Publications by authors named "Mahmoud Loubani"

73 Publications

Is the use of dual antiplatelet therapy following urgent and emergency coronary artery bypass surgery associated with increased risk of cardiac tamponade?

J Clin Transl Res 2021 Apr 13;7(2):229-233. Epub 2021 Mar 13.

Department of Cardiothoracic Surgery, Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, Hull, UK.

Background And Aim: Cardiac tamponade is a recognized post-cardiac surgery complication, resulting in increased morbidity and mortality. The 2016 American College of Cardiology and American Heart Association Guidelines recommended the use of Dual Antiplatelet Therapy (DAPT) in the management of patients undergoing urgent or emergency coronary artery bypass grafting (CABG). The effect of DAPT on cardiac tamponade rates was investigated in comparison to aspirin monotherapy (AMT).

Materials And Methods: Prospectively collected data from a tertiary cardiac surgery center was analyzed to identify the patients who underwent urgent and emergency CABG between January 2015 and January 2018. The patients were categorized as aspirin monotherapy (AMT) and Dual Antiplatelet Therapy (DAPT) groups. The primary outcome was total cardiac tamponade rate and secondary outcomes were length of hospitalization and 30-days and 1-year mortality.

Results: A total of 246 eligible patients were included across both arms and compared for confounding variables. Cardiac tamponade was observed in 9 (7.3%) and 8 (6.5%) of AMT and DAPT groups, respectively (P=0.802). The average hospital stay in days was similar in both groups (AMT=8.4 vs. DAPT=8.1, P=0.82), whereas tamponade patients experienced a significantly longer hospitalization when compared to non-tamponade patients (9.8 vs. 8.1 days, P=0.047). The 30-days and 1-year mortality were similar in both groups and were 0.8% and 1.6%, respectively.

Conclusion: Overall, this study demonstrated that DAPT in urgent or emergency CABG patients is not associated with an increased risk of cardiac tamponade, length of hospital stay or mortality.

Relevance For Patients: This study demonstrated that the use of DAPT in patients undergoing CABG as an urgent or emergency procedure following myocardial infarction is not associated with an increased risk of bleeding and has many associated benefits.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8177840PMC
April 2021

Revascularisation of type 2 diabetics with coronary artery disease: Insights and therapeutic targeting of O-GlcNAcylation.

Nutr Metab Cardiovasc Dis 2021 05 2;31(5):1349-1356. Epub 2021 Feb 2.

Centre for Atherothrombosis and Metabolic Disease, Hull York Medical School, University of Hull, Hull HU6 7RX, UK. Electronic address:

Aim: Coronary artery bypass graft (CABG) using autologous saphenous vein continues to be a gold standard procedure to restore the supply of oxygen-rich blood to the heart muscles in coronary artery disease (CAD) patients with or without type 2 diabetes mellitus (T2DM). However, CAD patients with T2DM are at higher risk of graft failure. While failure rates have been reduced through improvements in procedure-related factors, much less is known about the molecular and cellular mechanisms by which T2DM initiates vein graft failure. This review gives novel insights into these cellular and molecular mechanisms and identifies potential therapeutic targets for development of new medicines to improve vein graft patency.

Data Synthesis: One important cellular process that has been implicated in the pathogenesis of T2DM is protein O-GlcNAcylation, a dynamic, reversible post-translational modification of serine and threonine residues on target proteins that is controlled by two enzymes: O-GlcNAc transferase (OGT) and O-GlcNAcase (OGA). Protein O-GlcNAcylation impacts a range of cellular processes, including trafficking, metabolism, inflammation and cytoskeletal organisation. Altered O-GlcNAcylation homeostasis have, therefore, been linked to a range of human pathologies with a metabolic component, including T2DM.

Conclusion: We propose that protein O-GlcNAcylation alters vascular smooth muscle and endothelial cell function through modification of specific protein targets which contribute to the vascular re-modelling responsible for saphenous vein graft failure in T2DM.
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http://dx.doi.org/10.1016/j.numecd.2021.01.017DOI Listing
May 2021

Short-term and long-term impact of diagnosed and undiagnosed chronic obstructive pulmonary disease on coronary artery bypass grafting surgery.

Postgrad Med J 2021 Jan 12. Epub 2021 Jan 12.

Department of Cardiothoracic Surgery, Hull University Teaching Hospitals NHS Trust, Hull, UK.

Objectives: This study sought to compare clinical outcomes between three categories of patients: non-chronic obstructive pulmonary disease (COPD), diagnosed COPD and undiagnosed COPD in coronary artery bypass grafting surgery.

Methods: A single-centred retrospective study from January 2010 to December 2019. Primary outcomes were postoperative complications, length of ITU admission and in-hospital staying. Secondary outcomes were reintervention rate, in-hospital and long-term mortality.

Results: A total of 4020 patients were analysed and divided into three cohorts: non-COPD (group A) (74.55%, n=2997), diagnosed COPD (group B) (14.78%, n=594) and undiagnosed COPD (group C) (10.67%, n=429). The rate of respiratory complications was noted in this order: group B>group C>group A (p 0.00000002). Periooperative acute kidney injury and wound complications were higher in group B (p 0.0004 and p 0.03, respectively). Prolonged in-hospital staying (days) resulted in group B (p 0.0009). Finally, long-term mortality was statistically higher in group B and C compared with group A (p 0.0004). No difference in long-term mortality was noted in relation to the expected FEV1% in group B (p 0.29) and group C (p 0.82).

Conclusions: In CABG surgery, COPD is a well-known independent risk factor for morbidity. Patients with preoperative spirometry results indicative of COPD result in the same outcomes of known patients with COPD. As a result of that, greater value should be given to the preoperative spirometry in the EuroSCORE. Finally, the expected FEV1% appears not be a predictor for long-term survival.
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http://dx.doi.org/10.1136/postgradmedj-2020-139341DOI Listing
January 2021

Surgical factors associated with new-onset postoperative atrial fibrillation after lung resection: the EPAFT multicentre study.

Postgrad Med J 2020 Dec 11. Epub 2020 Dec 11.

Department of Thoracic Surgery, Castle Hill Hospital, Cottingham, East Riding of Yorkshire, UK.

Purpose Of The Study: Postoperative atrial fibrillation (POAF) is a recognised complication in approximately 10% of major lung resections. In order to best target preoperative treatment, this study aimed at determining the association of incidence of POAF in patients undergoing lung resection to surgical and anatomical factors, such as surgical approach, extent of resection and laterality.

Study Design: Evaluation of Post-operative Atrial Fibrillation in Thoracic surgery (EPAFT): a multicentre, population-based, retrospective, cross-sectional, observational study including 1367 patients undergoing lung resections between April 2016 and March 2017. The primary outcome was the presence of POAF following resection. POAF was defined as at least one episode of symptomatic or asymptomatic AF confirmed by ECG within 7 days from the thoracic procedure or prior to discharge from the hospital.

