This presentation aims to summarise a unique approach to Cardiac Surgery Advanced Life Support (CALS) at St Vincent’s Hospital Melbourne.

Background Pulmonary carcinoids are rare neoplasms, accounting for approximately 1%–2% of all lung malignancies. A retrospective analysis was undertaken of all patients who underwent surgical resection of pulmonary carcinoid tumours across multiple institutions in Melbourne, Australia. Methods From May 2000 through April 2020, 241 patients who underwent surgical resection of pulmonary carcinoid tumours were retrospectively reviewed. Patient demographics, pathologic data, and long-term outcomes were recorded. Results Median age was 57.7 years and the majority of patients were female (58.9% vs. 41.1%). Typical carcinoid was present in 77.1%. Histological subtype was associated with several factors. Atypical carcinoid was more likely to have larger tumour size and nodal involvement. Overall survival for typical carcinoid at 5, 10, and 15 years was 98%, 95%, and 84%, and for atypical carcinoid was 88%, 82%, and 62%, respectively. Histological subtype and age were found to be independent predictors of overall survival, with worse outcomes for atypical and those above 60 years of age. Disease-free survival was related to sublobar resection (p < 0.001, sub-hazard ratio (SHR): 6.89), lymph node involvement (p = 0.022, SHR: 3.18), and atypical histology (p < 0.001, SHR: 9.89). Conclusion Excellent long-term outcomes can be achieved following surgical resection of pulmonary carcinoids. Atypical histology and lymph node involvement are significant prognostic factors, and sublobar resection should not be considered in patients with either of the above features. Typical carcinoid tumour without nodal involvement may be appropriate for sublobar resection. Typical and atypical carcinoid tumours should be considered distinct disease entities, and as such treated accordingly.

A best evidence topic was written according to a structured protocol to answer the following question: “Is pre-operative neutrophil lymphocyte ratio an important predictor of adverse events following cardiac surgery?”

We describe a novel technique for the creation of a pleural tent and pleurectomy via the use of a laparoscopic hernia balloon. In this method a Spacemaker™ Structural Balloon Trocar (Covidien, USA) is tunnelled under the pleura at the site of thoracotomy or video assisted thoracoscopic surgery port and incrementally inflated under vision. This method is less traumatic than traditional methods, is more likely to provide an intact pleural tent, and allows the surgeon to operate in a near bloodless operative field.

Over one third of patients undergoing permanent pacemaker or cardiac defibrillator implantation have an indication for therapeutic anticoagulation. Accumulating evidence supports continuation of warfarin therapy for these procedures. The evidence is less clear for direct acting oral anticoagulants (DOAC), medications now more commonly prescribed than warfarin. A best evidence topic was written according to a structured protocol addressing the question "does continuation of direct acting oral anticoagulants affect bleeding outcomes compared to discontinuation among patients undergoing cardiac pacemaker or defibrillator implantation?" Altogether, 1507 papers were found searching Medline, Embase, and Pubmed databases of which five represented the best evidence to answer the clinical question. Although modest evidence exists to answer this question, two recent randomised trials as well as two cohort studies and one case series have addressed the issue with similar findings. Interrupted and uninterrupted DOAC therapy resulted in similar rates of major bleeding (0-2.1% vs 0-4% respectively, no significant p-values reported) particularly in pocket haematoma formation, a clinically important event that substantially increases risk for infection and reoperation. Other adverse events reported were similar between the two groups. In well-selected patients at high risk for thromboembolic complications, it is reasonable to undertake cardiac device implantation without cessation of DOAC therapy as rates of bleeding complications are not significantly higher compared to interrupted therapy.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, "In patients who have undergone Coronary Artery Bypass Grafting, does aspirin plus clopidogrel postoperatively improve vein graft patency when compared to aspirin alone?" Altogether, 165 papers were found using the reported search, of which five represented the best evidence to answer the clinical question. Overall analysis of these papers demonstrated similar rates of vein graft patency between the two groups. There was no difference between the groups with regard to mortality, adverse bleeding-related outcomes, or composite vascular events.

