Background Acute Type A aortic dissection (TAAD) is a life-threatening condition that carries significant mortality and morbidity; a proportion of the survivors might require further aortic procedures in the mid-/long-term follow-up. Quality of life (QoL) after TAAD is not well studied. Quality of life after Type A Aortic Dissection Surgery (QUADS) is the first multicentre study to assess QoL in survivors of surgically treated TAAD. Methods A tailored questionnaire for survivors of TAAD was designed with patient and public involvement. Patients who underwent surgery from 2018 to 2022 in eight United Kingdom centres were invited to participate. Preoperative, intraoperative, and postoperative prospectively collected data were collated and analyzed retrospectively. The data were analyzed with SPSS v29. Patient's questionnaire was validated with a Cronbach's alpha analysis, exploratory factor analysis, and AMOS confirmatory factor analysis. Three groups were created according to QoL (Good, Fair, Poor). Results A total of 162 patients were recruited. Majority were male with a mean age of 63 years (24–92). Surgical procedures for TAAD were root and ascending aorta replacement (n = 61, 38%), ascending (n = 81, 50%), and/or arch replacement (n = 20, 12%). Eleven patients (7%) required later intervention. Patient's answers regarding overall QoL were good (n = 67, 41%), fair (n = 89, 55%), and poor (n = 6, 4%). Neurological complications, circulatory arrest duration, reoperation for bleeding, postoperative myocardial infraction, arrhythmias, wound infection, and patient destination at discharge have been identified as main variables impacting on QoL after TAAD surgery across different domains of this questionnaire. Conclusion QUADS questionnaire is the first tailored and validated questionnaire for TAAD survivors. Results in the United Kingdom population suggest that it is a useful tool to assess QoL after TAAD surgery.

BACKGROUND Long-term clinical outcomes of catheter ablation (CA) compared to thoracoscopic surgical ablation (SA) to treat patients with long-standing persistent atrial fibrillation (LSPAF) are not known. OBJECTIVE The purpose of this study was to compare the long-term (36-month) clinical efficacy, quality of life, and costeffectiveness of SA and CA in LSPAF. METHODS Participants were followed up for 3 years using implantable loop recorders and questionnaires to assess the change in quality of life. Intention-to-treat analyses were used to report the findings. RESULTS Of the 115 patients with LSPAF treated, 104 (90.4%) completed 36-month follow-up [CA: n = 57 (95%); SA: n = 47 (85%)]. After a single procedure without antiarrhythmic drugs, 7 patients (12%) in the CA arm and 5 (11%) in the SA arm [hazard ratio 1.22; 95% confidence interval (CI) 0.81-1.83; P = .41] were free from atrial fibrillation/tachycardia (AF/AT) >= 30 seconds at 36 months. Thirty-three patients (58%) in the CA arm and 26 (55%) in the SA arm (hazard ratio 1.04; 95% CI 0.57-1.88; P = .91) had their AF/AT burden reduced by >= 75%. The overall impact on health-related quality of life was similar, with mean quality-adjusted life year estimates of 2.45 (95% CI 2.31-2.59) for CA and 2.32 (95% CI 2.13-2.52) for SA. Estimated costs were higher for SA (mean 24,682; pound 95% CI 21,746- pound 27,618) pound than for CA (mean 18,002; pound 95% CI 15,422- pound 20,581) pound. CONCLUSION In symptomatic LSPAF, CA and SA were equally effective at achieving arrhythmia outcomes (freedom from AF/ AT >= 30 seconds and >= 75% burden reduction) after a single procedure without antiarrhythmic drugs. However, SA is significantly more costly than CA.

