Volume 19 Supplement 2
SCTS Annual Meeting 2024: Abstracts
- Meeting Abstracts
- Open access
- Published:
Journal of Cardiothoracic Surgery volume19, Articlenumber:702 (2025) Cite this article
-
945 Accesses
-
2 Altmetric
-
Metrics details
A1 Surgical prehabilitation in an acute tertiary centre: an evaluation
Melissa Taylor
University Hospitals Bristol and Weston, Bristol, United Kingdom
Correspondence: Melissa Taylor
Journal of Cardiothoracic Surgery 2024, 19(2):A1
Objective: The aim of this study is to evaluate the impact of a physiotherapy led prehabilitation program on functional capacity, strength and health related quality of life in patients undergoing major surgery at UHBW.
Methods: A service evaluation of quantitative measures. In 2019, UHBW set up a physiotherapy led prehabilitation service to those listed for major surgery. Assessment screened for physical, nutritional and psychological risk factors. Personalised exercise programs, targeted nutritional, smoking, alcohol and wellbeing support were provided. Interventions were delivered both face to face and virtually. Strength, functional capacity and health related quality of life were measured by the 30 s sit to stand test, grip strength and EQ-5D-5L.
Results: 795 patients were enrolled in the prehabilitation programme between 15th June 2021 and 5th January 2023. Mean age 67 years. 380 (48%) patients were on a thoracic pathway. Other specialities included colorectal (20%) upper gastrointestinal (7%), hepatobiliary (9%), head and neck (5%) and gynaecology (5%). Data shows a significant improvement in 30 s sit to stand score, mean difference + 2.9 (P < 0.01) n = 305. No significant change in grip strength, mean difference -0.4 kg (P 0.42) n = 99. A significant Improvement in EQ-5D-5L index score. + 0.05 (P < 0.01) n = 325.
Conclusion: A physiotherapy led prehabilitation programme can improve functional capacity and health related quality of life in patients prior to major surgery, evidenced by a significant improvement in a 30 s sit to stand test and patient reported quality of life questionnaire.
A2 Using video-based discharge instructions as an adjunct to standard verbal and written instructions to improve patient comprehension and experience
Joseph Renwick
South Tees Hospitals NHS Foundation Trust, Middlesbrough, United Kingdom. Edge Hill University, Manchester, United Kingdom
Correspondence: Joseph Renwick
Journal of Cardiothoracic Surgery 2024, 19(2):A2
Introduction: This project examines the utilisation of video-based discharge instructions to assess their impact on the comprehension and experience of postoperative cardiac surgical patients. As the NHS evolves, innovative technologies are being sought to enhance patient information delivery, particularly focusing on individuals facing comprehension barriers due to low literacy levels.
Methods: A pre-and post-test design was utilised to assess the impact of video-based discharge instructions on improving comprehension and experience post-cardiac surgery. The project included a convenience sample of 20 postoperative cardiac surgical patients. Before receiving the video-based discharge instructions, participants completed a pre-test of 5 multiple-choice questions assessing their comprehension of postoperative care instructions. Upon completion, participants received a mobile electronic device to view the video-based discharge instructions. Approximately 10 min later, participants completed a post-test identical to the initial assessment. Statistical analysis used a paired t-test to compare pre-and post-test scores.
Results: The pre- and post-test analysis observed improvement in scores with a mean increase from 3.00 to 4.25. The statistical analysis produced a significant p-value of 0.000264. Among the participants who received the video-based discharge instructions, 63% rated their experience as 'Excellent', 30% as ‘Good and 6% as ‘Satisfactory”.
Conclusion: Video-based discharge instructions represent a promising approach to improving comprehension and experience for postoperative cardiac surgical patients. This project has demonstrated the effectiveness of integrating technology to bridge communication gaps and optimise patient care. Further studies are needed to confirm the validity of the findings.
A3 Patterns of cytokine release and association with new onset of post-cardiac surgery atrial fibrillation
Rahul Kota1, Marco Gemelli2, Arnaldo Dimagli2, Saadeh Suleiman2, Marco Moscarelli2, Tim Dong2, Gianni Angelini2, Daniel Fudulu2
1Bristol Medical School, Bristol, United Kingdom. 2Departement of Cardiac Surgery, Bristol Heart Institiute, Bristol, United Kingdom
Correspondence: Rahul Kota
Journal of Cardiothoracic Surgery 2024, 19(2):A3
Introduction: Postoperative Atrial Fibrillation (POAF) is a common complication of cardiac surgery, associated with increased mortality, stroke risk, cardiac failure and prolonged hospital stay. Our study aimed to assess the patterns of release of systemic cytokines in patients with and without POAF.
Methods: A post-hoc analysis of the Remote Ischemic Preconditioning (RIPC) trial, including 121 patients (93 males and 28 females, mean age of 68 years old) who underwent isolated coronary artery bypass grafting (CABG) and aortic valve replacement (AVR). Mixed-effect models were used to analyze patterns of release of cytokines in POAF and non-AF patients. A logistic regression model was used to assess the effect of peak cytokine concentration (6 h after the aortic cross-clamp release) alongside other clinical predictors on the development of POAF.
Results: We found no significant difference in the patterns of release of IL-6 (p = 0.52), IL-10 (p = 0.39), IL-8 (p = 0.20) and TNF-α (p = 0.55) between POAF and non-AF patients. Also, we found no significant predictive value in peak concentrations of IL-6 (p = 0.2), IL-8 (p = > 0.9), IL-10 (p = > 0.9) and Tumour Necrosis Factor Alpha (TNF-α) (p = 0.6), however age and aortic cross-clamp time were significant predictors of POAF development across all models.
Conclusions: Our study suggests no significant association exists between cytokine release patterns and the development of POAF. Age and Aortic Cross-clamp time were found to be significant predictors of POAF.
IL-6, IL-10, IL-8 and TNFα concentration at baseline and at 1, 6, 12, 24, 48 and 72 h postreperfusion in AF and non-AF patients. Data are the mean ± SEM, data were analyzed using a mixed model. Abbreviations: Atrial Fibrillation (AF), Interleukin (IL), Tumour Necrosis Factor (TNF)
A4 An evaluation of the content quality, readability, and reliability of publicly available web-based information on pneumothorax surgery in Ireland
Martin Ho1,2, Samin Abrar1,2, Patrick Higgins2, Kishore Doddakula2
1University College Cork, Cork, Ireland. 2Department of Cardiothoracic Surgery, Cork University Hospital, Cork, Ireland
Correspondence: Martin Ho
Journal of Cardiothoracic Surgery 2024, 19(2):A4
Background: The internet is often a first port-of-call for patients exploring treatment options for pneumothoraces. It is important that websites are of good quality, accurate and reliable so as to confer patients the ability to make informed health decisions. No study has evaluated online information regarding pneumothorax surgery.
Objective: Evaluate the readability, reliability, and content of online information regarding pneumothorax surgery.
Methods: A cross-sectional review of the most encountered websites concerning pneumothorax surgery was performed using the three most common search engines; Google, Bing and Yahoo. The first twenty websites encountered using each of the eleven search terms were assessed for inclusion. The Journal of American Medical Association (JAMA) and DISCERN criteria were used to assess website reliability while ten validated assessment tools were used to evaluate readability. Website content was evaluated using a novel ten-part criteria devised by the authors.
Results: N = 79 websites were analysed. The mean JAMA score was 1.69 ± 1.29 out of 4. The mean readability score was 15.19 ± 9.64 which corresponded to a 13th–14th school grade standard. Only four websites were written at a 6th-grade reading level. The mean number of content criteria met was 7 ± 2.18 out of 10. Notably, 31% of websites did not mention any side effects of pneumothorax surgery. 38% did not mention alternative treatment options.
Conclusions: Overall, the most encountered websites concerning pneumothorax surgery were written at a language level above the general population and often lacked expected content. This emphasises the need for comprehensive, reliable websites on pneumothorax surgery.
A7 Patient-reported outcome measures in congenital heart surgery: a systematic review
Jeevan Francis1, Sneha Prothasis1, Joseph George2, Serban Stoica3
1Aberdeen Royal Infirmary, Aberdeen, United Kingdom. 2Birmingham Children's Hospital, Birmingham, United Kingdom. 3Bristol Children's Hospital, Bristol, United Kingdom
Correspondence: Jeevan Francis
Journal of Cardiothoracic Surgery 2024, 19(2):A7
Background: Patient-reported outcome measures are commonly used to evaluate the effective- ness of treatments. CHD remains the most common congenital malformation. There has been a gradual shift in evaluating the outcome of surgery for CHD from mortality to morbidity and now to self-reported outcomes.
Aims: We aimed to review studies assessing patient-reported outcome measures as a useful marker of outcome for patients, both children and adults, who underwent surgery for CHD.
Methods: A systematic database search was conducted of original articles that explored the application of patient-reported outcome measures in the CHD surgical setting in PubMed and SCOPUS from inception to February 2022.
Results: Our search yielded 1511 papers, of which six studies were included in this review after screening abstract and full-text, with a total sample size of 5734 patients. The main areas of discussion were the utility of patient-reported outcome measures, determinants of patient-reported out- come measures, and the need for a congenital cardiac surgery-specific patient-reported out- come measure for paediatric patients and their parents/guardians and adult patients.
Conclusion: This systematic review reports the use of patient-reported outcome measures to be a useful indicator to gain insight into the patients’ perspective to provide holistic and patient-centred management. However, further studies are required to assess the utility of patient-reported outcome measures in a congenital cardiac surgical setting.
A8 Safe management of tension pneumothorax and reinforcement of LocSSIP: a quality improvement project
Michelle Lee, Al-Rehan Dhanji, Evgeny Raevsky, David Waller, Henrietta Wilson
Barts Thorax Centre, London, United Kingdom
Correspondence: Michelle Lee
Journal of Cardiothoracic Surgery 2024, 19(2):A8
Objectives: Tension pneumothorax is a life-threatening situation, and its management requires quick diagnosis and decisive treatment. We aim to evaluate the current alertness of the cardiothoracic team and availability of resources necessary to deliver safe and effective treatment for tension pneumothorax.
Method: During normal working hours, unannounced simulations would take place. Junior doctors were presented with a scenario of acute shortness of breath, leading to a diagnosis of tension pneumothorax. They had to follow a diagnostic process and present a management plan. Following the results of the first cycle, an intervention, consisting of teaching and sending distribution of information outlining the algorithm for decision making, was organised. The second cycle of audit was performed in the following weeks.
Results: 20 simulations involving junior doctors working at the Cardiothoracic surgery or the intensive care unit were recorded. Primary endpoints of the study are shown in the table below. We compared the results in two cycles and have demonstrated an improvement in each of the endpoints.
We managed to achieve a substantial improvement in all endpoints. We believe regular participation in hands-on training helped to prepare our team for what can be a very stressful clinical scenario. We plan to turn this into a cyclic audit to help maintain the skills, especially with the rotation of doctors.
Conclusion: Training through simulation of clinical scenarios is a proven method. We believe that this audit could be useful to every cardiothoracic department.
A9 Effects on glycaemic control by continuous intravenous regular insulin with or without subcutaneous glargine basal insulin in patients with diabetes following coronary artery bypass grafting surgery
Md Salahuddin Rahaman1, Iram Shahazadi2, Md. Kamrul Hasan3, Sanhjay Kumar Raha3
1National University Hospital (NUH), Singapore, Singapore. 2Dhaka Medical College Hospital (DMCH), Dhaka, Bangladesh. 3National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh
Correspondence: Md Salahuddin Rahaman
Journal of Cardiothoracic Surgery 2024, 19(2):A9
Background: Traditionally hyperglycemia in cardiac surgical inpatients has been managed with either subcutaneous sliding-scale or continuous intravenous infusion of regular insulin. However, this approach is usually ineffective in preventing hyperglycemia since no basal insulin is provided. We compared glycemic control using continuous infusion of regular insulin alone versus combined with glargine insulin in patients after CABG surgery postoperatively in the ICU.
Objectives: The purpose of the study was to determine the effect of controlling the blood sugar level following CABG up to 2nd POD in diabetic patients by the combined use of continuous intravenous regular insulin and subcutaneous glargine basal insulin.
Methods: A total of 60 patients were included in this study. Sample selected by purposive sampling technique. Blood glucose level was targeted at 7–10 mmol/L (120–180 mg/dL). The patients were divided into two groups. Diabetic patients in Group A had their blood glucose controlled by continuous regular insulin without subcutaneous glargine, while diabetic patients in Group B had their blood glucose controlled by continuous regular insulin plus subcutaneous glargine.
Result: In this study, the total postoperative blood glucose level (mmol/L) in patients with a history of diabetes was significantly lower in Group B (27.74 ± 2.52) than in GroupA (36.44 ± 2.30) (p < 0.001). Postoperative sternal wound infections, AKI, and postoperative hospital stay were significantly higher in Group A.
Conclusion: The current study demonstrates that postoperative DM can be effectively managed with subcutaneous Glargine added to continuous intravenous insulin infusion resulting in significantly better control over postoperative morbidity.
A10 The clinical impact of paravalvular leaks with Transcutaneous Aortic Valve Implantation (TAVI) versus Surgical Aortic Valve Replacement (SAVR) systematic review and meta-analysis
Karim R. Moawad1,2, Saifullah Mohamed1, Alaa Hammad1, Thomas Barker1
1University Hospital Coventry and Warwickshire NHS trust, Coventry, United Kingdom. 2University of Edinburgh, Edinburgh, United Kingdom
Correspondence: Karim R. Moawad
Journal of Cardiothoracic Surgery 2024, 19(2):A10
Background: Aortic valve stenosis is a common cardiac condition that requires intervention for symptomatic and prognostic reasons. The two most common interventions are (SAVR) and (TAVI).
The ratio of TAVI: SAVR has increased twofold over the past few years and is now being considered in intermediate-risk patients as well. One of the significant benefits of TAVI is being less invasive; however, one of the drawbacks is a high PVLs rate compared to SAVR.
Aim: To assess the impact of PVLs on survival, progression of heart failure, and the need for re-intervention.
Methods: We conducted a comprehensive systematic literature search from the conception of TAVI 2002 until December 2022 through Embase (Ovid), MEDLINE (Ovid), Science Direct, and (CENTRAL; Wiley). Following PRISMA guidelines and checklist.Review protocol registration ID in PROSPERO: CRD42023393742.
Results: We identified 28 studies that met our eligibility criteria, 24 studies were suitable for pooling in a meta-analysis (including their HR and a CI of 95%) assessing all-cause mortality. The remaining four studies were narratively synthesized. Revman V5.4 utilized meta-analysis data to assess effect estimates of PVLs, using a random effect model for calculation (HR 1.14 CI 95% 1.08–1.21 (P < 0.0001)) with a follow-up duration range of 30 days to 5 years.
Conclusion: Mild or higher degrees of PVLs in both intervention arms incurred unfavorable outcomes. The incidence of PVLs was significantly higher with TAVI; even a mild degree led to poor quality of life and increased all-cause mortality on long-term follow-up.

A11 Indications and outcome of pulmonary lobectomy and total pneumonectomy under ECMO support
Michael Schweigert1, Thomas Puehler1, Ana Beatriz Almeida1, Attila Dubecz2, Patrick Kellner1, Ahmed Hamdouna1, Stephan Ensminger1, Carla Nau1, Tobias Keck1
1University Hospital Schleswig–Holstein, Luebeck, Germany. 2Klinikum Nuremberg, Nuremberg, Germany
Correspondence: Michael Schweigert
Journal of Cardiothoracic Surgery 2024, 19(2):A11
Objectives: The application of ECMO in general thoracic surgery has become more common during recent years. However, there is still a scarcity of information regarding indications and outcome of major anatomical lung resections under ECMO support.
Methods: At a German university hospital all patients, who underwent pulmonary lobectomy or pneumonectomy under ECMO support, were identified from a prospectively collected database. Study period was 01/2018 to 06/2023.
Results: There was a total of 27 patients (9 female) with a median age of 59 years (IQR 11.5 years) and a median Charlson score of comorbidity of 1 (IQR 2). Indications for surgery were lung cancer (5), pulmonary abscess formation (20) and aspergilloma with aorto-pulmonary fistula (2). Operative procedures were pulmonary lobectomy (23) and total pneumonectomy (4). ECMO setting was VV-ECMO (24) or VVA-ECMO (3). Mean ECMO days were 6.65 (1–23 days), mean ICU days 24.3 ± 11.9 and mean LOS 31.3 days ± 17.2. Successful weaning from ECMO was achieved in 21 patients. In-hospital mortality was 7/27 and additional 90-day-mortality was 1. There was no significant difference in mortality between lobectomy and pneumonectomy (0/4 vs. 7/23; OR 0.24, 95% CI: 0.01 to 5.14; p = 0.36). Perioperative sepsis was associated with higher odds for fatal outcome (7/19 vs. 0/8; OR 10.20, 95% CI: 0.51–203.32, p = 0.13).
Conclusion: ECMO is an excellent tool to overcome marginal functional operability in elective patients with technical resectable lung cancer and to overcome temporal functional inoperability in emergency patients with conditions requiring pulmonary lobectomy or pneumonectomy.
A12 Left atrial dissection: an unique complication of mitral valve surgery
Hazem ALJASEM, Hani Ali-Ghosh, Sunil Ohri
University Hospital Southampton, Southampton, United Kingdom
Correspondence: Hazem Aljasem
Journal of Cardiothoracic Surgery 2024, 19(2):A12
Background: Left atrial dissection is an unique but an extremely rare complication associated with cardiac surgery especially mitral valve surgery.
Case Presentation: Here we presented a case report of a 76-year old lady who had mitral valve surgery complicated with left atrial dissection managed surgically. Interestingly, we proposed a new classification of left atrial dissection, which could guide the surgeon in the management of this complication.
Conclusions: left atrial dissection might be a lethal complication associated with mitral surgery and can be smanaged surgically and non surgically depending on the clinical courser and haemodynamic state. The new proposal can help the surgeons to put the management plan.

The proposed classification:
- I.
Partial rupture associated with LA dissection
- II.
Partial rupture associated with para prosthesis leak with or without LA dissection
- III.
Partial rupture associated with LA dissection with exit outside the heart causes bleeding
- IV.
Type I LV rupture (complete).
Ao: aorta, LA: left atrium, LV: left ventricle, T: true lumen, F: false lumen
The patient gave their written, informed consent to publish their information in an open access journal.
A13 Changes in surgical aortic valve replacement population and outcomes after the partner 3 trial
Casey Briggs, Jonathan Afoke, Elvis Camacho, Austin Todd, Gabor Bagameri
Mayo Clinic, Rochester, USA
Correspondence: Casey Briggs
Journal of Cardiothoracic Surgery 2024, 19(2):A13
Objectives: Transcatheter aortic valve implantation (TAVI) has changed the paradigm of treatment for aortic valve disease. The PARTNER 3 trial published in 2019 have demonstrated significantly better early outcomes after TAVI compared to surgical aortic valve replacement (SAVR). Our aim is to describe changes in the SAVR population and outcomes after publication of this trial.
Methods: We retrospectively reviewed the records of 2,952 consecutive patients who had first time SAVR ± coronary artery bypass grafting (CABG) in our institution from January 2017 through December 2022. The cohort was divided into the 2017 to 2019 and 2020 to 2022 time periods. Patient and procedure related characteristics were compared between the two cohorts.
Results: Patients in the 2020 to 2022 time period had significantly higher baseline renal failure (6.6% vs 3.8%, p < 0.001), recent congestive heart failure (18.7% vs. 11.8%, p < 0.001), recent atrial arrhythmia (18.9% vs. 15.1%, p = 0.005) with a trend to higher mean age (75.5 ± 10.8 vs. 74.7 ± 11.6 years, p = 0.051). This was associated with no significant difference in operative mortality (0.6% vs 0.6%, p = 0.94), but with a reduction in stroke (0.7% vs. 1.7%, p = 0.009) and increase in permanent pacemaker rate (15.1% vs 10.8%, p = 0.001).
Conclusions: After publication of the PARTNER 3 trial, there has been a significant increase in co-morbidities in the SAVR population. However, this has not led to an increase in mortality or post-operative morbidity. Surgical aortic valve replacement remains an intervention associated with low mortality and morbidity.
A14 Flap reconstruction for deep sternal wound infection with osteomyelitis and mycotic aneurysm of the aortic arch: a case report
Jenny Zhang1, Andre Lo1,2, Pradeep Kaul3, Ravi De Silva3, Marius Berman3, Charles Malata4, Kai Yuen Wong4
1University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom. 2University of Sydney Faculty of Medicine and Health, Sydney, Australia. 3Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom. 4Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
Correspondence: Jenny Zhang
Journal of Cardiothoracic Surgery 2024, 19(2):A14
Background: Deep sternal wound infection (DSWI) is an uncommon complication of cardiac surgery. We review the literature and present a rare case of sternal osteomyelitis and aortic aneurysm secondary to Aspergillus fumigatus in a combined heart and kidney transplant patient.
Case: A 55-year-old female developed an Aspergillus fumigatus DSWI 6 months following a combined heart and kidney transplant. Surgical debridement with vacuum assisted closure was performed with limited success. An interval CT revealed a progressive ascending aortic aneurysm in direct contact with the posterior surface of the sternum. There were signs of sternal osteomyelitis surrounded by a subcutaneous chest wall and retrosternal abscess.
A multidisciplinary team meeting involving the cardiothoracic, plastic surgery, radiology, microbiology and anaesthesiology teams discussed management options. The consensus was for a one-stage operation. Due to the aneurysm abutting the sternum, the first part of the operation involved cardiopulmonary bypass, excision of the mycotic aneurysm and replacing it with a homograft. Heparinisation was then reversed to allow radical debridement. The central chest defect was then reconstructed using a free anterolateral thigh musculocutaneous flap with vastus lateralis muscle. At two years follow up she remains well on lifelong prophylactic antimicrobials. The wound remains well healed with no recurrence of the infection.
Conclusion: Our patient had an excellent outcome despite using a single stage approach. This case highlights the importance of an MDT approach including radical debridement and robust reconstruction using vascularised healthy tissue for DSWIs.
The legend for the figure can be as follows: "Diagram with images demonstrating reconstruction of debrided central chest defect using free anterolateral thigh musculocutaneous flap."
Patient gave their written, informed consent to publish their information in an open access journal
A15 Surgical repair of aortic root aneurysms in young populations: a contemporary meta-analysis of valve-sparing and composite valve graft root replacements
Hayden Simmons
University of Bristol, Bristol, United Kingdom
Correspondence: Hayden Simmons
Journal of Cardiothoracic Surgery 2024, 19(2):A15
Objectives: Provide an overview of the two main aortic root replacement procedures and perform a random-effects meta-analysis to make a comparison of outcomes, primarily early mortality, between valve-sparing (David) and composite valve graft (Bentall) root replacement procedures.
Methods: A systematic literature search was performed; 29 potentially relevant studies were identified, 3 of which were included in quantitative synthesis. Articles that were duplicates, meta-analyses, systematic reviews, case reports, focused on aortic dissections, did not contain both required surgical procedures, or contained patient populations older than 50 years on average were not included. A random-effects meta-analysis of standardised mean difference of three main outcomes (early mortality, CVA), and reoperation for bleeding) was performed, and then results were analysed to assess for effect size and statistical significance.
Results: When pooled, the VSRR group contained 424 patients, and the Bentall group contained 318 patients, all with a mean age below 50 years. Early mortality data analysis produced a SMD of small effect size of − 0.20, CI [− 1.80; 1.41]. CVA data analysis gave a SMD of − 0.88, [− 12.96; 11.19], with large effect size. Reoperation for bleeding event data analysis gave a SMD of − 0.10, [− 0.72; 0.52]. Overall, all analyses yielded CIs that contained 0—deeming them to not be statistically significant.
Conclusions: We have shown that there is no statistically significant difference in the assessed post-operative outcomes between these two procedures. The recommendation made is to be informed by potential comorbid features and to encourage shared decision-making between surgeons expressing their preference, and aligning these with patient wishes.
A16 What needs to be done before embarking on radical surgery for mesothelioma? The implications for preoperative workup
Andres Salcedo
Guys Hospital London, London, United Kingdom
Correspondence: Andres Salcedo
Journal of Cardiothoracic Surgery 2024, 19(2):A16
Objective: Preoperative assessment of histological sub-type and nodal metastasis influences treatment selection and prognosis. We aimed to evaluate the accuracy of preoperative assessment and its effect on postoperative survival after pleurectomy/decortication (P/D).
Methods: P/D or extended P/D was performed in 73 patients: 62 male (85%), 11 female (15%), age 66.8 (33–79). All patients were evaluated with CT thorax/abdomen. 23 (32%) also had CTPET. Only 1 patient had invasive mediastinal staging. 56 (78%) had induction chemotherapy and all had restaging CT.
Results: Accurate preop assessment of both cell type and nodal stage was found in only 26 (36%) patients.
Cell type discordance between preop assessment and postop histology was found in 19 (26%) pts. In 16 (22%) there was negative discordance (epithelioid to biphasic) whilst 3 (4%) had positive discordance. Negative discordance was associated with significantly inferior survival to those with concordant findings (p = 0.029).
Cell type discordance was found in 9 of 39 pts (23%)- VATS biopsy; 6 of 15 (40%)—biopsy via medical thoracoscopy and 4 of 18 (22%)—US/CT guided percutaneous biopsy. The method of biopsy had no significant effect on the rate of discordance (p = 0.4).
Conclusions: Assessment before radical surgery should be maximized to improve postoperative survival. Multiple, multi-site pleural biopsies are needed to reduce cell type inaccuracy. Both cell type and nodal discordance should be noted as potential confounding factors in the interpretation of comparative survival between surgical and non-surgical modalities.

A17 Optimization of management for esophageal cancer patients
Oleg Kshivets
Bagrationovsk Hospital, Surgery Depaetment, Bagrationovsk, Russian Federation
Correspondence: Oleg Kshivets
Journal of Cardiothoracic Surgery 2024, 19(2):A17
Objective: 5-survival (5YS) and life span after radical surgery for esophageal cancer (EC) patients (ECP) (T1-4N0-2M0)—alive supersysems was analyzed. The importance must be stressed of using complex system analysis, artificial intelligence (neural networks computing), simulation modeling and statistical methods in combination, because the different approaches yield complementary pieces of prognostic information.
Methods: We analyzed data of 563 consecutive ECP (age = 56.6 ± 8.9 years; tumor size = 6 ± 3.5 cm) radically operated (R0) and monitored in 1975–2024 (m = 419, f = 144; esophagogastrectomies (EG) Garlock = 289, EG Lewis = 274, combined EG with resection of pancreas, liver, diaphragm, aorta, VCS, colon transversum, lung, trachea, pericardium, splenectomy = 170; adenocarcinoma = 323, squamous = 230, mix = 10; T1 = 131, T2 = 119, T3 = 185, T4 = 128; N0 = 285, N1 = 71, N2 = 207; G1 = 161, G2 = 143, G3 = 259; early EC = 112, invasive = 451; only surgery = 428, adjuvant chemoimmunoradiotherapy-AT = 135: 5-FU + thymalin/taktivin + radiotherapy 45-50Gy). Multivariate Cox modeling, clustering, SEPATH, Monte Carlo, bootstrap and neural networks computing were used to determine any significant dependence.
Results: Overall life span (LS) was 1915.4 ± 2284.8 days and cumulative 5-year survival (5YS) reached 52.6%, 10 years—46.3%, 20 years—33.3%, 30 years—27.5%. 193 ECP lived more than 5 years (LS = 4309.1 ± 2507.4 days), 105 ECP—more than 10 years (LS = 5860.8 ± 2469.2 days). 228 ECP died because of EC (LS = 629.8 ± 324.1 days). AT significantly improved 5YS (69% vs. 49.1%) (P = 0.0007 by log-rank test). 5YS of ECP of upper/3 was significantly better than others (65.3% vs. 50.3%) (P = 0.003). Cox modeling displayed that 5YS of ECP significantly depended on: phase transition (PT) N0—N12 in terms of synergetics, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), T, G, histology, age, AT, localization, prothrombin index, hemorrhage time, residual nitrogen, protein (P = 0.000–0.019). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and healthy cells/CC (rank = 1), PT N0—N12 (2), PT early-invasive EC (3), erythrocytes/CC (4), thrombocytes/CC (5); segmented neutrophils/CC (6), stick neutrophils/CC (7), lymphocytes/CC (8), eosinophils/CC (9), monocytes/CC (10), leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve = 1.0; error = 0.0).
Conclusions: 5YS of ECP after radical procedures significantly depended on: (1) PT “early-invasive cancer”; (2) PT N0–N12; (3) Cell Ratio Factors; (4) blood cell circuit; (5) biochemical factors; (6) hemostasis system; (7) AT; (8) EC cell dynamics; (9) EC characteristics; (10) tumor localization; (11) anthropometric data; (12) surgery type. Optimal diagnosis and treatment strategies for EC are: (1) screening and early detection of EC; (2) availability of experienced thoracoabdominal surgeons because of complexity of radical procedures; (3) aggressive en block surgery and adequate lymph node dissection for completeness; (4) precise prediction; (5) adjuvant chemoimmunoradiotherapy for ECP with unfavorable prognosis.

