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Yates MT, Smith A, Mistirian AA, Bigogno CM, Lee M, Lopez-Marco A. Inflammation in aortic surgery: postoperative evolution of biomarkers according pathologies and segments of the aorta. J Cardiothorac Surg 2024; 19:239. [PMID: 38632653 PMCID: PMC11022493 DOI: 10.1186/s13019-024-02672-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 03/22/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVES Aortic pathologies often present with elevated inflammatory biomarkers due to the nature of the disease. Open aortic surgery causes significant trauma to the body due to often mandatory ischemic periods, long cardiopulmonary bypass times and polytransfusion. We aim to determine postoperative trends on inflammation biomarkers for different aortic pathologies and type of surgery in different segments of the aorta. METHODS Retrospective review of prospectively collected data of 193 consecutive patients who underwent aortic surgery in our centre between 2017 and 2021, grouped according to the type of aortic intervention: (1) Type A aortic dissection (AD) repair with ascending aorta/hemiarch replacement, (2) Aortic root replacement (ARR), (3) Aortic arch + Frozen elephant trunk (FET), (4) Descending thoracic aorta (DTA)/Thoraco-Abdominal aortic repair (TAA). Primary outcomes were daily values of white blood cells (WBC) and C-Reactive Protein (CRP) during the first 15 postoperative days. RESULTS All groups had a similar inflammatory peak in the first 2-4 days (WBC 12-15 × 109 c/L). AD and FET groups show similar trends with WBC and CRP peaks on days 2 and 10. The ARR group didn't experience the 2nd peak as most patients were already discharged. DTA/TAA patients experienced a more prolonged inflammatory response, reaching a plateau by day 5-10. AD group shows the highest WBC levels and the DTA/TAAA group the highest CRP levels. CRP levels remain elevated (100-200 mg/L) in all groups after 15 postoperative days. CONCLUSIONS Inflammatory biomarkers show different postoperative trends depending on the clinical presentation and complexity of the aortic procedure performed. Further understanding of the inflammatory response to different aortic pathologies and surgical procedures will permit reduction on the liberal use of antibiotics that this cohort of patients are usually exposed to. An earlier version of the data included in this manuscript was presented as Oral Abstract in the UK Society of Cardiothoracic Surgery Annual meeting in 2021.
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Affiliation(s)
- Martin T Yates
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Alexander Smith
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Alina A Mistirian
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | | | - Michelle Lee
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Ana Lopez-Marco
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK.
- William Harvey Institute, Queen Mary University, London, UK.
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Lopez-Marco A, Oo AY. Commentary: The severity of chronic obstructive pulmonary disease affects outcomes of thoracoabdominal aortic aneurysms repair-is GOLD the answer? J Thorac Cardiovasc Surg 2023:S0022-5223(23)00996-0. [PMID: 37871830 DOI: 10.1016/j.jtcvs.2023.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 10/19/2023] [Indexed: 10/25/2023]
Affiliation(s)
- Ana Lopez-Marco
- Division of Aortovascular Surgery, Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom
| | - Aung Y Oo
- Division of Aortovascular Surgery, Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom.
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Lopez-Marco A, Thet MS, Sajiram S, Adams B, Oo AY. Intercostal artery reattachment for prevention of spinal cord ischaemia. Ann Cardiothorac Surg 2023; 12:511-513. [PMID: 37817843 PMCID: PMC10561330 DOI: 10.21037/acs-2023-scp-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 08/28/2023] [Indexed: 10/12/2023]
Affiliation(s)
- Ana Lopez-Marco
- Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Myat Soe Thet
- Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | | | - Benjamin Adams
- Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Aung Y Oo
- Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
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Holland LC, Harky A, Haqzad Y, Roman M, Hope E, Jahangeer S, Oo A, Lopez-Marco A. Effect of COVID-19 on outpatient services in patients with aortovascular disease: a UK multicentre study. Ann R Coll Surg Engl 2023; 105:S42-S45. [PMID: 35638905 PMCID: PMC10390245 DOI: 10.1308/rcsann.2022.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Abstract
INTRODUCTION The SARS-CoV-2 coronavirus disease 2019 (COVID-19) pandemic has disrupted healthcare services worldwide. Outpatient services have necessarily been restructured to accommodate COVID-19 patients and to maintain social distancing measures. The aim of our study was to investigate how the COVID-19 pandemic has affected outpatient healthcare provision for patients with aortovascular disease. METHODS In this prospective study, a standardised proforma was circulated to seven aortic centres in the UK. Data on outpatient encounters were collected from March to July 2020. Captured data included demographic details, disease pattern, type of encounter (face-to-face, video or telephone), clinic outcome and availability of imaging. RESULTS A total of 632 patients were included in the study, including 164 (25.9%) new referrals. In this cohort, clinic settings have shifted towards remote consultations, with 424 (67.1%) patients undergoing telephone appointments. Over a third of new patients (34.8%) had a delay in diagnostic tests, which might be attributable to the indirect effects of COVID-19. A total of 102 (16.1%) patients were added to a surgical waiting list following clinic. CONCLUSIONS To the best of our knowledge, this is the largest study of outpatient activity during the COVID-19 pandemic in patients with aortovascular disease. We demonstrate how the speciality has adapted to accommodate government-endorsed changes in healthcare provision, and question how COVID-19 may have affected access to diagnostics. Finally, we discuss how COVID-19 will affect patients added to surgical waiting lists.
