Guidelines recommend early aspirin loading (150–325 mg) within 6 h of coronary artery bypass grafting (CABG), which improves patency of vein grafts. Due to bleeding concerns, this is not standard practice. The aim of this study is to review early aspirin administration, within 6 h of CABG, to determine if there is an increased risk of bleeding. Bleeding risk was evaluated in 160 patients, undergoing CABG procedure from January 2022 to February 2023. Patients were divided into two groups: those that received 300 mg of aspirin within 6 h (group 1) and those that did not (group 2). Drainage output from different timepoints, red cell, platelet transfusion rates, pericardial effusion, and re-exploration for bleeding were reviewed. Statistical analysis was performed using STATA/BE version 18.0. Significance was demonstrated when p value < 0.05. Mean output drainage at 24 h was 695.7 mL for group 1 and 712.7 mL for group 2. Considering 11 timepoints, there were no significant difference between groups (p values = 0.731–0.117). Transfusion rates for red cells (p = 0.734) and platelets (p = 0.274), re-exploration for bleeding (p = 0.694), and pericardial effusion rates (p = 0.472) also showed no statistical difference. A comprehensive review of drainage output, red cell, platelet transfusion, re-exploration for bleeding, and pericardial effusion rates was performed, post early aspirin administration. Aspirin (300 mg) given within 6 h of CABG surgery did not lead to increased bleeding and associated complications.

Background and objective In the last decade, there has been significant evolution in thoracic surgery with the advent of robotic surgery. In this study, we aimed to evaluate the incidence of postoperative chronic pain (for six months and beyond) in robotic and video-assisted approaches to analyze the long-term effects of the two different techniques.Methods This was a retrospective study involving 92 patients who underwent various thoracic operations between six months and two years preceding the study. Patients were classified into two groups based on the type of surgery: video-assisted (VATS) (n=51), and robotic-assisted (RATS) (n=41) thoracoscopic Surgery. We employed the EuroQol (EQ-5D-5L) questionnaire to assess the utility values in terms of five quality-of-life measures (self-care, pain/discomfort, mobility, anxiety/depression, and usual activities).Results In the VATS group, the median age was 68 years while it was 57 years in the RATS group (p=0.001). A higher proportion of patients in the VATS group had anatomical lung resection (lobectomy) compared to the RATS group: 61.2 vs. 41.6% respectively (p=0.005). However, the groups were well-matched on other patient characteristics such as relevant past medical history, underlying disease pathology, and final disease staging (if malignant), with no significant differences between groups observed regarding these traits. In the VATS group, 62.7% of patients were pain-free at the time of the questionnaire-based evaluation compared to 51.2% in the RATS group. Additionally, 25.5% vs. 39% of patients had mild pain in the VATS and RATS groups respectively. Neither of these differences was statistically significant.Conclusion Patients who undergo RATS are known to have better recovery and less pain compared to those who have VATS in the immediate postoperative period. However, our results did not find RATS to be superior to VATS in terms of long-term pain. Additionally, robotic surgery is associated with higher hospital costs. In light of these findings, further comparative studies between the two approaches are recommended, while strategies to reduce postoperative pain and financial cost should continue to be explored.

