlled trials and multicentre registry analyses are also warranted to guide risk-stratified selection protocols.
Background: Acute type B aortic dissection (TBAD) is a rare condition that can be divided into complicated (CoTBAD) and uncomplicated (UnCoTBAD) based on certain presenting clinical and radiological features, with UnCoTBAD constituting the majority of TBAD cases. The classification of TBAD directly affects the treatment pathway taken, however, there remains confusion as to exactly what differentiates complicated from uncomplicated TBAD. Aims: The scope of this review is to delineate the literature defining the intervention parameters for UnCoTBAD. Methods: A comprehensive literature search was conducted using multiple electronic databases including PubMed, Scopus, and EMBASE to collate and summarize all research evidence on intervention parameters and protocols for UnCoTBAD. Results: A TBAD without evidence of malperfusion or rupture might be classified as uncomplicated but there remains a subgroup who might exhibit high-risk features. Two clinical features representative of “high risk” are refractory pain and persistent hypertension. First line treatment for CoTBAD is TEVAR, and whilst this has also proven its safety and effectiveness in UnCoTBAD, it is still being managed conservatively. However, TBAD is a dynamic pathology and a significant proportion of UnCoTBADs can progress to become complicated, thus necessitating more complex intervention. While the “high risk” UnCoTBAD do benefit the most from TEVAR, yet, the defining parameters are still debatable as this benefit can be extended to a wider UnCoTBAD population. Conclusion: Uncomplicated TBAD remains a misnomer as it is frequently representative of a complex ongoing disease process requiring very close monitoring in a critical care setting. A clear diagnostic pathway may improve decision making following a diagnosis of UnCoTBAD. Choice of treatment still predominantly depends on when an equilibrium might be reached where the risks of TEVAR outweigh the natural history of the dissection in both the short- and long-term.
Background: Initial clinical evaluation (ICE) is traditionally considered a useful screening tool to identify frail patients during the pre-operative assessment. However, emerging evidence supports the more objective assessment of cardiorespiratory fitness (CRF) via cardiopulmonary exercise testing (CPET) to improve surgical risk stratification. Herein, we compared both subjective and objective assessment approaches to highlight the interpretive idiosyncrasies. Methods: As part of routine pre-operative patient contact, patients scheduled for major surgery were prospectively ‘eyeballed’ (ICE) by two experienced clinicians prior to more detailed history taking that also included American Society of Anaesthesiologists score classification. Each patient was subjectively judged to be either ‘frail’ or ‘not frail’ by ICE and ‘fit’ or ‘unfit’ from thorough review of the medical notes. Subjective data were compared against the more objective validated assessment of post-operative outcomes using established CPET ‘cut-off’ metrics incorporating peak pulmonary oxygen uptake ( V̇O 2PEAK), V̇O 2 at the anaerobic threshold ( V̇O 2-AT) and ventilatory equivalent for carbon dioxide that collectively informed risk stratification. These data were retrospectively extracted from a single-centre prospective National Health Service database. Data were analysed using the Chi-square automatic interaction detection decision tree method. Results: A total of 127 patients examined that comprised 58 % male and 42 % female patients aged 69 ± 10 y with a BMI of 29 ± 7 kg/m 2. Patients were poorly conditioned with a peak pulmonary oxygen uptake almost 20 % lower than that predicted for age, sex-matched healthy controls with 35 % exhibiting a V̇O 2-AT <11 mL/kg/min. Disagreement existed between the subjective assessments of risk with ~34 % of patients classified not frail on ICE were considered unfit by notes review ( P < 0.0001). Furthermore, ~35 % of patients considered not frail on ICE and ~31 % of patients considered fit by notes review exhibited a V̇O 2-AT <11 mL/kg/min and of these, ~28 % and ~19 % were classified as intermediate-to-high risk. Conclusions: These findings highlight the interpretive limitations associated with the subjective assessment of patient frailty with surgical risk classification underestimated in up to a third of patients compared to the validated assessment of CRF. They reinforce the benefits of a more objective and integrated approach offered by CPET that may help improve perioperative risk assessment and better direct critical care provision in patients scheduled for ‘high-stakes’ surgery including open TAAA repair.
