To identify barriers perceived by medical students in entering cardiothoracic surgery (CTS) and propose interventions that combat identified barriers and equalise opportunities for medical students within CTS. An Equality, Diversity, and Inclusion (EDI)-focused survey was distributed to medical students across the UK and Ireland. The survey collected data on demographics, career ambitions, experiences in surgical fields, and specific perceptions of CTS. Quantitative and qualitative data were analysed. Chi-squared tests assessed associations between demographic factors and perceived barriers, with an alpha level of 0.05. Eighty-one responses identified three main barriers: financial constraints (37.8%), negative theatre experiences (37.8%), and perceived gender-based obstacles (56.1%). Financial challenges were associated with travel and portfolio-building, with a further association between self-funding students and perceived barriers (p=0.03). Negative theatre experiences included hostility, being ignored, and a lack of orientation to theatre and procedure. Gender-related barriers were reported by 56.1%, 91% of which were female. Additionally, first-generation medical students showed a significant correlation with perceived barriers in CTS (p=0.05). Findings reveal perceived barriers to accessing opportunities in CTS. The data rejects the null hypothesis, though limitations in sample size suggest a potential type-II error. To optimise the future of CTS, we need to maximise student-engagement now. Implementation of financial initiatives and distribution of orientation material are required. With female cardiothoracic surgeons constituting less than 10% of our workforce, measures to enhance the representation of women in CTS are essential. Ongoing collaboration between EDI and CTS committees is crucial to overcome these barriers and equalise opportunities in CTS.

Mentorship is critical to the professional development of junior colleagues in cardiothoracic surgery. Despite its presumed importance and frequent discussion, its impact within cardiothoracic surgery training remains uncharacterised within the UK. We aimed to evaluate mentorship experience and identify gaps in the system of mentorship education. The differences between men and women’s views on mentorship are also considered. We prospectively collected of 92 responses [50 M:42 F] over 18 weeks. ‘Society for Cardiothoracic Surgery in Great Britain and Ireland (SCTS) Critically Appraising mentorship’ survey was formulated using electronic questionnaire system and distributed via emails to health professionals and medical students by using SCTS membership directory. The survey domains explore respondents’ demographics, current or previous academic appointments, leadership roles, experience of mentorship, and opinions regarding ideal implementation of mentorship model, including the views on necessity for racial and gender concordance between mentor and mentee. 43

This study sought to compare the morbidity and mortality of redo aortic valve replacement (redo-AVR) versus valve-in-valve trans-catheter aortic valve implantation (valve-in-valve TAVI) for patients with a failing bioprosthetic valve. A multicentre UK retrospective study of redo-AVR or valve-in-valve TAVI for patients referred for redo aortic valve intervention due to a degenerated aortic bioprosthesis. Propensity score matching was performed for confounding factors. From July 2005 to April 2021, 911 patients underwent redo-AVR and 411 patients valve-in-valve TAVI. There were 125 pairs for analysis after propensity score matching. Mean age was 75.2±8.5 years. In-hospital mortality was 7.2% (n=9) for redo-AVR vs 0 for valve-in-valve TAVI, p=0.002. Surgical patients suffered more post-operative complications, including IABP support (p=0.02), early re-operation (p<0.001), arrhythmias (p<0.001), respiratory and neurological complications (p=0.02 and p=0.03) and multi-organ failure (p=0.01). The valve-in-valve TAVI group had a shorter intensive care unit and hospital stay (p <0.001 for both). However, moderate aortic regurgitation at discharge and higher post-procedural gradients were more common after valve-in-valve TAVI (p<0.001 for both). Survival probabilities in patients who were successfully discharged from hospital were similar after valve-in-valve TAVI and redo-AVR over the 6-year follow-up (log-rank p=0.26). In elderly patients with a degenerated aortic bioprosthesis, valve-in-valve trans-catheter aortic valve implantation provides better early outcomes, as opposed to redo surgical aortic valve replacement, although there was no difference in mid-term survival in patients successfully discharged from hospital.