© BMJ Publishing Group Limited 2021. No commercial reuse. See rights and permissions. Published by BMJ. DESCRIPTION A 43yearold woman was referred to our thoracic surgery department following multidisciplinary team (MDT) discussion for a concerning 7×5 mm pulmonary nodule in the medial right upper lobe which was discovered incidentally on a CT thorax abdomen pelvis (figure 1) as part of surveillance for her previous cervical cancer. This woman has a history of squamous cell carcinoma of the cervix (stage IIB), which was diagnosed in 2012 and managed with chemoradiotherapy. Unfortunately, she had a number of complications secondary to radiotherapy including a colovesical fistula (2013), defunctioning loop ileostomy formation (2014), vesicovaginal fistula (2014) and recurrent urirnary tract infection (UTIs). In late 2014, she developed a 4 cm cutaneous squamous cell metastasis in her right flank which was surgically excised. Her other medical history includes lupus and hypothyroidism. She is a nonsmoker. Following identification of the pulmonary nodule on CT TAP, she underwent PET CT. However, the subcentimetre nodule was too small to resolve with PET and remained indeterminant. No other concerning areas of uptake were identified. The differential diagnosis clinically was metastatic cervical carcinoma or a primary lung neoplasm. She subsequently underwent right videoassisted thoracoscopic surgery upper lobe wedge resection. Macroscopic examination of the lung wedge revealed a circumscribed, firm, white nodule, measuring 7 mm in largest dimension, excised by 1 mm to the closest resection margin. Microscopic examination revealed the nodule to be a wellcircumscribed tumour composed of nests of bland cells with clear and granular cytoplasm, set in a hyalinised stroma (figure 2). Significant cytological atypia was not seen. Mitoses were not evident. Immunohistochemistry showed that the lesional cells stained positively for HMB45, with focal positivity for melan A. The cytoplasmic granules stained positively with periodic acid–Schiff and negatively with periodic acid–Schiff diastase, confirming the presence of glycogen. Immunohistochemistry for SOX10, S100, desmin, synaptophysin, PAX8, ERG, oestrogen receptor, AE1/3, p63, CK5/6, TTF-1 and napsin A were negative. Features of metastatic squamous cell carcinoma were not seen. Following histopathological analysis (figure 2), the diagnosis of clear cell ‘sugar’ tumour (CCST) of the lung was made that showed no malignant features. As this was a benign pulmonary lesion, this woman’s followup will be guided by her primary cervical cancer. CCST has been recently recognised to belong to the perivascular epithelioid cell tumour (PEComa) family of tumours. These are rare mesenchymal neoplasms that appear to arise from perivascular epithelioid cells and have morphological, immunophenotypic and ultrastructural similarities. PEComas usually have a combined myogenic and melanocytic immunophenotype. They occur more commonly in women. PEComas include specific entities such as CCST of the lung, angiomyolipoma and pulmonary lymphangioleiomyomatosis, and can occur as PEComas in the viscera, soft tissue and skin. Most PEComas are sporadic, but an association with tuberous sclerosis complex has been shown in angiomyolipoma, lymphangioleiomyomatosis and very rarely CCST. CCST is a rare tumour arising in the lung. It was first described by Liebow and Castleman. CCST usually arise in the periphery of the lung, are often incidentally detected, and can measure up to 7 cm in size. They are composed of nests of uniform cells that have both clear and granular cytoplasm, welldefined cell borders Figure 1 CT thorax abdomen pelvis—new 7x5 mm nodule in medial right upper lobe. Figure 2 (A) nests of bland cells with clear and granular cytoplasm within a hyalinised stroma, H&E stain ×100 magnification, (B) H&E stain x400 magnification, (C) positive cytoplasmic periodic acid– Schiff staining of glycogen within tumour cells, x400 magnification, (D) tumour cells showing positive HMB45 immunohistochemistry, x400 magnification.

Disseminating the practice of minimally invasive mitral surgery (mini-MVS) can be challenging, despite its original case reports a few decades ago. The penetration of this technology into clinical practice has been limited to centres of excellence, and mitral surgery in most general cardiothoracic centres remains to be conducted via sternotomy access as a first line. The process for the uptake of mini-MVS requires clearer guidance and standardisation for the processes involved in its implementation. In this statement, a consensus agreement is outlined that describes the benefits of mini-MVS, including reduced postoperative bleeding, reduced wound infection, enhanced recovery and patient satisfaction. Technical considerations require specific attention and can be introduced through simulation and/or use in conventional cases. Either endoballoon or aortic cross clamping is recommended, as well as femoral or central aortic cannulation, with the use of appropriate adjuncts and instruments. A coordinated team-based approach that encourages ownership of the programme by the team members is critical. A designated proctor is also recommended. The organisation of structured training and simulation, as well as planning the initial cases, is an important step to consider. The importance of pre-empting complications and dealing with adverse events is described, including re-exploration, conversion to sternotomy, unilateral pulmonary oedema and phrenic nerve injury. Accounting for both institutional and team considerations can effectively facilitate the introduction of a mini-MVS service. This involves simulation, team-based training, visits to specialist centres and involvement of a designated proctor to oversee the initial cases.