A retrospective study was performed examining the trend of inflammatory markers, including D-dimers, in 29 COVID-19 patients requiring veno-venous (VV) extracorporeal membrane oxygenation (ECMO) support. We observed that COVID-19 patients with pre-cannulation D-dimer levels >3,000 ng/mL had a significantly shorter time from admission to cannulation (4.78 vs . 8.44 days, p = 0.049) compared to those with D-dimer <3,000 ng/mL. Furthermore, patients with D-dimer >3,000 ng/mL had a trend of lower pH (7.24 vs . 7.33), higher pCO 2 (61.33 vs . 50.69), and higher vasoactive inotropic score (7.23 vs . 3.97) at time of cannulation, however, these were not statistically significant. This cohort of patients also required a longer duration of ECMO support (51.44 vs . 31.25 days). However, 13 patients required at least one ECMO-circuit exchange and 16 patients did not require any exchanges. There was a consistent drop in D-dimer values after every circuit exchange, which was not observed in any of the other examined inflammatory markers, including ferritin, lactate dehydrogenase, or C-reactive protein. We propose that elevated D-dimer levels (>3,000 ng/mL) reflect increased disease severity in COVID-19, and predict a longer ECMO course. Once on ECMO, however, the D-Dimer level consistently decreased with every circuit exchange, which may reflect thrombus within the oxygenator rather than just disease severity.

Shakoor, Aqsa; Chen, Stacey; Hyde, Jonathan; Wu, Brendan; Kon, Zachary; Piper, Greta; Smith, Deane Author Information

We aim to examine potential predictors and safety of circuit exchanges (CE) in COVID-19 patients receiving veno-venous (VV) ECMO support. B Conclusions: b Severity of underlying lung injury, ECMO duration, and pre-cannulation lactate may be markers for potential CE in COVID-19 patients requiring ECMO. B Introduction: b An extracorporeal membrane oxygenation (ECMO) circuit exchange is a commonly encountered procedure with potential for significant hemodynamic risks in patients with already compromised physiology. [Extracted from the article] Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Introduction: There is limited data using continuous monitoring to assess outcomes of atrial fibrillation (AF) ablation. This study assessed long-term outcomes of AF ablation in patients with implantable cardiac devices. Methods: 207 patients (mean age 68.1 +/- 9.5, 50.3% men) undergoing ablation for symptomatic AF were followed up for a mean period of 924.5 +/- 636.7 days. Techniques included The Pulmonary Vein Ablation Catheter (PVAC) (59.4%), cryoablation (17.4%), point by point (14.0%) and The Novel Irrigated Multipolar Radiofrequency Ablation Catheter (nMARQ) (9.2%). Results: 130 (62.8%) patients had paroxysmal AF (PAF) and 77 (37.2%) persistent AF. First ablation and repeat ablation reduced AF burden significantly (relative risk 0.91, [95% CI 0.89 to 0.94]; P <0.0001 and 0.90, [95% CI, 0.86-0.94]; P <0.0001). Median AF burden in PAF patients reduced from 1.05% (interquartile range [IQR], 0.1%-8.70%) to 0.10% ([IQR], 0%-2.28%) at one year and this was maintained out to four-years. Persistent AF burden reduced from 99.9% ([IQR], 51.53%-100%) to 0.30% ([IQR], 0%-77.25%) at one year increasing to 87.3% ([IQR], 4.25%-100%) after four years. If a second ablation was required, point-by-point ablation achieved greater reduction in AF burden (relative risk, 0.77 [95% CI, 0.65-0.91]; P <0.01). Conclusion: Ablation reduces AF burden both acutely and in the long-term. If a second ablation was required the point-by-point technique achieved greater reductions in AF burden than "single-shot" technologies. Persistent AF burden increased to near pre ablation levels by year 4 suggesting a different mechanism from PAF patients where this increase did not occur.