Results: POAF was observed in 7.4% of patients: 3.1% in minor resection (video-assisted thoracoscopic surgery (VATS): 2.5%; thoracotomy: 3.8%), 9.0% in simple lobectomy (VATS: 7.3%, thoracotomy: 9.9%), 6.0% in complex resection (thoracotomy: 6.3%) and 11.4% in pneumonectomy. POAF was higher in left (4.0%) vs right (2.4%) minor resections, and in left (9.9%) vs right (8.3%) lobectomy, but higher in right (7.5%) complex resections, and the highest in right pneumonectomy (17.6%). No significant variations were observed as per sex, laterality or resected lobes. A positive univariable and multivariable association was observed for increasing age and increasing extent of resection, but not thoracotomy. Median (Q1-Q3) hospital stay was 9 (7-14) days in POAF and 5 (4-7) days in non-AF patients (p<0.001), with an increased cerebrovascular accident burden (p<0.001) and long-term mortality (p<0.001).

Conclusions: Among patients undergoing lung resection, POAF was significantly associated with age, increasing invasiveness of approach and increasing extent of resection. In addition, POAF carried a significant long-term mortality rate and burden of cerebrovascular accident. Appropriate prophylaxis should be targeted at these groups.
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http://dx.doi.org/10.1136/postgradmedj-2020-138904DOI Listing
December 2020

Prospective cohort study of elderly patients with coronary artery disease: impact of frailty on quality of life and outcome.

Open Heart 2020 09;7(2)

Centre for Atherothrombosis and Metabolic Disease, Hull York Medical School, University of Hull, Hull, United Kingdom.

Background: Elderly, frail patients are often excluded from clinical trials so there is lack of data regarding optimal management when they present with symptomatic coronary artery disease (CAD).

Objective: The aim of this observational study was to evaluate an unselected elderly population with CAD for the occurrence of frailty, and its association with quality of life (QoL) and clinical outcomes.

Methods: Consecutive patients aged ≥80 years presenting with CAD were prospectively assessed for frailty (Fried frailty phenotype (FFP), Edmonton frailty scale (EFS)), QoL (Short form survey (SF-12)) and comorbidity (Charlson Comorbidity Index (CCI)). Patients were re-assessed at 4 months to determine any change in frailty and QoL status as well as the clinical outcome.

Results: One hundred fifty consecutive patients with symptomatic CAD were recruited in the study. The mean age was 83.7±3.2 years, 99 (66.0%) were men. The clinical presentation was stable angina in 68 (45.3%), the remainder admitted with an acute coronary syndrome including 21 (14.0%) with ST-elevation myocardial infarction. Frailty was present in 28% and 26% by FFP and EFS, respectively, and was associated with a significantly higher CCI (7.5±2.4 in frail, 6.2±2.2 in prefrail, 5.9±1.6 in those without frailty, p=0.005). FFP was significantly related to the physical composite score for QoL, while EFS was significantly related to the mental composite score for QoL (p=0.003). Treatment was determined by the cardiologist: percutaneous coronary intervention in 51 (34%), coronary artery bypass graft surgery in 15 (10%) and medical therapy in 84 (56%). At 4 months, 14 (9.3%) had died. Frail participants had the lowest survival. Cardiovascular symptom status and the mental composite score of QoL significantly improved (52.7±11.5 at baseline vs 55.1±10.6 at follow-up, p=0.04). However, overall frailty status did not significantly change, nor the physical health composite score of QoL (37.2±11.0 at baseline vs 38.5±11.3 at follow-up, p=0.27).

Conclusions: In patients referred to hospital with CAD, frailty is associated with impaired QoL and a high coexistence of comorbidities. Following cardiac treatment, patients had improvement in cardiovascular symptoms and mental component of QoL.
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http://dx.doi.org/10.1136/openhrt-2020-001314DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7523192PMC
September 2020

The impact of closed incision negative pressure therapy on prevention of median sternotomy infection for high risk cases: a single centre retrospective study.

J Cardiothorac Surg 2020 Aug 19;15(1):222. Epub 2020 Aug 19.

Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, HU16 5JQ, UK.

Background: Sternal wound infection (SWI) following cardiothoracic surgery is a major complication. It may significantly impact patient recovery, treatment cost and mortality rates. No universal guideline exists on SWI management, and more recently the focus has become prevention over treatment. Recent studies report positive outcomes with closed incision negative pressure therapy (ciNPT) on surgical incisions, particularly for patients at risk of poor wound healing.

Objective: This study aims to assess the effect of ciNPT on SWI incidence in high-risk patients.

Methods: A retrospective study was performed to investigate the benefit of ciNPT post sternotomy. Patients 3 years before the introduction of ciNPT (Control group) and 3 years after ciNPT availability (ciNPT group) were included. Only patients that had two or more of the risk factors; obesity, Chronic Obstructive Pulmonary Disease, old age and diabetes mellitus in the High Risk ciNPT cohort were given the ciNPT dressing. Patient demographics, EuroSCOREs and length of staywere reported as mean ± standard deviation. The Fisher's exact test (two-tailed) and an unpaired t-test (two-tailed) were used to calculate the p-value for categorical data and continuous data, respectively.

Results: The total number of patients was 1859 with 927 in the Control group and 932 in the ciNPT group. No statistical differences were noted between the groups apart from the Logistic EuroSCORE (Control = 6.802 ± 9.7 vs. ciNPT = 8.126 ± 11.3; P = 0.0002). The overall SWI incidence decreased from 8.7 to 4.4% in the overall groups with the introduction of ciNPT (P = 0.0005) demonstrating a 50% reduction. The patients with two and above risk factor in the Control Group (High Risk Control Group) were 162 while there was 158 in the ciNPT Group (High Risk ciNPT Group). The two groups were similar in all characteristics. Although the superficial and deep sternal would infections were higher in the High Risk Control Group versus the High Risk ciNPT group patients (20(12.4%) vs 9(5.6%); P = 0.049 respectively), the length of postoperative stay was similar in both (13.0 ± 15.1 versus 12.2 ± 15.6 days; p + 0.65). However the patients that developed infections in the two High Risk Groups stayed significantly longer than those who did not (25.5 ± 27.7 versus 12.2 ± 15.6 days;P = 0.008). There were 13 deaths in Hospital in the High Risk Control Group versus 10 in the High Risk ciNPT Group (P = 0.66).

Conclusion: In this study, ciNPT reduced SWI incidence post sternotomy in patients at risk for developing SWI. This however did not translate into shorter hospital stay or mortality.
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http://dx.doi.org/10.1186/s13019-020-01265-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7437015PMC
August 2020

Validation of Cardiac Surgery Score (CASUS) in Postoperative Cardiac Patients.

