Publications by authors named "Amer Harky"

242 Publications

European registry of type A aortic dissection (ERTAAD) - rationale, design and definition criteria.

J Cardiothorac Surg 2021 Jun 10;16(1):171. Epub 2021 Jun 10.

Leipzig Heart center, Leipzig, Germany.

Background: Acute Stanford type A aortic dissection (TAAD) is a life-threatening condition. Surgery is usually performed as a salvage procedure and is associated with significant postoperative early mortality and morbidity. Understanding the patient's conditions and treatment strategies which are associated with these adverse events is essential for an appropriate management of acute TAAD.

Methods: Nineteen centers of cardiac surgery from seven European countries have collaborated to create a multicentre observational registry (ERTAAD), which will enroll consecutive patients who underwent surgery for acute TAAD from January 2005 to March 2021. Analysis of the impact of patient's comorbidities, conditions at referral, surgical strategies and perioperative treatment on the early and late adverse events will be performed. The investigators have developed a classification of the urgency of the procedure based on the severity of preoperative hemodynamic conditions and malperfusion secondary to acute TAAD. The primary clinical outcomes will be in-hospital mortality, late mortality and reoperations on the aorta. Secondary outcomes will be stroke, acute kidney injury, surgical site infection, reoperation for bleeding, blood transfusion and length of stay in the intensive care unit.

Discussion: The analysis of this multicentre registry will allow conclusive results on the prognostic importance of critical preoperative conditions and the value of different treatment strategies to reduce the risk of early adverse events after surgery for acute TAAD. This registry is expected to provide insights into the long-term durability of different strategies of surgical repair for TAAD.

Trial Registration: ClinicalTrials.gov Identifier: NCT04831073 .
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http://dx.doi.org/10.1186/s13019-021-01536-5DOI Listing
June 2021

Pedicled or skeletonized bilateral internal mammary artery harvesting - a meta- analysis and trial sequential analysis.

Expert Rev Cardiovasc Ther 2021 Jun 7. Epub 2021 Jun 7.

Department of Cardio-thoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.

Objective: There is varying evidence on the role of skeletonization of internal mammary artery in reducing the risk of sternal wound infections and ischemia following bilateral internal mammary artery grafting. Post-operative clinical outcomes of skeletonized bilateral internal mammary artery versus pedicled bilateral internal mammary artery harvesting in patients undergoing coronary artery bypass surgery were compared.

Methods: A comprehensive electronic search was conducted using MEDLINE, Scopus, EMBASE, Cochrane database and Google Scholar from inception until 15th June 2020. All studies directly comparing skeletonized and pedicled bilateral internal mammary artery harvesting were included. Meta-analysis and trial sequential analysis was conducted.

Results: Nine studies (one randomized controlled trial and eight observational studies) consisting of 3649 patients (2050 patients with skeletonized bilateral internal mammary artery grafting and 1599 patients with pedicled bilateral internal mammary artery grafting) were included. Pooled effects analysis and trial sequential analysis reported significantly lower risk of sternal wound infection with skeletonized bilateral internal mammary artery harvesting (OR 0.27, 95% CI 0.20 - 0.51, p < 0.00001).

Conclusions: Skeletonization reduces the risk of sternal wound infections by preserving vasculature as much as possible. This facilitates its use in patients at high risk of sternal wound infection.
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http://dx.doi.org/10.1080/14779072.2021.1939684DOI Listing
June 2021

Malperfusion in Acute Type A Aortic Dissection: Management Strategies.

Vasc Endovascular Surg 2021 May 27:15385744211017116. Epub 2021 May 27.

Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.

Over the decades, it has been well established that malperfusion complicates a number of acute type A aortic dissection (ATAAD) patients. Of the many complications that arise from ATAAD is malperfusion, which is the result of true lumen compression secondary to the dissection, and it is one of the most dangerous complications. Left untreated, malperfusion can eventually compromise circulation to the vascular beds of almost all vital organs. Clinicians must consider the diagnosis of malperfusion promptly following a diagnosis of acute aortic dissection. The outcomes post-surgery for patients with ATAAD with concomitant malperfusion remains poor, despite mortality for aortic surgery improving over time. Optimal management for ATAAD with associated malperfusion has yet to be implemented, further research is warranted to improve the detection and management of this potentially fatal pathology. In this review, we explore the literature surrounding the complications of malperfusion in ATAAD and the various symptom presentations, investigations, and management strategies available.
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http://dx.doi.org/10.1177/15385744211017116DOI Listing
May 2021

In patients undergoing coronary artery bypass grafting is semi-skeletonization superior to pedicled harvesting of the left internal mammary artery?

Interact Cardiovasc Thorac Surg 2021 May 25. Epub 2021 May 25.