Background: Standalone thoracoscopic surgical ablation may be more effective than catheter ablation in patients with long-standing persistent atrial fibrillation. Objectives: To determine whether or not surgical ablation is clinically superior to catheter ablation as the first-line treatment strategy in long-standing persistent atrial fibrillation. Design: This was a prospective, multicentre, randomised control trial. Setting: Four NHS tertiary centres in England. Participants: Adults with long-standing persistent atrial fibrillation, who had European Heart Rhythm Association symptom scores > 2 and who were naive to previous catheter ablation or thoracic/cardiac surgery. Interventions: Minimally invasive thoracoscopic surgical ablation and conventional catheter ablation (control intervention). Main outcome measures: The primary outcome was freedom from atrial fibrillation/tachycardia ≥ 30 seconds after a single procedure without antiarrhythmic drugs (class 1C/3) at 1 year, excluding a 3-month blanking period. The secondary outcomes include the intervention-related major complication rate; clinical success (≥ 75% reduction in arrhythmia burden); and changes in symptoms, quality of life and cost-effectiveness. Methods: Patients (n = 120) were randomised to surgical ablation (n = 60) or catheter ablation (n = 60). An implanted loop recorder provided continuous cardiac monitoring following ablation. Follow-up visits were at 3, 6, 9 and 12 months. Loop recorder data were reviewed monthly by a physiologist who was blinded to the randomisation outcome. Results: The study treatment was received by 55 patients in the surgical ablation arm and 60 patients in the catheter ablation arm; five patients withdrew from surgical ablation before treatment. Data from randomised and treated patients were analysed as per intention to treat. Patients had a mean age of 62.3 (standard deviation 9.6) years, were predominantly male (74%), had a mean left atrial diameter of 44.6 mm (standard deviation 6 mm) and were in continuous atrial fibrillation for 22 months (range 16–31 months). At 12 months, 26% of patients in the surgical ablation arm (14/54) and 28% of patients in the catheter ablation arm (17/60) were free from atrial arrhythmias after a single procedure without antiarrhythmic drugs (odds ratio 1.13, 95% confidence interval 0.46 to 2.83; p = 0.84). An arrhythmia burden reduction of ≥ 75% was seen in 36 out of 54 (67%) patients in the surgical ablation arm, compared with 46 out of 60 (77%) patients in the catheter ablation arm (odds ratio 1.64, 95% confidence interval 0.67 to 4.08; p = 0.3). Procedure-related serious complications within 30 days of the intervention occurred in 15% (8/55) of patients in the surgical ablation arm (including one death) compared with 10% (6/60) of patients in the catheter ablation arm (p = 0.46). Surgical ablation was associated with significantly higher costs (£23,221 vs. £18,186; p = 0.02) and fewer quality-adjusted life-years than catheter ablation (0.76 vs. 0.83; p = 0.02). Limitations: This study was conducted in four highly specialised cardiology centres that have substantial experience in both treatment modalities; therefore, the results may not be widely generalisable. The study was not powered to detect small differences in efficacy. Conclusions: We found no evidence to suggest that standalone thoracoscopic surgical ablation outcomes were superior to catheter ablation outcomes in achieving freedom from atrial arrhythmia after a single procedure without antiarrhythmic drugs. Moreover, surgical ablation is associated with a longer hospital stay, smaller improvements in quality of life and higher health-care costs than catheter ablation (standard care therapy). Future work: Evaluation of the impact of ablation treatments on sinus rhythm maintenance and quality of life with extended follow-up to 3 years. Model-based economic analysis to estimate long-term benefits, harms and costs of surgical and catheter ablation compared with antiarrhythmic drug therapy in long-standing persistent atrial fibrillation patients. Trial registration: Current Controlled Trials ISRCTN18250790 and ClinicalTrials.gov NCT02755688. Funding: This project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a Medical Research Council (MRC) and National Institute for Health Research (NIHR) partnership. This study was supported by the UK Clinical Research Collaboration-registered King’s Clinical Trials Unit at King’s Health Partners, which is part funded by the NIHR Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and King’s College London and the NIHR Evaluation, Trials and Studies Coordinating Centre. This will be published in full in Efficacy and Mechanism Evaluation; Vol. 8, No. 18. See the NIHR Journals Library website for further project information.

ObjectivesPrevious studies have been unable to identify patient or staff reservoirs for the majority of the nosocomial S. aureus acquisitions which occur in the presence of good infection control practice. We set out to establish the extent to which undetected pre-existing carriage explains apparent nosocomial S. aureus acquisition.MethodsOver two years elective cardiothoracic admissions were screened for S. aureus carriage before and during hospital admission. Routine screening (nose/groin/wound sampling), was supplemented by sampling additional body sites (axilla/throat/rectum) and culture-based methods optimised to detect fastidious phenotypes (small colony variants, cell wall deficient variants) and molecular identification by PCR.Results35% of participants (53/151) were S. aureus carriers according to routine pre-healthcare screening; increasing to 42% (63/151) when additional body sites and enhanced cultures were employed. 71% (5/7) of apparent acquisitions were explained by pre-existing carriage using augmented measures. Enhanced culture identified a minority of colonised individuals (3/151 including 1 MRSA carrier) who were undetected by routine and additional screening cultures. 4/14 (29%) participants who became culture-negative during admission had S. aureus genomic material detected at discharge.ConclusionsConventional sampling under-estimates carriage of S. aureus and this explains the majority of apparent S. aureus acquisitions among elective cardiothoracic patients.