Semin Cardiothorac Vasc Anesth 2020 Dec 3;24(4):304-312. Epub 2020 Jul 3.

Castle Hill Hospital, Cottingham, UK.

. Cardiac Surgery Score (CASUS) was introduced in 2005 as the first postoperative scoring system specific for patients who had cardiac surgery. Prior to this, European System for Cardiac Operative Risk Evaluation (EuroSCORE) has been used preoperatively, while Intensive Care National Audit and Research Centre Score (ICNARC) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, which are widely used in general intensive care unit population, have been used to score cardiac patients postoperatively. The development of CASUS by Hekmat and colleagues for use in postoperative cardiac patients aims to change this. We wanted to validate CASUS against the well-established preoperative Logistic EuroSCORE, and postoperative APACHE II and ICNARC scores. . Institutional approval for this study was granted by the Audit and Clinical Governance Committee. We analyzed prospectively collected data of patients who had cardiac surgery in Castle Hill Hospital between January 2016 and September 2018. All patients who underwent surgery in the unit would have had Logistic EuroSCORE, APACHE, and ICNARC scores calculated as standard. CASUS was then calculated for these patients based on their day 1 postoperative variables. The scoring systems were compared and data presented as area under the receiver operating characteristic curve. Our study shows that CASUS is the best predictor of mortality followed by ICNARC, Logistic EuroSCORE, and APACHE II. ICNARC score remains the most accurate predictor of renal and pulmonary complication followed by CASUS. CASUS is a useful scoring system in post-cardiac surgery patients. The accuracy of CASUS and ICNARC scores in predicting mortality, pulmonary, and renal complications are comparable.
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http://dx.doi.org/10.1177/1089253220936786DOI Listing
December 2020

Do age-associated changes of voltage-gated sodium channel isoforms expressed in the mammalian heart predispose the elderly to atrial fibrillation?

World J Cardiol 2020 Apr;12(4):123-135

Department of Cardiothoracic Surgery, Hull University Teaching Hospitals, Cottingham HU16 5JQ, United Kingdom.

Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide. The prevalence of the disease increases with age, strongly implying an age-related process underlying the pathology. At a time when people are living longer than ever before, an exponential increase in disease prevalence is predicted worldwide. Hence unraveling the underlying mechanics of the disease is paramount for the development of innovative treatment and prevention strategies. The role of voltage-gated sodium channels is fundamental in cardiac electrophysiology and may provide novel insights into the arrhythmogenesis of AF. Na1.5 is the predominant cardiac isoform, responsible for the action potential upstroke. Recent studies have demonstrated that Na1.8 (an isoform predominantly expressed within the peripheral nervous system) is responsible for cellular arrhythmogenesis through the enhancement of pro-arrhythmogenic currents. Animal studies have shown a decline in Na1.5 leading to a diminished action potential upstroke during phase 0. Furthermore, the study of human tissue demonstrates an inverse expression of sodium channel isoforms; reduction of Na1.5 and increase of Na1.8 in both heart failure and ventricular hypertrophy. This strongly suggests that the expression of voltage-gated sodium channels play a crucial role in the development of arrhythmias in the diseased heart. Targeting aberrant sodium currents has led to novel therapeutic approaches in tackling AF and continues to be an area of emerging research. This review will explore how voltage-gated sodium channels may predispose the elderly heart to AF through the examination of laboratory and clinical based evidence.
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http://dx.doi.org/10.4330/wjc.v12.i4.123DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7215965PMC
April 2020

Differential effects of atrial and brain natriuretic peptides on human pulmonary artery: An study.

World J Cardiol 2019 Oct;11(10):236-243

Centre for Cardiovascular and Metabolic Research, Hull York Medical School, Castle Hill Hospital, Cottingham HU16 5JQ, United Kingdom.

Background: The prevalence of cardiovascular diseases, especially heart failure, continues to rise worldwide. In heart failure, increasing levels of circulating atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) are associated with a worsening of heart failure and a poor prognosis.

Aim: To test whether a high concentration of BNP would inhibit relaxation to ANP.

Methods: Pulmonary arteries were dissected from disease-free areas of lung resection, as well as pulmonary artery rings of internal diameter 2.5-3.5 mm and 2 mm long, were prepared. Pulmonary artery rings were mounted in a multiwire myograph, and a basal tension of 1.61gf was applied. After equilibration for 60 min, rings were pre-constricted with 11.21 µmol/L PGF (EC), and concentration response curves were constructed to vasodilators by cumulative addition to the myograph chambers.

Results: Although both ANP and BNP were found to vasodilate the pulmonary vessels, ANP is more potent than BNP. pEC50 of ANP and BNP were 8.96 ± 0.21 and 7.54 ± 0.18, respectively, and the maximum efficacy (E) for ANP and BNP was -2.03 gf and -0.24 gf, respectively. After addition of BNP, the E of ANP reduced from -0.96gf to -0.675gf ( = 0.28).

Conclusion: BNP could be acting as a partial agonist in small human pulmonary arteries, and inhibits relaxation to ANP. Elevated levels of circulating BNP could be responsible for the worsening of decompensated heart failure. This finding could also explain the disappointing results seen in clinical trials of ANP and BNP analogues for the treatment of heart failure.
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http://dx.doi.org/10.4330/wjc.v11.i10.236DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6859300PMC
October 2019

Giant right coronary artery aneurysm presenting as an STEMI.

J Surg Case Rep 2019 Nov 4;2019(11):rjz282. Epub 2019 Nov 4.

Department of Cardiothoracic Surgery,Department of Cardiothoracic Anaesthesia,Department of Cardiology, Hull University Teaching Hospitals NHS Trust, Castle Hill Hospital, Castle Road, Cottingham HU16 5JQ, UK.

Giant coronary artery aneurysms are an infrequent finding. They are typically discovered incidentally, rarely presenting with any symptoms. We present the case of a 72-year-old gentleman who presented with an ST elevated myocardial infarction. On investigation, the gentleman was found to have a giant right coronary artery aneurysm which was partially filled with a fresh thrombus. The thrombus occluded the RCA, triggering the myocardial infarction which leads to this gentleman's presentation to a tertiary cardiac centre. The gentleman underwent a successful resection of the aneurysm and coronary artery bypass graft over the RCA lesion with a saphenous vein conduit. This gentleman has since been discharged from hospital after an uncomplicated postoperative course.
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http://dx.doi.org/10.1093/jscr/rjz282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6827552PMC
November 2019

Intermittent Cross-Clamp Fibrillation Versus Cardioplegic Arrest During Coronary Surgery in 6,680 Patients: A Contemporary Review of an Historical Technique.