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Affiliation(s)
| | - A Harky
- Liverpool Heart and Chest Hospital, UK
| | | | | | - E Hope
- Southampton General Hospital, UK
| | | | - A Oo
- St Bartholomew's Hospital, UK
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Pruna-Guillen R, Adams B, Ye Oo A, Lopez-Marco A. Open descending and thoracoabdominal aortic replacement: operative steps for patients with prior endovascular treatment. Multimed Man Cardiothorac Surg 2023; 2023. [PMID: 36744769 DOI: 10.1510/mmcts.2022.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Open surgery remains the gold standard for the treatment of the thoracoabdominal aorta. The rising number of endovascularly treated patients comes with an increase in the number of patients who require secondary open interventions due to the complex nature of the aortic disease or to treat endovascular complications. We describe our current approach to secondary open extent II thoracoabdominal aortic repair in patients with prior endovascular repair. In this case report, we show two different cases that exemplify this scenario.
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Affiliation(s)
- Robert Pruna-Guillen
- Department of Cardiovascular Surgery, Institut Cardiovascular, Hospital Clìnic, 170th Villarroel St., 08036 Barcelona, Spain
| | - Benjamin Adams
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE UK
| | - Aung Ye Oo
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Ana Lopez-Marco
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
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Lopez-Marco A, Yates MT, Adams B, Lall K, Yap J, Di Salvo C, Uppal R, Oo A. Managing the Root in Acute Type A Aortic Dissections: Are We Ready for a Standardized Approach? Aorta (Stamford) 2023; 11:1-9. [PMID: 36848907 PMCID: PMC9970750 DOI: 10.1055/s-0042-1757947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 07/11/2022] [Indexed: 06/18/2023]
Abstract
OBJECTIVES Surgical repair of Type A aortic dissection (TAAD) requires exclusion of the primary entry tear and reestablishment of flow into the distal true lumen. Provided that the majority of tears occur within the ascending aorta (AA), replacing only that segment seems a safe option; however, this strategy leaves the root susceptible to dilatation and need for reintervention. We aimed to review the outcomes of the two strategies: aortic root replacement (ARR) and isolated ascending aortic replacement. METHODS Retrospective analysis of prospectively collected data for all consecutive patients who underwent repair of acute TAAD at our institution from 2015 to 2020 was conducted. Patients were divided into two groups: (1) ARR and (2) isolated AA replacement as index operation for TAAD repair. Primary outcomes were mortality and need for reintervention during the follow-up. RESULTS A total of 194 patients were included in the study; 68 (35%) in the ARR group and 126 (65%) in the AA group. There were no significant differences in postoperative complications or in-hospital mortality (23%; p = 0.51) between groups. Seven patients (4.7%) died during follow-up and eight patients underwent aortic reinterventions, including proximal aortic segments (two patients) and distal procedures (six patients). CONCLUSION Both aortic root and AA replacement are acceptable and safe techniques. The growth of an untouched root is slow, and reintervention in this aortic segment is infrequent compared with distal aortic segments, hence preserving the root could be an option for older patients provided that there is no primary tear within the root.
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Affiliation(s)
- Ana Lopez-Marco
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, United Kingdom
| | - Martin T. Yates
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, United Kingdom
| | - Benjamin Adams
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, United Kingdom
| | - Kulvinder Lall
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, United Kingdom
| | - John Yap
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, United Kingdom
| | - Carmelo Di Salvo
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, United Kingdom
| | - Rakesh Uppal
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, United Kingdom
| | - Aung Oo
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, United Kingdom
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Mistirian AA, Lopez-Marco A, Adams B, Oo A. Thoracoabdominal Aneurysm Repair During Early Stage of Pregnancy: Can and Should We Save the Baby? Ann Thorac Surg 2023; 115:e45-e48. [PMID: 35305992 DOI: 10.1016/j.athoracsur.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 02/03/2022] [Accepted: 03/06/2022] [Indexed: 02/07/2023]
Abstract
Aortic dissection during pregnancy is a life-threatening condition for both mother and fetus. We present the case of a 34-year-old woman with a rapidly expanding abdominal aorta in the context of a chronic type B aortic dissection. A 4 to 6 weeks' viable pregnancy was incidentally diagnosed during the preoperative workup. She underwent urgent extent II thoracoabdominal aortic aneurysm repair with left-sided heart bypass. Postoperatively, vaginal ultrasound evaluation confirmed viability of the fetus, but the patient wished to terminate the pregnancy because of the possible unknown hypoxic effects on the fetus.
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Affiliation(s)
| | - Ana Lopez-Marco
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom
| | - Benjamin Adams
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom
| | - Aung Oo
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom
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Asemota N, Ike ID, Oo AY, Lopez-Marco A. Fulminant Herpes Pneumonia Postaortic Surgery with Known Ankylosing Spondylitis. Aorta (Stamford) 2022; 10:256-258. [PMID: 36539119 PMCID: PMC9767785 DOI: 10.1055/s-0042-1757791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Herpes simplex virus (HSV) pneumonitis is rare after cardiac surgery. A 36-year-old gentleman with ankylosing spondylitis underwent emergency surgery for a complex aortic aneurysmal disease. Preoperative treatment of aortitis with antitumor necrosis factor and steroid medication and surgical stress including cardiopulmonary bypass potentially created an immunosuppressive state and reactivation of undiagnosed HSV. Rapid HSV pneumonia ensued, culminating in fulminant organ failure and mortality. HSV pneumonia should be considered postoperatively in patients with severe respiratory distress, especially if immunocompromised.