A18 Fate of bioprosthetic surgical aortic valves in young adult patients
Halil Ibrahim Bulut Bulut, Maria Comanici, Nandor Marczin, Sunil K. Bhudia, Shahzad G. Raja
Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
Correspondence: Halil Ibrahim Bulut Bulut
Journal of Cardiothoracic Surgery 2024, 19(2):A18
Objective: There remains ongoing controversy regarding the use of bioprosthetic valves in young adult patients undergoing aortic valve replacement. We investigate the impact of using bioprosthetic valves on the need for redo surgery and long-term survival in individuals under the age of 60.
Methods: A total of 263 adult patients underwent elective or urgent isolated surgical aortic valve replacement (SAVR), between April 2011 and December 2018, using Perimount Magna Ease bioprosthetic aortic valves. Among them, 84 patients were aged between 18 and 59 years, while 179 patients were aged between 60 and 69. The median follow-up time extended to 71 months. Statistical analyses were performed using SPSS version 22.0.
Results: The average age of study cohort was 61.5 years with 34.6% of them being female. Among these individuals, 63.5% had pure aortic stenosis. There was more prevalence of PVD (P = 0.031), COPD (P = 0.007), and hypertension (P < 0.001) in the relatively older group. The logistic EuroSCORE (3.6%vs.5.2%) and the additive EuroSCORE (3.5%vs.5.3%) were higher in the 60–69 age group without reaching statistical significance (P > 0.05). Postoperative outcomes, 30-day survival (98.8%vs.99.4%;P = 0.582), 60-month survival (95.2%vs.97.2%; P = 0.413), and median survival at 71 months (95.2%vs.97.2%;P = 0.413) were comparable. No valve-related deaths or structural valve deterioration were observed in either group. However, infective endocarditis was reported in one patient in the under 60 years old group.
Conclusion: This study reports excellent clinical performance of the Perimount Magna Ease bioprosthetic valve as treatment option for aortic valve disease in patients under 60 years of age at a median follow-up of 71 months.

A19 Surgical aortic valve replacement for patients with severely impaired left ventricular function (LVEF < 30%): a single institutional experience
Halil Ibrahim Bulut, Maria Comanici, Nandor Marczin, Sunil K. Bhudia, Shahzad G. Raja
Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
Correspondence: Halil Ibrahim Bulut
Journal of Cardiothoracic Surgery 2024, 19(2):A19
Objective: While surgical aortic valve replacement (SAVR) is considered the gold standard treatment for aortic valve disease, structural heart teams often have concerns about offering it to patients with severely impaired left ventricular function (LVEF < 30%). We investigated the early and late clinical outcomes after SAVR in this specific patient group.
Methods: A total of 73 patients with severely impaired left ventricular function (LVEF < 30%) underwent SAVR between April 2011 and December 2018. Of these, 37 patients had isolated SAVR, 14 patients underwent CABG + SAVR, and 22 patients had SAVR + other cardiac procedures. The median follow-up time was 71 months. Statistical analyses were conducted using SPSS version 22.0.
Results: The study cohort had an average age of 65.8 years, with 17.8% of them being female. Pure aortic stenosis (49.3%) and pure aortic regurgitation (39.2%) were predominant haemodynamic lesions. Prior to surgery, 69.9% of patients exhibited features of heart failure with 35.6% in NYHA Class IV and 43.8% in NYHA Class III. The average logistic and additive Euroscore were 27.7% and 10.9%, respectively. In-hospital mortality rate was 6.8%, while the 60-month survival rate stood at 83.6%. Notably, there were no occurrences of valve-related deaths, infective endocarditis, or structural valve deterioration throughout the follow-up period.
Conclusion: SAVR is a safe and effective treatment option for aortic valve disease among a highly selective cohort of patients with LVEF < 30%. However, further studies are required to validate the reported findings as well as determine predictors of in-hospital mortality for this high-risk cohort.

A20 Off-pump versus on-pump coronary artery bypass grafting in severe heart failure patients with multivessel coronary artery disease
Maria Comanici, Halil Ibrahim Bulut, Nandor Marczin, Joyce Wong, Sunil K. Bhudia, Shahzad G. Raja
Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
Correspondence: Maria Comanici
Journal of Cardiothoracic Surgery 2024, 19(2):A20
Objective: The question of revascularization in patients with severe heart failure (LVEF < 30%) remains unresolved in the field of cardiovascular medicine. Furthermore, when it comes to surgical revascularization, the choice of technique to employ remains unanswered. This study endeavours to address both issues by examining coronary artery bypass grafting (CABG) outcomes in patients with severe heart failure, while also conducting a comparative analysis of the off-pump and on-pump techniques.
Methods: The pre-, intra-, and postoperative data of a cohort of 245 patients with severe heart failure (LVEF < 30%), who had undergone CABG procedure for multivessel coronary artery disease between January 2007 and December 2019 at our institution, was analysed. Statistical analyses were conducted using SPSS version 22.0.
Results: The study cohort had an average age of 65.4 years, with 8.6% of them being female. Among these individuals, 25.1% exhibited left main stem disease, while a significant 86.8% displayed stenosis of ≥ 50% in all three coronary arteries. Our investigation unveiled overall survival rates of 78.6% over a 5-year period and 59.3% over a 10-year period for the entire cohort. Notably, preoperative demographics were similar between those who underwent off-pump (n-108) and on-pump (n = 137) procedures. Furthermore, no substantial differences were observed in terms of postoperative morbidity or in-hospital mortality. Importantly, there was no statistically significant difference in survival between both techniques at 10-year follow-up (58.3%vs.59.1%; P = 0.447).
Conclusion: Surgical revascularization appears to be beneficial for HF patients regardless of surgical strategy. Further studies should be conducted for verifying our results.

A21 A comparative analysis of approaches of minimally invasive surgical aortic valve replacement: right anterior thoracotomy versus mini-sternotomy
Halil Ibrahim Bulut, Maria Comanici, Nandor Marczin, Sunil K. Bhudia, Shahzad G Raja
Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
Correspondence: Halil Ibrahim Bulut
Journal of Cardiothoracic Surgery 2024, 19(2):A21
Objective: The popularity of minimally invasive techniques in cardiac surgery is on the rise. Minimally invasive surgical aortic valve replacement (mini-AVR) is gaining popularity. However, there is no consensus on a standardized approach for mini-AVR. This study evaluates the early outcomes of mini-AVR comparing mini-sternotomy and right anterior thoracotomy approaches using the VARC-3 criteria.
Methods: A total of 316 underwent elective or urgent isolated mini-AVR procedure between April 2011 and March 2022 at our institution. Preoperative, intraoperative, and postoperative data were analysed. SPSS v.22.0 statistical package was employed statistical analyses.
Results: A total of 82 patients were assigned to the thoracotomy (T) group, whereas the mini-sternotomy (MS) group consisted of 234 patients. While the preoperative demographics exhibited substantial similarities between the two groups, it is noteworthy that the T group had certain disadvantages based on NYHA and CCS classifications (P < 0.05). Conversely, the MS group displayed disadvantages concerning the stability of aortic valve disease symptoms and pulmonary comorbidities (P < 0.05). Although intraoperative data showed substantial similarities, the CPB duration was significantly longer in the T group (P = 0.016). Despite postoperative outcomes featuring differences that did not attain statistical significance, the MS group exhibited advantages in terms of permanent pacemaker implantation (P = 0.012) and early safety composite results (P = 0.026).
Conclusion: Mini-AVR is feasible with acceptable early safety outcomes in this study. In our experience, mini sternotomy, as the preferred strategy, has been found to be advantageous compared to thoracotomy. Nevertheless, further studies are needed to resolve the debate about the preferred approach for mini-AVR.

A22 Long-term comparative analysis of off-pump versus on-pump redo coronary artery bypass grafting in multivessel coronary artery disease
Maria Comanici, Halil Ibrahim Bulut, Nandor Marczin, Sunil K. Bhudia, Shahzad G. Raja
Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
Correspondence: Maria Comanici
Journal of Cardiothoracic Surgery 2024, 19(2):A21
Objective: Coronary artery bypass grafting (CABG), renowned for its lasting benefits, does not guarantee an absolute cure for coronary artery disease and redo CABG is occasionally required. However, redo CABG has been linked to higher rates of both mortality and morbidity. This study investigated the feasibility and long-term effectiveness of redo CABG for cases involving multivessel disease. Additionally, this study also compared off-pump and on-pump techniques in this specific patient group.
Methods: We analysed the preoperative, intraoperative, and postoperative data of a cohort of 128 patients who had undergone redo CABG procedures between January 2007 and December 2019 at our institution. Statistical analyses were conducted using SPSS version 22.0, employing Kaplan–Meier survival analysis with log-rank test.
Results: The average age of the study cohort was 67.8 years, and 11.7% of them were female. Among these individuals, 27.8% displayed left main stem disease, while a notable 72.8% presented significant occlusion (> 50%) in all three coronary arteries. The overall survival rates for the entire cohort were 85.9% for a 5-year period and 76.6% for a 10-year period. Notably, preoperative demographics were quite similar between those who underwent off-pump and on-pump procedures. Similarly, there was no significant difference in postoperative morbidity or in-hospital mortality. Importantly, there was also no significant difference in the 10-year survival rates between these two groups (71.4% vs. 81.5%; P = 0.194).
Conclusion: CABG as a redo revascularization strategy offers promising outcomes for multivessel disease patients. Off-pump strategy has been found feasible and acceptable for redo operations.

A23 Assessment of ≥ 75-year-old threshold for surgical aortic valve replacement in geriatric patients
Halil Ibrahim Bulut, Maria Comanici, Nandor Marczin, Sunil K. Bhudia, Shahzad G. Raja
Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
Correspondence: Halil Ibrahim Bulut
Journal of Cardiothoracic Surgery 2024, 19(2):A23
Objective: Despite the well-established durability and long-term survival benefits associated with surgical aortic valve replacement (SAVR), the latest EACST/ESC guidelines recommend transcatheter procedures for patients aged ≥ 75 years. We conducted a comparative analysis of SAVR in geriatric patients, ranging from 65 to 89 years old, divided into two groups based on the ≥ 75 years age threshold.
Methods: A total of 465 geriatric patients underwent elective or urgent isolated SAVR between April 2011 and December 2018. Among them, 242 patients were aged ≥ 75 years, while 243 patients were aged between 65 and 74 years. The median follow-up time extended to 69 months. Statistical analyses were performed using SPSS version 22.0.
Results: The average age of the study cohort was 74.8 years with 43.9% females and pure aortic stenosis (77.0%) as the predominant haemodynamic lesion. Preoperative demographics, perioperative outcomes showed no statistically significant differences between the two groups. However, the logistic EuroSCORE (6.2%vs.10.1%;P < 0.001) as well as the additive EuroSCORE (6.0%vs.7.9%;) were significantly higher in the ≥ 75 age group(P < 0.001). Despite high EuroSCORE, early survival (99.1%vs.98.3%;P = 0.470) and the median survival at 69 months (93.7%vs.79.3%;P < 0.001) were extremely encouraging. No valve-related deaths or structural valve deterioration were observed in either group with one patient in the 65–74 years old group experiencing infective endocarditis during the follow-up.
Conclusion: This study validates SAVR as a safe and effective treatment option for aortic valve disease in patients ≥ 75 years old. Furthermore, in-hospital mortality is nearly five times better than the predicted mortality for this cohort of patients.

A24 Off-pump versus on-pump coronary artery bypass grafting for multivessel coronary artery disease with moderate to poor renal function: a propensity matched comparison
Maria Comanici, Halil Ibrahim Bulut, Nandor Marczin, Sunil K. Bhudia, Shahzad G. Raja
Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
Correspondence: Maria Comanici
Journal of Cardiothoracic Surgery 2024, 19(2):A24
Objective: Selection of surgical revascularization strategy for treatment of multivessel coronary disease in patents with declined renal function is still a controversial issue. We compared impact of off-pump (OPCAB) and on-pump (ONCAB) techniques on in-hospital outcomes and 10-year survival in this specific patient group.
Methods: A total of 2340 adult patients, meeting inclusion criteria, underwent isolated coronary artery bypass grafting for multivessel coronary artery disease at our institution between January 2007 and March 2023. Following propensity score matching (PSM), 831 OPCAB patients were matched to 831 ONCAB patients. Statistical analyses were conducted using SPSS version 22.0.
Results: Substantial disparities were noted between the two cohorts in terms of extent of coronary artery disease (P = 0.001) and left ventricular function (P = 0.013). For unmatched cohorts, there was prolonged length of stay (LOS) (P = 0.001), increased incidence of atrial fibrillation (AFib) (P = 0.001), and increased rate of renal replacement therapy requirement (RRT) (P = 0.001) in the ONCAB group. After PSM, all preoperative demographics were found to be statistically similar between the groups, except for a history of tobacco use (P = 0.049). Nevertheless, there was a statistically significant increase in the rate of reintubation (P = 0.015), postoperative RRT (P = 0.001), in-hospital mortality (P = 0.046), and prolonged LOS (P = 0.001) in the ONCAB group compared to the OPCAB group. Unmatched (98.5%vs.98.2%; P = 0.520) and matched cohorts (98.6%vs.97.2%; P = 0.063) demonstrated similar survival at 10 years.
Conclusion: Our findings strongly validate the substantial impact of OPCAB in reducing perioperative morbidity and mortality. This is accompanied by a comparable survival to OPCAB at 10 years.

A25 Off-pump versus on-pump coronary artery bypass grafting for multivessel coronary artery disease with moderate left ventricular dysfunction: a propensity matched comparison
Maria Comanici, Halil Ibrahim Bulut, Nandor Marczin, Sunil K. Bhudia, Shahzad G. Raja
Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
Correspondence: Maria Comanici
Journal of Cardiothoracic Surgery 2024, 19(2):A25
Objective: Moderate left ventricular dysfunction (ejection fraction = 30–49%) is a recognised risk factor for coronary artery bypass grafting (CABG). The application of off-pump coronary artery bypass grafting (OPCAB), a less invasive technique, for treating this high-risk cohort remains a debatable issue. We compared impact of OPCAB and on-pump coronary artery bypass grafting (ONCAB) on in-hospital and long-term outcomes of patients with ejection fraction = 30–49%.
Methods: A total of 1541 adult patients, meeting inclusion criteria, underwent isolated CABG for multivessel coronary artery disease at our institution between January 2007 and March 2023. Following propensity score matching (PSM), 500 OPCAB patients were matched to 500 ONCAB patients. Statistical analyses were conducted using SPSS version 22.0.
Results: Significant disparities were observed among the two cohorts in terms of cardiovascular comorbidities (P = 0.001). Most in-hospital outcomes were comparable, except for a prolonged length of stay (LOS) (P = 0.003) and an elevated incidence of atrial fibrillation (AFib) (P = 0.001) in the ONCAB group. Following PSM, all preoperative demographics were statistically similar between the groups, with the exception of OPCAB group exhibiting disadvantageous renal function (P = 0.05) and higher incidence of hypertension (P = 0.001). Nonetheless, there was a statistically significant increase in the reintubation rate (P = 0.013), postoperative AFib (P = 0.003), and prolonged LOS (P = 0.043) in the ONCAB group compared to the OPCAB group. Comparison of unmatched cohorts (88.8%vs.88.7%;P = 0.574) and matched cohorts(88.6%vs.88.4%;P = 0.947) demonstrated similar survival at 10 years.
Conclusion: Our findings strongly validate the substantial impact of OPCAB in reducing perioperative morbidity. This is accompanied by similar survival rate at 10 years compared to ONCAB.

A26 Impact of vein harvesting strategy on in-hospital outcomes and long-term survival of coronary artery bypass grafting in multivessel coronary artery disease: a propensity matched comparison
Halil Ibrahim Bulut, Maria Comanici, Nandor Marczin, Sunil K. Bhudia, Shahzad G. Raja
Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
Correspondence: Halil Ibrahim Bulut
Journal of Cardiothoracic Surgery 2024, 19(2):A26
Objective: Endoscopic vein harvesting (EVH) has gained popularity due to its minimally invasive nature. However, skepticism persists regarding its impact on long-term survival. We performed a comprehensive comparison of EVH and open vein harvesting (OVH) to determine their impact on in-hospital outcomes and long-term survival.
Methods: A total of 8128 adult patients, meeting inclusion criteria, underwent isolated CABG for multivessel coronary artery disease at our institution between January 2007 and March 2023. Following propensity score matching, 1847 OVH patients were matched to 1847 EVH patients. Statistical analyses were conducted using SPSS version 22.0 which included Kaplan–Meier survival analysis.
Results: There were notable disparities between the two cohorts for poor LV function (P = 0.001), extent of coronary artery disease (P = 0.001), diabetes mellitus (P = 0.001), moderately impaired renal function (P = 0.002) and COPD (P = 0.001). The OVH group exhibited significantly worse in-hospital outcomes including renal replacement therapy (P = 0.001), reintubation (P = 0.047), arrhythmias (P = 0.001), and GI tract complications (P = 0.034). After propensity matching, all preoperative demographics were found to be statistically similar between the groups, except for BMI (P = 0.001) and hypertension (P = 0.001). However, there was a statistically significant increase in the reintubation rate (P = 0.032) and wound site infections (P = 0.001) in the OVH group compared to the EVH group. Comparison of unmatched (96.2% vs. 81.1%; P = 0.001) and matched cohorts (93.1% vs. 81.6%; P = 0.001) demonstrated the superiority of EVH for 10-year survival.
Conclusion: Our findings strongly validate the substantial impact of EVH in reducing surgical site infections. This is accompanied by a superior survival advantage at 10 years compared to OVH.

A27 On-pump versus off-pump coronary artery bypass grafting in patients with left main stem disease: propensity matched comparison of in-hospital outcomes and long-term survival
Halil Ibrahim Bulut, Maria Comanici, Nandor Marczin, Sunil K. Bhudia, Shahzad G. Raja
Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
Correspondence: Halil Ibrahim Bulut
Journal of Cardiothoracic Surgery 2024, 19(2):A27
Objective: Left main stem (LMS) disease has major prognostic significance and its treatment presents challenges. Application of off-pump coronary artery bypass grafting (OPCAB), a less invasive alternative, to treat LMS disease remains controversial because of concern about the ability to tolerate haemodynamic instability. This study compares in-hospital and long-term outcomes for 1:1 propensity matched on-pump (ONCAB) and OPCAB cohorts to evaluate the feasibility and safety of OPCAB for this high-risk condition.
Methods: A total of 2157 individuals underwent isolated CABG for LMS disease between January 2007 and December 2019 at our institution. Following propensity score matching (PSM), 785 patients were allocated to the OPCAB group, and an equivalent number, 785 patients, were assigned to the ONCAB group. Statistical analyses were carried out using SPSS version 22.0.
Results: There were notable disparities between the cohorts for cardiovascular comorbidities. Most in-hospital outcomes demonstrated statistical similarity, except for prolonged LOS (P = 0.001) and increased need for surgical re-exploration (P = 0.001) in the ONCAB group. Following PSM, all preoperative demographics were found to be similar. However, there was a statistically significant increase in the need for inotropic support after surgery (P = 0.005) and deep SWI rates (P = 0.045) in the OPCAB group with increased need for re-exploration (P = 0.017) and extended stay (P = 0.006) in the ONCAB group. Survival at 10-year follow-up showed no discernible differences for both the unmatched (86.2%vs.86.8%;P = 0.650) and matched cohorts(86.0%vs.86.6%;P = 0.806).
Conclusion: Our findings suggest that OPCAB is feasible and safe alternative for patients with LMS disease, offering a potentially less invasive yet durable treatment option.

A28 Does obesity matter for minimally invasive aortic valve replacement? Insights from an institutional experience with 308 patients
Halil Ibrahim Bulut, Maria Comanici, Nandor Marczin, Sunil K. Bhudia, Shahzad G. Raja
Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
Correspondence: Halil Ibrahim Bulut
Journal of Cardiothoracic Surgery 2024, 19(2):A28
Objective: Performance of minimally invasive aortic valve replacement (mini-AVR) in obese patients (BMI ≥ 30.0 kg/m2) remains controversial. This study delves into a comparative analysis of outcomes of mini AVR between obese and non-obese patients.
Methods: Between April 2011 and March 2022, a total of 308 patients underwent elective or urgent isolated mini-AVR at our institution. Preoperative, intraoperative, and postoperative data was analysed. Statistical analysis was conducted using SPSS v.22.0, employing Chi-square with Fisher's Exact and F-ANOVA tests.
Results: In the study, a total of 108 patients were assigned to the obesity (O) group (BMI: 30.0–52.7 kg/m2), whereas the control (C) group (BMI: 20.1.0–29.9 kg/m2) consisted of 200 patients. While the preoperative demographics exhibited substantial similarities between the two groups, it is noteworthy that the Group O was disadvantaged compared to group C in terms of type II diabetes mellitus and pulmonary function (P = 0.010) and was advantaged in terms of renal functions (P < 0.001). However, there was no difference according to EuroSCORE II (1.4% vs. 1.5%; P = 0.303) and logistic EuroSCORE (4.9% vs. 5.1%;P = 0.692). Although intraoperative data were technically similar, operative times were significantly higher in the group O. Postoperative outcomes were similar, and the actual early mortality rate was significantly lower than the predicted early mortality and similar for both groups (P = 0.667).
Conclusion: This study demonstrates that even with the presence of accompanying comorbidities, obesity should not be considered a contraindication or a cause for concern in the planning of mini-AVR.

A29 Emergent and salvage coronary artery bypass grafting: outcomes and predictors of in-hospital mortality
Halil Ibrahim Bulut, Maria Comanici, Nandor Marczin, Sunil K. Bhudia, Shahzad G. Raja
Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
Correspondence: Halil Ibrahim Bulut
Journal of Cardiothoracic Surgery 2024, 19(2):A29
Objective: Emergent and salvage coronary artery bypass grafting (CABG) procedures, though infrequently performed, carry a significant mortality risk. Moreover, they represent a challenging aspect of surgical coronary revascularization that lacks extensive literature coverage. This study attempts to shed light on this understudied domain by assessing the determinants of in-hospital mortality as well as define intermediate and long-term survival of patients who underwent salvage and emergent CABG.
Methods: A total of 282 out of 11,820 patients underwent emergent or salvage CABG, between January 2007 and December 2019, at our institution. Preoperative, intraoperative, and postoperative data was analysed. Kaplan–Meier survival analysis with log-rank test was employed to determine the survival rate, and logistic regression test was used to identify independent predictors of In-hospital mortality. Statistical analyses were conducted using SPSS version 22.0.
Results: The average age of the group was 66.0 years, 28 of the patients received salvage and 254 had emergent CABG. Preoperatively, 48.6% had left main stem disease and 11.6% had cardiogenic shock. In addition, 7.1% received ventilation support and 32.6% were on intravenous nitrate preoperatively. In-hospital mortality was found to be 11%, and independent predictors were history of preoperative cerebrovascular accident and surgery under IABP support. Survival rates at 60-month and 120-month follow-up were 78% and 70.2%, respectively.
Conclusion: Emergent and salvage CABG procedures, although rare, carry significant operative risk, but post discharge survival is promising. More studies are essential to determine risk factors of postoperative morbidity and enhanced in-hospital mortality experienced by this challenging cohort.

A31 Retrospective audit of video-assisted thoracoscopic surgery (VATS) for diagnosis and management of unilateral pleural effusions: a single-centre experience
Younus Qamar1, Ahmed Shazly1, Hannah Yonis1, Youssef Abouelela1, Amna Qamar2, Heraa Islam3, Natalie Linkson1, Hatam Naase1, Tariq Minhas1
1The Essex Cardiothoracic Centre, Basildon & Thurrock University Hospital, Mid and South Essex NHS Foundation Trust, Basildon, United Kingdom. 2ohn Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom. 3Queen’s Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust, London, United Kingdom
Correspondence: Younus Qamar
Journal of Cardiothoracic Surgery 2024, 19(2):A31
Objectives: Video-assisted thoracoscopic surgery (VATS) is criterion standard for the diagnosis and/or management of cytology-negative, unilateral pleural effusions. Given that it’s an invasive procedure, we must ensure VATS is performed to the acceptable national standards, as outlined in the British Thoracic Society (BTS) guidelines.
Methods: From January 4, 2021, to June 15, 2022, 111 consecutive patients were referred to us for VATS pleural biopsy and/or pleurodesis ± intrapleural catheter (IPC) insertion. Primary audit points were diagnostic yield, efficacy of pleurodesis, and postoperative complications. Secondary audit points were documentation of pleural fluid volume and appearance, based on the “Good Practice Points” by the BTS.
Results: The cohort included 94 (85%) men and 17 (15%) women in the age range of 30–80 years (median age 74 years [IQR 69–78]). The mean bed-stay was 4.8 days with no operative mortality. A total of 110 diagnostic pleural biopsies were performed. As expected, the most common diagnosis was malignancy (48.2%); malignant mesothelioma (41.8%), non-small cell lung cancer (2.7%), and metastatic disease (3.6%). Reactive fibrous pleuritis was diagnosed in 40% of cases, and pleural plaques in 1.8%. 49 (44%) patients had concomitant pleurodesis with a 92% efficacy rate. Furthermore, 44 (40%) patients underwent simultaneous IPC insertion at the time of VATS procedure. Pleural fluid appearance and volume was documented in 49% and 46% of cases, respectively.
Conclusions: VATS was performed to the accepted national standards in the investigation and/or management of unilateral pleural effusions. Our study reassuringly confirms the safety of VATS.
A32 Microplastics in cardiopulmonary bypass: quantification and characterisation of particles across systems
Jordan Green1,2, Daniel Field1,2, Robert Bennett1,2, Lauren Jenner2, Emma Chapman3, Laura Sadofksy2, Jeanette Rotchell3, Mahmoud Loubani1,2
1Castle Hill Hospital, Hull, United Kingdom. 2Hull York Medical School, Hull, United Kingdom. 3School of Natural Sciences, University of Hull, Hull, United Kingdom
Correspondence: Jordan Green
Journal of Cardiothoracic Surgery 2024, 19(2):A32
Objectives: This study determines the microplastic (MP) levels, dimension, shape, and chemical composition generated from conventional and mini cardiopulmonary bypass circuits.
Methods: In vitro conventional and mini circuits, mimicking realistic setups with 2L of Hartmann’s solution were run for 90 min (n = 3 circuit runs each), filtered, and analysed using micro-Fourier-transform infrared spectroscopy alongside procedural blanks (n = 5).
Results: Conventional circuits produced 60.4 ± 7.6 particles L-1 h-1 MPs, representing 77.0% of the total particles identified. Mini circuits produced 48.4 ± 31.3 MPs L-1 h-1, representing 45.3% of the total identified particles. The MP levels in each circuit type was significantly elevated compared with the procedural blank (n = 5) samples (5.6 ± 10.4 MPs L-1 h-1) but did not differ with respect to the other. Twenty different MP polymer types were detected whereby polydimethylsiloxane, polydecylmethacrylate, and poly N-butylmethacrylate represented the most MPs within conventional circuits. For mini circuits, the most abundant were polypropylene, polyethylene, and polyamide. Average MP lengths differed significantly: 93.5 ± 98.6 mm (for conventional) versus 62.0 ± 54.4 mm (for mini) (p < 0.001), yet mean MP widths did not differ. Film particles (48.2%) were the predominant shape for conventional circuits and fragments (50.5%) for the mini circuits.
Conclusions: Significant levels of MP particles were produced across the two systems. Future studies can determine the time points at which they are produced in machine use, to mitigate their production, as well as inform cell/tissue culture investigations into the clinical significance of their introduction into patients undergoing cardiac surgery.
Legend—Microplastic production (mean and standard deviation) across the conventional and mini cardiopulmonary bypass (CPB) circuits (n = 3 for each), characterised by polymer type. Abbreviations: PDMS, poly-dimethyl siloxane; PBMA, poly N-butyl methacrylate; PDMA, poly decyl methacrylate; PMMA, poly methyl methacrylate; PMAA, poly N-methyl acrylamide; PP, polypropylene; PP/PE, polypropylene polyethylene co-polymer; PTFE, polytetrafluoroethylene; PA, polyamide (nylon); PS, polystyrene; PE, polyethylene; PES, polyester; PUR, polyether urethane; SR, silicone rubber; SP, silicone polymer; POM, polyacetal; PET, polyethylene terephthalate; EVA, poly ethylene vinyl acetate; PVA, polyvinyl acetate.

A34 Do doctors display differences in trait emotional intelligence (EI) depending on their sex or stage of training? A cross-sectional study of the cardiothoracic surgery department at a single institution
Tanisha Rajah
University of Birmingham, Birmingham, United Kingdom
Correspondence: Tanisha Rajah
Journal of Cardiothoracic Surgery 2024, 19(2):A34
Objectives: Emotional intelligence is an important non-technical skill that has been linked to preventing burnout, improving work performance, and improving academic performance in resident physicians. This study investigates the relationship between emotional intelligence (EI) and the sex and stage of training among members of the cardiothoracic surgery department at a single institution in the United States.
Methods: This hospital-based cross-sectional assessed 14 members of the cardiothoracic surgery department using a questionnaire carried out during the month of May 2023. The questionnaire included questions regarding demographic information and stage of training, as well as the Trait EI Questionnaire-Short Form.
Results: The response rate of the study was 53.8%. A total of 14 people participated in the study, 13 of whom were included in the data analysis. Global trait EI was found to be the same in men and women, however, EI differed depending on the participant’s stage of training. Residents had the highest overall trait EI scores, followed by attendings and then medical students.
Conclusions: The findings of this pilot study suggest that sex does not play a role in EI, however stage of training does have an influence.
A35 Robotic transcranial Doppler in aortic surgery: a new standard of care?
Muhammad Usman Shah1, Kevin Jones2, David Johnson2, Ayman Kenawy1, Ahmed Othman1, Deborah Harrington1, Manoj Kuduvalli1, Mark Field1
1Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom. 2Department of Perfusion, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
Correspondence: Muhammad Usman Shah
Journal of Cardiothoracic Surgery 2024, 19(2):A35
Introduction: Antegrade and/or retrograde cerebral perfusion (ACP & RCP) with hypothermia has improved outcomes in complex aortic surgery. Despite this significant risk of neurological complications depending on the cerebral perfusion, temperature and circulatory arrest time during DHCA. Robotic Transcranial Doppler (RTCD) is an evolving modality to measure cerebral perfusion and improving cerebral protection.
Methods: Retrospective observational study in 22 patients undergoing Major Aortic surgery to assess feasibility, utility and procedural outcomes with RTCD use.
Results: Cerebral blood flow measured during cooling and as circulatory arrest approached, we documented baseline flow during ACP “Minimal Therapeutic Target (MTT) flow”. MTT achieved with ACP flows of 3mls/kg/min rather than standard recommended 10mls/kg/min. Less selective cannulae used. We measured flow in all aspects of Circle of Willis (CoW), also Hyperemia on rewarming. RCP produces measurable flow reversal in Middle Cerebral Arteries (MCA) bilaterally. ACP in Right common carotid artery produces flow in bilateral MCAs establishing a patent CoW in avoiding unnecessary instrumentation of both carotids and stroke risk. Supplementing flow through left subclavian artery improved flow to the left MCA. Lateral TCD in 3 thoracoabdominal cases with measurements though one sensor demonstrated contralateral MCA flow in Lateral TCD.
Conclusion: We believe that RTCD guided, patient specific reduction in flows required for ACP and RCP, lesser instrumentation of cerebral vessels, leads to lesser cerebral complications. We demonstrated novel single-sensor RTCD in thoracoabdominal cases. Further data required to analyse effect on outcomes such as stroke and delirium before RTCD is set as a standard of care.