BackgroundNeutrophil activation drives lung complications after cardiopulmonary bypass (CPB). Evidence suggests the healthy, ventilated lung may beneficially re-condition pro-inflammatory neutrophils. However, evidence in humans is lacking, due to a paucity of good models. CPB with simultaneous central venous and bilateral pulmonary vein sampling provides an opportunity to model effects of one-lung ventilation. The study's primary objectives were to establish a model of intra-operative, bilateral pulmonary vein sampling and to determine whether neutrophil function differed after passing through inflated or deflated lungs. MethodsSeventeen patients having "on pump" coronary artery bypass grafting (CABG) with one-lung ventilation (in two cohorts with tidal volume 2ml kg(-1) and FiO(2) 0.21, or tidal volume 4 ml kg(-1) and FiO(2) 0.5 respectively) were recruited. Cohort 1 consisted of 9 patients (7 male, median age 62.0 years) and Cohort 2 consisted of 8 male patients (median age 65.5 years). Recruitment was via prospective screening of scheduled elective and non-elective CABG procedures with cardiopulmonary bypass. Each patient had five blood samples taken-central venous blood pre-operatively; central venous blood pre-CPB; central venous blood post-CPB; pulmonary venous blood draining the ventilated lung post-CPB; and pulmonary venous blood draining the deflated lung post-CPB. Neutrophil phagocytosis and priming status were quantified. Plasma cytokines were measured. ResultsPhagocytosis and priming were not significantly different in neutrophils returning from the ventilated lung as compared to the non-ventilated lung. Plasma IL-6, IL-8 and IL-10 were significantly elevated by CPB. ConclusionsThe intra-operative, bilateral pulmonary vein sampling model provides unique opportunities to assess biological effects of interventions to one lung, with the other lung acting as an internal control. Single-lung ventilation during CPB had no significant effects on neutrophil function.

Transcatheter aortic valve implantation (TAVI) program has started in the UK in 2007 performing 66 cases a year, the number of cases of TAVI done every year has been exponentially increasing since then to reach 6076 cases in the year 2020. (Ludman) The UK TAVI registry has shown a nationwide shift in practice from general anaesthesia to conscious sedation for trans-femoral access TAVI, analysis has shown a fall of In-hospital mortality from 4.7 in 2012 to 1.8% in 2016 (Ludman). This shift, however, has not occurred in the same way for other arterial access like trans-subclavian or trans-axillary, which is still widely practiced in the UK under general anaesthesia. The vast majority of cases in the UK are done through the femoral access, however, finding an alternative approach is sometimes needed due to contraindication to the standard femoral approach, mostly vasculopathy, which usually indicates higher risk patient and higher likelihood of associated co-morbidities. Performing the alternative access TAVI under general anaesthesia adds more risk to the patient and in some cases could be life threatening, some of these patients could be deemed unfit for the procedure. Finding an alternative anaesthetic technique will allow these patients to have their procedures done with lower risk and have the optimum chance for quicker recovery. The technique of combining Superficial cervical plexus block, interscalene block with Pectoral block type II was first described in 2018 by Alexander et al and reproduced by Block et al in the United States in the same year to allow for performing subclavian access TAVI without general anaesthesia. The same technique was partially adopted with some modification by Vivian et al in Canada and Toscano et al in Italy in 2020 and 2021 respectively. In this manuscript we share our experience doing a series of subclavian access TAVI under regional nerve block and conscious sedation at the Freeman hospital in Newcastle upon Tyne, to our knowledge, and from literature search, this is the first time this is performed successfully in the UK as we didn't see any published reports on this technique within the country. Transcatheter aortic valve implantation (TAVI) program has started in the UK in 2007 performing 66 cases a year, the number of cases of TAVI done every year has been exponentially increasing since then to reach 6076 cases in the year 2020. (Ludman) The UK TAVI registry has shown a nationwide shift in practice from general anaesthesia to conscious sedation for trans-femoral access TAVI, analysis has shown a fall of In-hospital mortality from 4.7 in 2012 to 1.8% in 2016 (Ludman). This shift, however, has not occurred in the same way for other arterial access like trans-subclavian or trans-axillary, which is still widely practiced in the UK under general anaesthesia. The vast majority of cases in the UK are done through the femoral access, however, finding an alternative approach is sometimes needed due to contraindication to the standard femoral approach, mostly vasculopathy, which usually indicates higher risk patient and higher likelihood of associated co-morbidities. Performing the alternative access TAVI under general anaesthesia adds more risk to the patient and in some cases could be life threatening, some of these patients could be deemed unfit for the procedure. Finding an alternative anaesthetic technique will allow these patients to have their procedures done with lower risk and have the optimum chance for quicker recovery. The technique of combining Superficial cervical plexus block, interscalene block with Pectoral block type II was first described in 2018 by Alexander et al and reproduced by Block et al in the United States in the same year to allow for performing subclavian access TAVI without general anaesthesia. The same technique was partially adopted with some modification by Vivian et al in Canada and Toscano et al in Italy in 2020 and 2021 respectively. In this manuscript we share our experience doing a series of subclavian access TAVI under regional nerve block and conscious sedation at the Freeman hospital in Newcastle upon Tyne, to our knowledge, and from literature search, this is the first time this is performed successfully in the UK as we didn't see any published reports on this technique within the country.