Aims Long-standing persistent atrial fibrillation (LSPAF) is challenging to treat with suboptimal catheter ablation (CA) outcomes. Thoracoscopic surgical ablation (SA) has shown promising efficacy in atrial fibrillation (AF). This multi-centre randomized controlled trial tested whether SA was superior to CA as the first interventional strategy in de novo LSPAF. Methods and results We randomized 120 LSPAF patients to SA or CA. All patients underwent predetermined lesion sets and implantable loop recorder insertion. Primary outcome was single procedure freedom from AF/atrial tachycardia (AT) >= 30 s without anti-arrhythmic drugs at 12 months. Secondary outcomes included clinical success (>= 75% reduction in AF/AT burden); procedure-related serious adverse events; changes in patients' symptoms and quality-of-life scores; and cost-effectiveness. At 12 months, freedom from AF/AT was recorded in 26% (14/54) of patients in SA vs. 28% (17/60) in the CA group [OR 1.128, 95% CI (0.46-2.83), P = 0.83]. Reduction in AF/AT burden >= 75% was recorded in 67% (36/54) vs. 77% (46/60) [OR 1.13, 95% CI (0.67-4.08), P = 0.3] in SA and CA groups, respectively. Procedure-related serious adverse events within 30 days of intervention were reported in 15% (8/55) of patients in SA vs. 10% (6/60) in CA, P = 0.46. One death was reported after SA. Improvements in AF symptoms were greater following CA. Over 12 months, SA was more expensive and provided fewer quality-adjusted life-years (QALYs) compared with CA (0.78 vs. 0.85, P = 0.02). Conclusion Single procedure thoracoscopic SA is not superior to CA in treating LSPAF. Catheter ablation provided greater improvements in symptoms and accrued significantly more QALYs during follow-up than SA. [GRAPHICS]

BACKGROUND:Improved catheter stability is associated with decreased arrhythmia recurrence after atrial fibrillation (AF) ablation. Recently, atrial voltage mapping in AF was demonstrated to correlate better with scar as compared to mapping in sinus rhythm (SR). However, it is unknown whether ablation of persistent AF in sinus rhythm with atrial pacing or in atrial fibrillation with ventricular pacing results in differences in catheter stability or arrhythmia recurrence.METHODS:We analyzed 53 consecutive patients undergoing first-time persistent AF ablation with pulmonary vein and posterior wall isolation: 27 were cardioverted, mapped, and ablated in sinus rhythm with atrial pacing, and 26 were mapped and ablated in AF with ventricular pacing. Ablation data was extracted from the mapping system and analyzed using custom MATLAB software to determine high-frequency (60Hz) catheter excursion as a novel metric for catheter spatial stability.RESULTS:There was no difference in catheter stability as assessed by maximal catheter excursion, mean catheter excursion, or contact force variability between the atrial-paced and ventricular-paced patients. Ventricular-paced patients had significantly greater mean contact force as compared to atrial-paced patients. Contact-force variability demonstrated poor correlation with catheter excursion. One year arrhythmia-free survival was similar between the atrial paced and ventricular paced patients.CONCLUSIONS:For patients with persistent AF, ablation in AF with ventricular pacing results in similar catheter stability and arrhythmia recurrence as compared to cardioversion and ablation in sinus rhythm with atrial pacing. Given the improved fidelity of mapping in AF, mapping and ablating during AF with ventricular pacing may be preferred.

BACKGROUND:Isolated aortic infection is rare and is typically associated with an underlying aortic aneurysm or a prosthetic aortic graft.CASE SUMMARY:A 38-year-old woman was admitted with symptoms of left upper limb ischaemia and had imaging findings suggestive of thrombus extending from the ascending aorta into the subclavian and brachial arteries. She underwent evacuation of the aortic masses and replacement of the ascending aorta. Citrobacter koseri was isolated from the excised tissue and the patient received 6 weeks of appropriate antibiotic therapy.DISCUSSION:This is an unusual case of acute upper limb ischaemia due to a mass infected with Citrobacter koseri in the ascending aorta without heart valve involvement.