A36 Pitfalls encountered in the imaging methods for the severity assessment of primary mitral regurgitation
Zakariya Mouyer
Imperial College, London, United Kingdom
Correspondence: Zakariya Mouyer
Journal of Cardiothoracic Surgery 2024, 19(2):A36
Objectives: The decision to perform mitral valve replacement in primary mitral regurgitation (MR) is decided upon severity from echocardiographic criteria. Current guidelines recommend intervention in asymptomatic patients, hence accurate severity assessment is important (Vahanian et al., 2021). Comparative analysis is needed both between and within the two main imaging modalities for MR, echocardiography and cardiac magnetic resonance imaging (CMR), to ascertain the optimal way to assess primary MR severity.
Methods: In this prospective dual centre study, MR severity was assessed in 34 patients using echocardiography and CMR. Quantitative comparisons in LV volumes, regurgitant volumes and fractions, as well as ranked qualitative comparisons were made both between and within echocardiography and CMR-Fig. 1:
Results: Echocardiography and CMR have poor concordance (17.6%, ICC = 0.325, p = 0.0118;95% CI:0.05 < ICC < 0.56) and weak moderate correlation in categorising and quantifying primary MR (regurgitant volume: r = 0.5, p = 0.00976,95%CI:-13.84–18.56 ml; regurgitant fraction:r = 0.0058,p = 0.9775; 95% CI:21.69%-63.65%) but have a moderate correlation in quantifying LV volumes (r = 0.58–0.74, p < 0.0006). Within CMR, there is little intraobserver variability and high reproducibility in categorising and quantifying LV and MR volumes and severity (ICC = 0.886,p = 1.96e-16;r = 0.78–0.87, p < 0.0001). Qualitative echocardiograms do not correlate in rankings to their quantitative counterparts in either echocardiography or CMR; though there is qualitative consistency between echocardiographic views.
Conclusion: This study suggests that CMR is more consistent and accurate at quantifying MR severity compared to echocardiography, current literature also concurs. The role of CMR, its diagnostic thresholds and importance in the primary MR management pathway should be given more weighting. Further research is needed, including larger comparative studies as well as original randomised controlled trials.

A37 Is there a need to apply external suction to chest drains after non-pneumonectomy lung resection in lung cancer patients?
Zakariya Mouyer
Manchester Foundation Trust—University of Manchester, Manchester, United Kingdom
Correspondence: Zakariya Mouyer
Journal of Cardiothoracic Surgery 2024, 19(2):A37
Background: Postoperative chest drains are commonly used after thoracic surgery to prevent complications such as air-leak. The choice between suction and non-suction drainage is controversial. Current guidelines advise against external suction, highlighting a discrepancy between current practice and recommendation. This report presents findings from the second largest thoracic unit in the UK.
Methods: In addition to a literature review, a single-centre prospective interventional study or audit was conducted at MFTW's cardiothoracic surgery department. Patients (n = 53) undergoing elective video-assisted thoracoscopic surgery non-pneumonectomy pulmonary resection were recruited from January to April 2023 and split into High (− 2.5 kPa), Low (− 1.5 kPa) and Non (− 0.8 kPa) suction groups. Primary outcomes were length of stay, drainage duration, air leak, and volumes drained.
Results: This study suggested a lack of difference of length of stay, chest drain duration, average air leak, and total air leak among the suction groups. Secondary outcomes of volume drained average was significantly higher in the High Suction group compared to the other groups. Similarly, the total fluid drained was significantly higher in the High Suction group compared to the other groups.
Conclusion: Suction levels had minimal impact on length of stay and air leak outcomes, but higher suction pressures resulted in increased volume and total fluid drained. There is a need for formal post lung resection drainage protocols to be developed based on newer randomised controlled trials and meta-analyses since air-leak is a common complication and cause of post-operative morbidity.
A38 Case report of a rare right sided aortic arch aneurysm with aberrant left subcalvian artery and kommerell’s diverticulum: lessons learnt!
Muhammad Usman Shah, Mauin Uddin, Sivaraj Govindasamy, Omar Nawaytou
Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
Correspondence: Muhammad Usman Shah
Journal of Cardiothoracic Surgery 2024, 19(2):A38
Introduction: Rare case of right sided aortic arch aneurysm (RAAA) with Kommerrll’s diverticulum aneurysm, treated with staged endovascular-hybrid and open techniques. Despite complications, good outcome achieved with collaborative approach.
Case Report: Patient with 54 mm Kommeral’s of aberrant left subclavian (LSA), dilated RAAA with compression of oesophagus and trachea. On echo Severe MR & AR. High-risk MDT: two stage procedure with Lt carotid (LCA) to LSA bypass and embolization of proximal LSA followed by MV repair, tAVR and FET. Extubated day-1 but reintubated for acute stridor due to total occluded Rt main bronchus. MDT with aortic, thoracic, vascular surgeons and Anaesthetic/ITU teams. Coiling of LSA done followed by tracheostomy due to failed extubation. Repeat bronchoscopy showed aneurysm sac still causing airway compression. Re-scheduled for urgent Rt thoracotomy, replacement of distal arch/proximal DTA under DHCA; aorta and FET cut back to the origin of the LSA. 30 mm graft anastomosed end to end to the transected proximal DTA and FET. Patient did well, although prolonged ITU stay but discharged in good medical condition.
Discussion: RAAA is exceedingly rare and presents with atypical symptoms, half of patients have aneurysm arising from Kommerell’s Diverticulum. Treatment experience limited to case reports or limited series. Improving experience with endovascular and hybrid techniques can present treatment options. Decision making not straight forward and needs Bespoke approach. Head and neck vessels bypass i.e., LCA to LSA bypass can be done as staged procedure before the arch replacement. Operating surgeon will need to stand on the left side.

A39 Closing the sex-equity gap cardiac surgery trials: strategies for researchers from the Women in Cardiovascular Trials Group
Julie Sanders1,2, Tim Clayton3, Stacey Matthews4, Lynn Laidlaw3, Sarah Murray5, Rochelle Wynne6
1St Bartholomew's Hospital, London, United Kingdom. 2Queen Mary University of London, London, United Kingdom. 3London School of Hygiene and Tropical Medicine, London, United Kingdom. 4Heart Foundation, Melbourne, Australia. 5Society of Cardiothoracic Surgery of Great Britain and Ireland, London, United Kingdom. 6Royal Melbourne Hospital, Melbourne, Australia
Correspondence: Julie Sanders
Journal of Cardiothoracic Surgery 2024, 19(2):A39
Objectives: Cardiovascular disease (CVD) is the leading cause of death for women, but women are consistently underrepresented in CVD trials. Only a third of CVD participants and a quarter of cardiac surgery participants are women. Although recent advances have aimed at addressing the sex-based equity gap, far more targeted sex-specific processes are needed.
Methods: Based on the results of our recent scoping review, which identified the barriers and facilitators to women participating in CVD research1, a list of strategies for researchers has been devised to increase the inclusion and retention of women.
Results: Researcher strategies include:
-
The inclusion of women patient representatives and stakeholders
-
Undertake research considered important to women
-
Increase equity of access and eligibility of women to be able to participate
-
Include sex stratification and sex-specific outcomes in statistical analysis plans
-
Provide sex-specific study information to address inherent misconceptions about research that women hold
-
Minimise study-related procedures and the burden of participation—time, travel, financial, childcare considerations
-
The background and rationale for each will be highlighted with specific recommendations on how these can be addressed.
Conclusions: Trial design, research culture and researcher biases considerably contribute to sex-inequality in CVD research. It is anticipated these strategies, devised in response to the existing evidence on the barriers and facilitators to women participating in CVD studies, will assist in addressing this imbalance. If implemented successfully, this should lead to the creation of more sex-appropriate evidence in the diagnosis, treatment and outcome of women from cardiac surgery.
A40 Surgical care practitioner initial experience and patient postoperative wound-related outcomes of endoscopic vein harvesting for coronary artery bypass grafting surgery
Rick Air, Giulio Citarella, Bhuvaneswari Krishnamoorthy
Manchester Foundation Trust, Manchester, United Kingdom
Correspondence: Rick Air
Journal of Cardiothoracic Surgery 2024, 19(2):A40
Current ISCMICS guidelines, the Endoscopic vein harvesting (EVH) is classed as 2B evidence, and it should be adapted as standard practice. Aim of this study was to share experience and patient outcomes post EVH training.
February to July 2023, we prospectively collected 16 cases post training. Demographics and patient followed up until discharge were collected. Patient selection is vital during learning period, with exclusion of obese patients or superficial veins provides sufficient time to harvest. 100% were scanned and no conversion to open technique. Hospital clinical governance gave ethical approval. Descriptive data analysis was performed, presented as frequencies and percentages.
Male were 94%. Average BMI was 29.44. 12 patients had right leg and 4 had left leg harvesting. 90% patients were non-diabetic, 5% Insulin dependent and 5% diet. 92% had 2 lengths and 8% had 3 lengths of veins harvested. 2500 units of heparin given prior to harvesting the conduit. Longest harvesting time was 85 min followed by 55 min were quickest time. Total average time was 66 min. 96% had no vein repairs but 4% vein had repaired done with 7/0 prolene. Postoperatively, 91% were satisfied and 9% were not satisfied due to slight pain and bruising. 30% had mild bruising on their leg. 25% had pain during movement. Mean hospital stay was 10 days.
It is important for new EVH practitioners to have sufficient time, conducive environment to perform harvesting. From our experience, patient selection and ultrasound scanning make a significant difference for yielding better vein conduit.
My name is Rick Air, and I am a Surgical Care Practitioner specialising in Cardiothoracic surgery at Wythenshawe Hospital in South Manchester. From 2018 to 2021, during my SCP training, I focused on refining my skills in open vein harvesting. In January 2021, I had the opportunity to learn Endoscopic Vein Harvesting (EVH) from my colleague, Professor Bibleraaj, utilising the Getinge device. Following the completion of my EVH training and consolidation period, I undertook an assessment and audit of my practice and patient wound outcomes to ensure adherence to best practices. I firmly believe that auditing the learning period during EVH is essential for reflecting on and adjusting practices to benefit patients and enhance the learner's experience.
A41 Discontinuation of routine physiotherapy review on post-operative day 1 for low-risk cardiac surgery patients on critical care in a tertiary cardiothoracic centre
Kira Neal, Elliott Pattison
The Essex Cardiothoracic Centre, Basildon Hospital, Basildon, United Kingdom
Correspondence: Kira Neal
Journal of Cardiothoracic Surgery 2024, 19(2):A41
Objectives: We aimed to develop a screening tool for physiotherapists to identify post-operative cardiac surgery patients at risk of developing post-operative pulmonary complications and who require specialist physiotherapy review on critical care.
Methods: A screening tool was developed using information collected during a bench-marking exercise with other UK cardiac centres regarding timing of physiotherapy review post cardiac surgery and referral processes. Data was concurrently collected from 43 consecutive patients undergoing cardiac surgery both pre and post implementation of the screening tool to capture length of critical care and post-operative stay, number of physiotherapy contacts on critical care and incidences of post-operative pulmonary complications.
Results: Prior to implementation of the screening tool, 41 patients were reviewed day 1 post-operatively on critical care with 17 patients “screened in” for review post implementation. This equated to a reduction in physiotherapy contact time of 3 h per week. There were no incidences of post-operative pulmonary complications. There was a small increase in critical care (0.15 day) and total post-operative stay (0.40 day) post implementation. There were no re-referrals for those patients “screened out”.
Conclusions: Implementation of a screening tool for physiotherapists to identify patients post cardiac surgery requiring physiotherapy intervention on critical care is time efficient and does not significantly impact on critical care or post-operative length of stay or incidence of post-operative pulmonary complications. The physiotherapy time saved from ‘screening out’ low-risk cardiac surgery patients can be re-directed to those with complex weaning or rehabilitation requirements and pre-operative interventions for high-risk patients.
A42 Patients restricted to upper limb precautions are more likely to require external agencies on discharge
Louisa Nielsen
University Hospital Southampton, Southampton, United Kingdom
Correspondence: Louisa Nielsen
Journal of Cardiothoracic Surgery 2024, 19(2):A42
Objectives: 926 cardiac surgical patients who underwent a median sternotomy transitioned from current restrictive ‘Upper Limb Precautions’ (ULP) to ‘Keep Your Move in the Tube’ (KMIT).
We hypothesised that implementation of KMIT would be safe, feasible and impacting:
Outcomes:
-
Hospital length of stay (LOS)
-
Number of patients discharging directly home
-
Sustainability
-
Functional ability
-
Pain and stiffness
Methods: 12-month Quality Improvement Project (QIP).
KMIT Principles: Patients can move into or out of an imaginary tube for load-bearing and non-load bearing activities if the original pre-activity pain level does not increase outside of the tube.
Results:
Data collection
1121 patient in the ULP group and 926 patients in the KMIT group.
Safety and feasibility
Analysis concluded sternal complications were not due to KMIT.
Hospital LOS
No difference was found between ULP’s (8.9 days) versus KMIT (8.6 days).
Discharge destination
There was a 51% increase with KMIT patients discharging directly to their usual residence.
Estimated Carbon footprint.
Abandoning towels resulted in a reduction in CO2 emissions by 8.2 tonnes with a cost saving of £8,000 per annum.
Functionality: Qualitative patient feedback demonstrated that the KMIT group returned to independence faster with less anxiety, pain or stiffness.
Conclusions: KMIT reduces the number of patients requiring support from external agencies, whilst safely facilitating discharge home.
KMIT enables quicker return to functional activities with less musculoskeletal impairments.
We anticipate these outcomes will have significant social, economic and environmental impact.
A44 A comprehensive systematic review of animal models in ex vivo lung perfusion
Shane Fisher1, James O'Connor2, Karen Redmond2
1University College Dublin, Dublin, Ireland. 2Mater Misericordiae University Hospital Dublin, Dublin, Ireland
Correspondence: Shane Fisher
Journal of Cardiothoracic Surgery 2024, 19(2):A44
Title: A comprehensive Systematic Review of Animal Models in Ex Vivo Lung Perfusion.
Objective: Animal models play a pivotal role in advancing ex vivo lung perfusion (EVLP) outcomes. The primary outcome of this systematic review was to provide a comprehensive overview of the various animal models employed in EVLP research. Secondary outcomes included evaluation of EVLP models and identification of novel EVLP applications.
Methods: Using electronic databases, a systematic review was conducted to identify relevant studies published between 2008 and 2023. The search strategy included keywords related to EVLP and its applications. Studies were then screened for predefined inclusion and exclusion criteria.
Results: 56 studies met the predefined inclusion criteria for this systematic review. Included studies explored a variety of animal models, including human, porcine, ovine, rat, and murine. Key areas of investigation included evaluation of donor lung function, donor lung preservation time, and EVLP as a platform of lung-injury repair and injury-specific treatment.
Conclusion: This systematic review provides a comprehensive overview of various EVLP animal models. Porcine models evidently appeared superior to other EVLP animal models due to their translational accuracy with human anatomy and physiology. Overall, evidence gathered from these studies supports potential for further advancements in optimisation of EVLP conditions and outcomes, as well as development of novel EVLP applications.
A45 Mitral valve repair versus replacement for degenerative mitral regurgitation in patients with poor ejection fraction
Fadi Al-Zubaidi, Hunaid Vohra
Bristol Heart Institute, Bristol, United Kingdom
Correspondence: Fadi Al-Zubaidi
Journal of Cardiothoracic Surgery 2024, 19(2):A45
Background: Mitral valve (MV) repair is the established gold standard treatment for patients with degenerative MV regurgitation. The UK has an ageing, increasingly co-morbid population. We sought to examine the impact of repair (MVr) versus replacement (MVR) on early postoperative outcomes in patients with poor left ventricular ejection fraction (LVEF) using a large UK database.
Methods: Preoperative characteristics, intraoperative variables and early postoperative outcomes were compared between unmatched MVr and MVR groups using univariate analyses. The primary outcome was early mortality; secondary outcomes included stroke, re-exploration for bleeding and prolonged admission (> 10 days). Propensity-score matching was used to balance cohorts. Binary logistic regression modelling was used to examine the independent relationship between procedure and mortality, as well as all other outcomes.
Results: We identified 606 consecutive patients between January 2000 and December 2019. Propensity-score matched cohorts were well-balanced (n = 250 in both groups), with standardized mean differences < 0.1 for all baseline characteristics. Regression model for mortality demonstrated no independent relationship between procedure and mortality (OR: 0.50, 95%CI: 0.22–1.12), stroke (OR: 0.11, 95%CI: 0.01–1.18) or prolonged admission (OR: 0.94, 95%CI: 0.64–1.39). MVr was found to be a strong independent predictor of re-exploration for bleeding (OR: 2.71, 95%CI: 1.28–5.72).
Conclusions:
- 1.
Repair offers no early-outcome advantage compared to replacement in patients with poor preoperative LVEF.
- 2.
Mitral repair is associated with significantly higher rates of post-operative bleeding in this cohort.
- 3.
Early post-operative mortality is 8%
- 4.
Repair rates have risen significantly to 68% in the latest time period.
A46 Spatial transcriptomic profiling of human saphenous vein exposed to ex vivo arterial haemodynamics: implications for coronary artery bypass graft patency and vein graft disease
Liam McQueen, Shameem Ladak, Gavin Murphy, Mustafa Zakkar
University of Leicester, Leicester, United Kingdom
Correspondence: Liam McQueen
Journal of Cardiothoracic Surgery 2024, 19(2):A46
Vein graft disease is the process by which saphenous vein grafts, utilised for revascularisation during coronary artery bypass graft surgery, undergo an inflammation-driven intimal hyperplasia and accelerated atherosclerosis process in subsequent years after implantation. The role of the arterial circulation, in particular the haemodynamic properties impact on graft patency, have been investigated but have not to date been explored in depth at the transcriptomic level. We have undertaken the first-in-man spatial transcriptomic analysis of the long saphenous vein in response to ex vivo acute arterial haemodynamic stimulation, utilising a combination of a custom 3D-printed perfusion bioreactor and the 10X Genomics Visium Spatial Gene Expression technology. We identify a total of 413 significant genes (372 upregulated, 41 downregulated) differentially expressed in response to arterial haemodynamic conditions, associated with pathways including NFkB, TNF, MAPK, PI3K/Akt among others, relating to initiation of an early pro-inflammatory response, leukocyte activation and adhesion signalling, tissue remodelling and cellular differentiation. Utilising unsupervised clustering analysis, we have been able to classify subsets of the expression based on cell type and with spatial resolution. These findings allow for further characterisation of the early saphenous vein graft transcriptional landscape during the earliest stage of implantation which contribute to vein graft disease, in particular validation of pathways which could contribute towards the therapeutic inhibition of processes underpinning vein graft disease.

A47 CD34+ vascular stem cells play a key role in vein graft remodelling
Simon Xu1,2, Bijan Modarai1, Alberto Smith1
1King's College London, London, United Kingdom. 2Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
Correspondence: Simon Xu
Journal of Cardiothoracic Surgery 2024, 19(2):A47
Introduction: Venous conduits that are grafted into arterial circulation undergo neointima remodelling, causing excessive hyperplasia that contributes to early graft failure which is a major drawback of surgical vein grafting. Stem cells expressing the CD34 surface protein have been hypothesised to have a key role in the process, but their full involvement is unknown.
Method: A segment of the inferior vena cava of wild-type mice was interposition grafted into mice in which CD34-expressing cells were located through their genetically induced expression of tdTomato red marker protein (CD34-CreERT2xRosa26-tdTomato mice). This enabled us to determine whether CD34 + derived cells found in the vein after grafting originated from the donor mouse or from the host. Grafts were explanted 4wks after surgery and analysed by immunohistology and single cell RNA sequencing to resolve cell-level gene expression. Cells from vein grafts were also cultured in vitro and proliferation/differentiation assays were carried out on purified CD34 + cells.
Results: 70% of cells in the vein graft neointima were derived from CD34 + graft lineage whereas there was no significant contribution of recipient-derived stem cells or bone marrow cells to the neointima. Vein graft neointima smooth muscle cells (SMC) are not stem cells derived. CD34 + stem cells differentiated predominantly into fibroblasts which induced vein SMC phenotype switching and proliferation.
Conclusion: The majority of CD34 + stem cells found in the neointima of veins, grafted into the arterial circulation were derived from the resident cell population. These cells differentiated mainly into fibroblasts that appeared to stimulate vein graft remodelling.
A48 Repair of left ventricular pseudoaneurysm: a case series
Tobin Mangel1, Sam Poon2, Aabha Divya3, Ravi De Silva2
1Royal Brompton & Harefield Hospital, London, United Kingdom. 2Royal Papworth Hospital, Cambridge, United Kingdom. 3Mass General Hospital, Boston, USA
Correspondence: Tobin Mangel
Journal of Cardiothoracic Surgery 2024, 19(2):A48
Objective: Left ventricular pseudoaneurysm (LVP) repair is technically challenging surgery associated with high mortality. We aim to identify an optimal repair technique.
Methods: All patients who underwent LVP repair from 2018 to 2023 were included. Electronic patient records reviewed. The primary outcome was to identify a successful surgical technique for LVP repair. Secondary outcomes examined morbidity and mortality.
Results: 24 patients underwent LVP repair between 2018 and 2023. 21 (87.5%) male, 3 (12.5%) female, average age of 64.5 (34–82) and with a mean EuroScore II of 9.2 (1.4–30.58).Surgical repair varied significantly: 6 (25%) used a patch and felt strips, 9 (37.5%) used a patch alone, and 9 (37.5%) closed the defect with sutures alone. 6 (25%) underwent only LVP repair. The remaining 18 (75%) underwent additional procedures to the LVP repair: 10 (41.6%) had bypass grafting, 7 (29.1%) had valve replacement, and 1 (4.1%) had both bypass grafting and valve replacement. 21 (87.5%) patients were alive at discharge, with 3 (12.5%) having died in hospital. 3 (12.5%) patients required a return to theatre for tamponade and 2 (8.3%) suffered from embolic stroke. 3 (12.5%) patients required central VA ECMO postoperatively, 1 (4.1%) electively was put onto VA ECMO. 2 (8.3%) patients required an IABP post operatively, and 1 (4.1%) patient had an IABP preoperatively. 6 patients who had some form of MCS, either pre- or post-operatively 3 (50%) died.
Conclusion: LVP repair can be performed with good results, and in our experience, there is no one technique superior to another.
A49 Convergent approach to persistent atrial fibrillation ablation: 3 year outcomes for single-centre safety and efficacy
Alexander Carpenter1, Laura Pannell1, Syed Rizvi1, Kirsty Maciver1, Cha Rajakaruna1, Franco Ciulli1, Edward Duncan1, Glyn Thomas1, Palash Barman1, Richard Bond2, Ashley Nisbet1
1Bristol Heart Institute, Bristol, United Kingdom. 2Gloucestershire NHS Foundation Trust, Gloucestershire, United Kingdom
Correspondence: Alexander Carpenter
Journal of Cardiothoracic Surgery 2024, 19(2):A49
Background: Efforts to maintain sinus rhythm in patients with persistent atrial fibrillation (PsAF) remain challenging, with sub-optimal long-term outcomes.
Methods: All patients undergoing convergent PsAF ablation at our centre were retrospectively analysed. The Atricure Epi-Sense® system was used to deliver LA posterior wall radiofrequency ablation surgically, with follow-on endocardial ablation.
Results: 24 patients underwent convergent PsAF ablation. 21 (84%) were male with a median age of 63. 12 (50%) were obese. 71% had a severely dilated left atrium and the majority (63%) had preserved left ventricular function. All were longstanding persistent. 18 (75%) had AF duration > 2 years.
There were no endocardial procedure complications. At 36 months all patients were alive with no new stroke/TIA. Freedom from documented AF at 3, 6,12,18, 24 and 36 months was 83%, 78%, 74%, 74%, 74% and 61%, respectively. There were no major surgical complications, with 5 minor complications recorded comprising minor wound infection, pericarditic pain and hernia.
Conclusions: Our data suggest convergent AF ablation is effective with excellent immediate and long-term safety outcomes in a real-world cohort of patients with a significant duration of AF and evidence of established atrial remodelling. Convergent AF ablation appears to offer a safe and effective option for those who are unlikely to benefit from existing therapeutic strategies for maintaining sinus rhythm and further evaluation of this exciting technique is warranted. Our cohort is unique within the published literature both in terms of length of follow-up as well as very low rate of adverse events.

A50 Removal of retrosternal goiter using VATS approach instead of sternotomy, a case report
Youssef Abouelela, Rajab Khan, Tariq Minhas, Hatam Naase, Abdallah Badran, Sayed Kabeer
Essex cardiothoracic Centre, Basildon, United Kingdom
Correspondence: Youssef Abouelela
Journal of Cardiothoracic Surgery 2024, 19(2):A50
Introduction: Enlarged thyroid extension below the level of the sternal notch (RSG) usually treated by total thyroidectomy (1). RSGs have been reported in the literature as causing increased symptoms in patients compared to cervical goiters (1,2).
The majority of RSGs can be excised through a cervical collar incision, however, some do require extracervical incisions which include thoracotomy, sternotomy, manubriotomy or mediastinotomy. Indeed, these surgical approaches are associated with increased hospital stay (3,4).
Case presentation: A 30-year-old woman was referred for surgical intervention following rapid enlargement of her thyroid gland. CT scan showed a multinodular goiter with 12 cm extension retrosternal mainly on the left side.
The surgeon were able to remove the left side of the gland from the collar incision, while the retrosternal component on the left side was delivered from the chest into the neck and removed. Using Video assisted thoracoscopic technique. After removal of the adhesion the mass delivered through the initial neck incision. The patient remained stable on the ward and was discharged one day following the procedure.
Discussion: A minimally invasive approach allows for a faster recovery post-operatively, improved cosmetic appearance, less post-operative pain and decreased morbidity; ultimately resulting in shorter hospital stays.
Conclusion: This was the first procedure of its kind undertaken at our center and we propose that RSG should be treated with a VATS approach given the excellent cosmetic outcomes and short hospital stay as witnessed for this patient. Early discussion should be done for this technique pre-operatively instead of sternotomy. (The patients have given permission for this).
The patient gave their written, informed consent to publish their information in an open access journal.

A51 Right anterior thoracotomy approach for RCA aneurysm repair as alternative approach to redo sternotomy
Youssef Abouelela, Arvind Singh, Alessia Rossi, Alberto Albanese, Antonio Biovona, Hasnat Khan, Sudhir Bhusari
Essex Cardiothorac Center, Basildon, United Kingdom
Correspondence: Youssef Abouelela
Journal of Cardiothoracic Surgery 2024, 19(2):A51
Introduction: Coronary artery aneurysms can present with angina, shortness of breath and non-specific symptoms. Treatment is required for intractable symptoms or demonstrated increase in size of the aneurysm with symptoms of compression or risk of rupture. Various treatment plans can be considered as conservative management, percutaneous intervention or surgery.
Case Presentation: A 79-year-old gentleman, with a background of coronary artery bypass grafts (CABG), AAA, hypertension and hernia repair. The patient presented with a six-month history of progressive shortness of breath. Investigations revealed a giant expanding right coronary artery aneurysm measuring 18 cm x 10 cm x 9 cm on CT aortogram. Echocardiogram and CT showed a large thrombus in situ with contrast within the thrombus. Aneurysm was approached via right anterior thoracotomy supported with peripheral cardiopulmonary bypass. The inflow to the aneurysm near RCA origin was controlled and the large thrombus was evacuated. Patient developed Adult Respiratory Distress Syndrome, eventually passed away due to multiorgan failure.
Discussion: Only case reports are available in literature for coronary artery aneurysms following coronary artery bypass grafts. Redo sternotomy was deemed hazardous due to the aneurysm and heart being stuck to the undersurface of the previous sternotomy. Aneurysm was large and a major portion was in right chest approachable via thoracotomy.
Conclusion: A reoperation was considered high risk strategy as expert interventional cardiologists opined that this was not feasible given the anatomy of the aneurysm. Standardizing surgical approach for such extremely rare clinical problems still not possible due to lack of evidence about the best surgical approach.
The patient gave their written, informed consent to publish their information in an open access journal.