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Affiliation(s)
- Nicole Asemota
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom
| | - Ikenna David Ike
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom
| | - Aung Ye Oo
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom
| | - Ana Lopez-Marco
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom,Address for correspondence Ana Lopez-Marco, PhD, FRCS-CTh Department of Cardiothoracic Surgery, St Bartholomew's HospitalWest Smithfield, London EC1A 7BEUnited Kingdom
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Lopez-Marco A, Adams B, Oo AY. Retrograde type A aortic dissection: a different evil? Interact Cardiovasc Thorac Surg 2022; 35:6769893. [PMID: 36271851 PMCID: PMC9642331 DOI: 10.1093/icvts/ivac264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/09/2022] [Accepted: 10/20/2022] [Indexed: 11/07/2022] Open
Abstract
Retrograde type A aortic dissection (RTAAD) can be spontaneous or secondary to the instrumentation of the descending and thoraco-abdominal aorta. It has anatomical differences compared to antegrade type A aortic dissection that impact the management and prognosis. Treatment is not standardized. We report our approach to spontaneous RTAAD in our institution between 2018 and 2022 (n = 15). The mean age was 60.1 years and 93% were male. Aortic valve, coronary arteries and supra-aortic trunks were spared by the dissection in 80% of the cases; distal extension to iliacs was common and lower limb malperfusion was present in 4 cases (27%). The ascending aorta was dilated at presentation in 60% of the cases. Emergency surgery with arch/FET replacement was offered to 11 patients (73%); 3 patients (20%) received a limited proximal aortic repair; 1 patient was treated conservatively. Overall mortality was 47% (100% for limited proximal repair and 22% for those who received arch/FET). We advocate for aggressive treatment of RTAAD excluding the primary entry tear to prevent immediate- and mid-term complications.
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Affiliation(s)
- Ana Lopez-Marco
- St Bartholomew’s Hospital Department of Cardiothoracic Surgery. , London, United Kingdom
| | - Benjamin Adams
- St Bartholomew’s Hospital Department of Cardiothoracic Surgery. , London, United Kingdom
| | - Aung Ye Oo
- St Bartholomew’s Hospital Department of Cardiothoracic Surgery. , London, United Kingdom
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Thet MST, Balmforth D, Lopez-Marco A, Ye Oo A. Resternotomy aortic root and arch replacement following previous complex type A aortic dissection requiring endovascular repair for malperfusion. Multimed Man Cardiothorac Surg 2022; 2022. [PMID: 36239233 DOI: 10.1510/mmcts.2022.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
A redo sternotomy, aortic root, and arch replacement in a patient following previous complex surgical and endovascular type A aortic dissection repair is presented in this video case report. Shortly after having the initial type A aortic dissection repair with replacement of the ascending aorta, the patient developed severe visceral malperfusion due to a compressed distal true lumen and underwent emergency endovascular repair with ascending arch and descending thoracic aorta stents and chimney grafts for the aortic arch vessels as well as fenestration of the intimal flap of the abdominal aorta. Unfortunately, the patient developed permanent paraplegia and progressive symptomatic severe aortic regurgitation. The patient underwent a redo sternotomy, aortic root, and arch replacement with explantation of the ascending stent graft and chimney stent grafts. Antegrade cerebral perfusion was maintained throughout the procedure. The aortic arch was replaced using a Terumo Aortic Plexus multibranched graft distally anastomosed to the endovascular stent graft, and the innominate and left common carotid arteries were reimplanted onto the graft. The aortic root was replaced with a Bioconduit graft, using a modified Cabrol technique to reimplant the left coronary artery. A satisfactory postoperative course and computed tomography imaging highlight the feasibility of this highly complex aortic arch repair with careful preoperative planning.
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Affiliation(s)
- Myat Soe Thet Thet
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Damian Balmforth
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Ana Lopez-Marco
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Aung Ye Oo
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
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Yates MT, Balmforth D, Kirmani BH, Acharya M, Jeganathan R, Ngaage D, Kanani M, Deglurkar I, Lopez-Marco A, Sanders J, Ye Oo A. A multi-centre prospective cohort study of patients on the elective waiting list for cardiac surgery during the COVID-19 pandemic. J R Soc Med 2022; 115:348-353. [PMID: 35485431 DOI: 10.1177/01410768221089016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES During the worldwide COVID-19 pandemic, elective cardiac surgery was suspended to provide ICU beds for COVID-19 patients and those requiring urgent cardiac surgery. The aim of this study is to assess the effect of the pandemic on outcomes of patients awaiting elective cardiac surgery. DESIGN A multi-centre prospective cohort study. SETTING The elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres. PARTICIPANTS Patients on the elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres. MAIN OUTCOME MEASURES Primary outcome was surgery, percutaneous therapy or death at one year. METHODS Data were collected prospectively on patients on the elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres. Primary outcome was surgery, percutaneous therapy or death at one year. Demographic data and outcomes were obtained from local electronic records, anonymised and submitted securely to the lead centre for analysis. RESULTS On 1 March 2020, there were 1099 patients on the elective waiting list for cardiac surgery. On 1 March 2021, 83% (n = 916) had met a primary outcome. Of these, 840 (92%) had surgery after a median of 195 (118-262) days on waiting list, 34 (3%) declined an offer of surgery, 23 (3%) had percutaneous intervention, 12 (1%) died, 7 (0.6%) were removed from the waiting list. The remainder of patients, 183 (17%) remained on the elective waiting list. CONCLUSIONS This study has shown, for the first time, significant delays to treatment of patients awaiting elective cardiac surgery. Although there was a low risk of mortality or urgent intervention, important unmeasured adverse outcomes such as quality of life or increased perioperative risk may be associated with prolonged waiting times.