Background Atrial tissue fibrosis is linked to inflammatory cells, yet is incompletely understood. A growing body of literature associates peripheral blood levels of the antifibrotic hormone BNP (B‐type natriuretic peptide) with atrial fibrillation ( AF ). We investigated the relationship between pro‐fibrotic tissue M2 macrophage marker Cluster of Differentiation ( CD )163+, atrial procollagen expression, and BNP gene expression in patients with and without AF . Methods and Results In a cross‐sectional study design, right atrial tissue was procured from 37 consecutive, consenting, stable patients without heart failure or left ventricular systolic dysfunction, of whom 10 had AF and 27 were non‐ AF controls. Samples were analyzed for BNP and fibro‐inflammatory gene expression, as well as fibrosis and CD 163+. Primary analyses showed strong correlations (all P <0.008) between M2 macrophage CD 163+ staining, procollagen gene expression, and myocardial BNP gene expression across the entire cohort. In secondary analyses without multiplicity adjustments, AF patients had greater left atrial volume index, more valve disease, higher serum BNP , and altered collagen turnover markers versus controls (all P <0.05). AF patients also showed higher atrial tissue M2 macrophage CD 163+, collagen volume fraction, gene expression of procollagen 1 and 3, as well as reduced expression of the BNP clearance receptor NPRC (all P <0.05). Atrial procollagen 3 gene expression was correlated with fibrosis and BNP gene expression was correlated with serum BNP . Conclusions Elevated atrial tissue pro‐fibrotic M2 macrophage CD 163+ is associated with increased myocardial gene expression of procollagen and anti‐fibrotic BNP and is higher in patients with AF . More work on modulation of BNP signaling for treatment and prevention of AF may be warranted.

BACKGROUND:Infective endocarditis (IE) is a potentially life-threatening infection of the heart's endocardial surface. Despite advances in the diagnosis and management of IE, morbidity and mortality remain high.AIM:To characterize the demographics, bacteriology and outcomes of IE cases presenting to an Irish tertiary referral centre.DESIGN:Retrospective cohort study.METHODS:Patients were identified using Hospital Inpatient Enquiry and Clinical Microbiology inpatient consult data, from January 2005 to January 2014. Patients were diagnosed with IE using Modified Duke Criteria. Standard Bayesian statistics were employed for analysis and cases were compared to contemporary international registries.RESULTS:Two hundred and two patients were diagnosed with IE during this period. Mean age 54 years. Of these, 136 (67%) were native valve endocarditis (NVE), 50 (25%) were prosthetic valve endocarditis (PVE) and 22 (11%) were cardiovascular implantable electronic device-associated endocarditis. Culprit organism was identified in 176 (87.1%) cases and Staphylococcal species were the most common (57.5%). Fifty-nine per cent of NVE required surgery compared to 66% of PVE. Mean mortality rate was 17.3%, with NVE being the lowest (12.5%) and PVE the highest (32%). Increasing age was also associated with increased mortality. Fifty-three (26.2%) patients had embolic complications.CONCLUSIONS:This Irish cohort exhibited first-world demographic patterns comparable to those published in contemporary international literature. PVE required surgery more often and was associated with higher rates of mortality than NVE. Embolic complications were relatively common and represent important sequelae, especially in the intravenous drug user population. It is also pertinent to aggressively treat older cohorts as they were associated with increased mortality.