A52 Current status of basic skills and lobectomy simulation in thoracic surgical training
George Whittaker1,2, Ioana-Alexandra Ghita3, Marcus Taylor1, M Yousuf Salmasi2, Felice Granato1, Thanos Athanasiou2
1Wythenshawe Hospital, Manchester, United Kingdom. 2Imperial College London, London, United Kingdom. 3University of Medicine and Pharmacy of Craiova, Craiova, Romania
Correspondence: George Whittaker
Journal of Cardiothoracic Surgery 2024, 19(2):A52
Objectives: To review the literature to identify simulators that are currently available to augment thoracic surgical training and analyse any evidence supporting or validating them.
Methods: A literature search of the MEDLINE® (1946 to November 2022) and EMBASE® (1947 to November 2022) databases was performed to identify simulators for basic skills and thoracic lobectomy in thoracic surgery. A selection of keywords were used to perform the literature search. After identification of appropriate articles, data were extracted and analysed.
Results: Twenty-eight simulators were found in twenty-five articles. Simulators for basic skills (n = 13) and thoracic lobectomy (n = 13) were described. The majority of models were a hybrid modality (n = 17). Evidence of validity was established in 50% (n = 14) of simulators. In total, 17.9% (n = 5) of simulators had three or more elements of validity demonstrated and only 3.6% (n = 1) accomplished full validation.
Conclusions: Numerous simulators of varying modality and fidelity exist for a variety of thoracic surgical skills and procedures, although validation evidence is frequently inadequate. Low-fidelity models can provide training in basic surgical skills and high-fidelity simulators can be used for immersive training scenarios. These should be utilised in early training, during the initial steep part of the learning curve, prior to gaining further experience in real-world clinical practice.
A53 Health-related quality of life and psychosocial effects of the diagnosis of aortovascular manifestations in Marfan syndrome patients: a quantitative observational exploratory study
Rosalie Magboo1,2, Aung Oo1,2, Jackie Cooper2, Gareth Owens3, Julie Sanders1,2
1St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom. 2William Harvey Research Institute, Queen Mary University of London, London, United Kingdom. 3Aortic Dissection Awareness UK and Ireland, London, United Kingdom
Correspondence: Rosalie Magboo
Journal of Cardiothoracic Surgery 2024, 19(2):A53
Objective: Marfan Syndrome (MFS) is a lifelong condition associated with life-threatening aortovascular manifestations. Consequently, it is expected that living with MFS severely impacts psychosocial health and health-related quality of life (HRQoL). However, evidence is limited, and none arises from the UK. This study aims to identify the HRQoL and the psychosocial effects of the diagnosis of MFS with aortovascular manifestation in a UK cohort.
Methods: This single-site quantitative observational exploratory study included adult patients (> / = 18 years) who were diagnosed with MFS and aortovascular manifestation, and gave written informed consent to participate. Sample size required was 75. Participants completed seven validated questionnaires relating to HRQoL (SF36, EQ-5D-5L) and psychosocial health (depression-CESD, illness perception-IPQ, fatigue-FSS, self-esteem-RSES, stigma-PSQ). Analysis consisted of descriptive and inferential statistics. Results were compared with English general population and adjusted for age and sex.
Results: Overall, 124 patients were eligible, 77 consented/completed all questionnaires and analysis was conducted on n = 75. The average age was 43 years, 46.7% were men and 72% were White British. HRQoL in MFS was found to be lower than the general population in all SF36 and EQ-5D-5L subscales (p < 0.0001). The majority of participants reported experiencing moderate/severe depression (n = 41; 54.7%), pain (n = 63;84%) and fatigue (n = 44;59.7%). However, most have positive self-esteem (n = 50, 66.7%) and do not felt devalued/discriminated (n = 40, 53.3%) due to their condition.
Conclusion: Diagnosis of aortovascular problem affects psychosocial and HRQoL of MFS patients, suggesting the need to develop new clinical pathway and interventions to include these aspects of care.
A54 Enhancing the quality of external referrals to thoracic surgery in a tertiary referral centre
Joe McLoughlin, Matthew Davey, Rachel Brown, Timothy Nugent, Shane Aherne, David Healy, Hossein Javadpour, Karen Redmond, Donna Eaton
Mater Misericordiae University Hospital, Dublin, Ireland
Correspondence: Joe McLoughlin
Journal of Cardiothoracic Surgery 2024, 19(2):A54
Background: To perform a closed loop audit and quality improvement initiative to improve the quality of referrals to our local thoracic surgery department.
Methods: A pre-intervention cycle was performed evaluating the quality of referrals (as compared to the York University Thoracic Surgery Referral Proforma) in consecutive patients referred over an 8-week period. A departmental thoracic surgery referral proforma was then designed. Thereafter, a post-intervention cycle was then performed over the subsequent 8-week period, where the referral proforma was shared with the referring doctor at the time of referral.
Results: In the preintervention cycle, 30 referrals were evaluated, compared to 21 in the post-intervention cycle. There was significant improvement in the quality of referrals made in the post-intervention cycle, where 93.2% (411/441) of York University criteria were included versus 63.0% (416/660) in pre-intervention referrals (P < 0.001). A significant improvement was observed in recording referral date (P = 0.001), patient’s addresses (P = 0.007), patient’s location (P < 0.001), the urgency of referrals (P < 0.001), details regarding patient imaging (P < 0.001), dates of relevant imaging (P = 0.013), other investigation details (P < 0.001), general practitioner names (P < 0.001) and contact numbers (P < 0.001).
Conclusion: This closed loop audit demonstrates the value of using a standardised thoracic surgery referral proforma to improve the quality of referrals to our service. We recommend our colleagues in other units adopting a similar template to improve the quality of prospective referrals to their service.
A56 Surgical site infection risk assessment: the Barts Surgical Infection Risk (B-SIR) tool outperforms other pre-operative risk assessment tools
Rosalie Magboo1,2, Jackie Cooper2, George Krasopoulos3, Bil Kirmani4, Enoch Akowuah5, Sandra Hutton3, Tracey Smailes5, Alex Shipolini1, Heather Byers1, Julie Sanders1,2
1St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom. 2William Harvey Research Institute, Queen Mary University of London, London, United Kingdom. 3Oxford University Hospital NHS Foundation Trust, Oxford, United Kingdom. 4Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom. 5The James Cook University Hospital, South Tees Hospital NHS Foundation Trust, Middlesbrough, United Kingdom
Correspondence: Rosalie Magboo
Journal of Cardiothoracic Surgery 2024, 19(2):A56
Objective: Surgical site infections (SSI) are serious complications after cardiac surgery associated with delayed discharge, readmissions and re-operations. Risk assessment can help reduce SSI but existing tools are insufficient. We previously developed and internally validated Barts Surgical Infection Risk (B-SIR)1. This study aims to explore the external validity of the B-SIR tool and compare with the Australian Clinical Risk Index (ACRI) and Brompton and Harefield Infection Score (BHIS).
Method: This multi-centre retrospective analysis of prospectively collected local data on adult (≥ 18 years) patients who underwent cardiac surgery between January 2018 and December 2019. Pre-pandemic data was used as a reflection of standard practice. Statistical analysis included area under the curves (AUC) to validate and compare the predictive power of the scores, calibration was assessed using Hosmer–Lemeshow test and missing data were dealt with multiple imputation using SPSS.
Results: Of the total data collected, 6,022 patients were included in the complete case analysis. The average age was 66 years, 75% were men and 3.19% developed SSI. The B-SIR has an AUC of 0.686, comparing well with developmental population1 (AUC = 0.682), and better than BHIS 0.610 (95% CI = 0.045 to 0.109; p = 0.000) and ACRI 0.614 (95% CI = 0.041 to 0.103; p = 0.000). After re-calibration, the B-SIR model gave accurate risk predictions (Hosmer–Lemeshow test p = 0.423). Multiple imputation result (AUC = 0.678) is similar to development data1 and is substantially higher than ACRI and BHIS AUC.
Conclusion: B-SIR predicts SSI after cardiac surgery better than ACRI and BHIS risk tools, suggesting that B-SIR could be useful to use routinely in practice.
Reference
- 1.
Magboo R, Drey N, Cooper J, Shipolini A, Byers H and Sanders J. (2020) Predicting Surgical Site Infection: Development and Validation of Barts Heart Centre Surgical Infection Risk (B-SIR) Tool. Journal of Clinical Epidemiology; 128: 57–65.
A57 The end of the starr-edwards era? A rare case of an explanted starr-edwards valve 31 years after aortic valve replacement
Philip Hartley1, William Crawford1, Giampaolo Martinelli1, Ben Adams2
1St. Bartholomew's Hospital, London, United Kingdom. 2St. Bartholomew's Hospital, London, United Kingdom
Correspondence: Philip Hartley
Journal of Cardiothoracic Surgery 2024, 19(2):A57
The development of the Starr-Edwards prosthetic valve in the mid-twentieth century heralded a new era in the treatment of valvular heart disease. For the first time structural valvular pathology could be corrected offering patients dramatically improved life expectancy. The fundamental design of the Starr-Edwards valve changed little during it’s almost 50 years of production, testament to the durability of their design.
The patient in this case underwent an aortic valve replacement in 1991 (31 mm Starr-Edwards prosthesis) at the age of 27 on a background of severe aortic stenosis in the context of a true bicuspid aortic valve. Surveillance CT imaging subsequently demonstrated the development of an aortic root and ascending aortic aneurysm reaching a maximum diameter of 62 mm. He proceeded to have a redo aortic root replacement 31 years after the index operation. The explanted Starr-Edwards valve appeared to be in good condition despite some panus formation on the sewing ring.
In the early 1990s the evidence for a higher thrombogenic risk associated with ball-and-cage prosthetic valves was building, and the transition away from the Starr-Edwards valve, towards bileaflet valves, had begun. Late re-intervention following aortic valve replacement for prosthetic endocarditis, valve dysfunction or aortic aneurysm formation is rare with a mean time between index procedure and redo surgery of approximately 9 years. Therefore, despite the impressive durability of the Starr-Edwards valve it is likely this explanted valve will be one of the last operations of this type performed in the UK.
A58 Evaluating outcomes of lobectomy and sublobar resection for non-small cell lung cancer: a propensity score matched analysis
Duaa Ali Faruqi1, Kareem Omran2, Azn Faruqi3, Mohammad Yousuf Salmasi4, Nizar Asadi4
1Imperial College London, London, United Kingdom. 2University of Cambridge, Cambridge, United Kingdom. 3University of Central Lancashire, Preston, United Kingdom. 4Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
Correspondence: Duaa Ali Faruqi
Journal of Cardiothoracic Surgery 2024, 19(2):A58
Objectives: Lung Cancer remains the leading cause of cancer-related mortality, with non-small cell lung cancer (NSCLC) accounting for 85% of cases. Lobectomy has long been regarded as the gold-standard treatment for early-stage NSCLC. A shifting paradigm towards lung-sparing procedures such as sublobar resection, may benefit patients with limited respiratory reserve or high comorbidity index. This study aims to compare survival outcomes between patients undergoing lobectomy and sublobar resection.
Methods: This was a tertiary retrospective cohort study comparing disease-free survival (DFS), overall survival (OS) and postoperative outcomes in lobectomy and sublobar patients between 2013 and 2023 (n = 3983). Propensity matched analysis was employed to adjust for treatment selection bias, calculated using a logistic regression model and incorporated eight covariates (n = 528). Baseline, post-operative, and survival data were extracted from the hospital database. Comparison of baseline and post-operative characteristics involved Wilcoxon rank sum test, Fisher’s exact test and Pearson’s Chi-squared test. Kaplan Meier estimates and Multivariate Cox Regression were used to evaluate survival. p < 0.05 was considered significant.
Results: No significant inter-cohort differences were observed in either DFS (log-rank p = 0.32), OS (log-rank p = 0.47), or 90-day mortality (log-rank p = 0.78). Sublobar resection exhibited shorter post-operative length of stay (p < 0.05). Conversely, both approaches demonstrated comparable resection margins and complication rates. Significant predictors of survival were age, gender and low Eastern Cooperative Oncology Group (ECOG) performance status (p < 0.05).
Conclusions: These findings further support the non-inferiority of sublobar resection to lobectomy for stage 1 lung cancer. Additionally, improved perioperative outcomes may make sublobar resection more desirable for higher risk patients.
A59 Agreement between observed and predicted postoperative FEV1, FVC and DLCO after anatomic lung resection
Jacie Jiaqi Law1, Euan Lim2, Karim Seif2, Theo Goetz2, Olivia Marsicola3, Paulo De Sousa4, Tuan Chen Aw4, Eric Lim4
1Royal Victoria Hospital, Belfast, United Kingdom. 2St Paul's School, London, United Kingdom. 3Latymer Upper School, London, United Kingdom. 4Royal Brompton and Harefield Clinical Group, Part of Guy’s and St Thomas’ Hospital, London, United Kingdom
Correspondence: Jacie Jiaqi Law
Journal of Cardiothoracic Surgery 2024, 19(2):A59
Background: Despite its importance in clinical guideline pathway selection and as an outcome in clinical trials, little work has been undertaken to understand the agreement between expected lung function loss and actual observed values. This is pertinent in view of the unexpected findings of JCOG0802 and CALBG140503 demonstrating no clinically meaningful difference in lung function loss between sub-lobar resection and lobectomy.
Methods: A retrospective analysis on preoperative and postoperative FEV1, FVC and DLCO was performed on 158 patients who underwent anatomical lung resection between January 2013and July 2023. Predicted postoperative lung function was derived using the 20-segment counting method. A formal testing of agreement between predicted and true postoperative lung function was undertaken using the Bland and Altman Method. A deviation of more than 5% defined as clinically minimally important difference.
Results: Scatter plots for effort dependent measures suggested tendency for underprediction (observed values were higher than predicted) for FEV1 and FVC but good agreement for DLco. Formal agreement confirmed mean difference for FEV1 was − 9.84% (95% confidence interval of − 39.33 to 19.65), FVC − 11.39% (− 50.14 to 27.37) and DLco − 4.83% (− 25.59 to 15.94).
Conclusions: Our study demonstrated that effort dependent parameters of lung function including FEV1 and FVC overestimate the amount of lung function loss after anatomic lung resection. Clinicians should be cautious in using these measures to determine suitability of surgery based on current guidelines. However, independent measures such as DLco demonstrate good agreement suggesting that predicted lung tissue loss is consistent with a 20-segment lung model.

A61 Poor achievement of lipid targets after coronary artery bypass grafting—cost implications
Mia Thomas1, Manraj Sandhu1, Lauren Dixon2, Gianni Angelini1,3
1Bristol Heart Institute, Bristol, United Kingdom. 2Royal College of Surgeons, London, United Kingdom. 3University of Bristol, Bristol, United Kingdom
Correspondence: Mia Thomas
Journal of Cardiothoracic Surgery 2024, 19(2):A61
Objectives: Lipid management is an important component of secondary prevention in coronary artery bypass grafting (CABG). We set to observe if CABG patients are reaching UK or European lipid targets > 3 months after surgery and to calculate the predicted cost of reaching target levels.
Methods: Retrospectively collected data from 2018 (100 patients/pre-COVID 19) and 2023 (100 patients/post-COVID 19). Data was collected on measurement of lipids (greater than 3 months from surgery) and statin use. The targets related to non-HDL-cholesterol (NHDL-C) using the European (≤ 2.2 mmol/L) and UK guidelines (≤ 2.5 mmol/L). Predicted cost of reaching target was calculated using UK tariff NHS drug prices.
Results: Out of 200 patients, 70.5% were urgent, 82% male, 2.5 mean number of grafts, mean age of 66.7 years, mean Euroscore II 2.14%. Lipid profile measurements were retrieved in 176 patients. Pre-operatively, lipid measurement was performed in 70.7% of patients and 79.8% post-operatively. There was statin use in 98.5% at discharge and appropriate statin dose in 85.25%. The mean pre-operative NHDL-C was 3.12 mmol/L and post-operatively was 2.59 mmol/L. Target NHDL-C was achieved in 62% and 42% at UK and European target respectively. The predicted annual cost for the measured cohort would be £7299.33 (£121.66 per person per year) to reach UK target and £10,618.28 (£127.66 per person per year) to reach European target.
Conclusions: We demonstrate poor target achievement of lipid control after CABG surgery, suggesting an interventional opportunity.
A62 Is fissure integrity affected by the severity of emphysema and does this direct the choice of lung volume reduction procedure?
Ben Shanahan, Luigi Ventura, Joanne Hargrave, David Waller
St Bartholomew's Hospital, London, United Kingdom
Correspondence: Ben Shanahan
Journal of Cardiothoracic Surgery 2024, 19(2):A62
Background: Endobronchial lung volume reduction (EBLVR) is dependent on near complete fissure integrity (FI). Some assume that fissure integrity declines with the progression and severity of underlying emphysema, leading to the misconception that some patients may become ‘too bad’ for EBLVR and encouraging premature surgical intervention.
Methods: In 98 patients (53 male, 45 female, mean age 68) undergoing lung volume reduction (48 by EBVLVR and 50 by surgery) we analysed emphysema anatomy using quantitative CT software program StratX. We have a policy of offering EBLVR as the first treatment option in those without collateral ventilation (CV) irrespective of severity of emphysema or operative risk. We correlated FI with emphysema severity and operative approach.
Results: There was significantly greater median FI in patients undergoing EBLVR than LVRS: 100% (IQR 97.8–100) vs 88% (IQR 83.1–93.9) p < 0.05 (Fig. 1). There was no significant difference in the mean severity of emphysema (%voxel density < 910 HU) in the target lobe in those undergoing EBLVR vs LVRS (60.1% vs 60% p = 0.1). There was no significant association between FI and emphysema severity in the target lobe (correlation coefficient 0.03, p = 0.74) overall.
Conclusions: FI is not associated with the degree of destruction in the target lung and therefore the severity of disease should not in itself influence the decision to treat by either EBLVR or LVRS. It follows that delaying intervention and risking disease progression will not necessarily reduce the chances of EBLVR being successful. Our results suggest that a reasonable cut-off for FI in EBLVR is 95%.

A67 Does interlobar fissure integrity affect the outcome of lung volume reduction surgery for emphysema?
Ben Shanahan, Periklis Perikleous, Maximilian Fend, David Waller
St Bartholomew's Hospital, London, United Kingdom
Correspondence: Ben Shanahan
Journal of Cardiothoracic Surgery 2024, 19(2):A67
Background: Fissure integrity (FI) is a marker of interlobar collateral ventilation (CV) and has been found to predict the efficacy of endobronchial lung volume reduction (EBLVR) for emphysema. Those patients with evidence of CV are treated preferentially by lung volume reduction surgery (LVRS). We aimed to evaluate whether the degree of FI affects the physiological outcome of LVRS.
Methods: We analysed 36 patients undergoing Robot assisted LVRS, in whom EBLVR was excluded due to low FI calculated using the StratX® software system and/or CV on intraoperative Chartis assessment. All patients had similar preoperative assessment and serial postoperative lung function measurements. Changes in FEV1 and RV were correlated with the degree of preoperative FI.
Results: Median FI was 86% [range 8 -100]. There was a statistically significant moderate positive correlation between FI and improvement in FEV1 (correlation coefficient 0.4, p = 0.04) with the correlation strongest after 6 months after LVRS. There was no correlation seen between FI and reduction in RV (correlation coefficient -0.2, p = 0.77). Improvement in FEV1 also did not appear to be significantly related to % perfusion of the target lobe on SPECT or preoperative DLCO.
Conclusions: Increased fissure integrity appears to correlate with greater improvement in FEV1 after LVRS and is independent of other factors. Could this mean that the LVRS procedure should include fissure completion?
A68 Atrial fibrillation after cardiac surgery (AFACS) prevention care bundle: assessment of implementation fidelity and sustainability
Rosalie Magboo1,2, Raquel Acala-Taylor1, Ankan Paul1, Edward Parkinson1, Maricar Lasar1, Mary Jane de Guzman1, Martina Buerge1
1St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom. 2William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
Correspondence: Raquel Acala-Taylor
Journal of Cardiothoracic Surgery 2024, 19(2):A68
Objective: Atrial fibrillation after cardiac surgery (AFACS) affects approximately 30–50% of patients, carrying significant morbidity. A prevention care bundle, adapted from an international practice advisory tool, was locally introduced in 2019. A baseline audit and subsequent quality improvement (QI) cycle revealed a marked reduction in AFACS following bundle implementation. This project aims to assess ongoing bundle implementation fidelity and sustainability as part of a wider national QI initiative.
Methods: Since implementation, continued teaching and training on the use of the care prevention bundle has been conducted for all ICU nurses and doctors. Prospective data was collected in a single centre for a 7-day period in October 2022 for patients undergoing cardiac surgery. Outcomes were compared with baseline and first-cycle data collected in 2019. Patients with pre-existing diagnoses of AF were excluded when assessing AFACS incidence, however, were included for bundle adherence analysis.
Results: A total of 129 patients (79.8% male, mean age 61 years, 60% undergoing coronary artery bypass grafts) were included. Bundle adherence was 88% for early B-blocker administration, 76% for electrolyte replacement, 81% for adequate oxygenation, and 85% for pain management. A further reduction in AFACS incidence was measured (18% vs 36% (p = 0.001) and 23.3% (p = 0.291) in baseline and first-cycle audits in 2019, respectively).
Conclusion: Fidelity and sustainability scores were high in all aspects of bundle implementation, suggesting despite frequent staff rotation, project sustainability is possible with good clinical induction, teaching, and training. This information may help increase implementation quality and dissemination of the AFACS care prevention bundle.
A69 Dexamethasone modulates Osteopontin activation and microcalcification in venous grafts
Shameem S. Ladak1, Liam W. McQueen1, Georgia Layton1, Lathishia JoelDavid2, Kerry Wadey3, Sarah J. George3, Gianni D. Angelini3, Gavin J. Murphy1, Mustafa Zakkar1
1Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom. 2NIHR Leicester Biomedical Research Centre (BRU2), cardiovascular theme, Glenfield Hospital, Leicester, United Kingdom. 3Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
Correspondence: Shameem S. Ladak
Journal of Cardiothoracic Surgery 2024, 19(2):A69
Osteopontin (OPN) has been implicated in vascular calcification and intimal hyperplasia in vein grafts and its expression can be triggered by pro-inflammatory activation of cells. The focus of this work is to study the impact of acute haemodynamic changes in vein grafts on the activation of OPN and the development of microcalcification.
A porcine model of vein interposition grafts and human long saphenous veins (LSV) ex-vivo perfusion bioreactor was used to study the activation of OPN at various time points. Changes in RNA and protein marker expression was evaluated using RT-PCR, immunostaining and ex-vivo 18F-sodium fluoride autoradiography.
A brief pre-treatment of LSV with dexamethasone was able to suppress OPN activation at the RNA and protein level following 4 h of exposure to acute arterial haemodynamics. Prolonged culture of veins following exposure to acute arterial haemodynamics resulted in the formation of microcalcification which was suppressed by a single brief pre-treatment with dexamethasone. Furthermore, 18F-sodium fluoride uptake was significantly increased as early as 1 week in the porcine model of vein interposition grafts and LSV with the pre-treatment of LSV with dexamethasone being able to abolish its uptake.
OPN is activated in vein grafts and is associated with microcalcification formation. However, its activation and associated microcalcification is suppressed by a brief pre-treatment of veins ex-vivo with dexamethasone.
A70 Simultaneous bilateral RATS metastasectomies
Ahmad Asqalan1, Haisam Saad1, Lu Wang1, Obada Alqudah1, Jonathon Francis2, Waldemar Bartosik1, Cristina Viola1, Jakub Kadlec1, Bartlomiej Szafron1, Vasileios Kouritas1
1Department of Thoracic Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom. 2Department of Anaesthesia Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom
Correspondence: Ahmad Asqalan
Journal of Cardiothoracic Surgery 2024, 19(2):A70
Objectives: Bilateral metastasectomies are usually performed in a staged approach, usually with an interval of 4–6 weeks between the 2 sides. We, herein, present the case of a patient who underwent RATS bilateral lung resections for metastasis, on the same day.
Methods: A 53-years-old male was diagnosed with bilateral metastasis from a colorectal adenocarcinoma. Two of the metastasis were in the left lung (1 in the S6 segment and 1 at the apex, Fig. 1a, b) whilst 1 was at the right apex (Fig. 1d). Ablation or radiotherapy could not be offered. The procedure was performed using the DaVinci X Robotic system.
Results: A S6 segmentectomy and a wedge resection in the left was performed utilizing 4 ports (2 × 12 mm, 2 × 8 mm) with the patient at a right lateral position. A 20Fr chest drain was left in the chest. Then the patient was turned at a left lateral position and a wedge of the right apex was performed utilizing 3 ports (1 × 12 mm, 2 × 8 mm). A 20Fr chest drain was again left in the chest. The patient was transferred to high dependency unit (Fig. 1d). He he was discharged home on day 5 with a flutter bag on the left side because of prolonged air leak. His drain was removed 10 days later and he remains well 3 months post-surgery. The histology showed metastatic colorectal adenocarcinoma R0 resections.
Conclusion: Bilateral lung resections are possible via RATS in selected patients. Especially in metastasis cases, this can expedite treatment and avoid the risks of staged resections.
Patient gave their written, informed consent to publish their information in an open access journal.