OBJECTIVE:High-grade gliomas (HGGs) continue to carry poor prognoses, and patient outcomes depend heavily on the extent of resection (EOR). The utility of conventional image-guided surgery is limited by intraoperative brain shift. More recent techniques to maximize EOR, including intraoperative imaging and the use of fluorescent dyes, combat these limitations. However, the relative efficacy of these two techniques has never been systematically compared. Thus, the authors performed an exhaustive systematic review in conjunction with quantitative network meta-analyses to evaluate the comparative effectiveness of 5-aminolevulinic acid (5-ALA) and intraoperative MRI (IMRI) in optimizing EOR in HGG. They secondarily analyzed associated progression-free and overall survival and performed subgroup analyses by level of evidence. METHODS:PubMed, Embase, Cochrane Central, and Web of Science were searched for studies evaluating conventional neuronavigation, IMRI, and 5-ALA in HGG resection. The primary study endpoint was the proportion of patients attaining gross-total resection (GTR), defined as 100% elimination of contrast-enhancing lesion on postoperative MRI. Secondary endpoints included overall and progression-free survival and subgroup analyses for level of evidence. Comparative efficacy analysis of IMRI and 5-ALA was performed using Bayesian network meta-analysis models. RESULTS:This analysis included 11 studies. In a classic meta-analysis, both IMRI (OR 4.99, 95% CI 2.65-9.39, p < 0.001) and 5-ALA (OR 2.866, 95% CI 2.127-3.863, p < 0.001) were superior to conventional navigation in achieving GTR. Bayesian network analysis was employed to indirectly compare IMRI to 5-ALA, and no significant difference in GTR was found between the two (OR 1.9 favoring IMRI, 95% CI 0.905-3.989, p = 0.090). A handful of studies additionally suggested that the use of either IMRI (2 and 4 studies, respectively) or 5-ALA (2 and 2 studies, respectively) improves progression-free and overall survival. CONCLUSIONS:IMRI and 5-ALA are individually superior to conventional neuronavigation for achieving GTR of HGG. Between IMRI and 5-ALA, neither method is clearly more effective. Future studies evaluating the comparative cost and surgical time associated with IMRI and 5-ALA will better inform any cost-benefit analysis.

Aims:To investigate the effect of minimally invasive thoracoscopic surgical ablation and nMARQ irrigated multi-electrode phased radiofrequency (RF) ablation to treat paroxysmal atrial fibrillation (AF) compared with PVAC multi-electrode phased RF ablation, with beat-to-beat device-derived Holter monitoring throughout the study duration.Methods and results:An investigator-initiated prospective trial of patients with paroxysmal AF randomized (1:1:1) to initial surgical, nMARQ or PVAC ablation. All patients had continuous beat-to-beat monitoring with an ILR or pacemaker to evaluate and document AF recurrence. There was a strong trend (P = 0.050) toward difference in AF outcome, with surgical AF ablation more efficacious than catheter ablation. At one year, the proportion of patients with less than 1% AF burden after one procedure and off all antiarrhythmic drugs was 63, 56, and 90% for PVAC, nMARQ and surgical ablations respectively. There were significantly more repeat ablations in the catheter ablation groups (P = 0.008): 25% PVAC, 27% nMARQ, 0% surgery. However, 7 of 20 (35%) of patients undergoing surgical ablation suffered a procedural complication, including two sternotomies for bleeding and one death. This was higher than for catheter ablation (P < 0.001). Surgical ablation took longer to perform (P < 0.001) and had a longer hospital admission (P < 0.001) than catheter ablation.Conclusion:Surgical AF ablation required significantly fewer repeat procedures than catheter ablation, and there was a clear trend towards improved arrhythmia outcome. However, it was associated with a significantly higher rate of procedural complications. Surgical ablation for paroxysmal AF is promising, however more prospective outcome data is required.Clinical Trial Registration:NCT01504451, http://clinicaltrials.gov/show/NCT01504451.