J Cardiothorac Vasc Anesth 2019 Dec 19;33(12):3331-3339. Epub 2019 Jul 19.

Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, United Kingdom.

Objective: Myocardial management during on-pump coronary artery bypass grafting (CABG) surgery includes aortic cross-clamping followed by fibrillation (XCF) and aortic cross-clamping followed by diastolic cardioplegia (cardioplegia). The authors wished to compare in-hospital and survival outcomes between these procedures.

Design: A retrospective observational study utilizing propensity matching.

Setting: Tertiary Referral Centre for Heart Surgery.

Participants: A total of 8,875 consecutive patients undergoing CABG surgery between August 1999 and February 2018.

Interventions: After 1:1 matching, the authors had 3,340 patients in the cardioplegia group and 3,340 in the XCF group.

Measurements And Main Results: Baseline characteristics were not significant between the matched cardioplegia and XCF groups. The XCF group had shorter pump times (61.8 minutes +/-26.8 v 74.7 minutes +/-29.5, p < 0.0001) and shorter cross-clamp times (27.80 minutes +/-10.5 v 44.44 minutes +/-18.0, p < 0.0001) compared with the cardioplegia group despite a similar median number of distal anastomoses (3 v 3, p = 0.08). After surgery, atrial arrhythmias (32% v 36%, p = 0.01) and inotropic requirement (25% v 28%, p = 0.006) were less in the XCF group compared with the cardioplegia group, respectively. Other postoperative outcomes (such as mortality and cerebrovascular events) were not statistically different. There was a mean survival advantage in using cardioplegia compared with XCF (15.4 years versus 14.7 years, log-rank, p = 0.014; 10-year survival 64% v 61% and 18-year survival 38% v 34%).

Conclusion: This is the largest analysis of XCF. XCF does not adversely affect in-hospital outcomes. Long-term results demonstrate cardioplegic arrest may convey a survival advantage that would preclude routine XCF in the modern era.
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http://dx.doi.org/10.1053/j.jvca.2019.07.126DOI Listing
December 2019

Prediction of Postoperative Outcomes and Long-Term Survival in Cardiac Surgical Patients Using the Intensive Care National Audit & Research Centre Score.

J Cardiothorac Vasc Anesth 2019 Nov 27;33(11):3022-3027. Epub 2019 May 27.

Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, UK.

Objectives: Scoring systems used in cardiac surgery, such as the European System for Cardiac Operative Risk Evaluation and the Society of Thoracic Surgeons scoring systems, do not adjust for events that take place intraoperatively. The authors hypothesized that intensive care unit scoring systems such as the Intensive Care National Audit & Research Centre (ICNARC) could predict accurately not only in-hospital mortality, but also other significant complications, as well as long-term survival after cardiac surgery.

Design: Prospective cohort study using perioperative data from the ICNARC Audit and Dendrite database.

Setting: Single tertiary referral cardiac surgery center.

Participants: A total of 4,446 consecutive cardiac surgical patients who had surgery between January 2011 and April 2018.

Interventions: Comparison of scoring systems to predict postoperative outcomes.

Measurements And Results: Receiver operating curves (ROCs) were used to evaluate how well the ICNARC scores predicted in-hospital mortality and postoperative complications (renal failure, pulmonary complications, gastrointestinal complications, and multiorgan failure). Cox regression analysis was used to determine factors affecting long-term survival. The C-indices for the ROC graphs for the ICNARC score were 0.840 for in-hospital mortality, 0.858 for renal failure, 0.665 for pulmonary complications, 0.764 for gastrointestinal complications, 0.702 for neurological complications in general and 0.654 for confusion, and 0.885 for multiorgan failure. From Cox regression analysis, the significant (p < 0.05) predictors of midterm mortality (5 years) were a higher ICNARC score, a higher age at surgery, chronic obstructive pulmonary disease, preoperative renal failure, preoperative neurological comorbidity, arteriopathy, and non-coronary artery bypass graft surgery.

Conclusion: The ICNARC scoring system is simple and can be used as an early warning screening tool to predict which patients are at higher risk for postoperative organ failure.
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http://dx.doi.org/10.1053/j.jvca.2019.05.034DOI Listing
November 2019

The inhibitory subunit of cardiac troponin (cTnI) is modified by arginine methylation in the human heart.

Int J Cardiol 2019 05 31;282:76-80. Epub 2019 Jan 31.

Biomedical Sciences, University of Hull, Cottingham Rd, HU6 7RX Hull, UK. Electronic address:

Background: The inhibitory subunit of cardiac troponin (cTnI) is a gold standard cardiac biomarker and also an essential protein in cardiomyocyte excitation-contraction coupling. The interactions of cTnI with other proteins are fine-tuned by post-translational modification of cTnI. Mutations in cTnI can lead to hypertrophic cardiomyopathy.

Methods And Results: Here we report, for the first time, that cTnI is modified by arginine methylation in human myocardium. Using Western blot, we observed reduced levels of cTnI arginine methylation in human hypertrophic cardiomyopathy compared to dilated cardiomyopathy biopsies. Similarly, using a rat model of cardiac hypertrophy we observed reduced levels of cTnI arginine methylation compared to sham controls. Using mass spectrometry, we identified cTnI methylation sites at R74/R79 and R146/R148 in human cardiac samples. R146 and R148 lie at the boundary between the critical cTnI inhibitory and switch peptides; PRMT1 methylated an extended inhibitory peptide at R146 and R148 in vitro. Mutations at R145 that have been associated with hypertrophic cardiomyopathy hampered R146/R148 methylation by PRMT1 in vitro. H9c2 cardiac-like cells transfected with plasmids encoding for a methylation-deficient R146A/R148A cTnI protein developed cell hypertrophy, with a 32% increase in cell size after 72 h, compared to control cells.

Discussion: Our results provide evidence for a novel and significant cTnI post-translational modification. Our work opens the door to translational investigations of cTnI arginine methylation as a biomarker of disease, which can include e.g. cardiomyopathies, myocardial infarction and heart failure, and offers a novel way to investigate the effect of cTnI mutations in the inhibitory/switch peptides.
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http://dx.doi.org/10.1016/j.ijcard.2019.01.102DOI Listing
May 2019

Changing clinical profiles and in-hospital outcomes of octogenarians undergoing cardiac surgery over 18 years: a single-centre experience†.

Interact Cardiovasc Thorac Surg 2019 04;28(4):602-606

Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, East Yorkshire, UK.

Objectives: With an ageing population, increasing numbers of octogenarians are undergoing high-risk cardiac surgery. We examine the changing characteristics and in-hospital outcomes for octogenarians over an 18-year period.