Abstract With both stenosis and aneurysm, repairing a severely tortuous and coarcted aorta can present certain difficulties. The advent of hybrid arch frozen elephant trunk techniques, as well as other endovascular solutions, has produced safer surgical repair methods for such cases. We present the reconstruction and repair of a Type-1 thoracoabdominal aortic aneurysm using a staged approach in less-than-optimal anatomy. Interventions included hybrid frozen elephant trunk, balloon dilation, and thoracic endovascular repair.

Objective: The COVID-19 pandemic has forced the cancellation of planned surgery and led to significant surgical service reductions. Early intervention in aortovascular disease is often critical and cannot be deferred despite these reductions. There is urgent need to evaluate the provision and outcomes of thoracic aortovascular intervention during the peak of the pandemic. Methods: Prospective data was collected for patients receiving open and endovascular thoracic aortovascular intervention over two-time points; January-May 2020 and January-May 2019 at three tertiary cardiovascular centres. Baseline demographics, cardiovascular risk and COVID-19 screening results were noted. Primary outcomes were median length of intensive care unit and hospital stay, intra-operative mortality, 30-day mortality, post-operative stroke, and spinal cord injury. Results: Patients operated in 2020 (41) had significantly higher median EuroSCORE II than 2019 (53) (7.44 vs. 5.86, P = 0.032) and rates of previous cardiac (19.5% vs. 3.8%, P = 0.019), aortic (14.6% vs. 1.9%, P = 0.041), and endovascular (22.0% vs. 3.8%, P = 0.009) intervention. There was an increase in proportion of urgent cases in 2020 (31.7% vs. 18.9%). There were no intra-operative deaths in 2020 and 1 in 2019 ( P = 1.00). There were no significant differences ( P >= 0.05) in 30-day mortality (4.9% vs. 13.2%), median intensive care unit length of stay (72 vs. 70 hr), median hospital length of stay (8 vs. 9 days), post-operative stroke (3 vs. 6), or spinal cord injury (2 vs. 1) between 2020 and 2019 respectively. Conclusions: Despite the increased mortality risk of patients and urgency of cases during COVID-19, complicated by the introduction of cohorting and screening regimens, thoracic aortovascular intervention remained safe with comparable in outcomes to pre-COVID-19.

Background: Lung transplantation is particularly susceptible to the impact of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic, and evaluation of changes to practice is required to inform future decision-making. Methods: A retrospective review of the UK Transplant Registry (UKTR) and national survey of UK lung transplant centers has been performed. Results: There was geographic variation in the prevalence of COVID-19 infection across the UK. The number of donors fell by 48% during the early pandemic period. Lung utilization fell to 10% (compared with 24% for the same period of 2019). The number of lung transplants performed fell by 77% from 53, March to May 2019, to 12. Seven (58%) of these were performed in a single-center, designated "COVID-light." The number of patients who died on the lung transplant waiting list increased, compared to the same period of 2019 (p = .0118). Twenty-six lung transplant recipients with confirmed COVID-19 infection were reported during the study period. Conclusion: As the pandemic continues, reviewing practice and implementing the lessons learned during this period, including the use of robust donor testing strategies and the provision of "COVID-light" hospitals, are vital in ensuring the safe continuation of our lung transplant program.