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Affiliation(s)
- Martin T Yates
- St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Damian Balmforth
- St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | | | | | | | - Dumbor Ngaage
- Hull and East Yorkshire NHS Trust, Hull, HU3 2JZ, UK
| | - Mayzar Kanani
- James Cook University Hospital, Middlesbrough, TS4 3BW, UK
| | - Indu Deglurkar
- University Hospital of Wales, Heath Park Way, Cardiff, CF14 4XW, UK
| | - Ana Lopez-Marco
- St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Julie Sanders
- St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK.,William Harvey Research Institute, Queen Mary University of London, London, E1 4NS, UK
| | - Aung Ye Oo
- St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK.,William Harvey Research Institute, Queen Mary University of London, London, E1 4NS, UK
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Thet MS, Kyaw Tun J, Oo AY, Lopez-Marco A. Ministernotomy repair of inadvertent proximal right subclavian artery injury following right internal jugular central venous catheter insertion. BMJ Case Rep 2022; 15:e247809. [PMID: 35459649 PMCID: PMC9036171 DOI: 10.1136/bcr-2021-247809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2022] [Indexed: 11/04/2022] Open
Abstract
A man in his 60s was referred for urgent coronary artery bypass grafting (CABG) procedure following acute coronary syndrome. After induction of general anaesthesia, right jugular venous catheterisation under two-dimensional ultrasound guidance was planned as part of perioperative management. While obtaining vascular access, the pulsatile flow was noted once the dilator was inserted, having to abandon the procedure and immediately apply manual pressure. CT angiogram showed proximal right subclavian artery injury with active contrast extravasation and resultant large haematoma in the neck. The patient underwent urgent exploration of the injured vessel through a J-shaped ministernotomy, and primary repair of the artery was performed. The patient recovered from the procedure without any complications. He continued to stay in the hospital for a few days, afterwards, he underwent the initially planned CABG surgery. He was discharged home on day 5 after surgery without further concerns.
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Affiliation(s)
- Myat Soe Thet
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Jimmy Kyaw Tun
- Department of Interventional Radiology, The Royal London Hospital, London, UK
| | - Aung Ye Oo
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Ana Lopez-Marco
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
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Lopez-Marco A, Jahangeer S, Adams B, Oo AY. Arch replacement following endovascular arch repair for an infected stent: case report. J Vis Surg 2022. [DOI: 10.21037/jovs-20-100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Hussain A, Rossi A, Smith A, Lopez-Marco A, Khalil A, Roberts N. Type A Aortic Dissection Masquerading as an Inferior Myocardial Infarction. Aorta (Stamford) 2021; 9:184-185. [PMID: 34879399 PMCID: PMC8654507 DOI: 10.1055/s-0041-1732396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Type A aortic dissection is a life-threatening condition with a wide range of clinical manifestations. Dissection can sometimes mimic an acute myocardial infarction due to similar presenting symptoms and initial clinical investigations. We report the case of a 52-year-old male who presented with an inferior ST-segment elevation myocardial infarction with two drug-eluting stents inserted as a stabilizing intervention prior to surgical repair of an acute aortic dissection.
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Affiliation(s)
- Azhar Hussain
- Department of Cardiac Surgery, St. Bartholomew's Hospital, London, United Kingdom
| | - Alessia Rossi
- Department of Cardiac Surgery, St. Bartholomew's Hospital, London, United Kingdom
| | - Alexander Smith
- Department of Cardiac Surgery, St. Bartholomew's Hospital, London, United Kingdom
| | - Ana Lopez-Marco
- Department of Cardiac Surgery, St. Bartholomew's Hospital, London, United Kingdom
| | - Amina Khalil
- Department of Cardiac Surgery, St. Bartholomew's Hospital, London, United Kingdom
| | - Neil Roberts
- Department of Cardiac Surgery, St. Bartholomew's Hospital, London, United Kingdom
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Lopez-Marco A, Harky A, Malvindi PG, Verdichizzo D, McPherson I, Roman M, Oo A, Ohri S. Type A aortic syndromes in COVID-19 positive patients: Case series from a UK multicentre study. J Card Surg 2021; 36:2692-2696. [PMID: 33982333 PMCID: PMC8242607 DOI: 10.1111/jocs.15625] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/23/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVE The coronavirus disease (COVID-19) increases the respiratory complications and carries a higher mortality in the immediate postoperative period. The aim of this study was to analyze the outcomes of patients with type A acute aortic syndromes (AAS) diagnosed with COVID-19 in the perioperative period. METHODS Retrospective analysis of prospectively collected data between March and August 2020 from 20 participating cardiac surgery centers in the United Kingdom. RESULTS Among 122 patients who underwent emergency surgical repair for type A AAS at the participating centers, 3 patients (2.5%) tested positive for COVID-19 in the preoperative screeing, and 4 cases turned to be positive in the postoperative period having been operated on an unknown COVID-19 status. Another patient was diagnosed of COVID-19 disease based on radiological features. These eight patients had increased postoperative complications, including respiratory failure, longer ventilation times, and Intensive Therapy Unit (ITU) stay and increased mortality when compared with COVID-19 negative patients. CONCLUSION COVID-19 disease in the perioperative period of type A AAS poses a challenge. Despite the increasing morbidity and mortality associated with the virus, the prognosis of the aortic disease is poorer and emergency surgery should not be contraindicated based on the COVID-19 diagnosis alone.