Department of Cardiothoracic surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, 'in patients undergoing coronary artery bypass grafting is semi-skeletonized harvesting superior to pedicled harvesting of the left internal mammary artery (LIMA) in terms of conduit length, flow, rate of sternal wound infections and post-operative bleeding?'. Altogether, 235 papers were found using the reported search, of which 5 represented the best evidence to answer the clinical question. Three studies were cohort studies and 2 were randomized controlled trials. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. One randomized controlled trial showed superiority with semi-skeletonized harvesting in terms of conduit length (P < 0.001), flow (P = 0.004) and diastolic filling (P = 0.005). Three studies included data on surgical wound infections/mediastinitis, all of which reported n = 0. One randomized controlled trial and 3 cohort studies reported that semi-skeletonized harvesting reduced postoperative bleeding. No studies reported a statistically significant difference in operative time. This review suggests that semi-skeletonized harvesting could possibly be associated with favourable outcomes when compared to pedicled harvesting with respect to graft length and flow, and lower postoperative bleeding, without increasing operative time; although there is insufficient data to compare sternal wound infections or long-term outcomes. In conclusion, the limited evidence base prevents robust informed decision-making when comparing both techniques.
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http://dx.doi.org/10.1093/icvts/ivab103DOI Listing
May 2021

Optimising risk factors for atrial fibrillation post-cardiac surgery.

Perfusion 2021 May 26:2676591211019319. Epub 2021 May 26.

Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK.

Postoperative atrial fibrillation (POAF) is an ongoing complication following cardiac surgery, with an incidence of 15%-60%. It is associated with substantial mortality and morbidity, as well increased hospital stays and healthcare costs. The pathogenesis is not fully understood, but the literature suggests that POAF occurs when transient, postoperative triggers act on vulnerable atrial tissue produced by preoperative, procedure-induced and postoperative processes such as inflammation, oxidative stress, autonomic dysfunction and electrophysiological remodelling of the atrial tissues. This sets the stage for arrhythmogenic mechanisms, such as ectopic firing secondary to triggered activity and re-entry mechanisms generating POAF. Preoperative factors include advanced age, sex, ethnicity, cardiovascular risk factors, preoperative drugs, electrocardiogram and echocardiogram abnormalities. Procedural factors include: the use of cardiopulmonary bypass and aortic cross clamp, type of cardiac surgery, use of hypothermia, left ventricular venting, bicaval cannulation and exclusion of the left atrial appendage. Postoperative factors include postoperative drugs, electrolyte and fluid balance and infection. This review explores the pathogenesis of POAF and the contribution of these perioperative factors in the development of POAF. Patients can be risk stratified for targeted treatment and prophylaxis, and how these factors can be attenuated to improve POAF outcomes following cardiac surgery.
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http://dx.doi.org/10.1177/02676591211019319DOI Listing
May 2021

Optimising bloodless cardiovascular surgery for Jehovah's Witnesses and beyond.

Coron Artery Dis 2021 May 18. Epub 2021 May 18.

Hull York Medical School, University of York, York School of Medicine and Dentistry, University of Central Lancashire, Preston Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London College of Medical and Dental Sciences, University of Birmingham, Birmingham Department of Cardiothoracic Surgery, Liverpool Heart and Chest Faculty of Health and Life Sciences, University of Liverpool Liverpool Centre for Cardiovascular Science - Liverpool Heart and Chest Hospital Department of Congenital Cardiac surgery, Alder Hey Children Hospital, Liverpool, UK.

Emerging evidence suggests surgical outcomes of patients undergoing cardiovascular surgery that refuse autologous transfusion is comparable to those who accept whole blood product transfusions. There are several methods that can be used to minimize blood loss during cardiovascular surgery. These methods can be categorised into pharmacological measures, including the use of erythropoietin, iron and tranexamic acid, surgical techniques, like the use of polysaccharide haemostat, and devices such as those used in acute normovolaemic haemodilution. More prospective studies with stricter protocols are required to assess surgical outcomes in bloodless cardiac surgery as well as further research into the long-term outcomes of bloodless cardiovascular surgery patients. This review summarizes current evidence on the use of pre-, intra-, and post-operative strategies aimed at the subset of patients who refuse blood transfusion, for example Jehovah's Witnesses.
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http://dx.doi.org/10.1097/MCA.0000000000001050DOI Listing
May 2021

Type A aortic syndromes in COVID-19 positive patients: Case series from a UK multicentre study.

J Card Surg 2021 May 12. Epub 2021 May 12.

Departments of Cardiothoracic Surgery, University Hospital Southampton, Southampton, UK.

Objective: The coronavirus disease (COVID-19) increases the respiratory complications and carries a higher mortality in the immediate postoperative period. The aim of this study was to analyze the outcomes of patients with type A acute aortic syndromes (AAS) diagnosed with COVID-19 in the perioperative period.

Methods: Retrospective analysis of prospectively collected data between March and August 2020 from 20 participating cardiac surgery centers in the United Kingdom.