Background A 34-year-old gentleman presented with Staphylococcus salivarius infective endocarditis 13 years after aortic homograft and mitral valve repair for degenerative bicuspid aortic valve associated with rheumatic heart disease. The homograft had calcified, and the mitral repair had deteriorated with severe regurgitation. Multidisciplinary team decision to restore best quality of life was for re-do Ross procedure with bi-leaflet preserving mitral valve replacement with an inverted RESILIA aortic valve as the patient was fundamentally against lifelong anti-coagulation. Case presentation The aortic homograft was excised, and coronary arteries dissected out followed by harvesting of the pulmonary autograft. The mitral valve was accessed via a trans-septal approach. On examination, there was a restricted and thickened posterior mitral valve leaflet. An inverted 27-mm INSPIRIS RESILIA aortic bio-prosthesis was placed with mitral cusps preserved. The pulmonary autograft was implanted in an intra-annular position, and a 26-mm pulmonary homograft was used to replace the pulmonary valve. Echocardiogram at 4 weeks revealed preserved LV function and well-functioning prosthetic, autograft and homograft. Conclusion An inverted RESILIA valve, with its anti-structural valve deterioration properties, can be used in the mitral position with preservation of the mitral cusps to avoid anti-coagulation with the hope of reducing need for re-operation in line with patient wishes.

Background We aim to evaluate practice and understand the impact of the first wave of the SARS-CoV-2 pandemic on heart transplantation in the UK. Methods A retrospective review of the UK Transplant Registry (UKTR) and a national survey of UK heart transplant centers have been performed. The early pandemic period is defined here as 1 March to 31 May 2020. Results There was geographic variation in the prevalence of COVID-19 across the UK. All centers reported adaptations to maintain the safety of their staff, candidate, and recipient populations. The number of donors fell by 31% during the early pandemic period. Heart utilization increased to 35%, compared to 26% during the same period of 2019. The number of heart transplants was well maintained, across all centers, with 38 performed, compared to 41 during the same period of 2019, with no change in 30-day survival. Twenty-seven heart transplant recipients with confirmed COVID-19 infection were reported during the study period. Conclusion All UK heart transplant centers have successfully adapted their programs to overcome the challenges of staff redeployment and ICU and hospital resource limitation, associated with the pandemic, whilst continuing heart transplant activity. On-going evaluation of practice changes, with sharing of lessons learned, is required as the pandemic continues.

Objectives To date the reported outcomes of surgical aortic valve replacement (SAVR) are mainly in the settings of trials comparing it with evolving transcatheter aortic valve implantation. We set out to examine characteristics and outcomes in people who underwent SAVR reflecting a national cohort and therefore ‘real-world’ practice. Design Retrospective analysis of prospectively collected data of consecutive people who underwent SAVR with or without coronary artery bypass graft (CABG) surgery between April 2013 and March 2018 in the UK. This included elective, urgent and emergency operations. Participants’ demographics, preoperative risk factors, operative data, in-hospital mortality, postoperative complications and effect of the addition of CABG to SAVR were analysed. Setting 27 (90%) tertiary cardiac surgical centres in the UK submitted their data for analysis. Participants 31 277 people with AVR were identified. 19 670 (62.9%) had only SAVR and 11 607 (37.1%) had AVR+CABG. Results In-hospital mortality for isolated SAVR was 1.9% (95% CI 1.6% to 2.1%) and was 2.4% for AVR+CABG. Mortality by age category for SAVR only were: <60 years=2.0%, 60–75 years=1.5%, >75 years=2.2%. For SAVR+CABG these were; 2.2%, 1.8% and 3.1%. For different categories of EuroSCORE, mortality for SAVR in low risk people was 1.3%, in intermediate risk 1% and for high risk 3.9%. 74.3% of the operations were elective, 24% urgent and 1.7% emergency/salvage. The incidences of resternotomy for bleeding and stroke were 3.9% and 1.1%, respectively. Multivariable analyses provided no evidence that concomitant CABG influenced outcome. However, urgency of the operation, poor ventricular function, higher EuroSCORE and longer cross clamp and cardiopulmonary bypass times adversely affected outcomes. Conclusions Surgical SAVR±CABG has low mortality risk and a low level of complications in the UK in people of all ages and risk factors. These results should inform consideration of treatment options in people with aortic valve disease.