Journal of Anaesthesia and Critical Care Case Reports 2017 Jan-Apr;3(1):8-10 Brighton and Sussex University Hospitals NHS Trust, United Kingdom. Address of Correspondence Dr. . Patrick Thomas Thorburn Brighton and Sussex University Hospitals NHS Trust, United Kingdom Email: P.t.thorburn@gmail.com © 2017 by Journal of Anaesthesia and Critical Care Case Reports| Available on www.jaccr.com | This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Journal of Anaesthesia and Critical Care Case Reports Volume 3 Issue 1 Jan-Apr 2017 Page 8-10 8 | | | | | Dr. Patrick T Thorburn Dr. Jonathan Hyde Dr. Michael Lewis Case report A 35-year-old male security guard was diagnosed with AF in August 2011. He underwent successful DC cardioversion in April 2013 but relapsed to persistent AF in June 2014. After failing to respond to medical therapy, he was referred for VATS ablation and left atrial appendage (LAA) occlusion. The procedure was performed under general anaesthesia with a left-sided doublelumen tube and standard monitoring supplemented with invasive arterial blood pressure monitoring and right-sided internal jugular vein cannula. VATS ablation was performed through a bilateral (right side first) approach as described by Yilmaz et al. [4] using the AtriCureâ endoclamp and monopolar pen. The pericardium was opened on each side for access but was not subsequently closed: this has been our technique for over 50 cases. Ablation (with LAA occlusion) led to clinical termination of AF and return to sinus rhythm in the operating room. Analgesia was provided with 2g intravenous (IV) paracetamol, 75mg IV diclofenac, 10mg IV morphine and 40ml 0.25% L-bupivicaine for intercostal nerve blocks and port site infiltration on both sides. At the end of the procedure, the patient was haemodynamically stable and was shifted to cardiac ITU for ongoing care after extubation. Soon after arrival in ITU his clinical condition deteriorated. He became hypotensive (88/40mmHg) and tachycardic (120bpm) with intermittent episodes of bradycardia (<60bpm). He was profoundly clammy with a reduced capillary refill time and consciousness level. There was evidence of venous congestion with significant engorgement of the neck veins, facial cyanosis and a high central venous pressure. He remained hypotensive despite repeated boluses of fluid and metaraminol. The cause of his acutely unstable condition remained unclear until a portable anteroposterior chest X-ray (CXR) was performed (Fig 1). When the image was initially reviewed at the bedside, it was flipped to place the cardiac shadow on the left side by the clinical team. However,the ECG lead orientation confirmed that the heart was on the right and acute cardiac herniation was diagnosed following discussion with a chest radiologist. The patient was transferred expeditiously back to the anaesthetic room whilst the operating theatre was prepared. He was maintained in a 'right side up' position resulting in an improvement in his clinical condition: mentation returned to normal and he felt better. The heart rate stabilised and blood pressure improved. Anaesthesia was induced in the operating room while the patient was subsequently prepared and draped. Anaesthetic and surgical teams were scrubbed and ready for two eventualities: (1) haemodynamic instability following induction, in which case a midline sternotomy would be performed; or (2) clinical stability, in which case thoracoscopic reduction of the cardiac herniation would be attempted. After induction of anaesthesia the patient's condition remained stable. An oral endotracheal tube was placed with a right-sided bronchial blocker. The right lung was deflated without any clinical compromise and the thoracoscope and instruments were inserted with caution through the original right-sided port sites. On careful digital insertion through the upper port, the left ventricle was found to be pressed up against the inner aspect of the chest wall. Using the blunt-tipped, soft pool-suction catheter as a lever between the heart and the chest wall, the herniated heart was carefully reduced back into the pericardium. Clinical stability was maintained throughout the procedure. The pericardium was then closed using two sutures to prevent recurrence. The patient returned to the cardiac ITU where he was ventilated overnight and extubated successfully the following morning. Postextubation CXR (Fig 1) shows return of the heart to the left side. He remained in sinus rhythm throughout his hospital stay and was discharged home 72 hours after the initial procedure, having had this rare complication explained to him. Discussion Cardiac herniation was first documented by Bettman and Tennenbaum in 1948 [5] and has since been described in patients with traumatic and iatrogenic defects to their pericardium [6,7]. As a surgical complication it is most commonly recognised in pneumonectomy with deliberate breach of the pericardium and the incidence can be as high as 3% in extrapleural pneumonectomy following chemotherapy [8]. To our knowledge it has not been described in the literature Thorburn et al www.jaccr.com Journal of Anaesthesia and Critical Care Case Reports Volume 3 Issue 1 Jan-Apr 2017 Page 8-10 9 | | | | | Figure 1: (Left) Acute cardiac herniation diagnosed by plain chest radiograph. Note the right internal jugular vein cannula, bilateral chest drains, pulmonary congestion and right sided cardiac herniation. (Right) features of cardiac herniation have resolved after surgical correction.

