Coronary artery bypass grafting (CABG) remains a cornerstone in the treatment of advanced ischemic heart disease, offering durable and effective revascularization. Despite surgical success, long-term patient outcomes are often shaped by the progression of native coronary disease and the development of comorbid conditions. This narrative review explores seven critical domains in secondary prevention following CABG: Early recognition of postoperative complications, evidence-based pharmacotherapy, management of atrial fibrillation, lifestyle modification, psychological well-being, preservation of ventricular function, and collaboration within the multidisciplinary team. Effective secondary prevention can significantly reduce the risk of further cardiovascular events and support the longevity of the graft. Interventions such as lipid management, smoking cessation, and structured cardiac rehabilitation promote both physiological recovery and emotional resilience. Timely treatment of arrhythmias and ventricular dysfunction further reduces the risk of heart failure and recurrent ischemia. Primary care practitioners are uniquely positioned to lead the delivery of long-term secondary prevention. By integrating evidence-based strategies into routine care, these strategies can play a pivotal role in improving quality of life and long-term outcomes for post-CABG patients.

The authors regret that the original article was published without appropriate credit for Figure 1. The authors would like to thank David Nahabedian, MSMI, CMI, for his assistance in creating the 3D model and prototype for this project. The authors would like to apologize for any inconvenience caused.

[No abstract, showing first paragraph] Sir Peter Medawar was a 20th century British biologist and Nobel prize winner. He was a pioneer in the field of tissue rejection and transplantation. He inspired many, including Christian Barnard and Sir Magdi Yacoub, surgeons who need no introduction to the reader (Figure 1).

Introduction A 58 year old man was referred to us with late presenting inferior STEMI, pulmonary oedema, and acute torrential MR secondary to ischaemic papillary muscle rupture (Panel A). An IABP was inserted and he was transferred to our centre in cardiogenic shock (INTERMACS 2), acute kidney and liver injury and on high-dose inopressors. Case Report Our cardiogenic shock team met and reviewed options: with him too unwell for immediate surgery, we planned short term mechanical circulatory support as bridge to mitral transcatheter edge-to-edge repair (TEER), itself intended to bridge to surgery. First, PCI to the occluded RCA was performed (Panel B) with Impella 5.0 support via subclavian cut-down and tunnelled graft, but despite high dose inopressors and Impella flows, refractory pulmonary oedema and end organ dysfunction persisted. 2 days later he underwent TEE-guided TEER (Panel C-E). Two clips were deployed centrally, with residual moderate MR, mean gradient 5-6 mmHg, and improved LA pressures. His multi-organ dysfunction thereafter stabilised and ventilation via tracheostomy and veno-venous haemofiltration were given; new significant Impella-associated AI was well tolerated. 21 days after TEER, his Impella abruptly stopped working yet he remained haemodynamically stable; that day he underwent emergency surgery with Impella removal, bioprosthetic AV replacement, and bioprosthetic MV replacement. Euroscore II was 42.8 %, cardiopulmonary bypass time 142 min, ischaemic time 120 min. On post-operative TTE, there was normal LV size with mildly reduced function and RWMA, visual LVEF 55%, normal RV size with preserved function, and normal prosthetic MV and AV function. He was subsequently discharged home on optimal medical therapy; in clinic he reported no exertional symptoms and was doing well. Summary This case highlights the potential for LV and RV recovery in selected cases of cardiogenic shock when the overall strategy is managed collaboratively by a multi-disciplinary cardiogenic shock team.

SLT, these data should be interpreted with caution given small patient numbers and lack of statistical power.Future research should be focused on and powered to assess differences in outcomes for SLT with and without the use of CLES.

There is no gold standard criterion for the diagnosis of cystic fibrosis‐related liver disease (CFRLD) and there is uncertainty over its impact on the outcome of lung transplantation.