Background: Uncomplicated type B aortic dissection (un-TBAD) has been managed conservatively with medical therapy in order to control the heart rate and blood pressure to limit disease progression, in addition to radiological follow-up. However, several trials and observational studies have investigated the use of thoracic endovascular aortic repair (TEVAR) in un-TBAD and suggested that TEVAR provides a survival benefit over medical therapy. Outcomes of TEVAR have also been linked with the timing of intervention. Aims: The scope of this review is to collate and summarise all the evidence in the literature on the mid- and long-term outcomes of TEVAR in un-TBAD, confirming its superiority. We also aimed to investigate the relationship between timing of TEVAR intervention and results. Methods: We carried out a comprehensive literature search on multiple electronic databases including PubMed, Scopus and EMBASE in order to collate and summarise all research evidence on the mid- and long-term outcomes of TEVAR in un-TBAD, as well as its relationship with intervention timing. Results: TEVAR has proven to be a safe and effective tool in un-TBAD, offering superior mid- and long-term outcomes including all-cause and aorta-related mortality, aortic-specific adverse events, aortic remodelling, and need for reintervention. Additionally, performing TEVAR during the subacute phase of dissection seems to yield optimal results. Conclusion: The evidence demonstrating a survival advantage in favour TEVAR over medical therapy in un-TBAD means that with further research, particular trials and observational studies, TEVAR could become the gold-standard treatment option for un-TBAD patients.
Background The use of thoracic endovascular aortic repair (TEVAR) for the management of uncomplicated type B aortic dissection (un-TBAD) remains controversial. There is a lack of consensus over whether pre-emptive TEVAR should be carried out in patients with un-TBAD at risk of progression to complicated TBAD. We present a review of current evidence and seek to suggest criteria where endovascular intervention in un-TBAD may prove beneficial relative to pharmacotherapy alone. Methods and Materials PubMed and Cochrane databases were searched using terms including: type B aortic dissection, risk factors, medical therapy, TEVAR, false lumen expansion, and mortality. Papers were selected based on title and abstract. Results Optimal medical therapy remains the mainstay treatment for patients with un-TBAD, however patients with un-TBAD present with varying degrees of disease progression risk. Factors such as age, aortic morphology, history of connective tissue disorders, false lumen thrombosis, and aortic branch involvement may potentiate progression from un-TBAD to complicated TBAD. Short- and long-term outcomes associated with TEVAR for TBAD remain promising. Conclusion Pre-emptive TEVAR may be beneficial in patients with un-TBAD presenting with the above factors, however further prospective research into the optimal timing for TEVAR in un-TBAD is required.
Background: Uncomplicated Stanford Type B aortic dissection (un-TBAD) is characterised by a tear in the aorta distal to the left subclavian artery without ascending aorta and arch involvement. Optimised cardiovascular control (blood pressure and heart rate) is the current gold standard treatment according to current international guidelines. However, emerging evidence indicates that Thoracic Endovascular Aortic Repair (TEVAR) is both safe and effective in the treatment of un-TBAD with improved long-term survival outcomes in combination with optimal medical therapy (OMT) relative to OMT alone. However, the optimal timeframe for intervention is not entirely clarified. Aims: This review critically addresses current state-of-the-art comparing TEVAR with OMT and corresponding clinical outcomes for un-TBAD based on timing of intervention. Methods: We carried out a comprehensive literature search on multiple electronic databases including PUBMED and Scopus in order to collate all research evidence on timing of TEVAR in uncomplicated Type B aortic dissection. Results: TEVAR has proven to be a safe and effective treatment for un-TBAD in combination with OMT through comparable survival outcomes, improved aortic remodelling, and relatively low periprocedural added risks. Though the timing of intervention remains controversial, it is becoming clear that performing TEVAR during the subacute phase of un-TBAD yields better outcomes compared to earlier and delayed (>90 days) intervention. Conclusions: Further research is required into both short and long-term outcomes of TEVAR in addition to its optimal therapeutic window for un-TBAD. With stronger evidence, TEVAR is likely to be adopted as the gold-standard intervention for un-TBAD with definitive timeframe guidelines.
Background Paget-Schroetter Syndrome (PSS) is an uncommon disorder involving thrombosis of the subclavian vein, often caused by repetitive overuse or compression by the surrounding anatomical structures. Optimal management of PSS is a subject of debate, but current trends suggest that a hybrid approach employing endovascular intervention and open decompression may yield the best clinical results. This original article examines the roles played by endovascular thrombolysis, surgical decompression, and postoperative secondary intervention in the management of PSS. Methods Current literature on the management of PSS was reviewed and evaluated to ascertain what strategy of intervention would be optimal. In addition, clinical data from the University Hospital of Wales on the clinical outcomes in PSS patients undergoing different surgical approaches for anatomical decompression are included. Results Evaluation of data from the included series and available literature seems to indicate that endovascular thrombolytic devices such as the AngioJet or mechanical thrombectomy offer superior results than traditional catheter-directed thrombolysis. In addition, adjunctive procedures such as superior vena cava filters and venous angioplasty or bypass may augment maintenance of the subclavian vein lumen. Nonetheless, the subclavian vein must still be relieved of pressure from surrounding structures for treatment to be successful. Conclusions A hybrid approach to the management of PSS, encompassing endovascular and surgical interventions could possibly offer optimal clinical outcomes as both intrinsic lesions and extrinsic compression of the subclavian vein are resolved. This article recommends prospective research to determine the ideal endovascular treatment, and best surgical approach for decompression.