Background: The diagnostic work-up for suspected interstitial lung disease often includes surgical lung biopsy or VATs (Video-Assisted-Thoracoscopy) biopsy. VATs is recommended where the underlying diagnosis is in question and has been shown in the past to have relatively high mortality and morbidity rates. Aims: To evaluate the mortality, morbidity, diagnostic efficacy and outcomes associated with surgical lung biopsy via VATs. Methods: We carried out a retrospective review of 144 patients with suspected interstitial lung disease who underwent VATs lung biopsy between 2010 and 2016. Biopsies were carried out in three Irish centres. Our main outcome measures were mortality at 30 and 90 days, morbidity, histological diagnoses and correlation with suspected radiological diagnoses. Results: 30 day mortality following VATs biopsy was 4.4%. All 6 patients who died within 30 days were in the Intensive Care Unit (ICU) at time of biopsy. 90 day mortality was 7.9%. 24% of patients had some morbidity at 30 days, primarily pain and pneumothorax. The most commonly diagnosed condition on biopsy was Hypersensitivity Pneumonitis in 25% of cases, followed by Usual Intersitial Pneumonia (UIP) in 16% of cases. There was no mortality in UIP cases. A definitive diagnosis was made at VATs biopsy in all cases, in 82% of cases it provided a new diagnosis or altered clinical treatment. Conclusion: This large review finds that mortality following VATs biopsy was low and in line with international findings. The 30 day mortality rate was 0% in patients not in ICU at the time of biopsy. We found that VATs biopsy is safe and effective and should be considered where the diagnosis is in question.

Background/IntroductionSurgical management of empyema remains a necessity in the modern era.In many cases the patients are already on anti-microbial therapy prior to referral for definitive surgical management.Surgeons will send samples during the operative case for analysis, but in the setting on ongoing microbiological therapy, these may not prove rewarding. Aims/ObjectivesWe examine the utility of intra-operative microbiology sampling in the setting of thoracic empyema.

Interstitial fibrosis with emphysema [also called smoking-related interstitial fibrosis (SRIF), or airspace enlargement with fibrosis] is increasingly recognised, described with co-existing lung cancer. ![Figure][1] . We undertook a prospective clinical, radiological and pathological analysis of non-cancerous lung from lung cancer resections (n=20), assessing smoking history, fibrosis and small airway changes by histology (see Katzeinstein AL et al 2010) and by protocol-derived high resolution CT (HRCT). Histological emphysema-associated interstitial fibrosis (SRIF) was found in 40%, distant to the lung cancer and associated with small airway changes. Gender and age distribution was similar in both SRIF and non-SRIF subjects, with SRIF observed in 87.5% in the right lung, (62.5% in the right upper lobe), and associated with decreased forced expiratory volume in 1 second (p=0.0026). In all, SRIF had no HRCT correlate. We assessed the histological findings in explanted lungs from radiologic emphysema subjects [n=20 chronic obstructive pulmonary disease (COPD), mean cigarette pack-years (PY)=45; n=20 alpha 1-antitrypsin deficiency (A1AT), mean PY=25]; SRIF was observed in 40% of COPD and 25% of A1AT (linear correlation with mean PY). In summary, histologic fibrosis with emphysema is radiologically occult, highly prevalent, with a dose-response relationship to smoking, and independent of the cancer in the nearby lung. [1]: pending:yes

We report a case of a 35-year-old man who presented with 4-week history of haemoptysis, with a history of intravenous drug use. There was no other significant medical or surgical history and no recollection of any foreign body aspiration. Chest X-ray and CT scan showed 40 mm long needle in left main bronchus, partly lying outside the bronchus into the mediastinum. Flexible and rigid bronchoscopes proved to be unsuccessful in retrieving the needle. We proceeded with left posterolateral thoracotomy and the left main bronchus was explored to take out this 21-gauge (green) injection needle. The distal half of the needle with the sharp end was lying in the mediastinum piercing through the bronchial wall. Surgery was uneventful with good postoperative recovery and the patient was discharged 4 days later.