Background: Angiotensin converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers ARB) are first-line therapies in hypertensive and heart failure. Their use in patients undergoing cardiac surgery is common. Concern regarding renal outcomes exists for patients administered these medications perioperatively, resulting in heterogeneous practice. Methods: A best evidence topic was written addressing the question "in patients undergoing cardiac surgery, is long-term preoperative ACEI/ARB therapy associated with postoperative renal dysfunction?" Altogether, 11 studies representing 47,072 patients comprised of two randomised trials, two prospective cohorts, and seven retrospective cohorts with 811, 5,818, and 40,443 patients respectively were identified searching Medline, Embase, and Pubmed databases from 1980 to February 2019. Results: Evidence is conflicting. The two randomised trials showed that preoperative ACEI/ARB were protective against the development of postoperative acute kidney injury (AKI). The two prospective cohorts showed opposite results and of the seven retrospective cohorts, four demonstrated increased risk, two no difference, and one a protective effect against AKI in relation to preoperative ACEI/ARB therapy. Conclusions: Most data are derived from large cohort studies of moderate quality (average Newcastle Ottawa Scale score of five) and overall suggest an increased risk of postoperative AKI with preoperative ACEI/ARB. However, more recent, higher quality, randomised studies have shown the opposite: preoperative ACEI/ARB therapy reduces incidence of postoperative AKI; emphasizing the impact of selection and confounders. Large randomised trials are necessary to identify patients who may benefit from continued ACEI/ARB therapy in the context of cardiac surgery.

A best evidence topic in cardiac surgery was written according to a structured protocol addressing the question 'for post-cardiac surgery atrial fibrillation (AF), do clinical outcomes differ between rate or rhythm control strategies?' Altogether, 2174 papers were found using the reported searches, of which 5 represented the best evidence to answer the clinical question. Hospital length of stay ranged from 5.0 to 13.2 days for rate control and 5.2 to 10.3 days for rhythm control. Freedom from AF at follow up was achieved in 84.2-91 and 84.2-96% in rate and rhythm control groups respectively. Minimal serious adverse events were noted in all studies analysed and there was no difference between rate and rhythm control groups. We conclude that in the management of post-cardiac surgery, AF, rate control and rhythm control are equivalent in terms of hospital length of stay, freedom from arrhythmia at follow up and complication rates.

A best evidence topic was written to address if perioperative levosimendan improves mortality following cardiac surgery. Fourteen papers represented the best available evidence. An older meta-analysis summarising 11 of these trials concluded that there were fewer deaths in the levosimendan group compared to the control group (OR 0.41, p <0.001) however, this was driven by the results of three included trials by the same author. Three larger and more recent randomised controlled trials failed to demonstrate significant differences in mortality. We conclude that levosimendan lacks robust evidence to substantiate claims of mortality benefit in cardiac surgery patients and should not be used routinely in such patients.

A best evidence topic was written addressing the question ‘in patients with saphenous vein graft lesions requiring percutaneous coronary intervention, do long-term clinical outcomes differ between drug-eluting and bare-metal stents?’ Altogether 1466 papers were found, of which seven represented the best evidence. Although one major recent randomised trial was neutral, the weight of earlier evidence supports drug-eluting stents as standard of care. Bare-metal stents may represent a reasonable, efficacious, and less expensive alternative to drug-eluting stents in well selected patient groups.

A best evidence topic was written according to a structured protocol. The question addressed was “Centrifugal vs axial left ventricular assist devices: Does device design change patient outcomes?” More than 38 papers were found, of which nine represented the best evidence to answer the clinical question. Available data from studies comparing the centrifugal flow HeartMate 3 (HM3) with the axial flow HeartMate II (HMII) demonstrated that HM3 is associated with a lower incidence of suspected or confirmed pump thrombosis (1.1% vs 15.7%), stroke events (10.1% vs 19.2%), and ischaemic stroke (6.3% vs 13.4%) at 2-year follow-up, and a higher incidence of 6-month survival free of haemocompatibility related adverse events (69 ± 4% vs 55 ± 4%), and severe haemocompatibility related adverse events requiring re-operation (0% vs 7%). Markers of quality of life and functional capacity were comparable between the two devices at 6 months. In studies comparing HVAD to HMII the incidence of sepsis (23.6% vs 15.4%), all stroke events (5.9–44% vs 3.8–12.1%), ischaemic stroke (17.6% vs 12.1%), haemorrhagic stroke (14.9% vs 4%), right heart failure (38.5–54% vs 26.8–39%), gastrointestinal bleeding (0–35.1% vs 0–34.2%), and right ventricular assist device use (0–29% vs 0–15%) tended to be higher; however, some studies showed no difference in these outcomes. Based on the available studies, it was concluded that patient outcomes may be better with the HM3 device compared with the HMII. In comparison, patient outcomes may be poorer with HVAD compared with the HMII device; however, there is much variability in reported outcomes and further research is needed.