Postcardiotomy (cardiac surgery) refractory cardiogenic shock after cardiac arrest is commonly a fatal condition. In some instances an intra-aortic balloon pump may bridge the failing heart to recovery. However, a stunned myocardium often requires a period of rest only provided through mechanical circulatory support. Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) works just like the standard cardiopulmonary bypass by draining blood from the venous system and returns it into the systemic circulation, hence providing immediate cardiorespiratory support. Failure to achieve spontaneous circulation after cardiac arrest in this situation is an indication for open cardiac massage and institution of either central or peripheral V-A ECMO. V-A ECMO is potentially a life-saving modality in this acute setting. It provides survival benefit with reasonable intermediate and long-term outcomes; however, survival of less than 50% is often expected. Death is commonly caused by complications that lead to multiorgan dysfunction. Hence, a high index of suspicion is needed for the early diagnosis and treatment of associated complications.

Purpose Direct procurement of thoracic organs as compared to using abdominal normothermic regional perfusion (aNRP) is the preferred method for thoracic organ procurement in donors after circulatory death (DCD). The use of aNRP improves outcomes from liver transplantation. We have developed a technique for thoracic organ isolation during aNRP that allows successful co-procurement of thoracic and abdominal organs. Methods In order to achieve successful thoracic isolation both the brain perfusion and volume loss must be prevented. After certification of circulatory death and a standoff period the thoraco-abdominal incision is performed. Blood is collected from the donor right atrium or a side-arm of the aNRP circuit to prime the organ care system (OCS) before isolation of vascular structures in a systematic way. 1. The left pleura is opened, and the lung retracted to allow identification and clamping of the descending thoracic aorta above the diaphragm. 2. The ascending aorta is clamped, and the aortic arch vented cranial to the clamp. Abdominal NRP can then commence. 3. The inferior vena-cava is clamped within the pericardium. 4. The superior vena-cava and azygos vein are tied off. 5. The heart is vented on the left and right side before induction of cardioplegia. The diagram illustrates complete vascular isolation of the thoracic cavity enabling explantation of the heart and lung after delivery of selective antegrade pneumoplegia while abdominal organs continue to be perfused for 2-hours before the start of abdominal procurement. Results Between 2019-21 we successfully performed seven such procurements. Three heart and lungs, three lungs and one heart procurement alone. All organs were successfully implanted with successful immediate outcome in all thoracic and abdominal recipients. Conclusion Direct procurement of thoracic organs is a feasible option during aNRP. This will potentially expand the thoracic organ donor pool and improve outcome of liver transplantation.

Background In recent years, rapid advances in cardiac surgery and changes in attitude towards patients with cognitive disability have led to these patients receiving cardiac transplantation. Method This is a retrospective report describing the experience of four patients with Down Syndrome who received heart transplantation in a single institution. Results Anthracycline-induced cardiomyopathy was the most common cause of heart failure in this group (3/4). Two patients were bridged to transplantation, one by using a combination of extra-corporeal membrane oxygenation and biventricular assist device and the other by using a durable implantable left ventricular assist device. All the four patients are alive with the longest surviving patient 17 years after transplantation. Against strong hypothetical predictions, we observed no propensity for the development of post-transplant infections or lymphoproliferative disorders. Conclusion Down Syndrome should not be the sole contraindication to heart transplantation. The decision for transplantation should be on a case-by-case basis provided adequate social support is in place.