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Affiliation(s)
- Ana Lopez-Marco
- Departments of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Amer Harky
- Departments of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Pietro G Malvindi
- Departments of Cardiothoracic Surgery, University Hospital Southampton, Southampton, UK
| | - Danilo Verdichizzo
- Departments of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford, UK
| | - Iain McPherson
- Departments of Cardiothoracic Surgery, Freeman Hospital, Newcastle, UK
| | - Marius Roman
- Departments of Cardiothoracic Surgery, Glenfield Hospital, Leicester, UK
| | - Aung Oo
- Departments of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Sunil Ohri
- Departments of Cardiothoracic Surgery, University Hospital Southampton, Southampton, UK
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Lopez-Marco A, Das S, Serafino-Wani R, Selvakumar S, Adams B, Oo A. Endovascular Graft Infection by Neisseria meningitidis: A Rare but Fatal Infection. Aorta (Stamford) 2020; 8:148-151. [PMID: 33368101 PMCID: PMC7758115 DOI: 10.1055/s-0040-1715088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Endovascular graft infection is a rare but challenging complication that requires a tailored approach to remove the infected graft and restore the arterial circulation combined with long-term antibiotic therapy. We present a case surgically treated with explant of the graft and reconstruction of the thoracoabdominal aorta. Microbiological investigation revealed growth of
Neisseria meningitidis
, which is extremely rare in this location, and to our knowledge, has not been previously published in the literature.
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Affiliation(s)
- Ana Lopez-Marco
- Department of Cardiac Surgery, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Satya Das
- Department of Microbiology, St. Bartholomew's Hospital, London, United Kingdom
| | | | | | - Benjamin Adams
- Department of Cardiac Surgery, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Aung Oo
- Department of Cardiac Surgery, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
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17
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Lopez-Marco A, Rosser B, Harky A, Verdichizzo D, McPherson I, Hope E, Qadri S, Oo A. The fate of patients with acute aortic syndrome during the coronavirus disease 2019 (COVID-19) pandemic: A UK multicenter study. ACTA ACUST UNITED AC 2020; 5:17-25. [PMID: 34172983 PMCID: PMC7690305 DOI: 10.1016/j.xjon.2020.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 11/17/2020] [Indexed: 01/04/2023]
Abstract
Objective The coronavirus disease 2019 (COVID-19) pandemic has posed challenges to health care services across the world. There has been a significant restructuring of health care resources to protect services for patients with COVID-19–related illness and to maintain emergency and urgent medical and surgical activity. This study assessed access to emergency treatment, logistical challenges, and outcomes of patients with acute aortic syndrome during the early months of the COVID-19 pandemic in the United Kingdom. Methods This was a multicenter study, from March 1 to May 20, 2020 that included 19 cardiac centers, was a retrospective analysis of prospectively collected data obtained from individual centers' national cardiac surgical databases. Demographic details, choice of treatment, operative details, and outcomes were collected. COVID-19 screening, timing of surgery, and outcomes of COVID-19–positive and –negative patients were also analyzed. Results In total, 88 patients presented with acute aortic syndrome to participating centers from March 1 to May 20, 2020. There were 79 aortic dissections (89.8%), 7 intramural hematomas (7.9%), and 2 penetrating aortic ulcers (2.3%). Seventy-nine patients (89.8%) underwent surgery. In-hospital mortality was 25.3% (n = 20). Postoperative complications included 13.9% postoperative stroke (11.4% permanent and 2.3% temporary), 16.5% rate of hemofiltration, and 10.1% rate of tracheostomy. Nine patients were treated conservatively with a mortality of 60%. Seven patients were diagnosed with COVID-19, and there was no associated mortality. Conclusions Despite extensive restructuring of health care resources, access to emergency and urgent treatment for patients with acute aortic syndrome was maintained in the early months of the COVID-19 pandemic in the United Kingdom. Clinical outcomes were similar to the prepandemic period.
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Affiliation(s)
- Ana Lopez-Marco
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom
| | - Barbara Rosser
- Department of Cardiothoracic Surgery, Royal Brompton and Harefield NHS Trust, London, United Kingdom
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Danilo Verdichizzo
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford, United Kingdom
| | - Iain McPherson
- Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle, United Kingdom
| | - Emma Hope
- Department of Cardiothoracic Surgery, Southampton University Hospital, Southampton, United Kingdom
| | - Syed Qadri
- Department of Cardiothoracic Surgery, Blackpool Victoria Hospital, Blackpool, United Kingdom
| | - Aung Oo
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom
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18
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Roman M, Harky A, Brazier A, Lim K, Gradinariu G, Oo A, Mariscalco G, Lopez-Marco A. Turn down of acute aortic syndrome cases during COVID-19: Results from UK multicentre studies. J Card Surg 2020; 36:199-202. [PMID: 33169430 PMCID: PMC7839712 DOI: 10.1111/jocs.15187] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 10/10/2020] [Accepted: 10/13/2020] [Indexed: 01/16/2023]
Abstract
Objective The coronavirus disease 2019 (COVID‐19) pandemic has restructured the healthcare systems, prioritizing resources to treat COVID‐19 patients. The aim of this study was to establish if patients affected by acute aortic syndrome (AAS) had unrestricted access to emergency treatment and evaluate outcome of these patients during the peak of the pandemic. Methods This is a retrospective analysis of prospectively collected data between March and June 2020 from 19 participating cardiac surgery centers in the United Kingdom. Results Among 95 patients who presented with an AAS in the participating centers; 85 (89%) underwent surgery, 7 (7%) were turned down for surgery because of their profile of comorbidities, and 3 (3%) died on transfer. Among the patients treated conservatively, three of them (43%) were alive at 30 days. We observed no significant restriction in access to treatment for AAS during the early months of the pandemic. Conclusion Services for life‐threatening aortic surgery patients were maintained during the COVID‐19 period through patient selection and timing of surgery. The rate of surgical turn‐down was comparable to published figures despite the challenges faced during the COVID‐19 pandemic.