INTRODUCTION AND OBJECTIVES:Pump thrombosis is a serious left ventricular assist device complication, though there are no guidelines regarding its treatment. The main aim of this study was to describe a strategy of intravenous anticoagulation as the initial treatment in these patients and then to compare intravenous heparin with bivalirudin.METHODS:All consecutive patients who received a HeartWare left ventricular assist device from July 2009 to March 2019 were retrospectively analysed. Patients developing a pump thrombosis were selected, and treatment, outcomes and complications were recorded.RESULTS:During this period of time (116 months), 220 patients underwent HeartWare left ventricular assist device implantation and 57 developed pump thrombosis, with an incidence rate of first pump thrombosis of 0.17 events per patient-year of support (incidence rate of all episodes of pump thrombosis: 0.30 events per patient-year of support). All the patients were initially treated medically, predominantly with either intravenous heparin (n = 26) or bivalirudin (n = 16). Patients treated with bivalirudin during the first pump thrombosis episode had less subsequent re-thrombosis episodes (18.7% vs 57.7%, p < 0.05). In addition, percentage time in therapeutic range was greater for bivalirudin compared with heparin (68.5% ± 16.9% vs 37.4% ± 31.0%, p < 0.01). During the first pump thrombosis episode, 26.3% of the patients needed surgery (left ventricular assist device exchange (n = 8), transplant (n = 6) or decommissioning (n = 1)). The overall survival at 1 year was 61.4%, and there was no significant difference in survival.CONCLUSION:Left ventricular assist device thrombosis is a serious life-threatening complication; hence, we propose an initial conservative management of pump thrombosis with enhanced intravenous anticoagulation with either intravenous heparin or bivalirudin, with surgery reserved for refractory cases.

Left ventricular assist devices (LVADs) have become an established treatment for advanced heart failure, although with long-term support these patients are potentially exposed to serious complications. Our purpose was to assess the role of the neutrophil to lymphocyte ratio (NLR) in LVAD complications and to evaluate if higher values of NLR after 4–6 months on LVAD support (NLR 4_6m) are associated with worse prognosis. All consecutive patients who received a HeartWare LVAD (N = 188, age 50 ± 13 years), as bridge to transplant from December 2009 to January 2018 were included. Neutrophil to lymphocyte ratio was recorded pre-LVAD, post-LVAD, after 4–6 months on support and in case of a first adverse event to occur after the 4–6 months NLR was recorded. Median NLR values were pre-LVAD 4.26 (interquartile range [IQR], 3.1–6.9), at 1 day postoperative 11.6 (IQR, 8.3–16.6), and NLR 4_6m 4.4 (IQR, 3.0–6.4) (p < 0.001). Neutrophil to lymphocyte ratio increased significantly when patients had an infection, stroke, or pump thrombosis, as compared with the NLR 4_6m (all p < 0.05). Patients with NLR 4_6m ≥ median had higher rates of stroke and mortality. Survival time was shorter among patients with NLR 4_6m ≥ 4.4 (log-rank test p = 0.006). Neutrophil to lymphocyte ratio 4_6m was found to be predictive of increased mortality (area under the curve of 0.62, p = 0.007). After multivariate analysis, NLR 4_6m remained independently associated with increased mortality (hazard ratio [HR] 1.67; 95% confidence interval [CI], 1.03–2.7; p = 0.037). Neutrophil to lymphocyte ratio 4_6m values significantly increase in association with adverse events on LVAD support and are independently associated with mortality. This association suggests presence of inflammation adversely affects LVAD outcomes.