Purpose Donation after circulatory death (DCD Maastricht III) increases the donor pool, but the induction of organ preservation solutions necessitates a staged approach. As the heart has a low ischemic tolerance it is vital in a DCD retrieval to reanimate the heart quickly without waiting for pneumoplegia to finish. We have devised a selective pneumoplegia delivery system to aid independent lung procurement from the heart to reduce ischemic times. Methods Figure 1 shows the customized pneumoplegia delivery system. It consists of two self-inflated soft balloon retrograde cardioplegia cannulae connected with a ¼ inch y-connector and ¼ inch silicone tubes. During cardioplegia the pulmonary artery is transacted, the cannulae inserted into the right and left pulmonary arteries to deliver simultaneous selective antegrade pneumoplegia (Figure 2). After cardioplegia, the heart procurement and its reanimation on the organ care system can commence as the pneumoplegia is running. The self-inflated balloons of the cannulae do not require manual fixation, saving time as there are several litres of pneumoplegia. The same cannulae may be used to deliver the retrograde pneumoplegia. Results Between 2019-21 we performed three such procurements, with good immediate outcomes in all lung transplant recipients. Conclusion Our customized system allows simultaneous delivery of selective antegrade and retrograde pneumoplegia during and after cardiectomy in a DCD retrieval. This may reduce ischaemia for the heart and lung and improve organ utilisation. More studies are required to assess the potential benefit of our pneumoplegia delivery system. Donation after circulatory death (DCD Maastricht III) increases the donor pool, but the induction of organ preservation solutions necessitates a staged approach. As the heart has a low ischemic tolerance it is vital in a DCD retrieval to reanimate the heart quickly without waiting for pneumoplegia to finish. We have devised a selective pneumoplegia delivery system to aid independent lung procurement from the heart to reduce ischemic times. Figure 1 shows the customized pneumoplegia delivery system. It consists of two self-inflated soft balloon retrograde cardioplegia cannulae connected with a ¼ inch y-connector and ¼ inch silicone tubes. During cardioplegia the pulmonary artery is transacted, the cannulae inserted into the right and left pulmonary arteries to deliver simultaneous selective antegrade pneumoplegia (Figure 2). After cardioplegia, the heart procurement and its reanimation on the organ care system can commence as the pneumoplegia is running. The self-inflated balloons of the cannulae do not require manual fixation, saving time as there are several litres of pneumoplegia. The same cannulae may be used to deliver the retrograde pneumoplegia. Between 2019-21 we performed three such procurements, with good immediate outcomes in all lung transplant recipients. Our customized system allows simultaneous delivery of selective antegrade and retrograde pneumoplegia during and after cardiectomy in a DCD retrieval. This may reduce ischaemia for the heart and lung and improve organ utilisation. More studies are required to assess the potential benefit of our pneumoplegia delivery system.

Background Acute Kidney Injury (AKI) adversely affects outcomes after cardiac surgery. A major mediator of AKI is the activation of leukocytes through exposure to the cardiopulmonary bypass circuit. We evaluate the use of leukodepletion filters throughout bypass to protect against post-operative AKI by removing activated leukocytes during cardiac surgery. Methods This is a single-centre, double-blind, randomized controlled trial comparing the use of leukodepletion versus a standard arterial filter throughout bypass. Elective adult patients undergoing heart valve surgery with or without concomitant procedures were investigated. The primary clinical outcome measured was the development of AKI according to the KDIGO criteria. Secondary measures included biomarkers of renal tubular damage (urinary Retinol Binding Protein and Kidney Injury Molecule-1), glomerular kidney injury (urinary Micro Albumin and serum Cystatin C) and urinary Neutrophil Gelatinase Associated Lipocalin, as well as the length of hospital stay and quality of life measures through EQ-5D-5L questionnaires. Results The ROLO trial randomized 64 participants with a rate of recruitment higher than anticipated (57% achieved, 40% anticipated). The incidence of AKI was greater in the leukodepletion filter group (44% versus 23%, risk difference 21, 95% CI − 2 to 44%). This clinical finding was supported by biomarker levels especially by a tendency toward glomerular insult at 48 h, demonstrated by a raised serum Cystatin C (mean difference 0.11, 95% CI 0.00 to 0.23, p = 0.068) in the leukodepleted group. There was however no clear association between the incidence or severity of AKI and length of hospital stay. On average, health related quality of life returned to pre-operative levels in both groups within 3 months of surgery. Conclusions Leukocyte depletion during cardiopulmonary bypass does not significantly reduce the incidence of AKI after valvular heart surgery. Other methods to ameliorate renal dysfunction after cardiac surgery need to be investigated. Trial registration The trial was registered by the International Standard Randomized Controlled Trial Number Registry ISRCTN42121335 . Registered on the 18 February 2014. The trial was run by the Bristol Clinical Trials and Evaluation Unit. This trial was financially supported by the National Institute of Health Research (Research for Patient Benefit), award ID: PB-PG-0711-25,090.