A71 The potential role of KCa3.1 in preventing saphenous vein graft stenosis following cardiac bypass
Shameem S. Ladak1, Georgia R. Layton1, Liam W. McQueen1, Lathishia JoelDavid2, Peter Bradding3, Mustafa Zakkar1
1Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom. 2NIHR Leicester Biomedical Research Centre (BRU2), cardiovascular theme, Glenfield Hospital, Leicester, United Kingdom. 3Institute for Lung Health, Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
Correspondence: Shameem S. Ladak
Journal of Cardiothoracic Surgery 2024, 19(2):A71
The long saphenous vein (LSV) is a commonly used conduit for CABG, however the long-term effectiveness of the graft is limited due to TGFβ1 -mediated progressive fibrosis and development of vein graft disease (VGD). The Ca2 + -activated K + channel KCa3.1 (encoded by KCNN4), is known to regulate TGFβ1-dependent pro-fibrotic activity, but its role in serving as a novel target for the prevention of VGD has not been assessed and it’s the focus of the study.
HUVECs and surplus LSV segments were subjected to high acute shear stress (HSS) and acute arterial haemodynamics respectively using an in vitro or ex-vivo model perfusion bioreactor. Changes in marker expression at the RNA and protein level were evaluated using Spatial scRNAseq, RT-PCR and immunofluorescence.
The exposure of LSV to acute arterial haemodynamics was associated with the activation of pro-inflammatory and endothelial- mesenchymal transition (EndMT) mediators such as CXCL8, TNFα, CCL2 and TWIST2. Data from spatial scRNAseq also showed significant upregulation of KCa3.1 mRNA under acute arterial flow. This was validated using PCR and immunofluorescence in LSV. Brief pre-treatment with Senicapoc, a KCa3.1 blocker, prevented the activation of KCa3.1 mRNA and protein in HUVECs and LSV subjected to HSS and acute arterial haemodynamics. Furthermore, Senicapoc pre-treatment also prevented the activation of pro-inflammatory and EndMT mediators following HSS and acute arterial haemodynamics.
Targeting KCa3.1 using senicapoc as a pre-treatment before implantation, and as preventative treatment post implantation, can reduce VGD by modulating inflammation, calcification, and EndMT induced by acute changes in haemodynamics, following implantation into arterial systems.
A72 Use of Amnion-Chorion Placental Allografts (ACPA) for Enhanced Chest Wound Healing in High-Risk Sternotomy Patients: Early Experiences from a Feasibility Study
Ujjawal Kumar1,2, Brynne Rozell3, Ezekiel Mendoza2, Anthony Cooper2, Zain Khalpey2
1Royal Papworth Hospital, Cambridge, United Kingdom. 2Division of Cardiothoracic Surgery, HonorHealth, Scottsdale, USA. 3General Surgery Residency Programme, HonorHealth, Phoenix, USA
Correspondence: Ujjawal Kumar
Journal of Cardiothoracic Surgery 2024, 19(2):A72
Objectives: Sternotomy wound dehiscence is a devastating complication following cardiac surgery. A range of adjunct measures including antibiotic wound impregnation and negative pressure dressings constitute an institutional chest wound healing protocol for high-risk patients. ACPAs are a novel technology, rich in growth factors, cytokines, and matrix proteins and have been shown to enhance wound healing. This study assessed the feasibility of ACPA technology to enhance sternotomy wound healing.
Methods: This study followed ninety-three patients who underwent cardiac surgery via median sternotomy. They were considered high risk for sternal complications due to frailty, immunocompromised status, obesity, or diabetes. During chest closure, 80 mg of ACPA was applied to the sternum and 80 mg to the subcutaneous tissues to aid wound healing.
Results: All ninety-three patients (clinical details in the Table) had uncomplicated post-operative recovery and were discharged home in a stable condition. None of the patients had any wound-related complications, such as superficial or deep wound infection warranting antibiotics or return to theatre. At follow-up, no patients experienced sternal wound complications and all chest wounds displayed excellent signs of healing.
Conclusions: Our study suggests that ACPAs are an effective adjunct for promoting sternal wound healing in high-risk patients. The preserved growth factors and matrix proteins within ACPAs address the unique challenges these patients encounter, providing an innovative, advanced approach for further facilitating wound healing. Compared to historical institutional experience, this is a significant improvement in wound healing that is encouraging and validates our continued evaluation.
A73 Increasing ED staff awareness of the STUMBL score to assess patients with rib fractures
Wei Yee Audrey Chew, Mohmad Salim
Walsall Manor Hospital, Walsall, United Kingdom
Correspondence: Wei Yee Audrey Chew
Journal of Cardiothoracic Surgery 2024, 19(2):A73
This is a 2 cycle Quality Improvement project in a district general hospital, investigating Emergency Department (ED) staff awareness of the STUMBL (STUdy of the Management of BLunt chest wall trauma) score in rib fracture management. Patients with cardiothoracic trauma are managed under General Surgery, as there is no on-site Cardiothoracic Surgery service. ED staff were surveyed on their existing knowledge of the STUMBL score, and multiple interventions (posters, teaching sessions) were taken to educate ED staff on the STUMBL score and how to apply them. Results revealed an overall increased awareness of the STUMBL score following the interventions, as well as increased knowledge on which specialties to involve. Prognosticating rib fracture patients accurately begins in the Emergency Department, and referral to the appropriate specialties is key to management. Using a single scoring system helps to unite different specialties by providing a common language in understanding the risk of clinical deterioration in patients with rib fractures. Hopefully, this project conveys the importance of staff education when it comes to establishing a new scoring system, as well as multi-disciplinary care in rib fractures.
A74 Dissecting misdiagnosis of acute aortic dissection: a decade-long retrospective observational cohort study at barts health NHS trust
Farhin Holia1, Samy Sadek2, Aung Oo3,4
1Emergency Department, Barts Health NHS Trust, London, United Kingdom. 2Emergency Department, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom. 3Professor Cardiovascular Surgery, The Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom. 4William Harvey Heart Research Institute, Queen Mary University of London, London, United Kingdom
Correspondence: Farhin Holia
Journal of Cardiothoracic Surgery 2024, 19(2):A74
Objective: To determine the scale of AAD misdiagnosis, elucidate contributing factors and common themes, and suggest a comprehensive action plan to mitigate these challenges.
Methods: A mixed-method retrospective observational study was conducted across all Barts Health NHS Trust hospitals, encompassing specialised aortic, tertiary, and district centres. Data spanning a decade (2012–2022) was gathered from the Trust's clinical governance database, diagnostic codes, post-mortem reports, and case logs.
Results: Of the 400 documented AAD cases, 21 were misdiagnosed; 90% of these were Type A and 10% Type B dissections. Within this cohort, 29% had missed diagnosis, while 57% experienced delayed diagnoses, with the median time to diagnosis at 5 h, leading to a 67% mortality rate. Alarmingly, AAD was overlooked in 90% of these cases. Half of these patients were under 60, including a subset of pregnant and post-partum individuals. About 48% displayed classic symptoms misattributed to Acute Coronary Syndrome or Pulmonary Embolism, while 52% had atypical symptoms, misdiagnosed as Mesenteric Ischemia, Limb Ischemia, Stroke, Renal Colic, or Costochondritis. The reliance on diagnostic tests like Chest X-Ray, Point-of-Care Ultrasound, D-dimer where normal outcomes provided false reassurance, and inter-hospital transfers, contributed further delays. Concerningly, younger patients with chest pain, but normal ECGs, faced triage misdirection, leading to missed diagnoses.
Conclusion: Recognition of AAD symptoms is vital for survival. This pilot study calls for transformative actions: intensifying educational efforts, formulating innovative diagnostic and treatment protocols from initial contact to post-discharge. It sets the foundation for broader initiatives at Pan-London, national, and potential global scales.
A75 Alternative operative procedures in repeat mitral valve surgery: a systematic review and meta-analysis
Manasi Shirke1,2, Nidhruv Ravikumar1,2, Shawn Tan2, Vernie Soh2, Nyasha Mutsonziwa2
1Nottingham University Hospitals, Nottingham, United Kingdom. 2Queen's University Belfast, Belfast, United Kingdom
Correspondence: Manasi Shirke
Journal of Cardiothoracic Surgery 2024, 19(2):A75
Objective: Median sternotomy remains the gold standard redo mitral valve surgery. However, this can be physically demanding for patients and affect mortality and morbidity. Alternative procedures such as the right anterolateral mini-thoracotomy have been explored to mitigate the risks of a re-sternotomy. This review aims to compare the clinical outcomes of re-sternotomy (MS) versus right mini-thoracotomy (MT) in mitral valve surgery.
Methods: A systematic, electronic search was performed according to PRISMA guidelines to identify relevant articles that compared outcomes of the MS versus MT procedures in patients who have had cardiac surgery via an MS approach.
Results: Twelve studies were identified, enrolling 4,514 patients. Length of hospital stay (MD = − 3.71, 95% CI [− 4.92, − 2.49]), 30-day mortality (OR = 0.59, 95% CI [0.39, 0.90]), and new-onset renal failure (OR = 0.38, 95% CI [0.22, 0.65]) were statistically significant in favour of the MT approach. Infection rates (OR = 0.56, 95% CI [0.25, 1.21]) and length of ICU stay (MD = − 0.55, 95% CI [− 1.16, 0.06]) was lower in the MT group; however, the difference was not significant. No significant differences were observed in the CPB time (MD = − 2.33, 95% CI [− 8.15, 3.50]), aortic cross-clamp time MD = -1.67, 95% CI [− 17.07, 13.76]), and rates of stroke (OR = 1.03, 95% CI [0.55, 1.92]).
Conclusion: Right MT offers a reduced length of hospital stay, ICU stay, and a lower risk of new-onset renal failure requiring dialysis and hence, can be considered a safe alternative. This review calls for robust trials in the field to further strengthen the evidence.
A76 Outcomes of robotic anterior mediastinal masses resection in comparison with vats and open approaches
Haisam Saad1, Joana Fuentes – Warr1, Obada Alqudah1, Jonathan Francis2, Thandayuthapani Santhosh2, Bartlomiej Szafron1, Jakub Kadlec1, Waldemar Bartosik1, Vasileios Kouritas1
1Department of Thoracic Surgery, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, United Kingdom. 2Department of Anesthetics, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, United Kingdom
Correspondence: Haisam Saad
Journal of Cardiothoracic Surgery 2024, 19(2):A76
Objectives: To investigate whether implementation of Robotic-Assisted Thoracic Surgery (RATS) has changed the practice with regards to the surgical treatment of anterior mediastinal masses.
Methods: Patients who underwent resection of an anterior mediastinal mass within the period of January 2015-October 2022 were included. They were grouped into a RATS, a Video-Assisted Thoracic Surgery (VATS) and an Open group (sternotomy and other open approaches). Multiple outcomes and survival were compared amongst groups.
Results: 128 patients were analyzed. The mean age was 60.3 ± 15.3 years and 60 (46.9%) were females. More cases were operated on after RATS was introduced (p = 0.032, Fig. 1a). 32 patients had Open, 69 VATS and 27 RATS procedures. The age, gender, co-morbidities, preoperative MG, preoperative biopsy performed, and performance status were similar, but smaller masses were resected with VATS (p = 0.001). In RATS, the duration of procedure, the length of stay (LOS), the critical care (CCC) LOS were shorter (p = 0.023, 0.001, 0.001, respectively), while the unplanned re-admissions to CCC were also lower (p = 0.002). RATS yielded similar size of specimen and mass size with the Open procedures (p = 0.002 and 0.047, respectively). The overall and respiratory complications were less in RATS (p = 0.048, 0.028, respectively). Phrenic nerve injuries were noted in VATS and open but not in RATS (p = 0.016). Survival was similar between the 3 groups (log-rank = 0.324, p = 0.850, Fig. 1b).
Conclusion: RATS induced more resections and showed better outcomes than VATS or open approaches.
A77 Should minimal access aortic valve replacement be the standard of care in the current era? Results of a UK multicentre study
Benjamin Omoregbee1, Mohamed Allam2, Ghazi Elshafie3, David Zicho1, Govind Chetty3, Enoch Akowuah2, Dumbor Ngaage1
1Castle Hill Hospital, Hull, United Kingdom. 2James Cook Hospital, Middlesbrough, United Kingdom. 3Northern General Hospital, Sheffield, United Kingdom
Correspondence: Benjamin Omoregbee
Journal of Cardiothoracic Surgery 2024, 19(2):A77
Objectives: Minimal access aortic valve replacement (miniAVR) has been shown to have equivalent outcomes with open aortic valve replacement in clinical trials. This study aims to examine the “real-world” clinical outcomes of miniAVR in current practice.
Methods: Data for consecutive patients who underwent miniAVR at 3 cardiac centres between January 2013 and January 2023 were retrieved from the institution’s databases and analysed. Patients who had concomitant procedures, infective endocarditis, emergencies/salvage or redo procedures were excluded. Patient demographics, preoperative, intraoperative and postoperative parameters were collated and analysed. Statistical analysis was performed using SPSS v28.
Results: There were 764 patients; majority (57.6%) were males and the mean age was 70.5 ± 10.1 years. Aortic stenosis was the dominant valve pathology (88.1%). Most miniAVRs were performed electively (87.3%) via a hemi sternotomy (96.7%) with biological valves (76.7%). The conversion rate to full sternotomy was 2.4%. The Mean logistic EuroScore was 5.8%. Valve sizes implanted ranged from 19 to 29 mm; with 23 mm (n = 338, 44.24%) being the most common, see Fig. 1. Permanent pacemaker requirement was 1.96% and in-hospital survival was 98.4%.
Conclusion: MiniAVR in current practice is associated with excellent outcomes. We observed a low permanent pacemaker requirement compared to publish rates for open AVR, and this is being investigated. However, this study suggests that miniAVR could be the standard of care for isolated aortic valve replacement.
Figure: Shows the different sizes of the aortic valves implanted in this Minimal Access Aortic Valve Replacement Multicentre study. Each valves size are colour coded from size 19–29.

A78 Comparing mini-sternotomy technique via 4th right or 4th left interspace for isolated AVR. Is mini-L a better alternative to mini-J?
Rickesh Karsan1, Tara Chan-A-Sue2, Gwyn Beattie1
1Department of Cardiothoracic Surgery, Royal Victoria Hospital, Belfast, United Kingdom. 2Department of Medicine & Surgery, Queens University, Belfast, United Kingdom
Correspondence: Rickesh Karsan
Journal of Cardiothoracic Surgery 2024, 19(2):A78
Objectives: Conventional mini-sternotomy is via the 3rd or 4th right intercostal space. Difficulties can arise due to access for cannulation or annulus. An alternate approach may be a ‘mini-L’ through the left intercostal space. This study aims to compare surgical and clinical outcomes between mini-J and mini-L sternotomy for isolated aortic valve replacement.
Methods: Single-surgeon data for all mini-sternotomy aortic valve replacements from 2019 to 2023 were reviewed and grouped by mini-J or mini-L sternotomy. Bypass, cross clamp and total surgical time were compared along with conversion to full-sternotomy, post-operative AKI, stroke and total hospital time. Groups were further stratified based on rapid deployment valve vs sutured technique.
Results: A total of 56 cases were analysed, 29 via mini-J through 4th right intercostal space and 27 via mini-L through 4th left intercostal space. Post-operative outcomes of stroke, AKI and hospital stay were similar in both groups (P > 0.05). Compared to conventional mini-J sternotomy, mini-L sternotomy showed significantly lower bypass times (112 ± 7.52 min, P = 0.024). Cross clamp times (89 min) and total surgical time (217 min) was also seen to be reduced in the mini-L group. Conversion to full sternotomy was seen to be higher in the mini-J group compared to mini-L.
Conclusion: Mini-L sternotomy appears to improve intra-operative measures by means of better visualisation and access. This results in lower bypass, cross-clamp and total surgical time, with a lower rate of conversion to full sternotomy. This may present a better viable mini-sternotomy technique for improved access in isolated aortic valve replacement.

A79 Management of benign airway stenosis: predictors of tracheal resection
Akshay Patel, Alina Budacan, Sajith Kumar, Huw Griffiths, Anita Sonsale, Maninder Kalkat
Queen Elizabeth Hospital, Birmingham, United Kingdom
Correspondence: Akshay Patel
Journal of Cardiothoracic Surgery 2024, 19(2):A79
Objective: We sought to analyze our airway practice and see if there are any factors associated with the need for cricotracheal/tracheal resection (CTR/TR) and reconstruction in cases of benign subglottic and tracheal strictures.
Methods: We performed a retrospective analysis of a prospectively maintained database of all patients ages 16 and over with benign subglottic and tracheal stenoses that underwent endoscopic or surgical treatment at our institution between January 2005 and January 2023.
Results: Ninety seven patients were included in our series, with a strong female preponderance (n = 79; 81%). The median age of the cohort was 44 years (range 16–73) and 80% (n = 78) were life-long never smokers. Subglottic stenosis (SGS) was the most common site of disease in the trachea (79%), and the common etiology of all stenoses was idiopathic (52%). The median number of dilatations was 3 (range 0–17); 41 patients (42%) underwent formal resection and reconstruction with a median length of post-operative stay of 6 days. Twenty-two patients (54%) had a laryngeal component removed. The median interval between first dilatation and CTR/TR was 5 months (0–173 months). Patients in the tracheal resection group had a higher Myer-Cotton grading; grade 3, p = 0.014. Pre-operative tracheostomy rate was significantly higher in those who underwent tracheal resection (51% versus 18%; p < 0.001) yet the number of dilatations was equivocal between the surgical and non-surgical groups (p = 0.3).
Conclusions: Endoscopic/open surgical airway interventions are successful in restoring airway patency in benign disease. Identifying when to intervene with formal CTR/TR is crucial.
The legend is ‘Kaplan Meier time to resection curve stratified according to risk modelling’.

A80 Euglycemic diabetic ketoacidosis post coronary artery bypass grafting: a case report and systematic literature review
Adina Pusok1, Andrew Brazier2, Thomas Barker2
1Warwick Medical School, Coventry, United Kingdom. 2University Hospitals Coventry and Warwickshire, Coventry, United Kingdom
Correspondence: Adina Pusok
Journal of Cardiothoracic Surgery 2024, 19(2):A80
Euglycemic diabetic ketoacidosis (EDKA) is a rare complication of diabetes mellitus associated with risk factors such as infection, fasting, and surgery. The use of sodium-glucose co-transporter 2 (SGLT 2) inhibitors, an antidiabetic class of medication, is associated with an increased risk of EDKA especially in patients faced with physiological stressors. The non-specific symptoms and lack of hyperglycemia, make the diagnosis very difficult and often lead to delays in treatment. Diagnosis is particularly challenging in patients who are sedated after undergoing major surgery. We present the case of a patient with type 2 diabetes mellitus (T2DM) treated with empagliflozin who developed EDKA after undergoing coronary artery bypass grafting (CABG). A systematic literature review was also undertaken to identify other cases of patients with T2DM treated with SGLT2 inhibitors that developed EDKA post-CABG. We identified seven papers, describing 13 patients who developed this complication after CABG, and a narrative synthesis was used to summarize these findings. The timing between the last dose of SGLT2 inhibitors and surgery ranged from zero to five days. This shows that there is a clear need to identify an optimal time to stop this medication before elective surgery, but also the need to develop monitoring protocols for these patients. Clinicians need to be aware of the EDKA risk in this group of patients especially as SGLT2 inhibitors are now recommended as part of the guidelines for heart failure management. Early recognition and a low threshold for suspecting this complication are needed in patients who undergo major surgery.
A81 Central vs peripheral cannulation in redo cardiac surgery—a 10-year review
Nikhil Sahdev, Guiqing Liu, Prakash Punjabi
Hammersmith Hospital, London, United Kingdom
Correspondence: Nikhil Sahdev
Journal of Cardiothoracic Surgery 2024, 19(2):A81
Objective: Redo-sternotomy and myocardial dissection in redo-surgery is extremely high risk for bleeding. Peripheral cannulation allows for quick transfer onto bypass in the event of tissue injury; however, risks including femoral dissection and stroke. We review central vs peripheral cannulation strategies in redo cases over a 10-year period.
Method: Patients undergoing redo coronary, tricuspid and mitral surgery between the 2013 and 2023 were included in the study.
Results: 94 patients were included in the study. 51(54%) patients underwent central cannulation and 43(46%) underwent peripheral cannulation. Both groups had similar pre-op co-morbidities and both groups also had a similar euroscore preoperatively 5% vs 4.5% (p = 0.42) (C vs P). Both cannulation strategies involved similar cross clamp time (98 vs 93 min(p = 0.19)), bypass time(158 vs 144 min (p = 0.26)) and length of operation(322 vs 329 min(0.19))(C v P). In central cannulation there were no major complications of myocardial injury, bleeding or innominate vein damage. Postoperatively there was no difference in atrial fibrillation (11(22%) vs 10(23%) (p = 0.29), renal failure (2(4%) vs 3(7%) (p = 0.29), stroke (3(6%) vs 3(7%) (p = 0.34) and in-hospital death (3(6%) vs 4(9%)(p = 0.42) (C v P).
Conclusions: If effective redo techniques for chest opening such as hyperinflation of the lungs to reduce cardiac output or using the oscillating saw between the angles of 60–80° are employed, the risk of opening a chest with central cannulation in redo cardiac surgery is reduced. This avoids the need for peripheral cannulation and avoids its associated complications.
A82 Peri-operative cannabinoids significantly reduce postoperative opioid requirement in cardiac surgery patients
Ujjawal Kumar1,2, Antoni Macko3, Jessa Deckwa4, Yash Suri5, Nayoung Kang6, Nicole Darian6, Mohammad Alrashed6, Ferena Salek6, Zain Khalpey2
1Royal Papworth Hospital, Cambridge, United Kingdom. 2Division of Cardiothoracic Surgery, HonorHealth, Scottsdale, USA. 3Arizona College of Osteopathic Medicine at Midwestern University, Glendale, USA. 4Nihon Kohden Digital Health Solutions Inc., Tucson, USA. 5University of Arizona College of Medicine, Tucson, USA. 6Department of Pharmacy, Northwest Medical Center, Tucson, USA
Correspondence: Ujjawal Kumar
Journal of Cardiothoracic Surgery 2024, 19(2):A82
Objectives: Opioids are commonly used for post-operative analgesia in cardiac surgery but are associated with prolonged mechanical ventilation, ICU and hospital stay. Cannabinoids are hypothesised to have potential utility as an adjunct analgesic and reduce opioid requirements.
Methods: 68 patients undergoing isolated CABG were randomised to either the Control Group or the Dronabinol Group (a synthetic cannabinoid). Pre-operative, intra-operative and post-operative parameters were compared, with a particular focus on post-operative opioid requirements, duration of mechanical ventilation, ICU and hospital length of stay.
Results: 68 patients were randomised to either Control Group (n = 37) or Dronabinol Group (n = 31). Groups were similar in terms of demographic features and comorbidities (Table). Total post-operative morphine milligram equivalent requirement was significantly lower in the Dronabinol Group (39.62 vs 23.68, p = 0.0037) representing 40% reduction in the opioid requirement. There was no significant difference between groups in the duration of mechanical ventilation (7.03 vs 6.03 h, p = 0.5004), ICU LOS (71.43 vs 63.77 h, p = 0.4227) and inotropic support requirement (0.6757 vs 0.6129 days, p = 0.7333). Interestingly, significantly better pre- to post-operative LVEF change was observed in the Dronabinol Group (3.51% vs 6.45%, p = 0.0451).
Conclusions: Our study found a 40% reduction in opioid use and a significantly greater improvement in LVEF in the Dronabinol Group. Mechanical ventilation duration, ICU length of stay, and inotropic support requirement tended to be lower in the Dronabinol Group, though this did not reach statistical significance. The results of this study, although limited by sample size, are very encouraging and validate our ongoing investigation.
A83 The implementation of endoscopic vein harvesting technique in establishing an enhanced recovery program: patient satisfaction and outcomes
Beth Casebow, April McCormack, Graham Bryson
Golden Jubilee National Hospital, Glasgow, United Kingdom
Correspondence: Beth Casebow
Journal of Cardiothoracic Surgery 2024, 19(2):A83
Cardiac Surgery enhanced recovery after surgery (ERAS) programs are typically further behind and under researched when compared to ERAS programs such as colorectal and orthopaedics (Ljungqvist et al., 2020). Endoscopic vein harvesting (EVH) technique allows for minimally invasive techniques, a vital component of ERAS, and improved outcomes (Heart Health, 2013; Lucchese and Jarral, 2019; Raja and Sarang; Zenati et al., 2021). EVH technique should therefore be considered when establishing an ERAS program in a cardiac centre.
We sought to show the link between EVH and the development of an ERAS program in a cardiac centre by using a patient reported outcome measures survey (PROMS) to measure patient satisfaction between patients who underwent EVH technique and those who received non-EVH technique. We also retrospectively looked at the difference in hospital length of stay (LoS) between the two groups.
The findings suggested that there are significant positive differences in patient beliefs that EVH is a positive experience allowing for faster recovery with less complications. There is currently no significant statistical difference in the mean average LoS between EVH and Non-EVH groups and further research into the reason for the prolonged stay in the EVH group is being undertaken.
An integral part of developing an ERAS program is involving the patient and early mobilisation, the inclusion of EVH technique in an ERAS program helps to enable these elements. Overall, our findings show that when establishing an ERAS program in a cardiac surgery centre, EVH should be considered.
Results table for the Patient Reported Outcome Measures Survey. PROMS was used to measure patient satisfaction in both EVH and Non-EVH technique, the mean, median and the t-test results are displayed
A84 Advanced nurse practitioner led prolonged air leak clinic: for patients with a portable ambulatory drain
Denise Baillie, Nicole Spence, Carole Herpich, Ghaith Qsous, Anthony Chambers, Malcolm Will, Sanjeet Singh
Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
Correspondence: Denise Baillie
Journal of Cardiothoracic Surgery 2024, 19(2):A84
Objective: To provide continuity of care and promote early discharge from hospital. Prolonged air leak (PAL) is one of the most common complications after thoracic surgery. With increase in the use of digital drains, it is easier to support patients on the ward with pleural drains and assist with decision-making on air leak management. A nurse –led outpatient clinic has been established by the advanced nurse practitioner (ANP) team for assessment and decision-making of patients with ambulatory chest drains. The pathway is in the form of a flowchart.
The protocol was divided into two stages:
-
I- Management of inpatients with air leak: Establish criteria to help in decision-making to switch from digital drain to ambulatory drain and criteria for discharge.
-
II- Management in outpatient clinic: Establish pathway for assessment of patients with ambulatory chest drain and develop a drain removal criteria.
Methods: A six month pilot study was conducted on 15 patients who met the criteria for the Nurse Led Ambulatory Chest Drain clinic. These patient’s experienced a PAL and were managed with Patient Ambulatory System (PAS). The mean in-hospital LOS was 6.87 days. The mean day of switching to a PAS was 5.3 days. Thirteen percent (n = 2) of patients were readmitted to hospital from the clinic (1 for worsening surgical emphysema and 1 for an empyema). Another 2 patients (13%) had their drains removed at a second visit (14 days post discharge). The remaining 74% patients (n = 11) had their drains removed on the first visit.
A85 Surgical management and outcomes of patients with empyema during the early phase of the COVID-19 pandemic
Alexandra Westcott, Aiman Alzetani, Bradley Yee, Alessandro Tamburrini, Edwin Woo, Martin Chamberlain, Lukacs Veres
University Hospital Southampton, Southampton, United Kingdom
Correspondence: Alexandra Westcott
Journal of Cardiothoracic Surgery 2024, 19(2):A85
Background: Empyema is multifactorial in pathogenicity and aetiology and treatment combines surgical and medical management to target both the infection and lung re-expansion. There was a perceived increase (Fig. 1) in the number of cases referred to surgery due to delayed medical management in 2020 with COVID-19.
Aims: This project looks to evaluate the surgical management and outcomes of patients with empyema at UHS in 2020 when the pandemic started.
Methods: Anonymised data of patients with an empyema diagnosis admitted to UHS in 2020 were collected, statistically analysed and described.
Results: A total of 72 patients (19–87 years) were identified. The median age was 57. Data for first symptoms to admission at UHS was available in 43 patients, with an average of 29.5 days. 46 patients were received via a hospital transfer with 13 admitted through A&E and 13 electives. 55 patients had a previous hospital admission within the last three months. The time to surgery from admission averaged at 3.5 days (0 to 23). The average hospital stay was 11.9 days (2–127). 37 patients had three or more co-morbidities and 3 patients died whilst inpatient. 22 patients had post-surgery complications, most commonly sepsis (12). The predominant organisms identified were streptococci and staphylococci (42%) with 36% of patients having sterile empyema.
Conclusions: Empyema management is time sensitive. A perceived delay in presentation led to a more advanced and complex stage disease to manage. This is likely multifaceted and further assessment is necessary to illicit the underlying causes.

A86 Barriers to cascade screening in people at risk of thoracic aortic disease: a mixed methods evaluation from the DECIDE-TAD initiative
Riccardo Giuseppe Abbasciano1, Joanna Dionne2, Simon Oczkowski2, Robert Grant3, Julian Barwell3, Nora Shannon4, Joanne Miksza3, Anne Cotton5, Haleema Saadia5, Lisa Skinner5, Mark Lewis5, Gordon McManus5, Hardeep Aujla3, Sue Page3, Aung Oo6, John Maltby3, Paul Clift7, Gareth Owens5, Gavin Murphy3
1Imperial College Healthcare NHS Trust, London, United Kingdom. 2McMasters University, Hamilton, Canada. 3University of Leicester, Leicester, United Kingdom. 4Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom. 5Aortic Dissection Awareness UK & Ireland, London, United Kingdom. 6Barts Health NHS Trust, London, United Kingdom. 7University Hospitals Birmingham, Birmingham, United Kingdom
Correspondence: Riccardo Giuseppe Abbasciano
Journal of Cardiothoracic Surgery 2024, 19(2):A86
Background: Cascade genetic and imaging screening for relatives of people with thoracic aortic diseases (TAD) is recommended by guidelines. However, availability and uptake of cascade screening are low. We applied mixed research methods to identify barriers to screening, and to identify strategies to overcome these.
Methods: Focus groups and a cohort study using routinely collected healthcare data evaluated barriers to imaging, genetic testing, and treatment for people with TAD and strategies to overcome them. A consensus exercise evaluated the evidence to support cascade screening.
Results: A cohort study of 33,793 patients with a TAD diagnosis between 2013 and 2018 demonstrated barriers to treatment and surveillance in females, non-whites, and people from low socioeconomic backgrounds. A survey of TAD survivors and relatives reported that 33/70 (47%) patients who responded had undergone genetic testing, including 10/22 (45%) with a positive family history. Only 19/70 (27%) probands and 20/155 (13%) relatives reported that they were involved in shared decision making. Barriers to the uptake of screening included limited awareness of the genetic aetiology, poor health literacy, concerns about the cost-effectiveness of screening if detection rates were low in an unselected cohort, the requirements for life-long surveillance, and the management of uncertain test results. The GRADE exercise demonstrated that the certainty of the evidence to guide cascade screening was Low or Very Low.
Conclusions: Barriers to the implementation of cascade screening in people at high risk for TAD occur at multiple levels suggesting that a complex intervention is required to improve equity of access.
A87 Navigational bronchoscopy in thoracic lesions and its effect on the cancer pathway
Shabarishan Mathava1, Bradley Yee2, Lukacs Veres2, Aiman Alzetani2
1University of Southampton, Southampton, United Kingdom. 2University Hospital Southampton, Southampton, United Kingdom
Correspondence: Shabarishan Mathava
Journal of Cardiothoracic Surgery 2024, 19(2):A87
Objectives: Assessing the effectiveness and safety of electromagnetic navigational bronchoscopy (ENB) in the management of thoracic lesions and its influence on the cancer pathway.
Methods: The patients were chosen from referrals to the thoracic surgery department from 8 regional lung cancer MDTs. Data collection included time of referral, date of procedure, pathology results, definitive management and dates and time intervals from referral to initial procedure and onto definitive management. The data will be analysed using simple descriptive statistics.
Results: 82 patients so far who have gone through navigational bronchoscopy. All cases were done as a day case with an average procedure time of 45 min (11–173) mins, there was a positive pathology in over 70% of cases, 54 (49%) were cancerous and 13 (15.8%) were non-cancerous. The average time take from the initial referral procedure to definite management on average was 82.5 (5–366) days. Table 1 demonstrates the different types of definite management and number of patients in each. There were only 2 complications of pneumothorax noted. Table 2 represents the number of referrals per month and how it has consistently increased overtime.
Conclusion: From the results we can see that majority of the lesions were cancerous and majority of the lesions went through surgery. The complication rate was very low. ENB makes it easier to gain biopsy samples of tumours in hard to access locations shortening the time to get a diagnosis.