We report our method of surgically repairing an unruptured giant aneurysm of the right coronary sinus of Valsalva, a lesion that caused moderate aortic regurgitation but no symptoms in a 61-year-old woman. We excised the aneurysm, reconstructed the right sinus of Valsalva with use of a patch, performed mechanical aortic valve replacement directly through the excised aneurysm's cavity, and constructed a single bypass graft to the right coronary artery. The patient was discharged from the hospital after 5 days. Twelve months postoperatively, her clinical and echocardiographic results were normal, and she was doing well. To our knowledge, our surgical approach to this repair has not been described previously.

Introduction: Percutaneous coronary intervention (PCI) has historically required cardiothoracic backup in the event of ischemic complications. However, many complications occurring during PCI can now be effectively treated at the time of the indexed procedure. Equally, ischemic complications, which occur following coronary artery bypass grafting (CABG), which were previously treated medically or with reoperation, may now also be effectively treated by acute PCI.Aims and Methods: To identify the rate, cause, treatment, and outcomes of ischemic complications from PCI or isolated CABG procedures undertaken from January 2004 to January 2011 where there was immediate crossover from PCI to CABG or vice versa, and to determine from the indexed revascularization procedure, whether or not the ischemic complications were rectified by either CABG with respect to PCI or PCI with respect to CABG.Results: Three hundred fifty-six PCI major ischemic complications were identified. Three hundred forty-seven (97.5%) were rectified percutaneously and 9 (2.5%) required emergency CABG. The commonest reason for emergency CABG was occlusive dissection (n=7). Of the 9 patients that underwent emergency CABG, 3 patients (33.3%) died. Forty CABG major ischemic complications were identified. Twenty-seven (67.5%) were treated medically. Thirteen (32.5%) underwent diagnostic angiography. The etiology of the ischemia was found in all cases. Consequently, 2 underwent reoperation, one was treated medically, and 10 underwent acute PCI.Conclusion: Acute coronary ischemia remains a small but significant complication of both PCI and CABG. Resolution of ischemia requires prompt diagnosis and early discussion between cardiothoracic surgeon and cardiac interventionalist to determine the safest and therefore most appropriate way to resolve the problem.

AIMS:Current quality measures of percutaneous coronary intervention (PCI) procedures are based on the incidence of major adverse cardiac events (MACE). This crude marker ignores the many clinical nuances that make for sound decision making in PCI. We have established a prospective peer review audit tool to determine the quality of PCI within our cardiac network, which consists of five PCI hospitals serving a population of 1.4 million people in Sussex, UK.METHODS AND RESULTS:Analysis of 10% of all PCI cases selected at random each month by a non-clinical audit manager is made by a rotating panel of two PCI operators and one cardiac surgeon. Each PCI case is assessed for anatomical suitability, lesion severity, strategic appropriateness and final outcome. Panel findings were reported back to the operator and the audit manager. A total of 326 cases were assessed by the review committee. Results were disseminated to individual operators. Coronary anatomy and lesion severity were considered appropriate for PCI in 94.2% and 96.0% of cases, respectively. Appropriateness of strategy was confirmed in 86.2% and the outcome considered satisfactory in 90.8%. A total of 242 subsequent cases were analysed to assess practice trends. This analysis demonstrated a statistically significant improvement in clinical decision making with respect to appropriateness of strategy (from 86.2% to 92.6%; p=0.004).CONCLUSIONS:Prospective peer review of percutaneous coronary intervention cases by a rotating regional committee is valuable in ensuring procedural quality.