Methods: Clinical data from our prospective database for all octogenarians who had cardiac surgery from March 1999 through May 2016 were reviewed. We examined trends, risk profiles and in-hospital outcomes over 3 eras, namely early (1999-2004), middle (2005-2010) and late (2011-2016). A multivariable analysis was performed to identify independent predictors for adverse outcomes.

Results: There were 1022 patients aged 80-94 years in our study cohort. The octogenarian population increased progressively from early to late eras (4.5%, n = 255 vs 7.1%, n = 321 vs 9.3%, n = 446), as the average logistic EuroSCORE predicted mortality (9% vs 9.7% vs 10.1%, P < 0.01). On the contrary, observed mortality declined substantially (9.4% vs 7.8% vs 4.7%, P = 0.04) over this period. While cardiac morbidity and respiratory comorbidities were more prevalent in the late era, chronic renal failure was more frequent in the early era. Over time, more procedures were performed electively (P = 0.05). Common operations across all eras were coronary artery bypass grafting (CABG), aortic valve replacement and CABG + aortic valve replacement. Emergency operation [odds ratio (OR) 4.96, 95% confidence interval (CI) 1.51-16.35; P < 0.01], poor ejection fraction (OR 3.38, 95% CI 1.80-6.32; P < 0.01) and bypass time (OR 1.01, 95% CI 1.00-1.02; P < 0.01) were predictors of in-hospital mortality. The late era of surgery (OR 0.41, 95% CI 0.23-0.73; P < 0.01) was associated with reduced mortality risk.

Conclusions: The operative outcome in this growing surgical population is steadily improving despite the increasing prevalence of comorbidities, and surgery should be performed electively as much as possible.
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http://dx.doi.org/10.1093/icvts/ivy293DOI Listing
April 2019

Colorectal Cancer Presenting as Single Pulmonary Hilar Lymph Node Metastasis.

Case Rep Surg 2018 18;2018:5474919. Epub 2018 Jan 18.

Cardiothoracic Surgery Department, Castle Hill Hospital, Cottingham, UK.

Colorectal carcinoma is the second biggest cancer responsible for mortality. Lung metastasis is the commonest, following the liver. It is not uncommon to perform pulmonary metastasectomy and identify mediastinal metastasis. Previous studies have identified incidental lymph node involvement following routine mediastinal lymph node clearance in 20-50% of cases. However, solitary intrathoracic lymph node metastasis is exceedingly rare. Even when present, it is usually metachronous. In our case, we present an exceedingly rare case whereby the intrathoracic lymph node metastasis is solitary, not accompanying pulmonary disease and with no liver metastasis. We also review the evidence for mediastinal lymphadenectomy in the literature.
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http://dx.doi.org/10.1155/2018/5474919DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5822825PMC
January 2018

Mini-extracorporeal circulation technology, conventional bypass and prime displacement in isolated coronary and aortic valve surgery: a propensity-matched in-hospital and survival analysis.

Interact Cardiovasc Thorac Surg 2018 07;27(1):13-19

Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, UK.

Objectives: Conventional cardiopulmonary bypass is the most commonly used means of artificial circulation in cardiac surgery. However, it suffers from the effects of haemodilution and activation of inflammatory/coagulation cascades. Prime displacement (PD) can offset haemodilution and mini-extracorporeal technology (MIECT) can offset both. So far, no study has compared all of these modalities together; hence, we compared the outcomes of these 3 modalities at our institution.

Methods: This was a retrospective analysis of our cardiac surgical database. A total of 9626 patients underwent conventional bypass (CB), 3125 patients underwent a modification of CB, called PD, and 904 underwent MIECT. A 1:1 propensity-matching algorithm was employed using IBM SPSS 24 to match (i) 813 MIECT patients with 813 CB patients and (ii) 717 MIECT patients with 717 PD patients. The patients included coronary artery bypass grafting and valve surgery.

Results: MIECT had significantly (P < 0.05) longer bypass and cross-clamp times compared to CB and PD. MIECT had significantly higher rates of postoperative atrial fibrillation associated with it compared to CB. The mean red cell blood transfusion was significantly lower in the MIECT group compared to the CB group as was the mean platelet transfusion and fresh frozen plasma transfusion. The overall 5-year survival was higher in the MIECT group compared to the CB group (log-rank, P = 0.018). Between the MIECT and the PD groups, we found the incidence of renal failure and gastrointestinal complications to be significantly higher in the PD group compared to the MIECT group.

Conclusions: MIECT has short-term advantages over CB and PD. However, due to the retrospective limitations of the study, including calendar time bias, a multicentre randomized controlled trial comparing all 3 modalities will be beneficial for the larger cardiac community.
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http://dx.doi.org/10.1093/icvts/ivy035DOI Listing
July 2018

A diagnostic cohort study on the accuracy of 18-fluorodeoxyglucose (FDG) positron emission tomography (PET)-CT for evaluation of malignancy in anterior mediastinal lesions: the DECiMaL study.

BMJ Open 2018 02 6;8(2):e019471. Epub 2018 Feb 6.

Imperial College and the Academic Division of Thoracic Surgery, Royal Brompton and Harefield NHS Foundation Trust, London, UK.

Objectives: The aim of this study is to collate multi-institutional data to determine the value by defining the diagnostic performance of fluorodeoxyglucose positron emission tomography (FDG PET)/CT for malignancy in patients undergoing surgery with an anterior mediastinal mass in order to ascertain the clinical utility of PET/CT to differentiate malignant from benign aetiologies in patients presenting with an anterior mediastinal mass SETTING: DECiMaL Study is a multicentre, retrospective, collaborative cohort study in seven UK surgical sites.

Participants: Between January 2002 and June 2015, a total of 134 patients were submitted with a mean age (SD) of 55 years (16) of which 69 (51%) were men. We included all patients undergoing surgery who presented with an anterior mediastinal mass and underwent PET/CT. PET/CT was considered positive for any reported avidity as stated in the official report and the reference was the resected specimen reported by histopathology using WHO criteria.

Primary And Secondary Outcome Measures: Sensitivity, specificity, positive and negative predicted values of [18F]-FDG PET in determining malignant aetiology for an anterior mediastinal mass.

Results: The sensitivity and specificity of PET/CT to correctly classify malignant disease were 83% (95% CI 74 to 89) and 58% (95% CI 37 to 78). The positive and negative predictive values were 90% (95% CI 83% to 95%) and 42% (95% CI 26% to 61%).

Conclusions: The results of our study suggest reasonable sensitivity but no specificity implying that a negative PET/CT is useful to rule out the diagnosis of malignant disease whereas a positive result has no value in the discrimination between malignant and benign diseases of the anterior mediastinum.
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http://dx.doi.org/10.1136/bmjopen-2017-019471DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5829887PMC
February 2018

The differential effects of systemic vasoconstrictors on human pulmonary artery tension.