Renal cell carcinoma (RCC) propagates into the IVC in 4% of cases with 1% extending into the right atrium. Radical surgical resection remains the definitive curative/palliative treatment in those without significant metastases. The aim was to review our experience in patients with different levels of IVC involvement, cardiopulmonary bypass (CPB) and perioperative/long term outcomes.Patients and methods: From 2001 to 2012, 24 radical nephrectomies with IVC thrombectomy were performed. A retrospective chart review was undertaken to record demographics, presenting symptoms, duration of surgery, pen-operative transfusion, CPB and peri-operative complications, tumour grade/stage, and patient survival.Results: We identified 24 patients (18 male, Age median 59 range 35-78). The commonest presenting symptoms were weight loss, pain and haematuria. The majority of tumours were right sided (n = 17) with 8 having lung metastases at presentation. Thrombus level Was 16 (infradiaphragmatic), 2 (supradiaphragmatic), 6 (intra-atrial). 15 patients required sternotomy for vascular control and 9 required CPB both with a significantly longer operative time compared (6.1 +/- 3.5 vs. 7.2 +/- 1.2 vs. 3.5 +/- 1.1 h, respectively). Pen-operative complications (n = 21) included cardiopulmonary, renal, gastrointestinal and septic problems. There were 2 peri-operative deaths. Blood transfusion was significantly less in those not requiring sternotomy or CPB using the "Cell Saver" device. The majority were Fuhrman grade 3 (n = 16) and clear cell type (n = 14). Overall 3-year survival was 100% (Laparotomy only), 40% (sternotomy + cross-clamp), and 20% (CPB).Conclusions: IVC thrombectomy has significant morbidity and requires careful patient selection and a multi-disciplinary approach to optimise patient outcomes. In this series, the level of IVC thrombus and requirement for CPB directly affects patient morbidity and outcome. (C) 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

INTRODUCTION:The female gender has been shown as high-risk factor for mortality and morbidity. We sought to assess the influence of female gender on coronary artery bypass graft (CABG) surgery from our own experience. METHODS:This is a retrospective analysis of prospectively collected database from a single centre. Patients were grouped according to gender and potential differences in pre-operative, intra-operative and post-operative factors were explored. Significant high-risk factors were then fitted in a multivariate model to account for differences in predicting gender influence on surgical outcomes. RESULTS:Two thousand eight hundred and four consecutive patients underwent isolated first-time CABG between February 2000 and December 2008; 562 (20%) patients were females. Pre-operatively, females were more likely to have significant comorbidities (age, congestive cardiac failure, hypercholesterolemia, hypertension, ischemic heart disease, peripheral vascular disease, pre-op arrhythmias, small body surface area and poor ejection fraction (p < 0.001)) consistent with higher Euroscore (p > 0.0001) and more urgent surgery (p < 0.002). Intra-operatively, they showed less extent pattern of disease requiring less bypass and cross-clamp time (p < 0.001). Observed surgical mortality was significantly higher in females (3.6 vs. 2.1%, p < 0.042); however, after adjusting for propensity score and significant factors identified in multivariate models, females only independently predicted a higher wound infection, lower neurological complications, lower rate of re-sternotomy, longer hospital stay and post-surgery stay (p < 0.01). CONCLUSIONS:Despite higher risk profile and higher observed surgical mortality, early outcomes in females were similar to their matched males' counterpart in isolated CABG surgery. Females were associated with higher incidence of wound infections but lower rate of neurological complications.

Atrial fibrillation remains the commonest arrhythmia encountered in cardiac surgery. Data on the effect of preoperative atrial fibrillation on postoperative outcome remain limited. We sought to assess the effects preoperative atrial fibrillation on patients' outcome following cardiac surgery. This is a retrospective review of prospectively collected departmental data of all patients who underwent cardiac surgery over 8-year period. Our cohort consisted of 3777 consecutive patients divided into atrial fibrillation (n=413, 11%) and sinus rhythm (n=3364, 89%). Postoperative complications and in-hospital mortality were analysed. Univariate analysis showed significantly increased mortality and major complications in atrial fibrillation compared to sinus rhythm patients. Using multiple logistic regression analysis and after accounting for Euro SCORE as a confounding variable, we found that preoperative atrial fibrillation significantly increases the risk of mortality (OR 1.7), low cardiac output state (OR 1.3), prolonged ventilation (OR 1.4), infective complication (OR 1.5), gastrointestinal complications (OR 2.0), and intensive care unit readmission (OR 1.6). Preoperative atrial fibrillation in cardiac surgery patients increases their risk of mortality and major complications following cardiac surgery. Surgical strategies such as Cox-Maze procedure may be beneficial in these patients.