Results: Among 122 patients who underwent emergency surgical repair for type A AAS at the participating centers, 3 patients (2.5%) tested positive for COVID-19 in the preoperative screeing, and 4 cases turned to be positive in the postoperative period having been operated on an unknown COVID-19 status. Another patient was diagnosed of COVID-19 disease based on radiological features. These eight patients had increased postoperative complications, including respiratory failure, longer ventilation times, and Intensive Therapy Unit (ITU) stay and increased mortality when compared with COVID-19 negative patients.

Conclusion: COVID-19 disease in the perioperative period of type A AAS poses a challenge. Despite the increasing morbidity and mortality associated with the virus, the prognosis of the aortic disease is poorer and emergency surgery should not be contraindicated based on the COVID-19 diagnosis alone.
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http://dx.doi.org/10.1111/jocs.15625DOI Listing
May 2021

Aortic valve surgery: management and outcomes in the paediatric population.

Eur J Pediatr 2021 May 10. Epub 2021 May 10.

Department of Paediatric Cardiac Surgery, Alder Hey Children's Hospital, Liverpool, UK.

Congenital anomalies of the aortic valve frequently necessitate intervention in childhood. The most common aortic valve pathologies present in childhood are aortic stenosis and insufficiency. Presentation of aortic valve disease depends on severity and presence of concomitant syndromes and valvular disorders. Treatment options are largely categorised as medical, percutaneous repair or surgical repair and replacement. Surgical techniques have been refined over the last few years making this the mainstay of treatment in paediatric cases. Whilst repair is considered in most instances before replacement, there are substantial limitations which are reflected in the frequency of reintervention and restenosis rate. Replacements are typically undertaken with tissue or mechanical prosthesis. The current gold-standard aortic valve replacement surgery is called the Ross procedure-where replacement is undertaken with a competent pulmonic valve and a simultaneous pulmonary homograft.Conclusion: In this review, we aim to outline the various surgical options and discuss efficacy and complications of various interventions. What is Known: • Congenital aortic valve defects repair options medically and surgically What is New: • Comparisons between surgical options for aortic valve repair including efficacy, risks and long-term outcomes.
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http://dx.doi.org/10.1007/s00431-021-04092-1DOI Listing
May 2021

In patients with multi-vessel coronary artery diseases, does hybrid revascularization provide similar outcomes to conventional coronary artery bypass grafting?

Interact Cardiovasc Thorac Surg 2021 May 7. Epub 2021 May 7.

Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: In [patients with multivessel coronary artery diseases (CAD)] is [hybrid revascularization (HCR)] equal to [coronary artery bypass grafting (CABG)] in regard to [mortality, myocardial infarction, stroke and target vessel revascularization (TVR)]? Three-hundred and fifty-five papers were found using the reported search, of which 8 represented the best evidence to answer the question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The studies included 4 observational studies, 3 randomized controlled trials (RCTs) and 1 meta-analysis. The meta-analysis consisted of predominantly observational data with 1 randomized controlled trial and suggested non-significant differences in all major clinical outcomes. The observational studies generally cited benefit towards hybrid revascularization on the basis of equivalent major clinical outcomes rates compared to coronary artery bypass grafting, yet favourable in-hospital outcomes. One randomized controlled trial provided robust evidence of equivalent 5-year outcomes; however, the others were insufficiently powered for an effective comparison. There is a paucity of robustly designed studies to answer our clinical question effectively, given hybrid procedures are not routine in clinical practice. On the basis of mostly observational and small randomized cohorts with relatively short follow-up intervals, we conclude that current evidence suggests similar mid-term rates of major clinical outcomes after hybrid revascularization and coronary artery bypass grafting. However, without longer-term follow-up, the comparison of the two techniques, particularly relating to repeat revascularization, is still very much uncertain.
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http://dx.doi.org/10.1093/icvts/ivab107DOI Listing
May 2021

Subcutaneous implantable cardioverter defibrillator: Can it overtake its transvenous counterpart.

Pacing Clin Electrophysiol 2021 Apr 20. Epub 2021 Apr 20.

Faculty of Cardiothoracic surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.

Over the past decade, the emergence of the subcutaneous implantable cardioverter defibrillator (S-ICD) has provided cardiologists with an option to provide both primary or secondary prevention treatment of sudden cardiac death (SCD) without the associated risks that come with the use of intracardiac leads. S-ICD may prove to be a useful option in those who are young, have thromboembolic risk, immunodeficiency states, unfavorable anatomy due to adult congenital heart disease (ACHD). This article reviews the existing literature to determine whether S-ICD can prove to be a safe alternative in comparison to Transvenous implantable cardioverter defibrillator (TV-ICD) and in which patient population should S-ICD be considered over TV-ICD.
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http://dx.doi.org/10.1111/pace.14246DOI Listing
April 2021

Infective endocarditis in paediatric population.

Eur J Pediatr 2021 Apr 14. Epub 2021 Apr 14.

Department of Congenital Cardiac Surgery, Alder Hey Children Hospital, Liverpool, UK.