Eur J Cardiothorac Surg 2017 May;51(5):880-886

Department of Respiratory Medicine, Castle Hill Hospital, Cottingham, UK.

Objectives: Acute pulmonary hypertension following cardiac surgery can have a significant effect on postoperative morbidity and mortality. However, limited data are available on the efficacy and potency of clinically used systemic vasopressors on the pulmonary vasculature. The aim of this study was to use human pulmonary artery to characterize the pharmacological effects of clinically used vasopressors on the human pulmonary vasculature.

Methods: Fifty-seven pulmonary artery rings of internal diameter 2-4 mm and 2 mm long, mounted in a multiwire myograph system, were used to measure changes in isometric tension. We constructed concentration response curves by cumulative addition to the myograph chambers of KCl, noradrenaline (NA), adrenaline (AD), vasopressin, endothelin-1 (ET-1) and prostaglandin F2a (PGF2a).

Results: AD, NA, ET-1, PGF2a and KCl caused dose-dependent vasoconstriction in the pulmonary artery samples (EC50 246 nM [95% confidence interval, CI, 153-394 nM], 150 nM [95% CI 51-447 nM], 1.46 nM [95% CI 0.69-3.1 nM], 6.35 µM [95% CI 3.58-11.2 µM] and 17.24 mM [95% CI 12.43-24.07 mM], respectively), whereas vasopressin had no significant effect. The order of efficacy was KCl = PGF2a > AD > NA > ET-1 and the order of potency was ET-1 T-AD = NA > PGF2a > KCl.

Conclusions: This study demonstrated the efficacy and potency of clinically used vasopressors and endogenous vasopressors on human pulmonary vascular tone. PGF2a and KCl equally caused maximal amounts of constriction, whereas ET-1 had less effect and vasopressin had no effect. These effects may need to be taken into account in the clinical setting because they might result in the development of pulmonary hypertension.
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http://dx.doi.org/10.1093/ejcts/ezw410DOI Listing
May 2017

Tracheal Lobular Capillary Haemangioma: A Rare Benign Cause of Recurrent Haemoptysis.

Case Rep Surg 2016 25;2016:6290424. Epub 2016 Sep 25.

Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, UK.

Lobular capillary haemangioma (LCH), previously known as pyogenic granuloma, is a benign vascular lesion commonly found within the oral and nasal cavity. However, it is rarely encountered within the trachea, where presenting features include recurrent haemoptysis, cough, and wheeze. We here describe a case of a 7 mm tracheal LCH in a 56-year-old woman, which was successfully resected at interventional bronchoscopy using biopsy forceps. Clinicians should be aware of tracheal LCH in the differential diagnosis for recurrent haemoptysis.
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http://dx.doi.org/10.1155/2016/6290424DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5055950PMC
September 2016

Characterization of optimal resting tension in human pulmonary arteries.

World J Cardiol 2016 Sep;8(9):553-558

Azar Hussain, Robert T Bennett, Mubarak A Chaudhry, Syed S Qadri, Mike Cowen, Mahmoud Loubani, Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham HU16 5JQ, United Kingdom.

Aim: To determine the optimum resting tension (ORT) for in vitro human pulmonary artery (PA) ring preparations.

Methods: Pulmonary arteries were dissected from disease free sections of the resected lung in the operating theatre and tissue samples were directly sent to the laboratory in Krebs-Henseleit solution (Krebs). The pulmonary arteries were then cut into 2 mm long rings. PA rings were mounted in 25 mL organ baths or 8 mL myograph chambers containing Krebs compound (37 °C, bubbled with 21% O: 5% CO) to measure changes in isometric tension. The resting tension was set at 1-gram force (gf) with vessels being left static to equilibrate for duration of one hour. Baseline contractile reactions to 40 mmol/L KCl were obtained from a resting tension of 1 gf. Contractile reactions to 40 mmol/L KCl were then obtained from stepwise increases in resting tension (1.2, 1.4, 1.6, 1.8 and 2.0 gf).

Results: Twenty PA rings of internal diameter between 2-4 mm were prepared from 4 patients. In human PA rings incrementing the tension during rest stance by 0.6 gf, up to 1.6 gf significantly augmented the 40 mmol/L KCl stimulated tension. Further enhancement of active tension by 0.4 gf, up to 2.0 gf mitigate the 40 mmol/L KCl stimulated reaction. Both Myograph and the organ bath demonstrated identical conclusions, supporting that the radial optimal resting tension for human PA ring was 1.61 g.

Conclusion: The radial optimal resting tension in our experiment is 1.61 gf (15.78 mN) for human PA rings.
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http://dx.doi.org/10.4330/wjc.v8.i9.553DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5039357PMC
September 2016

Single versus multiple lung biopsies for suspected interstitial lung disease.

Asian Cardiovasc Thorac Ann 2016 Oct 17;24(8):788-791. Epub 2016 Aug 17.

Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, UK.

Background: There is a belief that in patients with suspected interstitial lung disease, multiple biopsies from different lobes are more likely to result in a diagnosis. We compared the results of single biopsies with those of multiple biopsies in terms of positive yield of histological diagnoses and the patients' postoperative outcomes.

Methods: Data of 115 patients who underwent video-assisted thoracoscopic lung biopsy, between 2009 and 2015, for suspected interstitial lung disease were analyzed retrospectively and grouped according to single or multiple lung biopsies. High-resolution computed tomography of the chest was reviewed prior to the procedure, and the most appropriate areas for sampling were chosen. Data analysis was carried out with the Mann-Whitney U test, using MedCalc version 16.1 statistical software.

Results: Of the 115 patients, 67 had a single biopsy and 48 had more than one biopsy. A histological diagnosis was arrived at in all cases. The duration of chest drainage (p = 0.033) and postoperative hospital stay (p = 0.012) were longer in the multiple-biopsies group.

Conclusion: A single lung biopsy is sufficient to arrive at a diagnosis of interstitial lung disease when the sampling site is guided by high-resolution computed tomography and a multidisciplinary approach. Multiple biopsies are less cost-effective, offer no added advantage in terms of diagnostic yield, and are associated with more morbidities and a longer hospital stay.
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http://dx.doi.org/10.1177/0218492316665551DOI Listing
October 2016

Isolated Human Perfused Lung Models to Study Ex Vivo Lung Optimization.

Transplantation 2016 08;100(8):e41-2

1 Department of Thoracic Surgery, Leeds Teaching Hospitals, Leeds, United Kingdom.2 Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, United Kingdom.

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http://dx.doi.org/10.1097/TP.0000000000001272DOI Listing
August 2016

Good's syndrome: Is thymectomy the solution? Case report and literature review.

Asian Cardiovasc Thorac Ann 2016 Sep 28;24(7):712-4. Epub 2016 Jun 28.

Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, UK.

Good's syndrome is thymoma accompanied by immunodeficiency. A 69-year-old woman presented with recurrent chest infections, hypogammaglobulinemia, and radiological features of a thymoma. Immunoglobulin replacement therapy was not tolerated prior to surgery. Postoperative recovery was uneventful, and a Masaoka stage II type AB thymoma was confirmed on histology. One-year follow-up revealed no recurrence of the thymoma but the patient remained hypogammaglobulinemic and developed collagenous colitis. She declined immunoglobulin replacement therapy but remains under follow-up. Awareness of Good's syndrome to avoid overwhelming infection is emphasized. The finding of thymoma should prompt the thoracic surgeon to test for immunodeficiency.
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http://dx.doi.org/10.1177/0218492316655641DOI Listing
September 2016

A rare case of occult splenic rupture after left pneumonectomy.

J Surg Case Rep 2016 May 17;2016(5). Epub 2016 May 17.

Department of Cardiothoracic Surgery, Castle Hill Hospital, Hull HU16 5JQ, UK.

Cardiopulmonary resuscitation (CPR) techniques are now well-established and play a crucial role in improving survival in cardiac arrest. Recognized complications associated with CPR include injury to the upper abdominal viscera, including the liver, stomach and spleen. We present a rare case of occult splenic rupture following cardiac arrest in a 63-year-old male immediately after left pneumonectomy. We discuss potential mechanisms predisposing the spleen to injury in this case, and highlight the difficulty of promptly identifying such a traumatic injury within the confines of a cardiac arrest scenario. Clinicians should be aware that anatomical changes following thoracic surgery may render the intra-abdominal viscera at increased risk of injury following CPR.
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http://dx.doi.org/10.1093/jscr/rjw091DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4869514PMC
May 2016

Multicentre, propensity-matched study to evaluate long-term impact of implantation technique in isolated aortic valve replacement on mortality and incidence of redo surgery.

Interact Cardiovasc Thorac Surg 2016 05 17;22(5):599-605. Epub 2016 Feb 17.

Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield, UK.

Objectives: Studies suggest that the use of semicontinuous suture (SC) technique increases the risk of redo valve surgery after aortic valve replacement (AVR). The objective of this study was to identify 30-day mortality, rate of redo operation and long-term outcomes after AVR using either a semicontinuous suture or interrupted suture (IS) technique.

Methods: A total of 1617 patients from 2 cardiothoracic centres, undergoing isolated AVR between April 2005 and August 2013 were included. AVR was performed using SC technique in 765 patients and IS technique in 852 patients. Data were collected prospectively and follow-up was obtained to date for all patients. We compared 30-day mortality, rate of redo operation and long-term mortality in SC and IS groups. One-to-one propensity-matching analysis was performed using IBM SPSS version 22 to evaluate outcomes.

Results: Four hundred and eleven patients in the SC group were matched to 411 patients in the IS group (total of 822 patients) using propensity-score matching. The baseline characteristics were similar between SC and IS groups after matching. There were no statistically significant differences in 30-day mortality (3.9 vs 2.7%; P = 0.328), long-term mortality at 9-year follow-up (14.4 vs 15.3%; log-rank = 0.524) or rate of redo surgery (2.9 vs 2.0%; P = 0.320) between SC and IS, respectively. However, shorter cross-clamp time (51.9 ± 15.2 vs 60.9 ± 17.6 min; P < 0.001), bypass time (71.3 ± 23.0 vs 81.3 ± 37.8 min; P < 0.001) and the use of larger valve sizes (23.4 ± 2.1 vs 21.9 ± 2.2 mm; P < 0.001) were observed in SC patients compared with IS patients. Multivariate analysis did not show the suture technique as a significant determinant of redo valve surgery.

Conclusions: This multicentre study demonstrates that neither mortality nor the risk of redo surgery was influenced by the choice of implantation technique using semicontinuous vs interrupted suture techniques. The SC technique allowed shorter operations and larger size valves to be utilized.
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http://dx.doi.org/10.1093/icvts/ivw015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4892155PMC
May 2016

Short- and long-term outcomes of pneumonectomy in a tertiary center.

Asian Cardiovasc Thorac Ann 2016 Mar 2;24(3):250-6. Epub 2016 Feb 2.

Department of Cardiothoracic Surgery, Castle Hill Hospital, Hull, UK.

Background: Surgery is the most important therapeutic modality for lung cancer. Surgical outcomes are normally reported as 30-day or 90-day mortality or 5-year survival; 10-year survival is rarely mentioned in national data or international studies.

Methods: Three hundred and six patients (79% male) underwent pneumonectomy, mainly for lung cancer, from January 1998 to February 2013. Their short- and long-term outcomes up to September 2014 were analyzed retrospectively. The mean age was 64 years (range 22-82 years) and 24% were aged ≥70 years. Thoracoscore was used to calculate the risk of hospital mortality.

Results: Operative mortality was 4.5% whereas predicted mortality was 8%. The operative mortality for cancer patients was 3.3%; the national mortality for lung cancer is 6.5%. Only 2 patients died in hospital after a pneumonectomy in the last 5 years. Half of the patients who died in hospital were ≥70 years old; 29% (4 patients) died after urgent operations for nonmalignant disease. Overall 5- and 10-year survival was 32% and 20%. Median and mean survival was 26 and 57 months, respectively. Long-term survival was better in females aged <70 years, in left pneumonectomy patients, and in those with squamous cell lung cancer.

Conclusion: Our mortality for pneumonectomy was 50% less than the national mortality rate and significantly lower than that predicted by the Thoracoscore for lung cancer. This confirms that pneumonectomy is still an effective modality for the treatment of lung cancer, with low operative mortality and good long-term survival, especially in younger patients.
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http://dx.doi.org/10.1177/0218492316629851DOI Listing
March 2016

Long-term prognosis and a prediction model for acute bowel ischaemia following cardiac surgery.

Interact Cardiovasc Thorac Surg 2015 Sep 12;21(3):336-41. Epub 2015 Jun 12.

Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, UK.

Objectives: Bowel ischaemia following cardiac surgery is associated with a high postoperative mortality. No scoring system exists as yet to predict this complication following surgery. In addition, the long-term survival is not known. We sought to evaluate in-hospital outcomes and long-term outcomes in bowel ischaemia following cardiac surgery. We also sought to devise a simple risk prediction model for this catastrophic entity.

Methods: This was a retrospective study of data entered prospectively into our cardiac surgical database between July 1999 and May 2014. We compared the short- and long-term outcomes of patients who developed bowel ischaemia following cardiac surgery with those who did not develop bowel ischaemia using propensity-matched analysis. We developed a prediction model for bowel ischaemia from logistic regression.