A88 Multi-centre implementation of atrial fibrillation after cardiac surgery (afacs) prevention care bundle: a national quality improvement initiative
Rosalie Magboo1,2, Martina Buerge1, Nisha Bhudia3
1St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom. 2William Harvey Research Institute, Queen Mary University of London, London, United Kingdom. 3Royal Brompton and Harefield Hospital, Guy's and St Thomas NHS Foundation Trust, London, United Kingdom
Correspondence: Nisha Bhudia
Journal of Cardiothoracic Surgery 2024, 19(2):A88
Objective: Atrial fibrillation after cardiac surgery (AFACS) is a frequent complication and associated with an increase morbidity, mortality and hospital and intensive care unit (ICU) length of stay. We aim to implement a multi-centre AFACS prevention care bundle1 focusing on early postoperative (re)introduction of β-blockers to reduce AF incidence nationally.
Methods: Baseline AFACS incidence and β-blocker administration practices in 9 UK centres were audited for all patients undergoing coronary artery bypass graft ± valve surgery during a 4–6-week period. The care bundle, originally developed at Barts Heart Centre, was adapted and modified by participating centres according to local policies with sharing of practices/experiences between centres. It was subsequently introduced to each ICU/HDU using quality improvement methodology. Descriptive and inferential statistics were used for analysis.
Results: Of the nine centres who initially participated, six have implemented the care bundle and completed the post-implementation audit. A total of 1,142 patients (74.3% male, mean age 65 years, baseline AF incidence between 16 and 40%) in two cohorts were analysed. The majority of the centres (n = 5) had an average AF reduction of 12–13%, with only one centre reporting no improvement potentially due to higher number of valve surgery patients in their post-implementation cohort. Overall, a significant reduction in AF incidence (baseline = 34.2%, post-implementation = 24.4%; x2 = 13.018; p = 0.0003) and a 14.4% average increase in early β-blocker administration were found.
Conclusion: AFACS prevention care bundle improved adherence with early β-blocker administration and significantly reduced AFACS incidence. Collaboration among the participating centres were crucial to the success of this initiative.
A89 Electromagnetic navigational bronchoscopy learning curve, pnuemothorax rate and diagnostic yield
Nicolas Mwesigwa, Tentzeris Vasileios
Castle Hill Hospital, Hull, United Kingdom
Correspondence: Nicolas Mwesigwa
Journal of Cardiothoracic Surgery 2024, 19(2):A89
Introduction: This study assessed the diagnostic yield and pneumothorax rate of Electromagnetic Navigational Bronchoscopy (ENB). This highly accurate technique uses a pre-procedural CT of the chest to create a three-dimensional virtual airway map to reach and biopsy tiny lung nodules.
Materials and methods: We conducted a retrospective analysis of ENB results of 246 consecutively sampled patients in whom 358 lung biopsies were taken from January 2020 to September 2023. Pneumothorax was diagnosed using post-transbronchial biopsy chest radiographs, and its rates were categorized by lung lobes. We also determined the diagnostic yield of ENB and assessed a reduction in pneumothorax rates over the study period.
Results: The results of 358 lung biopsies were analysed. The overall diagnostic yield was 61.3%, and ENB had a positive predictive value (PPV) of 98.7%. From the total biopsies analysed, 80 (32.5%) were cancerous. Pneumothorax occurred in 35 (9.8%) of the cases, the majority 29 (82.8%) coming from upper lobe procedures indicating increased complexity in sampling these lesions. Procedure performance overtime showed a significantly reduced rate of pneumothorax from 13.9% in 2020–2021 to 5.6% in 2022–2023, (p = 0.009) suggesting improved surgical skills over time.
Conclusion: The overall pneumothorax rate (9.8%) was relatively higher than in previous studies (3 to 6%), although we saw a significant reduction over time as procedure numbers increased. Diagnostic yield was comparable to previous studies. The high PPV observed suggests the reliability of ENB for diagnostic use although more accurate technology with less operator dependence is required for improved outcomes.
A90 Should all trainees be taught to repair an acute type A aortic dissection?
Ayman Kenawy, Jakub Marczak, Ahmed Othman, Omar Nawaytou, Manoj Kuduvalli, Mark Field, Deborah Harrington
Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
Correspondence: Ayman Kenawy
Journal of Cardiothoracic Surgery 2024, 19(2):A90
Objectives: Mortality of acute type A aortic dissection (ATAAD) repair is high due to inherent risk and technical difficulties. Training during ATAAD repair is out of the comfort zone of most cardiac surgeons. We have a well-established Aortic team and Aortic fellowship program where aortic fellows are the primary operators for both elective and emergency aortic cases. The fellowship only accepts trainees who are independent at routine cardiac surgery. We, as six aortic consultants, have a standard approach to cannulation, organ protection, anastomosis construction and orchestration of surgery. Fellows become competent at elective root and hemiarch surgery first.
The aim of this abstract is to demonstrate the safety of training in ATAAD repair in a specialised aortic centre.
Methods: A retrospective review of our prospectively collected aortic dissection database was conducted. Cases with aortic fellow as first operator were identified and validated by cross checking with operation notes. All patients undergoing surgery for ATAAD at our institution from October 2018 to March 2023 were included. Repair of 113 ATAAD cases was performed during this time.
Results: A comparable outcome for trainee versus consultant performed cases was demonstrated. Almost 50% of cases were performed by fellows. Overall, in-hospital mortality was 12%, stroke 15% and mean post-operative length of stay 13 days.
Conclusions: Operative training in ATAAD repair is possible in high volume aortic centres with a dedicated aortic fellowship program. This is underpinned by training in elective aortic root and arch surgery, appropriate case selection, standardisation of systems and engagement of theatre teams.
A91 Effect of on-pump versus off-pump coronary artery bypass grafting in patients with non-dialysis dependant severe renal impairment: propensity-matched analysis from the UK registry dataset
Rahul Kota1, Americos Argyriou2, Jeremy Chan2, Hunaid Vohra2, Massimo Caputo2, Mustafa Zakkar2, Gianni Angelini2, Daniel Fudulu2
1University of Bristol, Bristol, United Kingdom. 2Bristol Heart Institute, Bristol, United Kingdom
Correspondence: Rahul Kota
Journal of Cardiothoracic Surgery 2024, 19(2):A91
On-pump coronary artery bypass (ONCAB) in patients with pre-existing poor renal reserve carries significant morbidity and mortality. There is limited evidence on the benefit of off-pump coronary artery bypass (OPCAB) in these patients. We compared early clinical outcomes in propensity-matched cohorts of patients with non-dialysis pre-operative severe renal impairment undergoing OPCAB vs. ONCAB in a large national dataset.
Data for patients with preoperative creatinine clearance of less than 50 ml/min undergoing elective or urgent isolated OPCAB or ONCAB from 1996 to 2018 was extracted from the UK NACSA database. Propensity matching was performed using 1:1 nearest neighbour matching without replacement using several baseline characteristics. We investigated predictors of adverse mortality in the matched cohort by double adjusting using generalised linear mixed models.
We identified 8628 patients with severe renal impairment undergoing isolated CABG, of which 1142 (13.23%) underwent OPCAB during the study period. We compared 1141 propensity-matched pairs of patients undergoing OPCAB vs. ONCAB. The median age was 78 years in both groups, with no significant imbalance post-matching in the rest of the variables. There was no difference between OPCAB and ONCAB on in-hospital mortality rates, postoperative dialysis, stroke rates and return to theatre for bleeding or tamponade (p > 0.9); however, OPCAB reduced hospital stay by one day (P = 0.02). After double adjustment, ONCAB did not increase mortality compared to OPCAB (OR: 1.09, CI: 0.66–1.79, P = 0.738).
In this propensity analysis, we found no difference in early clinical morbidity and mortality in patients with preoperative severe renal impairment undergoing OPCAB or ONCAB surgery.
A92 Revolutionizing surgical education: can Artificial Intelligence (AI) outperform human experts in cardiothoracic surgery board exams?
Zain Khalpey1, Ujjawal Kumar2,1, Amina Khalpey3
1Division of Cardiothoracic Surgery, HonorHealth, Scottsdale, USA. 2Royal Papworth Hospital, Cambridge, United Kingdom. 3GlobalHealth-AI LLC, Scottsdale, USA
Correspondence: Ujjawal Kumar
Journal of Cardiothoracic Surgery 2024, 19(2):A92
Objectives: Large language models (LLMs) such as ChatGPT have shown exceptional performance in various fields, with their previously reported success in postgraduate medical examination questions indicating their potential utility in surgical education and training. This study evaluated the performance of various LLM iterations, as well as on the American Board of Thoracic Surgery’s Self-Education and Self-Assessment in Thoracic Surgery (SESATS) XIII question bank to investigate the potential applications of LLMs for surgical education and training.
Methods: The dataset comprised of 400 SESATS XIII questions. Both GPT-3.5 and GPT-4 models were evaluated as well as Google’s MedPaLM2 and Anthropic’s Claude2, and their performance was compared. The subspecialities included were adult cardiac, general thoracic, congenital cardiac and critical care. Questions requiring visual information such as clinical images or radiology were excluded.
Results: GPT-4 demonstrated a significant improvement over GPT-3.5, Claude2 and MedPaLM2 overall (87.0% vs 51.7%, 52.3% and 55.8%) of questions answered correctly, p < 0.0001). GPT-4 also exhibited consistently improved performance across all subspecialties, (accuracy rates ranging from 70.0% to 90.0%, Table). GPT-4 performed significantly better on the adult cardiac and general thoracic subspecialties than other models (both p < 0.0001).
Conclusions: ChatGPT, particularly GPT-4, demonstrates a remarkable ability to understand complex cardiothoracic surgical clinical information, achieving an accuracy rate of 87.0% on the SESATS board questions. Our study shows significant improvement between successive GPT iterations. As LLM technology continues to evolve, its potential emerging roles in surgical education, training, and continuous medical education are anticipated to enhance patient outcomes and safety.
A93 Left atrial-to-left ventricle valved conduit for mitral stenosis with severely calcified annulus: a case series
Younus Qamar, Anastasiia Karadzha, Hartzell Schaff
Mayo Clinic, Rochester, USA
Correspondence: Younus Qamar
Journal of Cardiothoracic Surgery 2024, 19(2):A93
Objectives: Left atrial-to-left ventricle (LA-to-LV) valved conduit offers a safe alternative to conventional mitral valve (MV) replacement in patients with MV stenosis and heavily calcified annulus. Historically, bypass of MV with a LA-to-LV valved conduit has been described in patients with congenital MV stenosis. We describe our experience of LA-to-LV bypass in patients with MV stenosis, associated with mitral annular calcification (MAC), and concomitant hypertrophic cardiomyopathy (HCM).
Methods: From February 2016 to April 2023, 6 patients with HCM and severe calcific MV stenosis underwent LA-to-LV bypass with or without septal myectomy. Bypass of stenotic MV was achieved using a valved-conduit made from 25-mm aortic valve prosthesis sewn into 26-mm Hemashield graft.
Results: Median age was 66.5 years; 66.7% were females. Median EuroSCORE-II was 5.0% (3.6–20.1). All had successful LA-to-LV valved-conduit implantation. Five patients underwent simultaneous septal myectomy; two were performed through transapical approach for midventricular obstruction. No patient died within 30-days of surgery. Recovery was uneventful; but one patient presented four-weeks after dismissal with conduit occlusion due to compression by a pseudoaneurysm at the LV-conduit junction. Following repair of the pseudoaneurysm and thrombectomy, the patient was dismissed on postoperative day 16. For the remaining 5 patients, the median length of hospital stay was 16 days. Postoperatively, the median MV gradient was 4-mmHg, compared to 13.5-mmHg at baseline. At median follow-up of 44-months (IQR 34.3–68.8), all patients were alive.
Conclusions: LA-to-LV valved-conduit is safe for MV stenosis with severe MAC in high-risk HCM patients; particularly useful when midventricular myectomy is necessary.
A94 Lifetime management of mitral valve disease in the current worldwide scenario: surgery versus transcatheter mitral replacement techniques; will transcatheter mitral valve replacement (TMVR) threaten surgery in the future?
Saptarshi Paul1, Kaushal Pandey2, Uday Gandhe2
1University Hospital of Wales, Cardiff, United Kingdom. 2PD Hinduja National Hospital and Research Centre, Mumbai, India
Correspondence: Saptarshi Paul
Journal of Cardiothoracic Surgery 2024, 19(2):A94
Objectives: Mitral valve disease has an incidence of 1–2.5% and can occur across a wide age group. Clinicians across the world aim at formulating a lifetime management strategy, with minimal interventions, good quality of life and relief from symptoms.
Methods: A systematic literature review of Embase, Medline, Google Scholar and Pubmed databases was done, from 1991 until 2023, to assimilate and streamline the intervention strategies of mitral regurgitation (MR) and stenosis (MS) worldwide. Appropriate timings of surgical and transcatheter interventions, following guideline-directed medical therapy (GDMT), were positioned along the life span of the patient. Present status of valve-in-valve transcatheter mitral valve replacement and its outcome in comparison to surgical outcomes were evaluated based on comprehensive data.
Results: 10 papers, including meta-analyses, provided long term outcomes of mitral valve surgeries. 25 papers, including meta-analyses, provided data regarding transcatheter (TMVR) techniques. It was found that for primary and secondary MR, surgical repair is the best option for all age groups, unless anatomical factors and high risk preclude the same, when transcatheter repair (TMVr) should be contemplated. Post bioprosthetic valve failure, valve-in-valve TMVR has lesser complications like post-operative mortality, stroke, renal dysfunction, permanent pacemaker placement than redo surgery. Surgical replacement is better in rheumatic MR.
Conclusions: Although initial data looks encouraging, we need more studies with longer follow-ups to outline the mid-term and long-term outcomes of valve-in-valve TMVR, in order to establish its superiority over redo MVR. Surgery is still the best option for primary mitral repairs, unless precluded by high risk.
A95 Does 3D reconstruction software enhance pre-operative planning or is it an expensive method of reassurance in the practice of segmentectomy?
Gowthanan Santhirakumaran1, Luigi Ventura2, Sasha Stamenkovic1, Kelvin Lau1, Henrietta Wilson1, David Waller1, Tim Batchelor1
1Barts Thorax Centre, London, United Kingdom. 2Northern General Hospital, Sheffield, United Kingdom
Correspondence: Gowthanan Santhirakumaran
Journal of Cardiothoracic Surgery 2024, 19(2):A95
Background: As targeted segmental resection increases with the implementation of lung cancer screening, commercially available 3D reconstruction software (3DS) is becoming widely available with a view to improving accuracy in pre-operative planning. We aim to understand its practical implication for surgical outcomes.
Method: We analysed the outcomes of 3DS from Materialise Early Innovators Program (EIP) on 26 patients who underwent minimally invasive lung resection with an initial pre-operative plan of segmentectomy following conventional CT over a 3-month period. We assessed the discordance of the pre-operative plan with operative outcome using (CT vs EIP) and EIP’s automated recommendation for segment excision.
Results: 7 of 26 patients were deemed to have had an alteration to pre-operative planning following interpretation of EIP images. 4 (15%) patients had an increase in number of segments resected due to margin from nodule and 3 (12%) patients had vascular anomaly identified from EIP and not reported identified on CT (Fig. 1). There was no inter-lobar difference in discordance following use of EIP (p = 0.25). All patients achieved complete (R0) resection. 31% of patients had a discordance from the automated recommendation of segments resection from EIP and the operative outcome.
Conclusion: With extensive experience of applying PACS 3D image rendering with a previously reported adverse outcome in 4.8% of our patients undergoing segmentectomy, early experience of 3DS are promising. However, the artificial intelligence application of the software in predicting segment(s) excision requires further development and its financial burden would require further understanding in a larger patient group.

A96 Long-term outcomes from mitral valve surgery in elderly patients: a single centre experience
Anupama Barua1, Nicholas Wong2, Ravish Jeeji1, Prakash Nanjaiah1, Richard Warwick1, Lognathen Balacumaraswami1
1Royal Stoke University Hospital, Stoke- on-Trent, United Kingdom. 2Keele University, Stoke -on -Trent, United Kingdom
Correspondence: Anupama Barua
Journal of Cardiothoracic Surgery 2024, 19(2):A96
Background: There is an increasing trend to offer mitral valve surgery in patients ≥ 75 years of age. These patients have multiple comorbid conditions which may affect clinical outcomes. We present long-term outcomes following mitral valve surgery in patients ≥ 75 years.
Methods: A prospective institutional study was performed. We analysed data on patients ≥ 75 years who underwent mitral valve surgery from January 2013 to July 2023.
Results: 168 patients were included in the study with mean age 79 ± 1.2 years and median EuroSCORE II 4.7 and median Logistic EuroSCORE 11.02. Timing of surgery was urgent in 41.6% and emergency in 1.7% of patients [Table 1]. The most common valve pathology was degenerative, out of which 56% had mitral valve repair [Table 2]. Triple valve surgery was performed in five patients (3%), additional aortic valve and tricuspid valve in 16% and 11% respectively, concomitant coronary artery bypass grafting (CABG) in 35% of cases, AF ablation in 7% and left atrial appendage occlusion in 10% of cases [Table 3]. 12 patients (7.1%) had re-exploration for bleeding [Table 4]. 30-day mortality was 3.6%. Mean ITU stay was 6.1 ± 1.9 days and hospital stay was 20.0 ± 2.3 days. Long-term survival was 77% at 5 years and 72% at 10 years [Fig. 1].
Conclusion: Mitral valve surgery in association with concomitant valve or CABG operations can be safely performed in elderly patients with good early and late outcomes. Excellent 10-year survival outcomes are seen with minimal attrition in those patients who have survived to 5 years.
Kaplan Meier curve showing overall survival
A97 Long term outcome following mitral valve repair & replacement for acute infective endocarditis
Anupama Barua1, Nicholas Wong2, Isabel Soan1, Prakash Nanjaiah1, Richard Warwick1, Lognathen Balacumaraswami1
1Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom. 2Keele University, Stoke-on-Trent, United Kingdom
Correspondence: Anupama Barua
Journal of Cardiothoracic Surgery 2024, 19(2):A97
sdIntroduction: Early repair for mitral valve infective endocarditis (IE) is advocated with a view to delivering improved outcomes. We described our experience with a valve conserving strategy for surgical treatment of acute IE affecting mitral valve.
Methods: We analysed prospectively collected data from January 2012 to July 2023. 80 consecutive patients underwent MV surgery for IE. Of these, 71% (n = 57) underwent MV replacement (MVR) while 29% (n = 23) had mitral valve repair (MVr). In-hospital mortality and late outcomes were analysed in two groups. Study end points were overall survival and reoperation.
Results: MVR group had higher logistic EuroScore 10.3 ± 5.9 vs. 3.6 ± 1.5. Blood cultures were positive in 74% and 70% of MVR and MVr respectively. Mitral regurgitation was the lesion in MVr group (100%) whereas 12% patients had mitral stenosis or mixed pathology in MVR group. 21 patients in MVR (19 aortic valve replacement and 2 tricuspid valve repair) and 7 patients (all aortic valve replacement) in MVr had an additional valve surgery (Table 1). The 30-day mortality was 7% and 0%, respectively in MVR and MVr. No reoperation was required after repair and two patients had reinfection in MVR who needed further surgery. Kaplan–Meier analysis of 5-years survival (Fig. 1) showed that MVR group had tendency for higher long-term all-cause mortality compared to MVr group. However, there was no significant difference at 5 years (p = 0.35).
Conclusions: IE remains a life-threatening disease and valve conserving MVr is preferable when feasible with a tendency to improved outcomes.
Kaplan–Meier survival curve
A98 Autologous blood transfusion minimises blood and blood product usage in complex aortic surgery: analysis from a prospective data base
Anupama Barua, Avishekh Sammader, Pankaj Mishra, Prakash Nanjaiah, Ravish Jeeji, Richard Warwick, Lognathen Balacumaraswami
Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
Correspondence: Anupama Barua
Journal of Cardiothoracic Surgery 2024, 19(2):A98
Objective: The effect of autologous blood transfusion (ABT) strategy in complex aortic surgery is not well documented in literature. We have analysed the impact of autologous blood transfusion on the incidence of blood and blood product transfusion after complex aortic surgery.
Methods: We performed a single-centre observational cohort study comparing autologous blood transfusion and non-autologous blood transfusion in patients who underwent complex aortic surgery from January 2016 to January 2023.
Results: A total of 80 patients’ data were analysed. Among them 40 patients had autologous blood transfusion (ABT) and 40 patients did not have autologous blood transfusion (Non-ABT). There were no significant differences between the groups in terms of demographic or major perioperative characteristics. The largest procedure groups were aortic valve & interpositional graft followed by aortic root surgery (Fig. 1). The percentage of patients who received any transfusion was 30% in ABT group and 65% in non ABT groups (Fig. 2). The rate of transfusion of red blood cells were 30% vs. 47%, platelets 24% vs. 65%, cryoprecipitate 24% vs. 60%, and FFP transfusion, 27% vs. 60% in ABT groups and non ABT group respectively (Fig. 3). There was no significant difference in major adverse outcomes. The length of ITU stay and total hospital stay and deep sternal wound infection rate are similar.
Conclusion: Autologous blood transfusion is a safe blood conservation strategy for complex aortic surgery. It has significantly reduced the number of transfusion of packed red cell, FFP, platelets and cryoprecipitate.


A99 "Aortic Surveillance Clinic" versus standard follow-up of patients post DeBakey I aortic dissection repair
Hassan Kattach, Amit Modi, Emma Hope, Geoff Tsang
University Hospital Southampton, Southampton, United Kingdom
Correspondence: Hassan Kattach
Journal of Cardiothoracic Surgery 2024, 19(2):A99
Objectives: It is recommended that after repairing of acute aortic dissection patients should be followed-up with regular aortic imaging, one month, 6 months and then yearly after surgery. However, there is no evidence to support that an aortic team-led surveillance clinic benefits these patients.
Methods: We conducted a retrospective analysis of all patients who underwent DeBakey I acute dissection repair between 2015 and 2019 inclusive. Patients were followed-up either in aortic surveillance clinic supervised by an aortic surgeon, or by their local cardiologists. The rates of survival, aortic intervention and aortic complication were assessed.
Results: There were 121 patients available for analysis. Mean age 64 ± 4 years, 70(58%) were men. 67(55%) patients had their follow-up in the surveillance clinic, 54(45%) had their follow-up by the local cardiologists. There was no significant difference between the two groups in age, gender, hypertension, hypercholesterolemia, diabetes, or asthma/obstructive airways disease. Patients of the aortic clinic had lower mean EuroScore (20.1 ± 12.3 versus 28.6 ± 18.1, p = 0.004) and more had interventions on the aortic arch 46(69%) vs. 23(43%), p = 0.004.
The mean follow-up was 5.4 ± 1.9 years. By the end of the follow-up the mortality in the aortic clinic group was 3(4%) versus 16(30%), p < 0.001. Twelve (18%) patients in the aortic clinic group were diagnosed with aortic complication (aneurysm, rupture, or re-intervention) versus 2(4%) patients, p = 0.02.
Conclusions: Aortic team-led “aortic surveillance clinic” after acute DeBakey I dissection is very effective in diagnosing delayed aortic complications and it saves lives.
A100 In-hospital outcomes after mitral valve surgery for infective endocarditis: a multicentre study
Anupama Barua1, Nicholas Wong2, Emeka Kesieme3, Prakash Nanjaiah1, Richard Warwick1, Dumbor Ngaage3, Lognathen Balacumaraswami1
1Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom. 2Keele University, Stoke-on-Trent, United Kingdom. 3Castle Hill Hospital, Hull, United Kingdom
Correspondence: Anupama Barua
Journal of Cardiothoracic Surgery 2024, 19(2):A100
Objective: Infective endocarditis (IE) involving mitral valve carries high morbidity and mortality and requires prompt surgical intervention. We report in-hospital outcomes of mitral valve surgery for IE at UK centres.
Methods: We obtained data from collaborating institutions on mitral valve surgery for IE patients from January 2012 to July 2023. We analysed in-hospital mortality and early post-operative outcomes.
Results: 136 consecutive patients underwent MV surgery for IE. Of these, 75% (n = 102) underwent MV replacement (MVR) while 25% (n = 34) had mitral valve repair (MVr). MVR had a higher logistic Euroscore than MVr (10.1 vs 8.87). Blood cultures were positive in 50% and 16% of MVR and MVr respectively. All MVr group (100%) had mitral regurgitation whereas 26% had mitral stenosis or mixed pathology in MVR group. Concomitant valve surgery was performed in 34% of MVR and in 44% of MVr patients. No reoperation was required after MVr but four in MVR group needed further surgery for reinfection. Table 1 shows the postoperative morbidity in the two groups. Table 1 shows the postoperative morbidity in the two groups. The 30-day mortality was 8% and 1%, respectively in MVR and MVr.
Conclusion: Surgery for mitral valve IE has satisfactory in-hospital outcome. MVr is an effective strategy for patients with limited IE with no adverse risk of relapse of infection. Early post-operative outcomes depend on patient profile and response to treatment rather than the surgical strategy.
In-hospital outcomes after mitral valve surgery for infective endocarditis: a multicentre study
Anupama Barua, Nicholas Wong, Emeka Kesieme, Prakash Nanjaiah, Richard Warwick, Dumbor Ngaage, Lognathen Balacumaraswami
A101 A community approach to pulmonary rehabilitation in thoracic surgery
Edward Staniforth1, Lindsay Charlesworth2, Stefania Cavaliere2, Elizabeth Belcher2
1University of Oxford Medical School, Oxford, United Kingdom. 2Oxford University Hospitals NHS Foundation Trust Department of Thoracic Surgery, Oxford, United Kingdom
Correspondence: Edward Staniforth
Journal of Cardiothoracic Surgery 2024, 19(2):A101
Objectives: Pulmonary rehabilitation (PR) programs improve exercise capacity and lung function whilst reducing post-operative complications and length of stay in patients undergoing thoracic surgery. Providing programs is challenging due to competing departmental demands, timelines, and financial constraints. We sought to evaluate the feasibility of a community gym for the PR of patients undergoing thoracic surgery for malignancy.
Methods: We retrospectively reviewed the feasibility of a community PR program between September 2022 and August 2023 at a single institution for patients undergoing resection of presumed or proven lung cancer or mediastinal tumours. Gym sessions were delivered by dedicated NAHPs. Electronic patient records and PR databases were reviewed for class referrals, attendance, patient fitness (assessed with the 6-min walk test (6MWT)) and patient feedback. Information was analysed on Microsoft Excel and RStudio.
Results: 112 patients were referred to PR services over 11 months. 81 (72%) patients participated in PR, 39 (35%) of which attended the gym. Mean class attendance per week was 4.6, and mean sessions attended per patient was 3.2. Mean increases in 6MWT were 57.7 m (prehabiliation), and 68.2 m (rehabilitation) Patient feedback (n = 15) showed 71% felt walking speed improved, and 87% enjoyed the sessions. There were no safety concerns, and the cost of the community gym was £38/week.
Conclusions: Use of a community gym provided a safe, effective and cost-efficient option for PR of patients undergoing thoracic surgery who accept group sessions. Increases in 6MWT were observed beyond those described as minimally important differences in patients with lung cancer.
A102 Cyanosis is associated with alterations in perioperative cytokines in paediatric congenital heart disease patients
Katie Skeffington1, Mai Baquedano1, Alison Perry1, Francesca Bartoli-Leonard1, Giulia Parolari1, Ahmed ElSherbini1, Ikenna Omeje2, Gavin Murphy3, Massimo Caputo1
1Bristol Heart Institute, Bristol, United Kingdom. 2University Hospitals of Leicester NHS Trust, Leicester, United Kingdom. 3Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, Leicester, United Kingdom
Correspondence: Katie Skeffington
Journal of Cardiothoracic Surgery 2024, 19(2):A102
Objectives: Corrective surgery for congenital heart disease is associated with greater cardiac injury and worse clinical outcomes in cyanotic paediatric patients compared to acyanotic patients (Circulation, 2001; 103:1551–1556, J Thorac Cardiovasc Surg,2000;119:515–524). In this study we compared perioperative measurements of cytokines in patients grouped by pre-operative oxygen saturation.
Methods: Blood samples were used from the paediatric OMACp biobank (BMJ Open, 2023 Aug 8;13(8):e071629). Each patient had a blood sample taken at three timepoints: before surgery, upon admission to PICU following surgery and 24-h later. Multiplex kits (Bio-techne) were used to analyse the concentrations of IL1β, IL-6, IL-8, IL-10, TNI, GMcsf, TNFα and the IL-6 receptor (IL-6Rα). Patients were grouped in cyanotic (pre-operative oxygen saturation < 90%, n = 29) or acyanotic (pre-operative oxygen saturation > 90%, n = 31). The data were analysed using mixed model ANOVA.
Results: There were no significant differences (student’s t-test) between the groups in the duration of cardiopulmonary bypass (cyanotic 124 ± 12 min vs. acyanotic 110 ± 7 min) or cross-clamp time (cyanotic 97 ± 11 min vs. acyanotic 83 ± 8 min). The concentrations of IL-6 and IL-8 were significantly higher in cyanotic patients compared to acyanotic patients over the time course (Fig. 1a, b), whilst the concentration of GMcsf was significantly lower in cyanotic patients. IL-8 was significantly correlated to TNI levels in the cyanotic group only (Fig. 1c, d).
Conclusions: Cyanosis in paediatric patients is associated with altered cytokine release during the perioperative period. A better understanding of these differences may help to optimise treatment strategies for cyanotic patients, thus improving outcomes for this highly vulnerable group of patients.