Infective endocarditis is very uncommon in children; however, when it does arise, it can lead to severe consequences. The biggest risk factor for paediatric infective endocarditis today is underlying congenital heart defects. The most common causative organisms are Staphylococcus aureus and the viridans group of streptococci. The spectrum of symptoms varies widely in children and this produces difficulty in the diagnosis of infective endocarditis. Infective endocarditis in children is reliant on the modified Duke criteria. The use of blood cultures remains the most effective microbiological test for pathogen identification. However, in blood culture-negative infective endocarditis, serology testing and IgG titres are more effective for diagnosis. Imaging techniques used include echocardiograms, computed tomography and positron emission tomography. Biomarkers utilised in diagnosis are C-reactive protein, with recent literature reviewing the use of interleukin-15 and C-C motif chemokine ligand for reliable risk prediction. The American Heart Association (AHA) and European Society of Cardiology (ESC) guidelines have been compared to describe the differences in the approach to infective endocarditis in children. Medical intervention involves the use of antimicrobial treatment and surgical interventions include the repair and replacement of cardiac valves. Quality of life is highly likely to improve from surgical intervention.Conclusion: Over the past decades, there have been great advancements in clinical practice to improve outcomes in patients with infective endocarditis. Nonetheless, further work is required to better investigative and manage such high risk cohort. What is Known: • The current diagnostic techniques including 'Duke's criteria' for paediatric infective endocarditis diagnosis • The current management guidelines utilised for paediatric infective endocarditis What is New: • The long-term outcomes of patients that underwent medical and surgical intervention • The quality of life of paediatric patients that underwent medical and surgical intervention.
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http://dx.doi.org/10.1007/s00431-021-04062-7DOI Listing
April 2021

The Relationship Between Vitamin D Status and Cardiovascular Diseases.

Curr Probl Cardiol 2021 Jul 19;46(7):100836. Epub 2021 Mar 19.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK; Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK. Electronic address:

With cardiovascular conditions being a leading cause of mortality and morbidity globally, several studies have identified that there is an important correlation between the level of Vitamin D and cardiovascular diseases, including an increased risk of hypertension, heart failure, and coronary artery diseases. Current published studies are in the form of both in vivo and in vitro studies and they primarily showed the evidence of how Vitamin D can downregulate Renin-Angiotensin-Aldosterone system activity and therefore providing a cardioprotective role. Nevertheless, most of these studies are observational, and there yet to be large-scale randomized controlled trials which would increase the evidence of the findings.This review aims to capture the current evidence of Vitamin D as a metabolite which is critical in reducing cardiovascular conditions and the possible physiological pathways that it works via.
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http://dx.doi.org/10.1016/j.cpcardiol.2021.100836DOI Listing
July 2021

Exploring the potential of rapid evaporative ionization mass spectrometry (Intelligent Knife) for point-of-care testing in aortic surgery.

Eur J Cardiothorac Surg 2021 Apr 11. Epub 2021 Apr 11.

Liverpool Centre for Cardiovascular Science, Liverpool, UK.

Objectives: Many intraoperative decisions regarding the extent of thoracic aortic surgery are subjective and are based on the appearance of the aorta, perceived surgical risks and likelihood of early recurrent disease. Our objective in this work was to carry out a cross-sectional study to demonstrate that rapid evaporative ionization mass spectrometry (REIMS) of electrosurgical aerosol is able to empirically discriminate ex vivo aneurysmal human thoracic aorta from normal aorta, thus providing supportive evidence for the development of the technique as a point-of-care test guiding intraoperative surgical decision-making.

Methods: Human aortic tissue was obtained from patients undergoing surgery for thoracic aortic aneurysms (n = 44). Normal aorta was obtained from a mixture of post-mortem and punch biopsies from patients undergoing coronary surgery (n = 13). Monopolar electrocautery was applied to samples and surgical aerosol aspirated and analysed by REIMS to produce mass spectral data.

Results: Models generated from REIMS data can discriminate aneurysmal from normal aorta with accuracy and precision of 88.7% and 85.1%, respectively. In addition, further analysis investigating aneurysmal tissue from patients with bicuspid and tricuspid aortic valves was discriminated from normal tissue and each other with accuracies and precision of 93.5% and 91.4% for control, 83.8% and 76.7% for bicuspid aortic valve and 89.3% and 86.0% for tricuspid aortic valve, respectively.

Conclusions: Analysis of electrosurgical aerosol from ex vivo aortic tissue using REIMS allowed us to discriminate aneurysmal from normal aorta, supporting its development as a point-of-care test (Intelligent Knife) for guiding surgical intraoperative decision-making.
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http://dx.doi.org/10.1093/ejcts/ezab166DOI Listing
April 2021

Scoring Systems for Risk Stratification in Patients Undergoing Cardiac Surgery.

J Cardiothorac Vasc Anesth 2021 Mar 6. Epub 2021 Mar 6.

Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK; Department of Integrative Biology, Faculty of Health and Life Science, University of Liverpool, Liverpool, UK; Liverpool Centre of Cardiovascular Science, Liverpool Heart and Chest Hospital, Liverpool, UK. Electronic address:

Cardiac surgery is associated with significant mortality rates. Careful selection of surgical candidates is, therefore, vital to optimize morbidity and mortality outcomes. Risk scores can be used to inform this decision-making process. The European System for Cardiac Operative Risk Evaluation Score and the Society of Thoracic Surgeons score are among the most commonly used risk scores. There are many other scoring systems in existence; however, no perfect scoring system exists, therefore, additional research is needed as clinicians strive toward a more idealized risk stratification model. The purpose of this review is to discuss the advantages and limitations of some of the most commonly used risk stratification systems and use this to determine what an ideal scoring system might look like. This includes not only the generalizability of available scores but also their ease of use and predictive power.
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http://dx.doi.org/10.1053/j.jvca.2021.03.005DOI Listing
March 2021

Evolving Diagnostic and Therapeutic Options for Visceral Artery Aneurysms.

Ann Vasc Surg 2021 Apr 3. Epub 2021 Apr 3.

Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK. Electronic address:

Background: Visceral artery aneurysms (VAAs) are associated with a very high mortality rate when ruptured and may present as a surgical emergency. Due to their rarity and varying pathophysiology, literature concerning the optimal management of VAAs is limited. This review evaluates the evolving management options for VAAs with a focus on open and endovascular repair.

Methods: A combination of databases including OVID, PubMed and Medline were used to perform a literature search. Search terms employed include 'visceral artery aneurysms', 'angiography', '3D-volumetric rendering', 'management', 'open repair' and 'endovascular repair', amongst others.

Results: 3D modelling in conjunction with existing diagnostic techniques, such as computed tomography and angiography, may improve diagnostic sensitivity. The literature surrounding operative management of VAAs highlights the effectiveness of endovascular repair for anatomically suitable aneurysms. Advances in endovascular technologies may expand the type and number of aneurysms amenable to catheter-based treatment approaches. For aneurysms not amenable to endovascular treatment, or those with an emergency indication, open repair remains an appropriate management choice.

Conclusion: Although rare, VAAs pose a high mortality risk, especially when ruptured. Practical limitations that restrict current operative approaches may be overcome by recent developments including novel neurointerventional techniques that have been applied in VAA management.
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http://dx.doi.org/10.1016/j.avsg.2021.03.012DOI Listing
April 2021

Vocal cord palsy as a sequela of paediatric cardiac surgery - a review.

Cardiol Young 2021 Apr 5:1-9. Epub 2021 Apr 5.

Department of Congenital Cardiac Surgery, Alder Hey Children Hospital, Liverpool, UK.

Background: Vocal cord palsy is one of the recognised complications of complex cardiac surgery in the paediatric population. While there is an abundance of literature highlighting the presence of this complication, there is a scarcity of research focusing on the pathophysiology, presentation, diagnosis, and treatment options available for children affected by vocal cord palsy.

Materials And Methods: Electronic searches were conducted using the search terms: "Vocal Cord Palsy," "VCP," "Vocal Cord Injury," "Paediatric Heart Surgery," "Congenital Heart Surgery," "Pediatric Heart Surgery," "Vocal Fold Movement Impairment," "VFMI," "Vocal Fold Palsy," "PDA Ligation." The inclusion criteria were any articles discussing the outcomes of vocal cord palsy following paediatric cardiac surgery.

Results: The two main populations affected by vocal cord palsy are children undergoing aortic arch surgery or those undergoing PDA ligation. There is paucity of prospective follow-up studies; it is therefore difficult to reliably assess the current approaches and the long-term implications of management options.

Conclusion: Vocal cord palsy can be a devastating complication following cardiac surgery, which if left untreated, could potentially result in debilitation of quality of life and in severe circumstances could even lead to death. Currently, there is not enough high-quality evidence in the literature to aid recognition, diagnosis, and management leaving clinicians to extrapolate evidence from adult studies to make clinical judgements. Future research with a focus on the paediatric perspective is necessary in providing evidence for good standards of care.
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http://dx.doi.org/10.1017/S1047951121001165DOI Listing
April 2021

Mitral valve diseases: Pathophysiology and interventions.

Prog Cardiovasc Dis 2021 Apr 2. Epub 2021 Apr 2.

Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK.

Valvular heart disease is common and increasingly prevalent among the elderly. The end result of valvular pathologies is cardiac failure and can lead to sudden death; thus, diagnosis and interventions are very important in the early stages of these diseases. The usual treatment methods of mitral regurgitation include percutaneous mitral valve repair, mitral valve replacement and minimally invasive surgery, whereas the treatment methods of mitral stenosis include percutaneous transluminal mitral commissurotomy and mitral commissurotomy as well as open surgical repair. Nonetheless, ongoing clinical trials are a clear indicator that the management of valve diseases is ever evolving. The focus of this paper is on the various pathologies of the mitral valve, their etiology and clinical management, offering a comprehensive view of mitral valve diseases.
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http://dx.doi.org/10.1016/j.pcad.2021.03.008DOI Listing
April 2021

Response to Letter to the Editor.