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Affiliation(s)
- Marius Roman
- Department of Cardiothoracic Surgery, Glenfield Hospital, Leicester, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Integrative Biology, Faculty of Life Sciences, University of Liverpool, Liverpool, UK.,Liverpool Heart and Chest Hospital, Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | - Andrew Brazier
- Department of Cardiothoracic Surgery, University Hospital Coventry, Coventry, UK
| | - Kelvin Lim
- Department of Cardiothoracic Surgery, The Royal Infirmary of Edinburgh, Edinburgh, UK
| | - George Gradinariu
- Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Aung Oo
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | | | - Ana Lopez-Marco
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
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19
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Yates MT, Balmforth D, Lopez-Marco A, Uppal R, Oo AY. Outcomes of patients diagnosed with COVID-19 in the early postoperative period following cardiac surgery. Interact Cardiovasc Thorac Surg 2020; 31:483-485. [PMID: 32791519 PMCID: PMC7454553 DOI: 10.1093/icvts/ivaa143] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/12/2020] [Accepted: 07/01/2020] [Indexed: 12/04/2022] Open
Abstract
The coronavirus 2019 (COVID-19) pandemic has disrupted patient care across the NHS. Following the suspension of elective surgery, priority was placed in providing urgent and emergency surgery for patients with no alternative treatment. We aim to assess the outcomes of patients undergoing cardiac surgery who have COVID-19 infection diagnosed in the early postoperative period. We identified 9 patients who developed COVID-19 infection following cardiac surgery. These patients had a significant length of hospital stay and extremely poor outcomes with mortality of 44%. In conclusion, the outcome of cardiac surgical patients who contracted COVID-19 infection perioperatively is extremely poor. In order to offer cardiac surgery, units must implement rigorous protocols aimed at maintaining a COVID-19 protective environment to minimize additional life-threatening complications related to this virus infection.
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Affiliation(s)
- Martin T Yates
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Damian Balmforth
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Ana Lopez-Marco
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Rakesh Uppal
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Aung Y Oo
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
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20
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Balmforth D, Yates MT, Lau K, Hussain A, Lopez-Marco A, Edmondson S, Oo A, Uppal R. Cardiothoracic surgery in the midst of a pandemic: Operative outcomes and maintaining a coronavirus disease 2019 (COVID-19)-free environment. ACTA ACUST UNITED AC 2020; 4:107-114. [PMID: 34173548 PMCID: PMC7510586 DOI: 10.1016/j.xjon.2020.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/18/2020] [Indexed: 11/16/2022]
Abstract
Objective In the United Kingdom, the coronavirus disease 2019 (COVID-19) pandemic has led to the cessation of elective surgery. However, there remains a need to provide urgent and emergency cardiac and thoracic surgery as well as to continue time-critical thoracic cancer surgery. This study describes our early experience of implementing a protocol to safely deliver major cardiac and thoracic surgery in the midst of the pandemic. Methods Data on all patients undergoing cardiothoracic surgery at a single tertiary referral center in London were prospectively collated during the first 7 weeks of lockdown in the United Kingdom. A comprehensive protocol was implemented to maintain a COVID-19-free environment including the preoperative screening of all patients, the use of full personal protective equipment in areas with aerosol-generating procedures, and separate treatment pathways for patients with and without the virus. Results A total of 156 patients underwent major cardiac and thoracic surgery over the study period. Operative mortality was 9% in the cardiac patients and 1.4% in thoracic patients. The preoperative COVID-19 protocol implemented resulted in 18 patients testing positive for COVID-19 infection and 13 patients having their surgery delayed. No patients who were negative for COVID-19 infection on preoperative screening tested positive postoperatively. However, 1 thoracic patient tested positive on intraoperative bronchoalveolar lavage. Conclusions Our early experience demonstrates that it is possible to perform major cardiac and thoracic surgery with low operative mortality and zero development of postoperative COVID-19 infection.
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Affiliation(s)
- Damian Balmforth
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom.,Queen Mary University of London, London, United Kingdom
| | - Martin T Yates
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom
| | - Kelvin Lau
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom
| | - Azhar Hussain
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom
| | - Ana Lopez-Marco
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom
| | - Stephen Edmondson
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom
| | - Aung Oo
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom.,Queen Mary University of London, London, United Kingdom
| | - Rakesh Uppal
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom.,Queen Mary University of London, London, United Kingdom
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21
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Hussain A, Balmforth D, Yates M, Lopez-Marco A, Rathwell C, Lambourne J, Roberts N, Lall K, Edmondson S. The Pan London Emergency Cardiac Surgery service: Coordinating a response to the COVID-19 pandemic. J Card Surg 2020; 35:1563-1569. [PMID: 32598501 PMCID: PMC7361315 DOI: 10.1111/jocs.14747] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Over the last 4 months, the novel coronavirus, SARS-CoV-2, has caused a significant economic, political, and public health impact on a global scale. The natural history of the disease and surge in the need for invasive ventilation has required the provision of intensive care beds in London to be reallocated. NHS England have proposed the formation of a Pan-London Emergency Cardiac surgery (PLECS) service to provide urgent and emergency cardiac surgery for the whole of London. In this initial report, we outline our experience of setting up and delivering a pan-regional service for the delivery of urgent and emergency cardiac surgery with a focus on maintaining a COVID-free in-hospital environment. In doing so, we hope that other regions can use this as a starting point in developing their own region-specific pathways if the spread of coronavirus necessitates similar measures be put in place across the United Kingdom.