A103 Aortic dilation post type-A aortic dissection repair: single uk centre, 8 year experience
Edward Staniforth1, Simon Braithwaite2, Ben Kemp2, Danilo Verdichizzo3, Iakovos Ttofi3, Jasmina Djordjevic3, Daniel Kearns2, Raman Uberoi2, George Krasopoulos3
1University of Oxford Medical School, Oxford, United Kingdom. 2Oxford University Hospitals NHS Foundation Trust Department of Radiology, Oxford, United Kingdom. 3Oxford University Hospitals NHS Foundation Trust Department of Cardiac Surgery, Oxford, United Kingdom
Correspondence: Edward Staniforth
Journal of Cardiothoracic Surgery 2024, 19(2):A103
Purpose: Type-A Aortic Dissection (TAAD) is a surgical emergency requiring urgent intervention performed at specialist cardiothoracic services. Whilst this optimises surgical outcomes, patient follow-up is then scattered between tertiary centres and local hospitals. There is little evidence suggesting who and for how long these patients should be followed up for. We used radiological data to identify high risk groups who might benefit from tertiary centre follow-up.
Materials: A retrospective analysis of all operated TAADs in a single centre from 2012 to 2019 identified 143 patients. Clinical information, operation details and post-operative outcomes were collected from patient records. All available CT at years 0, 1/2 and 2/3/4 following TAAD repair were reviewed (TeraRecon-3D) and the information were statistically analysed.
Results: From the 143 patients, only 23 had CT-scans at all three follow-up intervals. The re-operation rate was 17%. Radiological analysis identified that the extension of the dissection flap to the aorta or the aortic branches following the aortic repair remained unchanged. Linear regression identified an initial negative remodelling to the non-repaired parts of the ascending aorta and arch which was also associated with further dilation (P = 0.001, R2 = 0.42) at follow up scans. There were no observed significant changes to the dimensions of the native aortic root or descending aorta measurements.
Conclusions: TAADs are at high risk for re-operation. Negative remodelling affects more often the non-operated parts of the ascending aorta and aortic arch. TAAD patients should remain on regular follow-ups by dedicated, specialist aortic clinics. Large studies will be required to validate our results.
A104 Predictors of long-term outcomes in major aortic surgery: a single centre 11 year experience
Edward Staniforth1, Iakovos Ttofi2, Jasmina Djordjevic2, Rohit Vijjhalwar1, Raman Uberoi3, Ediri Sideso4, George Krasopoulos2
1University of Oxford Medical School, Oxford, United Kingdom. 2Oxford University Hospitals NHS Foundation Trust Department of Cardiac Surgery, Oxford, United Kingdom. 3Oxford University Hospitals NHS Foundation Trust Department of Radiology, Oxford, United Kingdom. 4Oxford University Hospitals NHS Foundation Trust Department of Vascular Surgery, Oxford, United Kingdom
Correspondence: Edward Staniforth
Journal of Cardiothoracic Surgery 2024, 19(2):A104
Objectives: Thoracic aortic aneurysms and dissections provide a complex surgical cohort termed major aortic surgery. Regular follow-up at specialist clinics with cross-sectional imaging is recommended. Identifying risk factors that lead to re-operations as well as the requirement for and appropriate length of follow-up remain points of debate.
Methods: All major aortic operations performed at a single centre, from January 2012 to December 2022 were retrospectively reviewed. The clinical information, operation details, histological reports, post-operative outcomes and follow up were collected from electronic patient records. All information was statistically analysed.
Results: 409 patients met the inclusion criteria for the study with a median follow-up of 3.8 years (IQR 1.6–7.6). The prevalence of all cause re-operations was 10.8% (n = 44) (excluding surgical site infections). The median time to re-operation was 1.8 years. 68% of the reoperations occurred within the first 5 years. Multi and univariate logistic regression identified young age, arteritis and/or aortitis as the main risk factors associated with increased risk of re-operation. Connective tissue disease and systemic inflammatory diseases approached but didn’t meet statistical significance. Bicuspid aortic valve pathology was not associated with increased risk of re-operation.
Conclusions: Patients undergoing major-aortic surgery have a high rate of re-operation. The first 5 years represent a high-risk period and follow-up with cross-sectional imaging during that time by specialist aortic services is essential. Patient with aortitis remain at high risk and should be treated by appropriate by specialist aortic services with subspecialty interest and expertise on treating patients with aortitis.
A105 Unmet need for aortitis services in the United Kingdom
Edward Staniforth1, Iakovos Ttofi2, Jasmina Djordjevic2, Rohit Vijjhalwar1, Raman Uberoi3, Ediri Sideso4, Shirish Dubey5, George Krasopoulos2
1University of Oxford Medical School, Oxford, United Kingdom. 2Oxford University Hospitals NHS Foundation Trust Department of Cardiac Surgery, Oxford, United Kingdom. 3Oxford University Hospitals NHS Foundation Trust Department of Radiology, Oxford, United Kingdom. 4Oxford University Hospitals NHS Foundation Trust Department of Vascular Surgery, Oxford, United Kingdom. 5Oxford University Hospitals NHS Foundation Trust Department of Rheumatology, Oxford, United Kingdom
Correspondence: Edward Staniforth
Journal of Cardiothoracic Surgery 2024, 19(2):A105
Objectives: Aortitis is defined as inflammation of the aorta and can lead to aneurysms and dissections. Aortitis increases the risk of re-operations and intra-operative sampling is essential as many cases are idiopathic, presenting with no symptoms. Previous studies investigating aortitis in major aortic surgery have been limited by low intra-operative sampling. We performed an 11-year, retrospective, cross-sectional study to investigate the true prevalence of aortitis in thoracic aortic aneurysms and dissections.
Methods: All major aortic operations performed in a single centre from January 2012 to December 2022 were analysed retrospectively. The medical history, histological reports, post-operative outcomes and follow-up were collected from electronic patient records. All information was analysed with Excel and RStudio.
Results: 537 patients met the inclusion criteria for the study, representing an 88% histological sampling rate. The prevalence of aortitis was 10.6% (n = 57), of which 75% were idiopathic. The re-operation rate in aortitis was twice that of the non-aortitis patients (17.5% v 9.4%, Pearson’s Chi Squared, P = 0.054). Multivariate logistic regression identified increased age, female sex, current smoking, and other inflammatory diseases as significantly associated with increased risk of aortitis, whilst bicuspid aortic valve was associated with a significantly decreased risk.
Conclusions: The prevalence of aortitis in our study is twice that reported in previous studies with lower sampling rates. The true prevalence is likely higher than reported. Due to the increased increased re-intervention rate, multi-disciplinary follow-up with cardiothoracics, vascular and rheumatology is essential, and specialist referral centres should be formed.
A106 The INTEGRAL ROLE of the Surgical Care Practitioner (SCP) as first assistant for robotic thoracic surgery
Esther Lewis, Karen Elbrow, Mohammad Diab, Kofi Ackah, Adrian Marchbank
University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
Correspondence: Esther Lewis
Journal of Cardiothoracic Surgery 2024, 19(2):A106
Objective: The Surgical Care Practitioner (SCP) role is expanding and includes first assisting during robotic thoracic surgery (RTS). We examined the safety and efficacy in console docking and SCP sole assistance in RTS.
Methods and Results: Retrospective data collection & analysis between 20th May 2022 and 5th October 2023 was extracted from the electronic theatre scheduling for a single surgeon.
There were 51 Lobectomies/segmentectomies, 2 mediastinal mass resections and 6 thymectomies.
The mean and median time for the SCP to dock was 14 and 15 min respectively, with the mean and median operating times being 179 and 172 min.
The data demonstrated a positive trend in learning curves (graphs to follow).
There were 2 controlled conversions to open, due to difficult anatomy.
All paravertebral and chest tube catheters were inserted and safely secured by the SCP.
The SCP was often accompanied by a registrar as 2nd assistant, in total 7 registrars were individually present during this timeframe, making the SCP and Consultant the only consistent members of the theatre team.
Conclusion: It was noted that within the chosen timeframe, the surgical start time to console activation had become more efficient, was safe and improved theatre efficiency.
A107 Sternal fixation and bone grafting: a synergy of osteosynthesis
Hiral Jhala1, Patricia McFarlane2, Sanjeet Singh Avtaar Singh3,4, Kamal Deep5, Nawwar Al-Attar6
1Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Aberdeen, United Kingdom. 2University of Glasgow School of Medicine, Glasgow, United Kingdom. 3Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom. 4University of Glasgow, School of Medicine, Glasgow, United Kingdom. 5Department of Orthopaedic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom. 6Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom
Correspondence: Hiral Jhala
Journal of Cardiothoracic Surgery 2024, 19(2):A107
Background: Sternal non-union is a rare but serious complication post cardiac surgery. It consists of sternal pain with clicking, instability or both for > 6 months in the absence of infection, seen in the outpatient setting, confirmed with a CT-scan. Given the paucity of data regarding the ideal surgical management of such patients, we describe the use of sternal plating combined with autologous iliac crest bone grafting (AICBG) for sternal-fixation in patients with non-union.
Methods: Patients who underwent sternal non-union surgery between 2015 and 2020 were included. Demographic, clinical and outcome data obtained from a local database was analysed retrospectively. Surgical procedure: sternal fragments freshening of margins, fixation and plating with AICBG. With variable pathoanatomy of non-union, wires and multiple fragments of poor bone quality were cut and stabilised using sternal metal plates and screws.
Results: N = 7. Primary cardiac surgical intervention occurred between 2011 and 2018. Median age was 65 (54–75). 4(57.1%) were male. Median Euroscore 3.99 (Table 1). No perioperative deaths. Primary sternal closure methods: Modified-Robiscek (n = 5), and “figure-of-8” (n = 2). Median interval between primary surgery and sternal-fixation was 821 days. Post-operative complications: chest infection (n = 2), acute kidney injury (n = 1), post-discharge chest trauma (n = 1). Complications after sternal plating: iliac crest pain (n = 3), acute tubular necrosis (n = 1). After median follow-up of 1106 days, no patients required further intervention post sternal-fixation.
Conclusions: Sternal non-union can have variable anatomy necessitating appropriate prefixation planning. Use of the sternal plating system alongside AICBG is a viable and innovative method of treating sternal non-union post cardiac surgery with lasting effects.
A108 The development, implementation and evaluation of a protocol for pre-operative ultrasound conduit assessment for patients undergoing coronary artery bypass grafting
Ellyn Small
NHS Lothian, Edinburgh, United Kingdom
Correspondence: Ellyn Small
Journal of Cardiothoracic Surgery 2024, 19(2):A108
Harvesting Great Saphenous Vein (GSV) as a conduit for Coronary Artery Bypass Graft surgery (CABG) is a common procedure performed by the Surgical Care Practitioners (SCPs). Ultrasound venous assessment (USVA) has been identified as an accurate method for ascertaining the suitability of GSV for use as conduit and is considered an important element of preoperative planning. As with any procedure within the healthcare setting, a protocol is vital to ensure safe and effective outcomes.
At our centre, we started a QI project to develop, implement and evaluate a protocol for preoperative ultrasound conduit assessment. The aim was to improve the standard of preassessment and reduce unnecessary surgical incisions.
Method: With support of the MDT, a local evidence based protocol was developed and implemented for every patient undergoing CABG from January to March 2023. We compared data between the visual assessment and USVA. A satisfaction survey was completed by the SCP Team to rate the protocol.
Result: Total sample size was n = 39. In 41% of the cases the plan for conduit harvest changed following ultrasound. Two of the veins reviewed were deemed unusable. The survey results were positive with 100% of respondents strongly agreeing that the protocol was clear and covered important areas for examination. It supported continuity of care and all of them would continue using it. 50% of respondents also strongly agreed that the USVA made them feel more confident.
Conclusion: We implemented a USVA protocol leading to improved preoperative conduit assessment, better patient outcomes and staff satisfaction.
A109 Platelet activation and platelet leukocyte aggregates are associated with acute kidney injury after cardiac surgery
Naomi Brown1, Nikol Sullo2,1, Bryony Eagle-Hemming1, Florence Lai1, Sophia Sheikh1, Kristina Tomkova1, Lathishia Joel-David3,1, Hardeep Aujla1, Gavin Murphy1, Marcin Woźniak1
1Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom. 2Medical School, Swansea University, Swansea, United Kingdom. 3NIHR University Hospitals of Leicester, Leicester, United Kingdom
Correspondence: Naomi Brown
Journal of Cardiothoracic Surgery 2024, 19(2):A109
Cardiac surgery-associated acute kidney injury (AKI) affects up to 30% of patients, independently driving patient morbidity and mortality. However, current markers of AKI are ineffective and its pathogenesis is poorly understood. We hypothesised that circulating extracellular vesicles (EVs) and micro-RNAs will act as novel biomarkers for AKI in cardiac surgery patients.
Plasma samples were collected from 95 patients recruited to the MaRACAS study before, immediately after, and 6–12, 24 and 48 h after surgery. Particle size distribution and concentration were measured using NanoSight. EV derivation, as well as platelet and leukocyte activation were measured with flow cytometry. The quantification of circulating soluble biomarkers and platelet function were determined using MAGPIX and Multiplate assays, respectively. Micro-RNA analysis was performed in batched samples using TaqMan arrays and validated by qRT-PCR.
AKI patients exhibited increased levels of platelet-derived EVs 24 h post-surgery. TaqMan assays detected a downregulation of microRNA-668 before surgery, and an upregulation of microRNA-92a-1, -920, -518a3p, -133b and -1262 immediately after surgery. Subsequent validation confirmed the upregulation of microRNA-1262 after surgery and further identified that microRNA-133b is downregulated before surgery in AKI patients. Multiplate assays showed that platelets 6–12 h after surgery were were desensitised to ADP. Furthermore, platelet-granulocyte aggregates were increased before and 24 h after surgery, and soluble ICAM1 levels were elevated before surgery in AKI patients.
To conclude, AKI is associated with platelet activation, suggesting that platelet inhibition treatments may be renoprotective. Studies in larger cohorts should look to verify miR-1262 as a diagnostic marker of AKI.
A110 Patient selection for robotic mitral valve repair: experience of a conservative screening algorithm
Ujjawal Kumar1, Daniel Burns2, Marc Gillinov2
1Royal Papworth Hospital, Cambridge, United Kingdom. 2Department of Thoracic and Cardiovascular Surgery: Heart and Vascular Institute, Cleveland Clinic, Cleveland, USA
Correspondence: Ujjawal Kumar
Journal of Cardiothoracic Surgery 2024, 19(2):A110
Objectives: Robotic mitral valve repair confers many benefits over a median sternotomy approach. However, patient selection remains contentious. We investigated the outcomes of a conservative screening algorithm developed to select patients with degenerative mitral valve disease for isolated robotic mitral valve repair.
Methods: A screening algorithm utilising pre-operative transthoracic echocardiography and computed tomography was applied to 1000 consecutive patients with isolated degenerative mitral valve disease. Screening results and hospital outcomes were compared.
Results: 605 patients met criteria for and were selected for robotic surgery. Common indications for sternotomy (n = 395) were aortoiliac atherosclerosis (n = 74), femoral artery diameter < 7 mm (n = 60), mitral annular calcification (n = 83), aortic regurgitation (n = 100), and reduced left ventricular function (n = 126).
Mitral valve repair was successfully undertaken in all robotic candidates (605/605, 100%). Of note, amongst the 395 sternotomy candidates, mitral valve repair was also successfully completed in 391 patients (99%).
Clinical outcomes were significantly better for the robotic group: postoperative atrial fibrillation (25% vs 34%; p = 0.0030), red blood cell transfusions (10% vs 17%; p = 0.0008), ICU admission (25 vs 27 h, p = 0.001) and hospital admission (5.2 vs 5.9 days, p < 0.0001). No hospital deaths occurred in either group. Rates of post-operative stroke, re-operation for valve dysfunction or bleeding were similar between groups.
Conclusions: This institutional algorithm qualified 60% of patients with degenerative mitral valve disease for robotic surgery. Outcomes for robotic surgery were at least non-inferior to sternotomy with many superior outcome parameters, validating this algorithm as a suitable approach to select patients for robotic mitral valve repair.
A111 Prospective evaluation of acute neurological events after pediatric cardiac surgery
Olivia Frost1,2, Deborah Ridout3, Warren Rodrigues4,5, Paul Wellman6, Jane Cassidy7, Victor Tsang1,4, Dan Dorobantu8, Serban Stoica8, Aparna Hoskote1,4, Katherine Brown1,4
1Institute of Cardiovascular Science, University College London, London, United Kingdom. 2St George's Medical School, London, United Kingdom. 3Population, Policy and Practice Programme, University College London, Great Ormond Street Institute of Child Health, London, United Kingdom. 4Heart and Lung Division, Great Ormond Street Hospital, London, United Kingdom. 5Department of Paediatric Cardiac Surgery, Royal Hospital for Children Glasgow, Glasgow, United Kingdom. 6Departments of Paediatric Cardiology, Intensive Care and Cardiac Surgery, Evelina London Children's Hospital, London, United Kingdom. 7Department of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom. 8Department of Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, United Kingdom
Correspondence: Olivia Frost
Journal of Cardiothoracic Surgery 2024, 19(2):A111
Background: Children with congenital heart disease are at heightened risk of neurodevelopmental problems however the contribution of acute neurological events specifically linked to the perioperative period is unclear.
Aims: This secondary analysis aimed to quantify the incidence of acute neurological events in a UK paediatric cardiac surgery population, identify risk factors and assess how acute neurological events impacted the early postoperative pathway.
Methods: Post-operative data was collected prospectively on 3090 consecutive cardiac surgeries between October 2015 and June 2017 in 5 centres. The primary outcome of analysis was acute neurological event, with secondary outcomes of 6-month survival and postoperative length of stay. Patient and procedure-related variables were described, and risk factors were statistically explored with logistic regression.
Results: Incidence of acute neurological events after paediatric cardiac surgery in our population occurred in 66 of 3090 (2.1%) consecutive cardiac operations. 52 events occurred with other morbidities including renal failure (21), re-operation (20), cardiac arrest (20) and extracorporeal life support (18). Independent risk factors for occurrence of acute neurological events were congenital heart disease complexity 1.9 (1.1–3.2), P = 0.025, longer operation times 2.7 (1.6–4.8), P < 0.0001 and urgent surgery 3.4 (1.8–6.3), P < 0.0001. Unadjusted comparison found that acute neurological event was linked to prolonged postoperative hospital stay (median 35 versus 9 days) and poorer 6-month survival (OR 13.0, 95% CI 7.2–23.8).
Conclusion: Ascertainment of acute neurological events relates to local measurement policies and was rare in our population. The occurrence of acute neurological events remains a suitable post-operative metric to follow for quality assurance purposes.
A113 Development and delivery of prehabilitation exercise interventions for UK lung transplant candidates
Paula Agostini1, Jessica Pearson1, Anna Tarrant1, Richard Thompson1, Aaron Ranasinghe1, Matar Alzahrani2, Babu Naidu2
1University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom. 2University of Birmingham, Birmingham, United Kingdom
Correspondence: Paula Agostini
Journal of Cardiothoracic Surgery 2024, 19(2):A113
Background: Reduced functional status is an important predictor of post-transplant outcome, frailty associated with postoperative/wait-list mortality. The International Consensus Document for selection of lung transplant candidates therefore recommends pulmonary rehabilitation (PR), which may also optimise the window patients with advancing lung disease remain on waiting lists. Due to geographical limitations UK candidates generally attend local PR programmes, however, these are not transplant specific, or offered longer-term. Transplant centre led PR/prehabilitation programmes would be more appropriate, but such UK services are not yet developed.
Objective: To develop and enable engagement in pre-transplant specific prehabilitation exercise.
Methods: Exercise interventions were developed and delivered utilising existing UK lung transplant centre 3-monthly follow-up clinics. From September 2023 Physiotherapists attended clinics weekly to assess candidates and offer patient-centred exercise plans and advice. The suitability of a more structured, virtual exercise plan, using the Fit-for-surgery prehabilitation App, was also investigated.
Results: To date 45% of waiting list (n = 14) received 1:1 Physiotherapy assessment; 79% required bespoke plans (73% strength/aerobic; 27% step counting); all accepted advice, 43% requiring telephone follow-up (monitoring/motivation). Intervention was well received and data collection continues. App exercise components were found to be consistent with evidenced pre-transplant PR regimens; a transplant specific PPI group can now assess utility and Physiotherapists remote monitoring/feedback.
Conclusion: It is feasible to deliver/monitor exercise using existing clinic attendance, and potentially educate candidates to use structured, virtual PR exercise. With further development an App could be a novel solution to UK transplant MDT prehabilitation limitations.
A114 Standardising assessment of cardiac surgery specialist nurses
Scott Hopkins-Brown, Matt Petty, Jo-anne Fowles, Nicola Jones
Royal Papworth Hospital, Cambridge, United Kingdom
Correspondence: Scott Hopkins-Brown
Journal of Cardiothoracic Surgery 2024, 19(2):A114
Cardiac Surgery Specialist (CSS) are specialist nurses who have undergone additional training to manage patients in the first 48 h following cardiac surgery. Nurse-led recovery potentially improves patient care through timely intervention. Competency have previously been assessed by a Consultant Intensivist who works with the CSS and who provided an informal VIVA- style examination.
Objectives: To develop a robust methodology to ensure that assessment is:
-
Valid
-
Fair
-
Reliable
-
Transparent
Methods: Devise a standardised assessment process in which candidates will be assessed against pre-defined learning objectives:
The assessment was designed as an OSCE in which the elements were based around the taught theory, with several subject matter experts having input. Taught theory was muti modal:
-
Study Days
-
Online Module (provided by CSU-ALS)
-
Supervised Practice
The Angoff Method was utilised to establish the pass mark. Judges were Senior Cardiothoracic ICU Nurses and Doctors. In addition to a pass mark, criteria for failure were encompassed in the assessment.
Following establishment of a pass mark, the OSCE was trialled to establish validity.
Results: Creation of the OSCE has led to greater confidence in the assessment process and reassured staff that the process is fair and consistent.
This has ensured fairness for all specialists undertaking assessments and ensures transparency.
Furthermore, this will improve patient flow throughout the Trust by decreasing length of stay on ICU.
Conclusions: A formal OSCE created by the CCA Education Team, Leadership Team, and Consultants.
Has been successfully introduced. The improvement will provide confidence within individual’s practice.
A115 Risks associated with lung resection in octogenarians: our 5 year experience
Hiral Jhala1,2, Mathew Thomas2
1Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Aberdeen, United Kingdom. 2Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom
Correspondence: Hiral Jhala
Journal of Cardiothoracic Surgery 2024, 19(2):A115
Objective: An increasingly large proportion of patients undergoing curative surgery for lung cancer, are octogenarians. We have evaluated our outcomes after oncological lung resections which may help in counselling these patients towards surgery.
Methods: Octogenarians undergoing resection for confirmed or suspected lung cancer at a single-centre between January 2016 and December 2021 were included. Retrospective analysis of demographic, clinical and operative data was performed and correlated with mortality and long-term outcomes.
Results: N = 214 (age < 85 n = 182; ≥ 85 n = 32). Median age 82(range 80–89). Median overall-survival (OS) was 3.45 years (< 85) vs 5.10 years (≥ 85). 30-day and 90-day mortality was 2.2% and 4.4% in < 85 respectively; with none in ≥ 85. All-cause mortality was 56.6% (< 85) vs 46.9% (≥ 85) after a median follow-up of 4.6 years. Most patients underwent lobectomy (< 85 n = 119, ≥ 85 n = 22), and video-assisted (VATS) approach (< 85 n = 113; ≥ 85 n = 28). Extent of resection (< 85 p = 0.8; ≥ 85 p = 0.4) and surgical approach (< 85 p = 0.8; ≥ 85 p = 0.3) had no statistically significant effect on mortality. Post-operative complications were more likely in those with COPD in both age groups, and in smokers aged < 85 (Table 1). In those with primary non-small cell lung cancer, median disease-free-survival (DFS) was 2.38 years (< 85) vs 3.75 years (≥ 85)(p = 0.2). As expected, higher pathological stage conferred a worse DFS in < 85(p = 0.03) vs ≥ 85 (p < 0.01).
Conclusions: Curative surgery is safe and feasible with acceptable long-term outcomes in octogenarians. One could counsel patients regarding the risks as noted in our table, but this would need a larger study for confirmation.
A116 Should octogenarians receive adjuvant chemotherapy following primary lung cancer resection? Our 5-year experience
Hiral Jhala1,2, Mathew Thomas2
1Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Aberdeen, United Kingdom. 2Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom
Correspondence: Hiral Jhala
Journal of Cardiothoracic Surgery 2024, 19(2):A116
Objectives: The value and impact of adjuvant chemotherapy in primary non-small cell lung cancer (NSCLC) in octogenarians is sometimes questioned. In this study we analyse our 5-year experience of short and long-term outcomes for primary NSCLC.
Methods: Octogenarians with a pathological stage of ≥ IIA following anatomical resection for confirmed primary NSCLC at a single-centre between January 2016 and December 2021 were included. Retrospective analysis of demographic, clinical and operative data was performed and correlated with survival outcomes. Multiple lung resections in the same operation were classified according to the larger primary resection.
Results: N = 67. Median age was 81 (80–86). 5 patients received adjuvant chemotherapy (< 85 n = 4, ≥ 85,n = 1). Median overall survival (OS) in those who received adjuvant chemotherapy compared to those who did not in < 85 was (3.7 vs 2.4 years; p = 0.26) and (1.0 vs 1.5 years; p = 0.16) in those ≥ 85 (Fig. 1A and B). Median disease-free survival (DFS) was comparable in those receiving adjuvant chemotherapy compared to those who did not, in < 85 (1.9 vs 1.8 years; p = 0.89) and ≥ 85 (0.6 vs 1.1 years; p = 0.16) (Fig. 1C and D).
Conclusion: It is difficult to draw definite conclusions regarding benefit or differences in survival in a smaller sample size. However, we observed a better OS and DFS post adjuvant chemotherapy with no difference in mortality in those < 85. Multimodal treatment therefore, may be safe and feasible in patients aged 80–85. We hope this stimulates discussion and debate from other centres surrounding the role of adjuvant chemotherapy in octogenarians.
Overall survival and disease-free survival for those receiving adjuvant chemotherapy and those who did not, under 85s vs ≥ 85s
A117 Crafting excellence: elevating surgeons skills with a heart transplant simulator
Richard Arm1, Mylvaganam Jeyakanthan2, Stephen Clark2
1Nottingham University, Nottingham, United Kingdom. 2Freeman Hospital, Newcastle, United Kingdom
Correspondence: Mylvaganam Jeyakanthan
Journal of Cardiothoracic Surgery 2024, 19(2):A117
Objectives: Training surgeons in heart transplantation is limited by opportunity, accessibility and concerns over prolonged ischaemic times inherent in the learning process. We developed an affordable realistic cardiopulmonary simulator for heart transplant training applications.
Methods: CT scan data was used to develop two models—one donor heart with normal characteristics and secondly a recipient cardiopulmonary model developed from an actual heart transplant waiting list case for maximal realism. From the CT scans, digital models were prepared for additive 3D printing, manufacturing and tooling. A range of synthetic, fibre-filled polydimethylsiloxane composite gels were used to recreate analogous cardiac tissues with realistic pigmentation and hardness. Embedded fabrics facilitated a realistic suturing experience aiding repairability and reusability.
Results: The model was qualitatively assessed by both experienced heart transplant surgeons and trainees. Simulated heart transplantation using the model will be shown in video to demonstrate its realism permitting cannulation for bypass, recipient heart excision and donor heart implantation to teach technique and size matching maneuvers. We will demonstrate how the model is quickly repurposed for multiple use allowing training surgeons to perfect their technique before being exposed to real life opportunities.
Conclusions: This affordable, reusable model may encourage widespread use of cardiac transplant simulators to mitigate the risks associated with experiential learning and improve surgical proficiency through improved access to inclusive learning opportunities outside of traditional environments, not possible with cadaver or animal model training provisions.
Model containment provides practical storage and transportation while reproducing visuospatial aspects of cardiopulmonary anatomy, unique to this work.