J Card Surg 2021 Jul 29;36(7):2605-2606. Epub 2021 Mar 29.

Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.

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http://dx.doi.org/10.1111/jocs.15528DOI Listing
July 2021

"Proximalization is Advancement"-Zone 3 Frozen Elephant Trunk vs Zone 2 Frozen Elephant Trunk: A Literature Review.

Vasc Endovascular Surg 2021 Mar 23:15385744211002493. Epub 2021 Mar 23.

Vascular & Endovascular Surgery, 155510Royal Blackburn Teaching Hospital, Blackburn, United Kingdom.

Over the decades, the Frozen Elephant Trunk (FET) technique has gained immense popularity allowing simplified treatment of complex aortic pathologies. FET is frequently used to treat aortic conditions involving the distal aortic arch and the proximal descending aorta in a single stage. Surgical preference has recently changed from FET procedures being performed at Zone 3 to Zone 2. There are several advantages of Zone 2 FET over Zone 3 FET including reduction in spinal cord injury, visceral ischemia, neurological and cardiovascular sequelae. In addition, Zone 2 FET is a technically less complicated procedure. Literature on the comparison between Zone 3 and Zone 2 FET is scarce and primarily observational and anecdotal. Therefore, further research is warranted in this paradigm to substantiate current surgical treatment options for complex aortic pathologies. In this review, we explore literature surrounding FET and the reasons for the shift in surgical preference from Zone 3 to Zone 2.
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http://dx.doi.org/10.1177/15385744211002493DOI Listing
March 2021

Tetralogy of Fallot: stent palliation or neonatal repair?

Cardiol Young 2021 Mar 8:1-9. Epub 2021 Mar 8.

Department of Cardiac Surgery, Alder Hey Children Hospital, Liverpool, UK.

Surgical repair of Tetralogy of Fallot has excellent outcomes, with over 90% of patients alive at 30 years. The ideal time for surgical repair is between 3 and 11 months of age. However, the symptomatic neonate with Tetralogy of Fallot may require earlier intervention: either a palliative intervention (right ventricular outflow tract stent, ductal stent, balloon pulmonary valvuloplasty, or Blalock-Taussig shunt) followed by a surgical repair later on, or a complete surgical repair in the neonatal period. Indications for palliation include prematurity, complex anatomy, small pulmonary artery size, and comorbidities. Given that outcomes after right ventricular outflow tract stent palliation are particularly promising - there is low mortality and morbidity, and consistently increased oxygen saturations and increased pulmonary artery z-scores - it is now considered the first-line palliative option. Disadvantages of right ventricular outflow tract stenting include increased cardiopulmonary bypass time at later repair and the stent preventing pulmonary valve preservation. However, neonatal surgical repair is associated with increased short-term complications and hospital length of stay compared to staged repair. Both staged repair and primary repair appear to have similar long-term mortality and morbidity, but more evidence is needed assessing long-term outcomes for right ventricular outflow tract stent palliation patients.
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http://dx.doi.org/10.1017/S1047951121000846DOI Listing
March 2021

Bio-chemo-mechanics of the thoracic aorta.

Vasc Biol 2021 12;3(1):R25-R33. Epub 2021 Jan 12.

Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.

The pathophysiology of thoracic aortic aneurysm and dissection is poorly understood, despite high mortality. An evidence review was conducted to examine the biomechanical, chemical and genetic factors involved in thoracic aortic pathology. The composition of connective tissue and smooth muscle cells can mediate important mechanical properties that allow the thoracic aorta to withstand and transmit pressures. Genetic syndromes can affect connective tissue and signalling proteins that interrupt smooth muscle function, leading to tissue failure. There are complex interplaying factors that maintain thoracic aortic function in health and are disrupted in disease, signifying an area for extensive research.
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http://dx.doi.org/10.1530/VB-20-0015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7923035PMC
January 2021

The Role of the Lung Ultrasound in Coronavirus Disease 2019: A Systematic Review.

J Med Ultrasound 2020 Oct-Dec;28(4):207-212. Epub 2020 Dec 22.

Department of Cardiothoracic surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.

The coronavirus disease 2019 (COVID-19) pandemic has now infected six million people and is responsible for nearly four hundred thousand deaths. We review the potential role of the lung ultrasound to evaluate its benefits and potential roles to compare it to the current gold standard of computed tomography. A literature search was carried out utilizing electronic search engines and databases with COVID-19. Keywords related to the lung ultrasound (LUS) were used to refine this search - only the relevant articles found are cited. This review showed that there exists a strong correlation between the CT and LUS scan in COVID-19. Prominent features include the vertical B-lines, thicker pleural lines, and subpleural consolidation. Potential roles include reducing transmission between health-care workers and monitoring the progress of the disease. However, the current research is scarce compared to well-established imaging modalities, and as such, there is a necessity for more research to confirm the findings of this review.
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http://dx.doi.org/10.4103/JMU.JMU_87_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869739PMC
December 2020

The Effects of COVID-19 on Cancer Care Provision: A Systematic Review.