Background: Anaemia is an important complication affecting cardiac surgery patients. Following cardiac surgery, transfusion of red blood cells is often required for haemodynamic support. Traditionally, haemoglobin cutoffs of 9–10 g/dL were used for to trigger transfusion. New randomised trial evidence has recently bolstered support for restrictive protocols with haemoglobin cutoffs of 7–8 g/dL. Methods: A best evidence topic was written addressing the question “does post-operative mortality among adult patients undergoing cardiac surgery differ with restrictive versus liberal transfusion strategies?” Altogether, ten randomised trials representing 11,826 patients were identified searching Medline, Embase, and Pubmed databases from 1980 to February 2019 which represented the best evidence to answer the question. Results: Some older trials have suggested a trend toward long-term mortality benefit with liberal transfusion protocols: Hazard Ratio (HR) 0.7 [95% confidence interval (CI) 0.49–1.02, p = 0.06] from a meta-analysis summarising six trials. However, more recent, larger, high-quality contemporary trials have demonstrated noninferiority with regard to mortality for a restrictive strategy, with the largest of which producing an odds ratio of 0.85 (95% CI 0.62–1.16) for 28-day mortality and 1.02 (95% CI 0.87–1.18, p = 0.006) for 6-month mortality. Conclusions: Among cardiac surgery patients, restrictive and liberal transfusion strategies do not differ with respect to mortality. Adverse outcomes such as stroke, nonfatal myocardial infarction, and renal failure did not differ between the two groups. Restrictive strategies result in fewer transfusions and less health care expenditure.

A best evidence topic was written according to a structured protocol. The question addressed was 'Do patients with centrifugal flow HeartMate 3 (HM3) or HeartWare left ventricular assist device (HVAD) have better outcomes compared to those with the axial flow HeartMate II (HMII)?' Altogether 1791 papers were found using the reported search, of which 21 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. In publications reporting on MOMENTUM 3 randomized control trial (RCT), HM3 had better outcomes compared to HMII with a lower rate of pump thrombosis (1.1% vs 15.7%), stroke events (10.1% vs 19.2%) and ischaemic stroke (6.3% vs 13.4%) at 2-year follow-up. Markers of quality of life and functional capacity were comparable between the 2 devices at 6 months. In publications reporting on ENDURANCE RCTs, compared to HMII, patients with HVAD had poorer outcomes with an increased rate of sepsis (23.6% vs 15.4%), stroke (29.7% vs 12.1%) and right heart failure (38.5% vs 26.8%) postoperatively. Outcomes were improved for the HVAD group in a more recent RCT where strict blood pressure control was instigated postoperatively. Outcomes from retrospective studies comparing HMII with HVAD varied, with some publications reporting higher rates of right ventricular assist device use (29% vs 15%), gastrointestinal bleeding (30% vs 0%), cerebrovascular accident (44% vs 10%), transient ischaemic attack (5% vs 2%) and higher cumulative risk of infection and haemorrhagic cerebrovascular accident with HVAD. This is not consistent across these studies, and 9 studies including a systematic review reported no difference in any outcomes. In conclusion, patients with centrifugal flow HM3 have better outcomes than those with axial flow HMII. Although there is some variability in outcomes in retrospective studies, patients with centrifugal flow HeartWare HVAD have similar outcomes to those with axial flow HMII when strict blood pressure control is instigated postoperatively. By inference, centrifugal flow HM3 would appear to be the superior device, although all conclusions are based on 1 large (industry-sponsored) RCT.

This study presented the case of a 34-year-old male who underwent an excision of a 15 × 15 × 12 cm left-sided thoracic malignant neoplasm that exhibited morphological and immunohistochemical features of pure embryonal carcinoma without evidence of concurrent extra-pleuropulmonary disease on positron emission tomography scan or testicular ultrasound. Primary extra-gonadal germ cell (EGGCT) tumours are rare and exhibit different tumour biology and behaviour compared with gonadal germ cell tumours. Previously reported locations of EGGCT include mediastinum, pineal or suprasella regions, sacrococcyx, retroperitoneum, vagina, prostate, liver, gastrointestinal tract, and orbital regions. This is the first reported case of a thoracic primary extragonadal germ cell tumour. Whilst the lungs are a frequent destination of metastasis for germ cell tumours of gonadal and extra-gonadal primary sites, a primary lung EGGCT has not yet been described. The patient's presentation and surgery, the diagnostic challenges and work-up for EGGCT, and the importance of differentiating between metastatic germ cell tumours versus primary EGGCT were discussed.