PurposeThe effect of the COVID 19 pandemic had the potential to have a major impact on patients during their journey through transplant assessment and heart or lung transplantation. Patients awaiting cardiopulmonary transplantation form a vulnerable group at increased risk because of their end stage cardiovascular or respiratory disease. We evaluated the impact of COVID pandemic on our transplant program.MethodsWe retrospectively reviewed our adult and paediatric heart and lung transplant activity from 2015. We assessed deaths on the active waiting list between Jan - 27th May for each yearly period and compared our transplant activity for each financial year up to April 2020 and our activity between Jan - 27th May 2020 (the first UK pandemic peak) comparing this to the same period over the last five years. This allowed us to directly compare the effect of COVID with previous years activity.ResultsA total of 19 heart patients died during Jan to 27th May 2020. Out of the total deaths 4 were from paediatric group, 11 were post-transplant and 5 on the active list. There were no cardiac deaths related to COVID 19. The total deaths during the same period were 19, 24, 20 and 32 in the years 2019, 2018, 2017 and 2016 respectively. A total of 41 lung patients died during Jan to 27th May 2020. Out of the total 11 were on the active list awaiting transplant and 19 were post-transplant deaths. Of these 2 were COVID deaths. The corresponding deaths during year 2019, 2018, 2017 and 2016 were 46, 51, 49 and 46 respectively. Transplant activity from Jan to 27th May in 2016-19 averaged 32 (16 hearts,16 lungs); activity during the same time period in 2020 was 4 lungs and 13 hearts, clearly affected by reduced activity due to COVID19.ConclusionThis audit does not suggest a significant rise in mortality due to the COVID 19 pandemic in vulnerable patients either pre or post-transplantation. Measures such as shielding were highly effective in this population. Transplant activity for the year was affected. The effect of the COVID 19 pandemic had the potential to have a major impact on patients during their journey through transplant assessment and heart or lung transplantation. Patients awaiting cardiopulmonary transplantation form a vulnerable group at increased risk because of their end stage cardiovascular or respiratory disease. We evaluated the impact of COVID pandemic on our transplant program. We retrospectively reviewed our adult and paediatric heart and lung transplant activity from 2015. We assessed deaths on the active waiting list between Jan - 27th May for each yearly period and compared our transplant activity for each financial year up to April 2020 and our activity between Jan - 27th May 2020 (the first UK pandemic peak) comparing this to the same period over the last five years. This allowed us to directly compare the effect of COVID with previous years activity. A total of 19 heart patients died during Jan to 27th May 2020. Out of the total deaths 4 were from paediatric group, 11 were post-transplant and 5 on the active list. There were no cardiac deaths related to COVID 19. The total deaths during the same period were 19, 24, 20 and 32 in the years 2019, 2018, 2017 and 2016 respectively. A total of 41 lung patients died during Jan to 27th May 2020. Out of the total 11 were on the active list awaiting transplant and 19 were post-transplant deaths. Of these 2 were COVID deaths. The corresponding deaths during year 2019, 2018, 2017 and 2016 were 46, 51, 49 and 46 respectively. Transplant activity from Jan to 27th May in 2016-19 averaged 32 (16 hearts,16 lungs); activity during the same time period in 2020 was 4 lungs and 13 hearts, clearly affected by reduced activity due to COVID19. This audit does not suggest a significant rise in mortality due to the COVID 19 pandemic in vulnerable patients either pre or post-transplantation. Measures such as shielding were highly effective in this population. Transplant activity for the year was affected.

Explantation of a left ventricular assist device (LVAD) may be challenging even in the most experienced hands. We aim to describe the technique for explantation of an LVAD together with the heart as applicable to all contemporary implantable mechanical assist devices. In order to ensure safe explantation, particular care must be taken at three distinct stages: at the time of LVAD implantation, at pre-transplant assessment and at the time of heart transplantation. The preparation for a safe explantation at LVAD implantation includes positioning the driveline and the outflow graft away from the back of the sternum to ensure protection from injury during re-entry into the chest. At transplant assessment, essential investigations include computed tomography (CT) of the chest and ultrasound imaging of femoral vessels. At the time of heart transplantation, the site of peripheral access should be prepared and vessels exposed in case of a need for emergency bypass. We advise careful dissection starting from the lower aspect of the under surface of the sternum, moving as proximally as possible before attempting to use the oscillating saw. Much of the dissection of the heart is done off-pump. Cardiopulmonary bypass may be established either through peripheral vessels or the outflow graft in an emergency. Central direct cannulation is then established. After the heart and major vessels are isolated, explantation of the heart may begin either en-bloc or after splitting the ventricles in a sagittal plane. The basal regions of both ventricles and both atria are removed, leaving generous cuffs for anastomosis of the left atrium, pulmonary artery, aorta, inferior and superior vena cava (SVC). The apex of the heart is then removed with the device taking care not to injure the phrenic nerve.