Cancer Control 2021 Jan-Dec;28:1073274821997425

Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.

This systematic review aims to gather primary data from cancer institutions that have implemented changes to cancer service provision amid the COVID-19 outbreak to inform future intervention and health care facility response strategies. A comprehensive literature search was done on Global Health Medline and EMBASE using pertinent key words and MeSH terms relating to COVID-19 and Cancer service provision. A total of 72 articles were selected for inclusion in this systematic review. Following the narrative synthesis that was conducted of the literature, 6 core themes that encompassed common cancer service intervention adopted by institutions were identified: (1) Testing and Tracking, (2) Outreach and Communication, (3) Protection, (4) Social Distancing (5) Treatment Management, (6) Service Restructuring. Since cancer patients are a high-risk population amid the COVID-19 pandemic, these areas of targeted intervention can be used to inform necessary actions in institutions facing similar risks, based on previous learning from numerous cancer centers globally.
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http://dx.doi.org/10.1177/1073274821997425DOI Listing
March 2021

Advances in revascularization of the left coronary artery.

Coron Artery Dis 2021 May;32(3):247-255

Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.

Ischaemic heart disease is the most common cardiovascular disease worldwide, and it contributes to a significant source of morbidity and mortality internationally. It can be asymptomatic for many years and present suddenly with acute coronary syndrome or can be progressive with angina and eventual acute myocardial infarction. Diseases of the left coronary system can be drastic and fatal if not managed correctly. With ongoing increase in the practice of percutaneous intervention; patient demographics for conventional coronary artery bypass grafting surgery have more risk factors than before. Conventional bypass surgery has also evolved to include minimally invasive and hybrid techniques. Although some evidence supports each approach, controversies remain.
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http://dx.doi.org/10.1097/MCA.0000000000001005DOI Listing
May 2021

Glycated Haemoglobin Levels and Its Effect on Outcomes in Cardiac Surgery.

Braz J Cardiovasc Surg 2021 Feb 1. Epub 2021 Feb 1.

Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.

There remains a significant paucity of information evaluating the effect of glycated HbA1c levels and its theorized effect on mortality and morbidity rates following cardiac surgery. Diabetes is a very common comorbidity in patients undergoing open heart surgery, as there is a shift in patient characteristics and greater risk. Currently, there is no clear consensus that an increase in HbA1c level is associated with increased perioperative mortality rate. However, the reported literature is more commonly able to demonstrate that elevated HbA1c levels is associated with increased rates of wound infection, cardiovascular events and renal failure, and thus, higher post-operative morbidities. This review aims to examine and synthesis the evidence behind each of the morbidities and mortalities associated with open heart surgery and the impact of high HbA1c on the reported outcomes.
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http://dx.doi.org/10.21470/1678-9741-2020-0188DOI Listing
February 2021

Artificial intelligence and cardiac surgery during COVID-19 era.

J Card Surg 2021 May 10;36(5):1729-1733. Epub 2021 Feb 10.

Vascular & Endovascular Surgery, Royal Blackburn Hospital, Blackburn, UK.

The coronavirus disease 2019 (COVID-19) pandemic has increased the burden on hospital staff world-wide. Through the redistribution of scarce resources to these high-priority cases, the cardiac sector has fallen behind. In efforts to reduce transmission, reduction in direct patient-physician contact has led to a backlog of cardiac cases. However, this accumulation of postponed or cancelled nonurgent cardiac care seems to be resolvable with the assistance of technology. From telemedicine to artificial intelligence (AI), technology has transformed healthcare systems nationwide. Telemedicine enables patient monitoring from a distance, while AI unveils a whole new realm of possibilities in clinical practice, examples include: traditional systems replacement with more efficient and accurate processing machines; automation of clerical process; and triage assistance through risk predictions. These possibilities are driven by deep and machine learning. The two subsets of AI are explored and limitations regarding "big data" are discussed. The aims of this review are to explore AI: the advancements in methodology; current integration in cardiac surgery or other clinical scenarios; and potential future roles, which are innately nearing as the COVID-19 era urges alternative approaches for care.
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http://dx.doi.org/10.1111/jocs.15417DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8013221PMC
May 2021

The role of computed tomography scan in the diagnosis of COVID-19 pneumonia.

Curr Opin Pulm Med 2021 05;27(3):163-168

Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital.

Purpose Of Review: To summarize current literature evidence on the role of computed tomography (CT) scan in the diagnosis and assessment of coronavirus disease 2019 (COVID-19) pneumonia.

Recent Findings: Recent guidelines on the use of CT scans in COVID-19 vary between countries. However, the consensus is that it should not be used as the first line; a notion supported by the WHO. Currently, several investigations are being used including reverse transcription PCR testing, chest radiographs, and ultrasound scans, and CT scans. They are ideally performed later during the disease process as the sensitivity and specificity are highest by that time. Typical COVID-19 features on CT scans vary but include vascular enlargement, ground-glass opacities, and ground glass opacification together with consolidation.