Background: The Cox-Maze IV procedure for the treatment of atrial fibrillation (AF) is faster, less technically complex, portends fewer complications, and results in lower morbidity compared to the traditional cut-and-sew Cox-Maze III procedure. Cox-Maze IV is highly effective, with recurrence rates of only 5–10%. The most studied energy sources are radiofrequency and cryoablation. Methods: A best evidence topic was written according to a structured protocol addressing the question "for patients undergoing maze procedure, do cryoablation and radiofrequency ablation differ with respect to rate of recurrence of atrial fibrillation?" Altogether, 480 papers were found searching Medline, Embase, and Pubmed databases of which ten represented the best evidence to answer the question. Randomised trials or cohort studies among adults undergoing cardiac surgical procedures that included maze procedure were included. Results: Rates of sinus rhythm or freedom from AF at long-term follow-up (usually 12 months) ranged from 70–95% and 73–89% in the radiofrequency and cryoablation groups respectively. Both methods were much more effective at maintaining sinus rhythm compared to placebo. The two groups were also evenly matched in terms of reported rates of complications. Mortality, when reported, ranged from 0–2% in both groups. Conclusions: We conclude that radiofrequency and cryoablation are equiefficacious in terms of freedom from AF recurrence at long-term follow-up. Rates of complications such as bleeding and cardiac tamponade as well as mortality did not differ between groups. Choice of energy source for Cox-Maze IV procedure does not appear to markedly affect outcomes and should depend on centre and operator experience.

A best evidence topic was written addressing the question 'in patients with saphenous vein graft lesions requiring percutaneous coronary intervention, do long-term clinical outcomes differ between drug-eluting and bare-metal stents?' Altogether 1466 papers were found, of which seven represented the best evidence. Although one major recent randomised trial was neutral, the weight of earlier evidence supports drug-eluting stents as standard of care. Bare-metal stents may represent a reasonable, efficacious, and less expensive alternative to drug-eluting stents in well selected patient groups.

A best-evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was in patients who have undergone coronary artery graft surgery (CAGs) does aspirin + clopidogrel postoperatively improve vein graft patency when compared with aspirin only? Altogether, 81 papers were found using the reported search, of which four represented the best evidence to answer the clinical question. An additional two papers were included following more extensive analysis of the literature available. The authors, title, journal, date and country of publication, patient group studied, study type, relevant outcomes, and results of these papers were tabulated. Of the six papers analysed, three did not demonstrate statistical significance between the two treatment arms and rates of vein graft patency. However, the three remaining papers suggest, with statistical significance, that aspirin + clopidogrel does improve vein graft patency. In total, 219 of 239 (91.6%) versus 198 of 231 (85.7%; p = .043), 238 of 257 (92.6%) versus 232 of 267 (86.9%; p = .04), and 803 of 860 (93.4%) versus 755 of 846 (89.2%; p = .003) of vein grafts were found to be patent when comparing aspirin + clopidogrel with aspirin only. Comparing aspirin + clopidogrel with aspirin only, we conclude that clopidogrel in combination with aspirin improves vein graft patency following CAGS. Given the low incidence of morbidity/mortality associated with the administration of aspirin + clopidogrel post–CAGS, we recommend that aspirin + clopidogrel be administered post–CAGS to improve rates of vein graft patency.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients undergoing off-pump coronary artery bypass grafting, for single or multivessel disease, does minimally invasive direct coronary artery bypass (MIDCAB) or off-pump coronary artery bypass (OPCAB) provide the superior outcome including a reduction in morbidity and mortality?'. A total of 187 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, date, journal and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. It was found that compared to OPCAB, MIDCAB surgery can offer decreased intensive care unit length of stay (4.5-57.4 h vs 5.2-52.7 h) and total hospital length of stay (4.5-8.5 days vs 5.2-12 days), with 1 paper showing a decrease in mortality at 1 year (3% vs 14%). However, there were several papers that showed significant risks with MIDCAB surgery in patients with either single or multivessel disease. These include increased risk of incomplete revascularization (29% vs 0%), significant early complications (22.5 vs 0%), urgent reintervention (16% vs 0%), repeat revascularization events (12.2% vs 3.7%), progression of native disease (4.8% vs 0.9%), rehospitalization by 3 months (20% vs 2%) and postoperative infarction (2.9% vs 1.45%). These risks did not translate to an increase in early mortality (0-1% vs 0-1.6%) or late mortality (0-3% vs 0-14%) in papers that included mid-term follow up. However, they do represent significant potential risks that cannot be overlooked when considering the use of MIDCAB. We conclude that MIDCAB is associated with greater morbidity and reintervention compared to OPCAB via sternotomy, but both techniques are equivalent in terms of operative and mid-term mortality.