Aortic dissection is often regarded as a catastrophic aortic syndrome with high rates of mortality. The sensitivity and specificity of transthoracic echocardiography when diagnosing acute type A aortic dissection has been reported as high as 97% and 100%, respectively, in patients with optimal imaging quality when compared to computed tomography. In this article, we discuss the benefit of transthoracic echocardiography in a patient with type A aortic dissection extending from ascending aorta to iliac arteries.

Authors have nothing to disclose with regard to commercial support. Authors have nothing to disclose with regard to commercial support. We read with interest the letter from Fukunaga and Rao1Fukunaga N. Rao V. Do not forget late pseudoaneurysm after heart transplantation.J Thorac Cardiovasc Surg. 2020; 159: e127Abstract Full Text Full Text PDF Scopus (1) Google Scholar about late aortic pseudoaneurysm after heart transplantation. They address in part an article we previously commented on from Bojko and colleagues,2Bojko M. Eisen H. Mather P. Vallabhajosyula P. Delayed aneurysmal complication of bicuspid aortic valve disease after heart transplantation.J Thorac Cardiovasc Surg. 2019; 158: e185-e186Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar who describe the development of a pseudoaneurysm in native aortic tissue 22 years after heart transplantation on the background of aortic valve replacement for bicuspid aortic valve (BAV) in the recipient. The outcome of the report is a recommendation for regular surveillance in this clinical setting. Fukunaga and Rao1Fukunaga N. Rao V. Do not forget late pseudoaneurysm after heart transplantation.J Thorac Cardiovasc Surg. 2020; 159: e127Abstract Full Text Full Text PDF Scopus (1) Google Scholar are in agreement with us that pseudo-aneurysmal disease could be found irrespective of the native recipient BAV disease.2Bojko M. Eisen H. Mather P. Vallabhajosyula P. Delayed aneurysmal complication of bicuspid aortic valve disease after heart transplantation.J Thorac Cardiovasc Surg. 2019; 158: e185-e186Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar They quote late aneurysmal disease in patients who are undergoing cardiovascular surgery outside of the field of transplantation and the asymptomatic nature of the presentation of disease. At a rate of 0.4%, it is a rare but a life-threatening complication that is challenging to treat and needs identification on surveillance scanning.3Fukunaga N. Koyama T. Outcomes of surgical repairs for thoracic aortic pseudoaneurysms after cardiovascular surgery.J Card Surg. 2016; 31: 535-540Crossref PubMed Scopus (6) Google Scholar We also questioned the significance of the underlying BAV disease and suggested more evidence would need to be provided to secure this theory.4Booth K. Dark J. Commentary: pseudoaneurysm after aortopathy heart transplantation—a link too far?.J Thorac Cardiovasc Surg. 2019; 158: e187-e188Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar But in practice, long-term follow-up of heart transplant recipients will usually be in the hands of transplant cardiologists who will not be aware of the evolving BAV literature. To agree with them, as the authors suggest, the need for surveillance is sound advice, although not fully supported by the report from Bojko and colleagues.2Bojko M. Eisen H. Mather P. Vallabhajosyula P. Delayed aneurysmal complication of bicuspid aortic valve disease after heart transplantation.J Thorac Cardiovasc Surg. 2019; 158: e185-e186Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar We have also seen late pseudo-aneurysmal disease after heart transplantation and report a similar case to that of Fukunaga and Rao.1Fukunaga N. Rao V. Do not forget late pseudoaneurysm after heart transplantation.J Thorac Cardiovasc Surg. 2020; 159: e127Abstract Full Text Full Text PDF Scopus (1) Google Scholar A patient underwent transplantation in 1994 after left ventricular failure after emergency aortic and mitral valve replacement for native bacterial endocarditis at another center. The endocarditis was on a background of long-standing mitral valve prolapse, with no suggestion of BAV. He presented 7 years post-transplant on screening angiography for cardiac allograft vasculopathy with an 8 × 7-cm aortic pseudoaneurysm. The scan is no longer available, but the aneurysm was successfully treated and the patient died of renal cell carcinoma 11 years later. The link with bicuspid aortic valve, originally proposed by Bojko and colleagues2Bojko M. Eisen H. Mather P. Vallabhajosyula P. Delayed aneurysmal complication of bicuspid aortic valve disease after heart transplantation.J Thorac Cardiovasc Surg. 2019; 158: e185-e186Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar remains one of interest, but in reality we think Fukunaga and Rao1Fukunaga N. Rao V. Do not forget late pseudoaneurysm after heart transplantation.J Thorac Cardiovasc Surg. 2020; 159: e127Abstract Full Text Full Text PDF Scopus (1) Google Scholar will join with us in agreeing that pseudo-aneurysmal disease is more common and needs identification because it presents asymptomatically. Do not forget late aortic pseudoaneurysm after heart transplantationThe Journal of Thoracic and Cardiovascular SurgeryVol. 159Issue 2PreviewWe read with great interest the case report by Bojko and colleagues1 of a patient with aortic aneurysm very late after heart transplantation (HTx). The patient, who had a history of aortic valve replacement for bicuspid aortic valve (BAV) disease, underwent HTx for developed cardiomyopathy secondary to sarcoidosis. An incidental computed tomographic image of the chest taken to rule out pneumonia revealed a distal ascending aortic aneurysm with maximal diameter of 7.2 cm. The patient had been followed up with transthoracic echocardiography, which had shown no evidence of dilatation of the thoracic aorta. Full-Text PDF Reply from the authors: Pseudoaneurysm after heart transplantation—Did bicuspid aortopathy contribute?The Journal of Thoracic and Cardiovascular SurgeryVol. 159Issue 2PreviewWe read with great interest a Letter to the Editor regarding our case report, which described a patient with native bicuspid aortic valve (BAV) disease who developed a pseudoaneurysm of the distal ascending aorta more than 20 years after heart transplantation.1 In this letter, the authors contend that pseudoaneurysm of the thoracic aorta is known to occur after previous cardiovascular surgery with an incidence of 0.4%2 and could occur independent of the underlying diagnosis of BAV. They further point out that there are no data describing differences in the incidence rates of pseudoaneurysm formation in patients with BAV versus tricuspid aortic valves. Full-Text PDF