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Affiliation(s)
- Azhar Hussain
- Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Damian Balmforth
- Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Martin Yates
- Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Ana Lopez-Marco
- Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Claire Rathwell
- Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | | | - Neil Roberts
- Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Kulvinder Lall
- Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Stephen Edmondson
- Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | -
- Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
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22
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Lopez-Marco A, Adams B, Oo AY. Thoracoabdominal aneurysmectomy: Operative steps for Crawford extent II repair. JTCVS Tech 2020; 3:25-36. [PMID: 34317802 PMCID: PMC8303063 DOI: 10.1016/j.xjtc.2020.06.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 06/09/2020] [Accepted: 06/19/2020] [Indexed: 10/29/2022] Open
Abstract
Background Open surgical repair remains the gold standard for treatment of thoracoabdominal aortic aneurysm (TAAA). Surgery aims to replace the whole length of the diseased distal aorta while protecting the spinal cord and the visceral organs to limit ischemia-related complications. The substantial associated surgical risks, including death, paraplegia, renal failure requiring permanent dialysis, and respiratory complications leading to prolonged intensive care unit stay, still outweigh the natural history of TAAA with conservative treatment. Methods We describe in detail our current approach to open extent II TAAA repair with a step-by-step illustration of the technique and the surgical adjuncts. Results We routinely perform left heart bypass with mild passive hypothermia (34°C), cerebrospinal fluid drainage, sequential aortic cross-clamping, monitoring of motor evoked potentials (MEPs) and cerebral, paraspinal, and lower limb oxygen saturation by near-infrared spectrometry, as well as selective visceral perfusion via the celiac and superior mesenteric arteries and renal protection with intermittent administration of Custodiol HTK (histidine-tryptophan-ketoglutarate) solution via the renal arteries. We advocate for individual branch reimplantation using a branched thoracoabdominal graft when possible, and we selectively reattach 1 or more pairs of the lower thoracic intercostal arteries and/or high lumbar arteries, even in the absence of a significant reduction in the MEPs signal. The distal anastomosis is usually constructed above the aortic bifurcation and occasionally to each iliac separately using a bifurcated graft. Conclusions Favorable early outcomes and a durable TAAA repair can be achieved at experienced high-volume centers with standardized preoperative selection and multidisciplinary team-based intraoperative and postoperative management of these patients.
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Affiliation(s)
- Ana Lopez-Marco
- Department of Cardiac Surgery, St Bartholomew's Hospital, London, United Kingdom
| | - Benjamin Adams
- Department of Cardiac Surgery, St Bartholomew's Hospital, London, United Kingdom
| | - Aung Ye Oo
- Department of Cardiac Surgery, St Bartholomew's Hospital, London, United Kingdom
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23
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Lopez-Marco A, Miller H, Kumar P, Ashraf S, Zaidi A, Bhatti F, Ionescu A, Youhana A. Outcome of isolated aortic valve replacement in patients with classic and paradoxical low-flow, low-gradient aortic stenosis. J Thorac Cardiovasc Surg 2017; 154:435-442. [PMID: 28412115 DOI: 10.1016/j.jtcvs.2017.02.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 01/20/2017] [Accepted: 02/20/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To analyze operative outcomes and mid-term results after isolated aortic valve replacement (AVR) in low-flow, low-gradient aortic stenosis (LFLG AS) by comparing the 2 subcategories (classic low-flow, low-gradient aortic stenosis [CLFLG] and paradoxical low-flow, low-gradient aortic stenosis [PLFLG]). METHODS This was a retrospective analysis of prospectively collected data for all isolated AVR in LFLG AS performed in our center during the last 13 years (n = 198; CLFLG AS, n = 66, 33% and PLFLG AS, n = 132, 67%). Median follow-up was 3.7 ± 3.3 years. RESULTS Preoperative mean gradient was 30.2 ± 8.8 mm Hg in the CLFLG AS group and 31.4. ± 7.0 mmHg in the PLFLG AS group (P = .001). Female sex, hypertension, and neurologic and renal disease were more frequent in the PLFLG AS group (P < .01) whereas advanced New York Heart Association class, atrial fibrillation, and pulmonary hypertension were more frequent in the CLFLG AS group (P < .01). In-hospital mortality was 3% in the CLFLG AS group and 2.3% in the PLFLG AS group, P = .08. One- and five-year mortality rates were significantly greater in the CLFLG AS group (27% and 42% vs 6% and 20% in the PLFLG AS group, respectively, P = .001). On follow-up, 90% of the total survivors were in New York Heart Association class I-II, and 51% of the patients in the CLFLG AS group had an improvement in their ventricular function. CONCLUSIONS AVR can be performed in LFLG AS with low in-hospital mortality. CLFLG AS carries similar in-hospital mortality to PLFLG AS but greater mid-term mortality. Surgery provided excellent functional status among survivors.
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Affiliation(s)
- Ana Lopez-Marco
- Department of Cardiothoracic Surgery, Morriston Hospital, Swansea, United Kingdom.