PURPOSE:We looked at the complications and hospital resources of an elderly population undergoing first-time isolated coronary artery bypass graft surgery (CABG) in comparison to a younger counterpart for a propensity matched cohort.METHODS:A retrospective analysis of prospectively collected data was conducted on 2804 CABG patients. Two age groups, >75 years and ≤75 years, were generated. Potential differences in demographic, baseline, preoperative, and intraoperative characteristics were investigated. A propensity score based on these differences was calculated and used to create a matched set of patients. Major postoperative complications were recorded, and data on indicators of resource utilization were collected.RESULTS:In all, 311 (11.1%) patients were identified as >75 years of age. The observed complication rate was significantly higher in overall, pulmonary, cardiac, renal, gastrointestinal (GI), neurological, infective, and mortality categories (P < 0.0001). Observed hospital resource utilization was significant in the elderly group in terms of initial stay in the intensive care unit (ICU) and ICU readmission (P < 0.05) and in all preoperative, postoperative, cardiac surgery, and total hospital stays (P < 0.001). However, after propensity matching to 311 patients ≤75 years, the overall postoperative complication rate maintained its significance (P < 0.0001), in addition to atrial fibrillation and neurological, renal, and GI complications (P < 0.05). Elderly patients required longer duration of ventilation postoperatively and longer postoperative stay, cardiac surgery stay, and total hospital stay; and they maintained a higher surgical mortality rate (6.1% vs. 2.6%) (P < 0.05).CONCLUSION:Elderly patients undergoing CABG had significantly higher rates of postoperative complications. Their prolonged hospital stay and consequently higher resources utilization need to be adequately highlighted to heath care officials and appropriately addressed.

Objective: The outcome of patients with solitary kidney undergoing on-pump cardiac surgery is unknown. We sought to assess the in-hospital mortality and complications in these patients compared with patients with normal renal function. Methods: This is a retrospective review of prospectively collected data over an 8-year period of all patients who underwent cardiac surgery. Our cohort consisted of 3363 consecutive patients divided into: solitary kidney (n = 31, 0.9%) and normal kidneys (n = 3332, 99.1%). Postoperative complications and in-hospital mortality were analysed. Results: Solitary kidney patients had higher incidence of renal failure (26% vs 5%, p-value < 0.001), higher incidence of gastrointestinal complications (10% vs 1%, p-value 0.009) and higher blood transfusions (74% vs 43%, p-value < 0.001) compared with patients with normal kidneys. There was an increased length of both intensive care unit stay (3.8 vs 2.2 days, p-value 0.031) and hospital stay (15.6 vs 8.5 days, p-value 0.026) among patients with solitary kidney compared with normal kidney patients. Multivariate analysis showed that solitary kidney is an independent predictor of postoperative renal failure (odds ratio (OR) 7.1 (95% CI 3.1-16.6)), gastrointestinal complications (OR 8.5 (95% CI 2.5-29.4)) and blood transfusion (OR 3.8 (95% CI 1.6-9.0)) after adjusting for age and gender. In-hospital mortality, however, was similar in both groups. Conclusion: Although solitary kidney patients have similar short-term mortality as normal kidney patients, the rates of postoperative renal failure, gastrointestinal complications and blood transfusion are significantly higher among solitary kidney patients. Our findings have important clinical implications and prior knowledge of such entity with appropriate risk stratification at admission could help in reducing the risk of these potential complications. (C) 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B. V. All rights reserved.