Results: In total, 13 853 patients underwent cardiac surgery. Of these, 85 had confirmed bowel ischaemia following surgery. The in-hospital mortality rate for those with bowel ischaemia was 60%, while in those without bowel ischaemia, the mortality rate was 3% (P < 0.0001). In those bowel ischaemia patients who had a laparotomy for corrective surgery, the in-hospital mortality was significantly less compared with those who did not have a laparotomy (39.2 vs 91.2%, P < 0.0001). The long-term survival for bowel ischaemia at 2, 6 and 10 years was 35% (±5), 31% (±5) and 26% (+/6), respectively. Multivariable analysis revealed that advanced age at surgery, peripheral vascular disease, intra-aortic balloon pump usage, NYHA IV and postoperative atrial fibrillation were the significant (P < 0.005) determinants of developing postoperative bowel ischaemia. We developed a model to predict bowel ischaemia and validated it within our population (c-index = 0.781).

Conclusions: We have shown that whilst bowel ischaemia carries a higher short-term mortality, the long-term mortality is not significantly greater for those few who survive to discharge. We have developed a simple prediction model to identify those at high risk of developing bowel ischaemia following cardiac surgery in order to optimize perioperative strategies in future.
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http://dx.doi.org/10.1093/icvts/ivv148DOI Listing
September 2015

Minimally invasive aortic valve replacement: Comparison of long-term outcomes.

Asian Cardiovasc Thorac Ann 2015 Sep 19;23(7):814-21. Epub 2015 May 19.

Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, UK.

Background: Minimally invasive aortic valve replacement tends to be performed in specialist centers. Little data exists with regard to long-term outcomes of the upper hemi-sternotomy technique. We sought to evaluate the short- and long-term outcomes of this procedure in our institution.

Methods: Data were collected from our cardiac surgical database. We compared the outcomes of all patients who underwent minimally invasive aortic valve replacement with all who underwent conventional aortic valve replacement between July 1999 and December 2013. Propensity-matching analysis was performed to evaluate hospital outcomes.

Results: There were 125 patients who underwent minimally invasive aortic valve replacement and 1446 who had conventional surgery. After propensity score matching, there were no differences in postoperative mortality or complications between the 2 groups. The only significant differences were longer bypass (62.69 ± 10.12 vs. 68.94 ± 14.79 min, p = 0.002) and crossclamp times (45.48 ± 8.08 vs. 52.30 ± 16.29 min, p < 0.001) in conventional surgery. Long-term survival after minimally invasive aortic valve replacement at 2, 6, and 10 years was 88% ± 3.0%, 79% ± 4.0%, and 66% ± 6.0%, respectively. Predictors of long-term survival were age, peripheral vascular disease, and low ejection fraction (p < 0.005).

Conclusion: Minimally invasive aortic valve replacement has similar hospital outcomes compared to conventional aortic valve replacement. The operation is quicker and does not confer any significant increase in complications or length of hospital stay. The long-term outcomes are favorable and justify its continued use by specialist surgeons in the United Kingdom.
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http://dx.doi.org/10.1177/0218492315587606DOI Listing
September 2015

Thoracoscore and European Society Objective Score Fail to Predict Mortality in the UK.

World J Oncol 2015 Feb 14;6(1):270-275. Epub 2015 Feb 14.

Department of Cardiothoracic Surgery, Castle Hill Hospital, Hull, HU16 5JQ, UK.

Background: Thoracoscore and the European Society Objective Score (ESOS.01) are two scoring systems used in thoracic surgery to estimate operative mortality risk. We aimed to evaluate if these are valid tools for use in the UK population.

Methods: A multi-center, prospective study was carried out on patients undergoing lung resection at six UK centers. Data were submitted electronically using our online data collection tool. Data were analyzed to determine the factors affecting mortality. A receiver operating characteristic analysis determined the ability of the thoracoscore and ESOS.01 to predict in-hospital mortality.

Results: Data were complete for 2,245 patients. The observed in-hospital mortality was 31 patients (1.38%). Mean thoracoscore was 2.66 (SD ± 3.21). Gender (P = 0.004, hazard ratio 4.786) and co-morbidity score (P = 0.005, hazard ratio 3.289) were identified as risk factors for mortality. A sub-analysis was performed using data from 1,912 patients with complete data for ESOS.01. In this group, mean thoracoscore was 2.55 (SD ± 2.94), mean ESOS.01 was 2.11(SD ± 1.41), and these were statistically significantly different (P < 0.0001). The observed in-hospital mortality was 28 patients (1.46%). The c-index for thoracoscore was 0.705, and for ESOS.01 was 0.739.

Conclusions: Both thoracoscore and ESOS.01 overestimated mortality in the UK population. There is a continued need to develop an appropriate risk prediction system for the UK.
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http://dx.doi.org/10.14740/wjon897wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5649945PMC
February 2015

Validation of the Intensive Care National Audit and Research Centre Scoring System in a UK Adult Cardiac Surgery Population.

J Cardiothorac Vasc Anesth 2015 6;29(3):565-9. Epub 2015 Jan 6.

Department of Cardiothoracic Anaesthesia Castle Hill Hospital, Cottingham, UK.

Objective: The Intensive Care National Audit and Research Centre (ICNARC) scoring system was conceived in 2007, utilizing 12 physiologic variables taken from the first 24 hours of adult admissions to the general intensive care unit (ICU) to predict in-hospital mortality. The authors aimed to evaluate the ICNARC score in predicting mortality in cardiac surgical patients compared to established cardiac risk models such as logistic EuroSCORE as well as to the Acute Physiology and Chronic Health Evaluation (APACHE) II.

Design: Retrospective analysis of data collected prospectively.

Setting: Single-center study in a cardiac intensive care in a regional cardiothoracic center.

Participants: Patients undergoing cardiac surgery between January 2010 and June 2012.

Methods: A total of 1,646 patients were scored preoperatively using the logistic EuroSCORE and postoperatively using ICNARC and APACHE II. Data for comparison of scoring systems are presented as area under the receiver operating characteristic curve.

Measurements And Main Results: The mean age at surgery was 67 years±10.1. The mortality from all cardiac surgery was 3.2%. The mean logistic EuroSCORE was 7.31±10.13, the mean ICNARC score was 13.42±5.055, while the mean APACHE II score was 6.32±7.731. The c-indices for logistic EuroSCORE, ICNARC, and APACHE II were 0.801, 0.847 and 0.648, respectively.

Conclusion: The authors have, for the first time, validated the ICNARC score as a useful predictor of postoperative mortality in adult cardiac surgical patients. This could have implications for postoperative management, focusing the utilization of resources as well as a method to measure and compare performance in the cardiothoracic ICU.
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http://dx.doi.org/10.1053/j.jvca.2014.09.013DOI Listing
February 2016