Rapid advances in cardiac surgery and a change in attitude towards patients with cognitive disability has meant that patients with Down Syndrome (DS) now live longer. In the majority of cases corrective cardiac surgery is possible but occasionally cardiac transplantation is the only solution.

Age, race, gender and income are widely recognized sources of disparities in access to healthcare. Patient and referring physician choice often means that some lung transplant recipients may reside considerable distances from their transplant centre compared with others. We reviewed a single centre experience to examine the effect of distance from home to the transplant centre on outcome.

We review the contemporary management of end-stage heart disease with cardiac transplantation and the use of ventricular assist devices. When indicated, cardiac transplantation remains the gold standard therapy for end-stage heart disease. The outcome of transplantation is dependent upon the entirety of the transplantation process which consists of recipient factors, donor factors, organ retrieval, organ preservation, implantation and long-term management of transplant-related complications such as infection, rejection, malignancy and immunosuppression. However, despite best efforts a number of patients will die every year on the transplant waiting list. This is primarily due to a shortage of donors. In the recent years we have developed strategies to increase the number of organs, quality of donors and developed ways to support decompensated patients until a suitable organ has become available. The latter is known as bridging to transplantation. The most recent and promising development in this field has been in heart procurement. The traditional mode of preservation and transport of hearts on ice has been replaced by a sophisticated, device assisted organ care system (OCS). This probably reduces the ischaemic burden, permits longer cross-clamp times and may significantly increase the number of donor organs.

We describe a staged approach to the management of a rare acute condition—contained rupture of a large right coronary artery aneurysm. A covered stent was deployed percutaneously to isolate the aneurysm at presentation followed by planned coronary bypass grafting. Treatment interval was complicated by new-onset pulmonary tuberculosis and subacute thrombosis of the covered stent leading to nonfatal inferior myocardial infarction. Coronary surgery was performed after complete antitubercular treatment and resolution of the acute pericarditis/thrombosis as a consequence of the contained rupture. The advantages of this staged approach included the following: (a) The covered stent prevented both acute myocardial infarction and progressive pseudoaneurysm expansion in the acute phase. (b) Deferred surgery was rendered technically less hazardous while avoiding the undesirable option of having to exclude an extremely calcified dominant right coronary artery. The patient made an excellent postoperative recovery with complete resolution of her symptoms at 6 weeks’ follow-up.

Background We assessed the midterm outcome and the incidence of major adverse cardiovascular events in UK’s largest Da Vinci assisted robotic coronary revascularisation cohort. This study was set up at the Imperial College NHS Trust, St. Mary’s Hospital, London, United Kingdom. Method Benchmarking approach through retrospective audit of the regional outcomes against standards in the published literature. Data was collected from the patient’s records, communication with the primary care physicians and the national strategic tracing service. The results were compared with the published literature. Patients who underwent robotic assisted coronary revascularisation were included. Other robotic procedures or minimally invasive revascularisation without the use of the Da Vinci robot were excluded. The main outcome measure was the midterm survival up to five years and the incidence of major adverse cardiovascular events (MACE) up to three years. Results Since April 2002, one hundred consecutive patients underwent either off pump robotic assisted single vessel small thoracotomy (SVST, n = 88), or off pump total endoscopic coronary artery bypass grafting (TCAB, n = 12). All patients were operated on by the same primary surgeon but different assisting surgeons. All patients received a left internal mammary arterial (LIMA) graft as planned. The primary outcome of total one month and three years MACE and up to five year survival was 0, 9 and 96% respectively. Conclusions The procedural success rates in terms of morbidity and mortality up to five years are compatible to the outcomes observed outside the United Kingdom. These results are not inferior to that of conventional off pump single vessel coronary surgery or percutaneous coronary intervention to the LAD.