Pump thrombosis (PT) is a serious left ventricular assist device (LVAD) complication, though there are no guidelines regarding its treatment. We have adopted a strategy of intravenous anticoagulation as the initial treatment strategy in these patients. All consecutive patients who received a HeartWare LVAD from July-2009 to January-2018 were retrospectively analyzed. Patients developing a PT were selected, and treatment, outcomes and complications were recorded. 197 patients underwent HVAD, and 49 developed PT. All the patients were initially treated medically, though during the first PT 26.5% of the patients needed surgery [VAD exchange (n=6), transplant (n=6), or decommissioning (n=1)]. The overall survival at 1 year was 63.3%. Patients were treated predominantly with either intravenous heparin or bivalirudin. There were no significant differences neither in complications nor in survival between the 2 treatments (Figure 1); however, patients treated with bivalirudin during the first PT episode had less subsequent re-thrombosis episodes (18.2% vs 57.7%, p<0.05), and percentage time in therapeutic range was greater for bivalirudin compared with heparin (59.7±4.2 vs 36.3±7.1, p<0.01). Nevertheless, time to normalisation of LDH levels with bivalirudin was longer than with heparin (17.2±2.6 vs 10.2±4.5 days, p<0.01) (Table 1). Table 1. Comparison of baseline characteristics and outcomes between Heparin and Bivalirudin Heparin (n=26) Bivalirudin (n=11) p-value Male, gender n (%) 20 (76.9) 9 (81.8) 1.00 Age when implant (years) 48±11.8 49.8±11.4 0.67 AF n (%) 9 (34.6) 6 (54.5) 0.50 Diagnosis:   Dilated cardiomyopathy n (%) 13 (50) 7 (63.6)   Ischemic heart disease n (%) 12 (46.2) 3 (27.3)   Congenital heart disease n (%) 1 (3.8) 1 (9) 0.50 Thrombolysis (+ alteplase) n (%) 19 (73.1) 4 (36.4) 0.08 Treatment duration (days) 11.5±7.2 15.3±6.5 0.15 % Time in range 36.3±7.1 59.7±4.2 0.009 Hospitalisation (days) 19.1±16.4 31.9±18.2 0.06 Complications:   Ischemic Stroke n (%) 2 (7.7) 4 (36.4) 0.09   Intracraneal bleeding n (%) 2 (7.7) 0 (0) 0.88   Gastrointestinal bleeding n (%) 1 (3.8) 0 (0) 1.00   Serious bleeding n (%) 5 (19.2) 0 (0) 0.29   Any bleeding n (%) 7 (26.9) 2 (18.2) 0.88 LDH   Baseline 271.7±79.3 221.6±41.3 0.10   Admision 727.8±448.2 517.5±171.3 0.21   Maximum 827.1±424.7 1217.6±1004 0.03   Discharge 334.9±135.9 308.6±111.8 0.70   Time to normalisation (days) 10.2±4.5 17.2±2.6 0.004 Outcomes:   Transplant (total) n (%) 7 (26.9) 2 (18.2) 0.88   VAD Exchange (total) n (%) 8 (30.8) 4 (36.4) 1.00   Mortality at 2 years n (%) 15 (57.7) 5 (45.4) 0.831 Rethrombosis:   Rethrombosis n (%) 15 (57.7) 2 (18.2) 0.03   Number of episodes of rethrombosis 0.15     +1 n=6 n=1     +2 n=4 n=1     +3 n=4 n=0     +4 n=1 n=0 Figure 1 VAD thrombosis is a serious life threatening complication, though an initial strategy with enhanced intravenous anticoagulation is an acceptable strategy with either intravenous heparin or bivalirudin. N. Bouzas-Cruz would like to thank the Spanish Society of Cardiology (Sociedad Española de Cardiología), for her research grant and fellowship.