Summary: Since COVID-19 was declared as a global pandemic, there was a push towards identifying appropriate diagnostic tests that are both reliable and effective. There is a general agreement that CT scans have a high sensitivity but low specificity in diagnosing COVID-19. However, the quality of available studies is not optimal, so this must always be interpreted with the clinical context in mind. Clinicians must aim to weigh up the practicalities and drawbacks of CT scans when considering their use for a patient. The ease and speed of use of CT scans must be balanced with their high radiation doses, and infection control considerations.
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http://dx.doi.org/10.1097/MCP.0000000000000765DOI Listing
May 2021

Translational Sciences in Cardiac Failure Secondary to Arteriovenous Fistula in Hemodialysis Patients.

Ann Vasc Surg 2021 Feb 6. Epub 2021 Feb 6.

Vascular & Endovascular Surgery, Royal Blackburn Teaching Hospital, Blackburn, UK. Electronic address:

High-output cardiac failure is a rare form of heart failure associated with the formation of arteriovenous fistula (AVF) in hemodialysis patients. The pathophysiology underlying the HOCF is complex and multifactorial. Presence of AVF can cause long term hemodynamic changes that ultimately lead to increased cardiac output and consequently cardiac failure. A number of risk factors have been associated with the development of HOCF post-AVF construction, including male sex, a proximally located AVF and a state of volume overload. Dysregulation of tissue inhibitor of matrix metalloproteinase 4, Sirtuin-1 and Sirtuin-3 gene expression have been associated with the development of heart failure. The differences observed between genders have been attributed to altered activity of the β-adrenoceptor system. Numerous biomarkers including cardiac troponin T and I, atrial natriuretic peptide, brain natriuretic peptide among others have shown both prognostic and diagnostic potential; however further research is needed to establish their utility in clinical practice for patients with AVF associated HOCF. In recent years risk stratification models have been developed to help identify patients at the highest risk of developing HOCF post AVF which could be revolutionary in its identification and management. Potential options for managing HOCF post-AVF include AVF ligation, banding and anastoplasty however these procedures are not without their own associated risks. In this review, we discuss the pathophysiology, risk stratification and management of patients with AVF associated HOCF.
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http://dx.doi.org/10.1016/j.avsg.2021.01.071DOI Listing
February 2021

Pernicious pregnancy: Type B aortic dissection in pregnant women.

J Card Surg 2021 Apr 2;36(4):1232-1240. Epub 2021 Feb 2.

Vascular Surgery Department, Royal Blackburn Teaching Hospital, Blackburn, UK.

Background: Type B aortic dissection (TBAD) occurs seldomly, particularly in pregnancy, but has disastrous consequences for both mother and fetus. The focus of immediate surgical repair of type A aortic dissection due to higher mortality of patients is less clear in its counterpart, TBAD, in which management is controversial and debated. This article collates knowledge so far on this rare event during pregnancy.

Methods: A comprehensive literature search was performed in PubMed, Scopus, Google Scholar, Embase, and Medline. Key search terms included "type B aortic dissection," "pregnancy," and corresponding synonyms. Non-English papers were excluded.

Results: Risk factors for TBAD include aortic wall stress due to hypertension, previous cardiac surgery, structural abnormalities (bicuspid aortic valve, aortic coarctation), and connective tissue disorders. In pregnancy, pre-eclampsia is a cause of increased aortic wall stress. Management of this condition is often conservative, but this is dependent on a number of factors, including gestation, cardiovascular stability of the patient, and symptomology. In most cases, a cesarean section before intervention is carried out unless certain indications are present.

Conclusions: Due to a scarce number of cases across the decades, it is difficult to determine which management is optimal. The gold-standard management of TBAD has traditionally been the medical treatment for uncomplicated cases and open surgery for those needing urgent intervention, but with the advent of techniques, such as thoracic endovascular aortic repair, the management of these group of patients continues to develop.
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http://dx.doi.org/10.1111/jocs.15354DOI Listing
April 2021

Surgery for heart failure: Treatment options and implications.

J Card Surg 2021 Apr 1;36(4):1511-1519. Epub 2021 Feb 1.

Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.

Heart failure is considered one of the leading causes of death worldwide. Over the years, etiological risk factors, diagnostic criteria, and classifications have been revised to create guide management needed to alleviate the global health burden caused by heart failure. Pharmacological treatments have progressed over time but are insufficient in reducing mortality. This leads to many patients developing advanced heart failure who will require surgical intervention often in the form of the gold standard, a heart transplant. However, the number of patients requiring a transplant far exceeds the number of donors. Other surgical inventions have been utilized, yet the rate of patients being diagnosed with heart failure is still increasing. Future developments in the surgical field of heart failure include the 77SyncCardia and atrial shunting but long-term clinical trials involving larger cohorts of patients have not yet taken place to view how effective these approaches can be.
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http://dx.doi.org/10.1111/jocs.15384DOI Listing
April 2021