| | - Harriet Miller
- Department of Cardiothoracic Surgery, Morriston Hospital, Swansea, United Kingdom
| | - Pankaj Kumar
- Department of Cardiothoracic Surgery, Morriston Hospital, Swansea, United Kingdom
| | - Saeed Ashraf
- Department of Cardiothoracic Surgery, Morriston Hospital, Swansea, United Kingdom
| | - Afzal Zaidi
- Department of Cardiothoracic Surgery, Morriston Hospital, Swansea, United Kingdom
| | - Farah Bhatti
- Department of Cardiothoracic Surgery, Morriston Hospital, Swansea, United Kingdom
| | - Adrian Ionescu
- Department of Cardiology, Morriston Hospital, Swansea, United Kingdom
| | - Aprim Youhana
- Department of Cardiothoracic Surgery, Morriston Hospital, Swansea, United Kingdom
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24
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George J, Combellack T, Lopez-Marco A, Aslam U, Ahmed Y, Nanjaiah P, Youhana A, Kumar P. Winning Hearts and Minds: Inspiring Medical Students into Cardiothoracic Surgery Through Highly Interactive Workshops. J Surg Educ 2017; 74:372-376. [PMID: 27789191 DOI: 10.1016/j.jsurg.2016.10.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 08/01/2016] [Accepted: 10/01/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND The cardiothoracic surgical (CTS) specialty has witnessed a decline in the applicant pool. Early exposure, positive experiences, inspiring role models, and career insight are key in the decision-making process for specialty choice. Our objective was to assess the effect of high tutor:student ratio interactive CTS workshops in influencing the career choice of UK undergraduate medical students. METHODS Medical students attended a workshop comprising (1) guided dissection of fresh animal hearts, (2) surgical skills practice on models and fresh hearts, (3) operative videos (adult, congenital, transplant, and aortic) with interactive commentary, and (4) careers seminar. The tutor:student ratio was very high (between 3-1 and 5-1). A questionnaire was completed at the end of each workshop to assess its effect, including a 10-point Likert scale on the perceived attraction to CTS before and after the workshop. RESULTS A total of 96 delegates attended 5 workshops in 3 UK medical schools. Response rate was 83% from 80 undergraduate students. In all, 58% were male (46/80). There was an equal proportion of sexes in the early years of medical school, but was significantly skewed toward male in the later years. There was a statistically significant increase of 2.1 (standard deviation [SD] = 1.5) in the Likert scores before (μ = 5.0, SD = 2.1) and after (μ = 7.1, SD = 1.9) (p = 0.001). This represents a 42% increase in the perceived attraction to the CTS specialty because of the workshops. CONCLUSIONS Our workshops have a significant effect in stimulating undergraduate medical students toward a career in cardiothoracic surgery. We encourage national take-up of these easily organized daylong workshops to foster interest in the next generation of cardiothoracic surgeons.
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Affiliation(s)
- Joseph George
- Department of Cardiothoracic Surgery, Morriston Hospital, Swansea, United Kingdom.
| | - Tom Combellack
- Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Ana Lopez-Marco
- Department of Cardiothoracic Surgery, Morriston Hospital, Swansea, United Kingdom
| | - Umair Aslam
- Department of Cardiothoracic Surgery, Morriston Hospital, Swansea, United Kingdom
| | - Yasir Ahmed
- Department of Cardiothoracic Surgery, Morriston Hospital, Swansea, United Kingdom
| | - Prakash Nanjaiah
- Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Aprim Youhana
- Department of Cardiothoracic Surgery, Morriston Hospital, Swansea, United Kingdom
| | - Pankaj Kumar
- Department of Cardiothoracic Surgery, Morriston Hospital, Swansea, United Kingdom
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25
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Lopez-Marco A, Syed A, Combellack T, Mehta D. Iatrogenic Lesion of an Anomalous Circumflex Coronary Artery During Mitral Surgery. Ann Thorac Surg 2016; 102:e525-e527. [DOI: 10.1016/j.athoracsur.2016.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 04/06/2016] [Accepted: 05/03/2016] [Indexed: 10/20/2022]
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26
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Lopez-Marco A, Miller H, Youhana A, Ashraf S, Zaidi A, Bhatti F, Ionescu A, Kumar P. Low-flow low-gradient aortic stenosis: surgical outcomes and mid-term results after isolated aortic valve replacement. Eur J Cardiothorac Surg 2016; 49:1685-90. [DOI: 10.1093/ejcts/ezv449] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 11/19/2015] [Indexed: 12/17/2022] Open
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Abstract
We present a patient with a large thymoma on the right thoracic cavity developing from the visceral pleura. This is a rare location for this tumour, and only a few had been reported to date in the literature.
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Affiliation(s)
- Ana Lopez-Marco
- Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, UK
| | - Naail Al-Zuhir
- Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, UK
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28
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Lopez-Marco A, Tymko R, Von Oppell U. Valve Replacement for Moderate Aortic Stenosis in Octogenarians Undergoing Revascularization. J Heart Valve Dis 2015; 24:405-411. [PMID: 26897807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY The study aim was to determine if the 'prophylactic' replacement of the aortic valve to treat moderate aortic valve stenosis (AS) in octogenarians undergoing cardiac surgery for coronary disease can influence outcome, and is also justified. METHODS In a retrospective analysis of octogenarians operated on at the authors' center between 1998 and 2012, the patients were allocated to: Group I, isolated coronary artery bypass graft surgery (CABG; n = 159); Group II, combined CABG and aortic valve replacement (AVR) with the primary indication for surgery being severe AS (n = 156); and Group III, combined AVR +CABG with coronary disease being the primary indication and concomitant 'prophylactic' AVR (n = 34). RESULTS The hospital mortality for octogenarians undergoing CABG+AVR was 8% compared to 2% for isolated CABG (p = 0.02). Survival at one year was higher in the isolated CABG group (94%) than in the CABG+AVR group (86%) (p = 0.01), but was no different at five years. Mortality according to AVR indication was similar (Group II 8% versus Group III 9%), as was one- and five-year survival. Group III had a higher preoperative co-morbid risk profile, including logistic EuroSCORE 21.7% versus 18% in Group II (p = 0.05), more recent myocardial infarctions, previous percutaneous interventions, peripheral vascular disease, and poor left ventricular function. Long-term symptomatic relief was excellent in Group III. Patients whose predominant disease profile was ischemic (Groups I and III) had a higher long-term risk of recurrent angina and stroke. CONCLUSION In-hospital mortality is higher for octogenarians undergoing CABG+AVR compared to those undergoing isolated CABG. In the present study, a 'prophylactic' AVR was justified in patients with moderate AS, and their increased mortality (versus isolated CABG) was congruent with a higher preoperative co-morbid risk profile. Excellent long- term symptom-free survival further justifies 'prophylactic' AVR in octogenarians undergoing CABG with coexistent moderate AS.
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