Purpose Donor specific antibodies (DSA) to mismatched human leukocyte antigens have been reported to adversely affect the outcomes of lung transplantation. This study aimed to identify the risk factors for the development of DSA within 1-year post-transplant and examine its impact on recipients' medium-term survival. Methods Recipients' age, type of transplantation (single lung or bilateral lungs), pre-existing antibodies, post-op DSA, method of transplantation (ECMO, off-pump or on-pump), primary graft failure (PGD) grade 3 at 72hrs, blood transfusion, post-op ITU stay, ECMO usage and renal support, and survival status were collected from the unit's database. Binary logistic regression was used to identify risk factors for the development of post-op DSA within 1-year post-transplant. Multivariable Cox regression was performed to identify risk factors for survival. Results From January 2012 to October 2017, 259 adult patients received lung transplantation in our unit and 242 (93.4%) survived beyond 30-day post-op. Recipients who died within 30-day post-transplant were not included, as the causes of their death were less likely to be influenced by or associated with post-op DSA. Among these 242 recipients, 46 (19.0%) had pre-existing antibodies and 129 (53.3%) had DSA detected within 1-year post-transplant. Among all the potential risk factors, transplantation performed with ECMO (p = 0.007, OR 3.06, 95% CI: 1.36-6.90) are significantly associated with post-op DSA within 1-year post-transplant. Age (p = 0.009, OR 1.03, 95% CI: 1.01-1.05), post-op renal support (p = 0.015, OR 2.23, 95% CI: 1.17-4.26), PGD grade 3 at 72hrs (p = 0.001, OR 2.79, 95% CI: 1.54-5.05), and red blood cell transfusion (p < 0.001, OR 1.17, 95% CI: 1.11-1.23) are associated with worse medium-term survival, but neither pre-existing antibodies (p = 0.454) or post-op DSA (p = 0.479) has an impact on survival. Conclusion Use of ECMO for lung transplantation is associated with DSA development within 1-year post-transplantation. However, the presence of DSA within 1-year post-transplant has no impact on medium-term survival in this cohort. Further study is required to look at the effect of DSA on the development of chronic lung allograft dysfunction and long-term survival.