A118 Aortic arch replacement with descending thoracic aorta stenting using a hybrid stent-graft, (frozen elephant trunk technique), for chronic aortic dissection: early clinical and radiological outcomes
Hassan Kattach, Amit Modi, Mohammed Hadi, Iain Wilson, Robert Allison, Benjamin Patterson, Ian Nordon, Geoff Tsang
University Hospital Southampton, Southampton, United Kingdom
Correspondence: Hassan Kattach
Journal of Cardiothoracic Surgery 2024, 19(2):A118
Objectives: Frozen elephant trunk (FET) has been used to treat patients with arch and descending aortic disease. However, the outcome data for FET in chronically dissected aorta, particularly relating to aortic remodelling is limited.
Methods: Prospectively collected data of all patients operated between 2017 and 2022 at a single institution was analysed. Clinical and radiological assessments with CT scans were performed at discharge, 6 months and then yearly. The thrombosis of the false lumen, total diameter of the aorta and that of the true and false lumens were assessed at three levels: the proximal stented descending, the distal thoracic descending, and the abdominal aorta.
Results: There were 23 patients, mean age 63.8 ± 12.1 years, 17(74%) were men. Two patients (9%) had a connective tissue syndrome. Ten (43%) had re-do surgery. One had concomitant TEVAR. There was no in-hospital mortality. One patient (4%) had a stroke and one (4%) had paraplegia. There was no in-stent thrombosis. The mean follow-up was 3.0 ± 1.8 years, with three interval deaths (13%), and three interventions on the downstream aorta. The false lumen thrombosed around the stent in all patients, and there was a progressive thrombosis of the false lumen in the distal descending aorta. There was an increase in true lumen diameter and decrease in false lumen diameter in all segments.
Conclusion: The early clinical outcome in FET for chronic dissection is promising.
A119 Transforming surgical outcomes: novel postoperative chest support reduces infections following Coronary Artery Bypass Grafts (CABG): preliminary findings
Karen Cariaga1, Melissa Rochon1, Sean Derick Ingusan1, Angila Jawarchan1, Garry Cowell2, Kabeer Umakumar3, María Monteagudo Vela3, Sunil Bhudia3, Shahzad Raja3
1Directorate of Infection, GSTT, London, United Kingdom. 2Royal Brompton Hospital, GSTT, London, United Kingdom. 3Harefield Hospital, Harefield, United Kingdom
Correspondence: Sean Derick Ingusan
Journal of Cardiothoracic Surgery 2024, 19(2):A119
Objectives: Surgical site infection (SSI) is a leading cause of readmission and need for reoperation. Surgical support vests may reduce the risk of deep SSI. The CATS vest (CUI International Ltd) supports the thorax with uniform pressure. This retrospective study aims to compare the outcomes of patients who received a CATS vest with those who did not.
Methods: A single-centre clinical audit was registered. Patients undergoing CABG ± concomitant procedures between 1st January and 30th September 2023 were included. CATS vests were provided based on consultant preference. Data on SSI were collected by trained surveillance staff. Post-discharge SSI data was collected using Islacare Ltd. Simple descriptive statistics were performed using Excel. Comparisons between groups were done using unpaired t-test for continuous variables and χ2-test for categorical variables. Significance was set at p < 0.05.
Results: A total of 422 patients were included. 22 patients from 10 surgical teams received the CATS vest (median 2 per surgical team, range 1–6). There was no significant difference between age, gender, surgical urgency, use of bilateral internal mammary artery or post-discharge SSI. Patients with diabetes and higher body mass index are more likely to receive the CATS vest. Patients who wore a CATS vest had an absolute risk reduction of 0.8% for both readmission and reoperation for SSI. See Table 1.
Conclusion: Our preliminary use of the novel CATS vest stays in line with previous cardiac studies which reported reductions in deep sternal wound infections with this type of chest support.
A120 Consenting patients for thoracic surgery in St. George's Hospital (SGH) London
Xing Qing Low1, Robin Nicholas Wotton2
1St. George's University of London, London, United Kingdom. 2St. George's Hospital, London, United Kingdom
Correspondence: Xing Qing Low
Journal of Cardiothoracic Surgery 2024, 19(2):A120
Objectives: Informed consent is an ethico-legal obligation and its importance has been highlighted in many publications. This study was designed to evaluate the current practice of consent-taking and consent form completion against national guidelines, identifying areas of weaknesses and making improvements on them.
Methods: Between December 2022 and May 2023, an audit was conducted to evaluate the consent forms of consecutive patients scheduled for elective thoracic surgery. The audit aimed to assess the baseline of the current practice, focusing on the completeness of the form and whether a paper copy was provided to the patient. We presented our findings at the local clinical governance meeting and provided education to the Thoracic surgical team members. The audit loop was subsequently completed with a re-audit following this educational intervention.
Results: The re-audit demonstrated an improvement in fully completed forms, from 90 to 97%. There was also a large increase in patients receiving their copy of the completed form from 45 to 17%
Conclusion: This is the first study of its kind to evaluate the consent process in the department. The findings demonstrated that simple measures can be taken to address the areas of weaknesses in current consent-taking practice, and hence reduce medico-legal risks associated with poor consent-taking and documentation.
A121 Eurolung risk score is a valuable predictor for short and long term outcome after curative lung cancer resection
Hesham Ahmed1,2, Mohammad Hawari1
1Nottingham University Hospital, Nottingham, United Kingdom. 2Faculty of medicine-Menoufia University, Menoufia, Egypt
Correspondence: Hesham Ahmed
Journal of Cardiothoracic Surgery 2024, 19(2):A121
Background: This study aimed to assess the parsimonious Eurolung risk scoring system as a predictor for short and long term outcome after curative lung resection.
Methods: 2413 patients with primary lung cancer had anatomic curative lung resection (210 segmentectomies, 2015 lobectomies, 103 pneumonectomies) from 2010 to 2021.Patients were grouped into 4 classes according to their Eurolung scores (A:0–2.5, B: 3–5, C: 5.5–6.5, D 7–11.5). The parsimonious aggregate Eurolung2 score was calculated for each patient. Median follow-up was 1336 days.
Results: Patients were in class A (37.5%), B (36.3%), C (12.6%), and D (13.6%). Hospital stay increased across the categories (A: 5.7, B:7.4,C: 9.9 and D: 12.1 days), (p < 000.1). Overall hospital mortality was 1.9% and was increasing across the categories (0.2%, 1.7%, 3.6% and 6.1%). AUC for Eurolong 2 to predict hospital mortality was 0.792.
-
Five-year overall survival decreased across the categories (A: 71.8%; B: 54.7%; C: 52.1%; D: 41.2%) and ten years survival was (48.6, 30.8%, 35.6% and 20%), (P < 0.0001).
-
The different classes were associated with significant risk of long-term overall mortality in patients with pN0 (P < 0.0001) and pN1 nodes (P < 0.0001) and pN2 (P = 00.1).
-
Cox proportional hazard showed that Eurolung aggregate score remained significantly associated with overall survival (hazard ratio, 1.13; P < 0.0001).
Conclusion: Eurolung aggregate score was a valuable predictor for short and term long outcome resection for lung cancer. This may help in risk assessment and decision making for patients undergoing lung cancer resection.
A122 A comparison of the segmental pulmonary anatomy for interactive three-dimensional models produced from lung cancer screening programme low dose computed tomography versus high dose contrast CT computed tomography
James Kofi Ackah, Mohammad Diab, Adrian Marchbank
Derriford Hospital, Plymouth, United Kingdom
Correspondence: James Kofi Ackah
Journal of Cardiothoracic Surgery 2024, 19(2):A122
Introduction: Lung cancer screening programmes utilising low dose non-contrast CT scans (LDCTs) are being rolled out nationally, following trials demonstrating reduced all-cause mortality. Segmentectomy is becoming the standard of care for managing small peripheral lung cancers. For sub-lobar resections many surgeons use interactive three-dimensional modelling (3D-CT) for surgical planning to enhance appreciation of segmental anatomy.
Objective: A comparison of the quality of 3D-CT models obtained from screening programme LDCTs to those obtained from high dose contrast CT scans (HDCT) to determine whether HDCTs are required, to reduce the radiation and cost burden associated with these scans.
Methods: A retrospective analysis (March-October 2023) of segmental/subsegmental vascular & bronchial anatomy and tumour size and location of the 3D-CT models (Innersight™ labs) obtained from the LDCTs vs HDCT scans were analysed and compared by 2 assessors.
Results: 10 patients were screened. There was subtly increased detail for the segmental pulmonary arterial system for the HDCT versus LDCT 3D-CT models. Whilst the overall morphology was similar, the HDCTs demonstrated more distinct origins for the segmental arteries (Fig. 1a/Fig. 1b). The morphology of the bronchial and pulmonary venous anatomy was similar with only minor non-surgically relevant differences observed beyond the sub-segmental anatomy (Fig. 1c).
Tumour size and location were almost identical for all patients screened (Fig. 1d) with only minor non-surgically relevant differences detected.
Conclusions: Screening programme LDCTs can be used to produce high quality 3D-CT models. However, a degree of caution is required when interpreting the segmental pulmonary arteries.

A123 Solitary fiborus tumours: surgical and long-term outcome
Hesham Ahmed1,2, Mohammad Hawari1, Adnan Raza1
1Nottingham University Hospital, Nottingham, United Kingdom. 2Faculty of Medicine-Menoufia University, Menoufia, Egypt
Correspondence: Hesham Ahmed
Journal of Cardiothoracic Surgery 2024, 19(2):A123
Objective: Solitary fibrous tumours (SFTs) are uncommon fibroblastic neoplasms with diverse biological behaviour. We reviewed and analysed the surgical and long-term outcome of patient who underwent surgical resection.
Method: Retrospective data collection from November 2009 till November 2022. 31 patients underwent surgery for SFT. The Kaplan–Meier method was used to estimate overall survival, and the log-rank test was used to compare the survival curves.
Results: Out of 31 patients 16 (52%) were male and two patients had surgery twice for recurrence. Median age was 66 years (Range 46–79). 18 patients (58%) had thoracotomy and 13 (42%) had minimally invasive surgery. early post operatively, 2 (6.4%) patients developed atrial fibrillation, 2(6.4%) developed prolong airleak, 2 (6.4%) developed pleural effusion and one (3.2%) developed pneumonia. There was no immediately pot-operative mortality. Average shospital stay was 5(± 2) days. Tumour size was 80 mm (± 30). Increased mitotic activity with pleomorphism noted in malignant SFTs. Two (6.4%) patients had recurrence and had further surgery. Overall survival: 1,3,5 & 10 year survival are: 96.2%, 92.3%, 82.1% and 63.8%. Thoracotomy Vs minimally invasive approach in 5 and 10 years was 80.9% vs 93.3% and 73.5% vs 41.7% (p = 0.9). Five-year and 10 year freedom from recurrence for patients with benign and malignant SFTPs was 92.6%% and 92.6% %.
Conclusion: The standard treatment of localised fibrous tumour consists of surgical resection with clear margins. Recurrences are rare, following adequate resection. However, malignant SFTs recurrence rate is higher than the benign variant. Patients should be followed up with CT Scan.
A124 AVSD repair, using a two-patch technique, in a 3D printed model with a novel removable AV valve
Linton-Jude Tony-Harshan1, Michele Bertolini2, Cameron Dent1, Mehar Bijral1, Ruby Silvera3, Georgios Belitsis3
1University College London Medical School, London, United Kingdom. 2Department of Mechanical Engineering, Politecnico di Milano, Milan, Italy. 3University College London, Research Department of Children's Cardiovascular Disease, London, United Kingdom
Correspondence: Linton-Jude Tony-Harshan
Journal of Cardiothoracic Surgery 2024, 19(2):A124
Objectives: The aim was to prove the feasibility of using a 3-Dimensional (3D) printed atrioventricular septal defect (AVSD) replica to model complex, intracardiac repair. Such a model would permit tangible insight into both native and post-surgical anatomy relevant to treatment and educational contexts, overcoming current limitations in trainee exposure to complex operative cases and supporting informed patient consent.
Methods: A 3D AVSD model, including a first of its kind removable atrioventricular (AV) valve, was designed and printed with compliant resins (Fig. 1). An experienced surgeon septated the heart and divided the AV valve (Fig. 1). Pre- and post-operative models were individually appraised by institutional professionals via questionnaires to assess the model’s potential for training and consent purposes.
Results: The results supported the accuracy of the model, with 90.48% (n = 19) of pre-operative appraisals identifying fine anatomical features and 100% of post-operative appraisals (n = 26) finding the model an accurate representation of two-patch AVSD repair. 100% of respondents found both the pre-operative (n = 21) and post-operative (n = 26) models useful for training, with 100% of surgeons (n = 6) agreeing such a model should be used in surgical training. 85.71% (n = 18) and 96.15% (n = 25) of respondents supported the model’s use for consent, in the pre- and post-operative appraisal groups, respectively.
Conclusions: This study strongly supports the utility of 3D-printed models as a tool to support morphological understanding and surgical training with implications for modelling other complex cardiac abnormalities.

A125 Migrating urological laser fibre as a unique cause of massive haemothorax
Fathima Shafra Mubarak, Perikles Perikleous, Jonathan Finch
Harefield Hospital, Harefield, United Kingdom
Correspondence: Fathima Shafra Mubarak
Journal of Cardiothoracic Surgery 2024, 19(2):A125
Introduction: A unique case of a retained 26.5 cm length of laser fibre migrating over 6 months from bladder, through abdomen and then traversing diaphragm causing massive haemothorax.
Background: A 72-year-old gentleman, anticoagulated with Apixaban for AF, presented with sudden pain, vomiting and collapse and found to have a massive left-sided haemothorax necessitating ventilation and cardiothoracic transfer for evacuation. On questioning he recounted 6 months of new, shifting pains, and temporary paraumbilical firmness, commencing 2 weeks after Holmium Laser Enucleation of Prostate (HoLEP) at local district general hospital. The Urology team noted ‘a small fragment of laser fibre broke during the procedure’, which is a common occurrence and he described subsequent cystoscopy and CTs.
However, re-review of the imaging at the receiving centre identified a linear opacity of varying intraabdominal location across serial CTs and was hypothesised that this might represent a substantial length of laser fibre, whose length and stiffness allowed to it act as a mobile needle, likely traversing abdominal viscera at such slow rate that no acute intra-abdominal or other catastrophe occurred, until it reached the chest.
Procedure: Two-port left VATS procedure was performed identifying massive residual haemothorax and stiff, green, cylindrical foreign body traversing diaphragm and propelled into 9th intercostal neurovascular bundle with each diaphragmatic excursion. A third port allowed removal of 26.5 mm length of laser fibre along its long axis without incident.
He was discharged on 6th day without complications. It was concluded by the Urology team that ‘all laser fibres should be measured before and after surgery’.
The patient gave verbal, informed consent to publish their information in an open-access journal.
A126 A real-world propensity-matched analysis of single vs bilateral internal mammary artery use
Marcus Taylor, Mohamad Nidal Bittar, Carmelo Raimondo, Tony Walker, David Rose, Grzegorz Laskawski, Cristiano Spadaccio, Joe Zacharias
Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom
Correspondence: Marcus Taylor
Journal of Cardiothoracic Surgery 2024, 19(2):A126
Objective: Conflicting evidence exists as to whether bilateral internal mammary artery (BIMA) use in coronary artery bypass grafting (CABG) conveys any benefit over single internal mammary artery (SIMA) use. The aim of this study was to compare short and long-term outcomes between these patient groups.
Methods: Single-centre retrospective review of all patients undergoing CABG between 1997 and 2017. Patients undergoing single-vessel CABG and patients receiving alternative arterial conduits were excluded. Primary outcomes were in-hospital mortality and overall survival. Propensity matching (caliper size 0.1) using age, diabetes, ventricular function, sex, hypertension, smoking, previous myocardial infarction and off-pump surgery was performed.
Results: After propensity matching was performed, a total of 385 matched pairs remained for analysis. The mean age was 57.8 years (± 10.2) and 91.0% (n = 701) were male. Ventricular function was preserved in 86.8% (n = 668) of patients and 76.1% (n = 586) underwent on-pump surgery. The mean number of grafts performed was similar between groups (BIMA: 3.0 [± 0.9] vs SIMA: 3.1 [± 0.8], p = 0.219). Overall in-hospital mortality was 0.9% (n = 7). There was no significant difference between groups in terms of in-hospital mortality (BIMA: 1.6% [n = 6] vs SIMA: 0.3% [n = 1], p = 0.058) or post-operative length of stay. Median follow-up time was 151 months (105–181). On univariable analysis (Fig. 1), SIMA was associated with significantly reduced overall survival (log-rank analysis p = 0.032).
Kaplan–Meier curve comparing overall survival in patients undergoing bilateral internal mammary artery (BIMA) use and single internal mammary artery (SIMA) use
Conclusion: This real-world retrospective study suggests that despite a trend towards higher short-term mortality, BIMA use conveys greater long-term survival benefit over SIMA in multi-vessel CABG.
A127 A single-centre experience of the introduction of an endoscopic radial artery harvest programme
Donna Croft, Marcus Taylor, Cristiano Spadaccio, David Rose
Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom
Correspondence: Donna Croft
Journal of Cardiothoracic Surgery 2024, 19(2):A127
Objectives: Endoscopic radial artery harvest (ERAH) is recognised as a safe and effective approach to harvesting the radial artery. Our aim was to examine our initial experience after introducing an ERAH programme.
Methods: Single-centre retrospective review of all consecutive patients undergoing ERAH as part of coronary artery bypass grafting (CABG) surgery between October 2022 and October 2023. Primary outcomes were ERAH-related complications and in-hospital mortality.
Results: A total of 23 patients underwent radial artery harvest during the time period, of which 52.2% (n = 12) underwent ERAH, and thus comprised the study population. Of these 12 patients, all were male and all underwent isolated CABG. The mean age was 56.2 years. The mean tourniquet time for the harvest was 26.3 min. There was no in-hospital mortality, and the median post-operative length of stay was 8 days (5–18). One patient experienced a post-operative haematoma which required re-exploration in theatre within 12 h of the index procedure. No other ERAH-related complications were reported. Amongst patients who had attended their 6-week post-operative review at the time of writing, no additional ERAH-related complications emerged.
Conclusions: In our centre ERAH is a safe and effective harvesting technique for CABG. Given that this cohort represents our initial experience with the procedure, the low rate of procedure-related morbidity and the acceptable mean tourniquet time are encouraging. The programme is continuing to increase in scope across the department and patients are being monitored to assess mid and long-term outcomes.
A128 Examining outcomes after cardiac surgery in dialysis-dependent patients
Marcus Taylor, Grzegorz Laskawski
Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom
Correspondence: Marcus Taylor
Journal of Cardiothoracic Surgery 2024, 19(2):A128
Objectives: Cardiac surgery is usually offered to patients to provide both symptomatic and prognostic benefit. Patients who are chronically dialysis-dependent (DD) are often functionally limited and have a reduced life expectancy. The aim of this study was to examine short and long-term outcomes for DD patients undergoing cardiac surgery.
Methods: A single-centre retrospective review of all consecutive patients recorded as DD undergoing elective or urgent cardiac surgery between 1997 and 2017. Primary outcomes were in-hospital, 1-year, 5-year mortality and overall survival. Univariable analysis was performed to examine the impact of variables on overall survival.
Results: A total of 85 patients were included in the study. Mean age was 65.2 years (± 11.9) and 72.9% (n = 62) were male. Mean body mass index (BMI) was 27.3 kg/m2 (± 4.9) and 72.9% (n = 62) had preserved ventricular function. Overall, 54.1% underwent isolated coronary artery bypass grafting (CABG) and 12.9% (n = 11) underwent off-pump surgery. Mean logistic Euroscore was 9.8% (± 10.4%). In-hospital mortality was 5.9% (n = 5) and median post-operative length of stay was 8 days (6–17). 1-year and 5-year mortality were 22.4% (n = 19) and 49.4% (n = 42), respectively. Median follow-up time was 60 months (14–95) and estimated median overall survival was 60 months (39–81). Age, diabetes, ventricular function, sex, urgency were all not associated with survival on univariable analysis.
Conclusion: These results suggest that DD patients can undergo cardiac surgery with acceptable short-term mortality. Despite conveying limited prognostic benefit, cardiac surgery should still be considered for symptomatic relief in this patient group.
A129 Extent of intervention in patients undergoing surgery for acute type A aortic dissection: less is more or more is more?
Marcus Taylor, Mohamad Nidal Bittar, Grzegorz Laskawski
Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom
Correspondence: Marcus Taylor
Journal of Cardiothoracic Surgery 2024, 19(2):A129
Objectives: Surgery for type A acute aortic dissection (AAAD) can be technically challenging and is associated with high mortality. Uncertainty remains as to whether more extensive intervention affects outcomes.
Methods: A single-centre retrospective review of all patients undergoing surgery for AAAD between 2011 and 2021. Patients were grouped based on whether or not they underwent concomitant aortic arch surgery. Primary outcomes were in-hospital mortality, peri-operative complications and overall survival.
Results: A total of 91 patients were included in the study. Mean age was 62.4 years (± 13.3) and 64.8% (n = 59) were male. Overall, 47.3% (n = 43) underwent surgery on the aortic arch. The incidence of arch surgery was significantly higher in cases performed by surgeons with a dedicated aortic surgery subspecialty interest (70.5% vs 25.5%, p < 0.001). In-hospital mortality was 20.9% (n = 19) and was significantly lower for patients undergoing arch surgery (11.6% vs 29.2%, p = 0.040). There was no significant difference in the incidence of stroke, filtration, reintubation, ischaemic bowel and re-operation for bleeding between groups. Median follow-up time was 41 months (16–75) and estimated median overall survival was 104 months (74–134). On univariable analysis (Fig. 1), undergoing aortic arch intervention was significantly associated with improved survival (log-rank analysis, p = 0.049). After multivariable adjustment for age, urgency, previous cardiac surgery and cardiopulmonary bypass time, undergoing aortic arch intervention remained independently associated with improved survival (hazard ratio 0.484, 95% confidence interval 0.238–0.986, p = 0.046).
Conclusion: These findings suggest that aortic arch surgery can be safely performed in AAAD patients and may be associated with improved long-term survival.
Kaplan–Meier curve comparing overall survival for patients who did and did not undergo aortic arch surgery
A130 The impact of nutritional measures on outcomes after isolated coronary artery bypass surgery
Asmita Singhania, Marcus Taylor, Nnamdi Nwaejike
Manchester University NHS Foundation Trust, Manchester, United Kingdom
Correspondence: Asmita Singhania
Journal of Cardiothoracic Surgery 2024, 19(2):A130
Objectives: The aim of this study was to analyse the impact of nutritional measures including pre- and post-operative serum albumin levels and body mass index (BMI) on short and long-term outcomes after isolated coronary artery bypass grafting (CABG).
Methods: Consecutive patients undergoing isolated CABG performed by a single surgeon between September 2017 and July 2022 were included. Albumin levels immediately pre- and post-surgery and the difference between these two values were recorded. Patients with missing albumin or BMI data were excluded. The primary outcomes were in-hospital mortality and overall survival.
Results: A total of 290 patients were included, of whom 77.5% (n = 225) were male. The mean age was 64.2 years (± 9.8) and 37.9% (n = 110) of patients underwent off-pump surgery. The mean difference between pre-operative and post-operative albumin levels was − 8.5 g/dL (± 4.7) and was significantly greater for on-pump CABG (-9.6 [± 4.7] vs -6.8 [± 4.1], p < 0.001). Mean BMI was 28.8 kg/m2 (± 4.6) and 38.3% (n = 111) of patients were obese. Only one patient was underweight. Median follow-up time was 29 months (12–47). A greater mean drop in albumin levels was independently associated with reduced overall survival (hazard ratio 1.131, 95% confidence intervals 1.009–1.269, p = 0.035) after adjustment for age, sex, ventricular function, urgency of procedure, use of cardiopulmonary bypass and BMI.
Conclusions: These results suggest that greater peri-operative drop in serum albumin levels may adversely impact long-term survival after isolated CABG. The significantly greater drop in albumin levels seen in patients undergoing on-pump surgery indicates that off-pump surgery may act as a protective factor.
A131 The impact of valve prosthesis choice on short and long-term outcomes in patients aged 50–59 years undergoing isolated aortic valve replacement
Marcus Taylor1,2, David Rose2, Mohamad Nidal Bittar2, Joe Zacharias2, Vipin Mehta1, Rajamiyer Venkateswaran1
1Manchester University NHS Foundation Trust, Manchester, United Kingdom. 2Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom
Correspondence: Marcus Taylor
Journal of Cardiothoracic Surgery 2024, 19(2):A131
Objectives: Surgical aortic valve replacement (AVR) is a safe and effective treatment. However, prosthesis selection is dependent upon several factors and can be particularly challenging in middle-aged patients. Our aim was to review outcomes for patients aged 50–59 undergoing surgical AVR.
Methods: All consecutive patients aged 50–59 undergoing isolated first-time surgical AVR in two cardiac surgery centres between 1997 and 2017 were included. Outcomes between patients receiving a mechanical or tissue valve were compared. Outcomes were in-hospital, 5-year, 10-year & 15-year mortality and overall survival.
Results: The study comprised 438 patients. Mean age was 55.4 years (± 2.9) and 68.0% (n = 298) were male. 69.2% (n = 303) received a mechanical valve and 30.8% (n = 135) received a tissue valve. There was no significant difference in mean cardiopulmonary bypass time or mean implanted valve size between groups. Overall in-hospital mortality was 0.7% (n = 3). The rates of 5, 10 and 15-year mortality were not significantly different between groups. Median follow-up time was 140 months (90–197). On univariable analysis (Fig. 1), the tissue valve group experienced significantly reduced overall survival (log-rank analysis, p = 0.017). After multivariable analysis (adjusting for age, sex, diabetes, functional status, extracardiac arteriopathy and ventricular function), receiving a tissue valve remained independently associated with reduced overall survival (hazard ratio 1.572, 95% confidence interval 1.068–2.315, p = 0.022).
Conclusion: Surgical AVR remains a safe operation with excellent outcomes. These results suggest that implanting a mechanical valve into patients aged 50–59 may convey additional survival benefit although this may not become apparent until at least 10–12 years after surgery.
Kaplan–Meier curve comparing overall survival in patients stratified by valve prosthesis
A132 The impact of body mass index on outcomes after lung resection
Marcus Taylor1,2, Felice Granato1, Michael Shackcloth3, Stuart W Grant2,4, RESECT-90 Collaborators3
1Manchester University NHS Foundation Trust, Manchester, United Kingdom. 2University of Manchester, Manchester, United Kingdom. 3Liverpool Heart and Chest Hospital, Liverpool, United Kingdom. 4South Tees Hospitals NHS Foundation Trust, Middlesbrough, United Kingdom
Correspondence: Marcus Taylor
Journal of Cardiothoracic Surgery 2024, 19(2):A132
Objectives: Some studies have suggested that extremes of body mass index (BMI) convey the highest risk of complications after lung resection, whilst other research has suggested that increased BMI is protective against adverse outcomes. The aim of this study was to examine the impact of BMI on outcomes after lung resection.
Methods: Multi-centre retrospective review of patients undergoing lung resection in 12 different UK centres between 2016 and 2020 with available BMI data. The primary outcome was 90-day mortality. Univariable and multivariable analyses were performed to determine the impact of BMI on 90-day mortality.
Results: A total of 11,901 patients were included. The mean age was 65.6 years (± 12.9) and 49.6% (n = 5905) were male. The mean BMI was 26.8 kg/m2 (± 5.4). Overall, 3.6% (n = 428) were underweight, 71.1% (n = 8467) were normal/overweight and 25.3% (n = 3006) were obese. 90-day mortality for the whole cohort was 3.0% (n = 355) and for the three groups was 3.7% (n = 16), 3.0% (n = 254) and 2.8% (n = 85), respectively. 90-day mortality was significantly higher for underweight patients compared to normal/overweight patients (p = 0.006) and obese patients (p < 0.001). There was no significant difference in 90-day mortality between the normal/overweight and obese groups (p = 0.130). After adjusting for age, sex, Performance Status score, laterality, approach, number of resected bronchopulmonary segments and presence of malignant disease, BMI remained independently associated with 90-day mortality (odds ratio 0.982, 95% confidence intervals 0.975–0.988, p < 0.001).
Conclusions: This study has shown that even after adjusting for other risk factors, lower BMI remains a risk factor for 90-day mortality.
A134 Hospital resource utilization in a national cohort of patients with simple coarctation of the aorta with and without ventricular septal defect undergoing treatment
Dan-Mihai Dorobantu1, Qi Huang2, Shubhra Sinha3, Ferran Espuny Pujol2, Rodney Franklin4, Katherine Brown3, Christina Pagel2, Sonya Crowe2, Serban Stoica5
1University of Exeter, Exeter, United Kingdom. 2University College London, London, United Kingdom. 3Great Ormond Street Hospital, London, United Kingdom. 4Royal Brompton and Harefield Hospitals, London, United Kingdom. 5University Hospitals Bristol and Weston, Bristol, United Kingdom
Correspondence: Shubhra Sinha
Journal of Cardiothoracic Surgery 2024, 19(2):A134
Objective: This study aims to report an overview of health resource utilization (HRU) and associated risk factors from birth to 18 years old in patients with coarctation of the aorta (CoA) treated nationally.
Methods: All patients with CoA treated between 2000 and 2017 in England and Wales were linked to national hospital, intensive care and outpatient records nationally. Hospital stay was described in yearly age intervals, and associated risk factors were explored using quantile regression.
Results: A total of 3321 patients with CoA were included, of which n = 669 (20.1%) had CoA with large VSD, n = 331 (10.0%) CoA with small VSD, and n = 2321 (69.9%) isolated CoA. Mortality and cardiac reintervention at 10 years were 3.7% [3.0%;4.4%] and 13.3% [12.1%;14.5%], respectively. During the first year of life, the median days spent in hospital was 26 (interquartile range, [17;44]), and decreased to 1 [0; 2] day by 8 years old and beyond (Figure). CoA with large VSD (-12 [-16;-8] days), premature birth (-31 [-41;-22] days), congenital comorbidly (-26 [-31;-20] days), low weight (-23 [-37;-11] days) and younger age at first procedure (-5 [-6;-4] days) were associated with reduced median days at home in the first year of life.
Conclusions: In a national CoA cohort, mortality and HRU were low, with cardiac reintervention increasing during follow-up. Risk factors associated with HRU in the first year of life are useful in risk stratification and informing future measures for improving quality of care.

A136 Stroke outcomes following cardiac surgery are improved by involvement of a Stroke Team
Amer Harky1, Vanessa Chow2, Kratik Goyal3, Callum Voller3, Matthew Shaw1, Anurodh Bhawnani1, Ayman Kenawy1, Ian Wilson1, Gregory Lip1, Mark Field1, Manoj Kuduvalli1
1Liverpool Heart and Chest Hospital, Liverpool, United Kingdom. 2Royal Berkshire Hospital, Oxford, United Kingdom. 3University of Liverpool, Liverpool, United Kingdom
Correspondence: Amer Harky
Journal of Cardiothoracic Surgery 2024, 19(2):A136
Objectives:
Stroke post-cardiac and aortic surgery is a serious potential morbidity that can have a significant impact on the outcomes during the postoperative period. We report our experience demonstrating the efficacy of a stroke team in recovery from stroke following cardiac surgery.
Methods:
This was a retrospective, single-centre, observational cohort study. Consecutive patients who underwent cardiac and aortic surgery at our institution between August 2014 and December 2020 were included. The main outcome measures were stroke incidence, factors predicting stroke rate (through clinical and radiological diagnosis) and resolution or persistence of the neurological deficit at the time of discharge and at follow-up in the clinic.
Results:
A total of 12,135 procedures were carried out in the reference period. Of those 436 (3.7%) suffered a stroke. Stroke incidence was highest in the over 80 s and in those who underwent non-elective surgery. Overall survival to discharge and follow-up was 87.6% and 73.5% respectively. Survival to discharge was highest in patients who had a stroke diagnosed clinically. Residual neurological deficit was present in 70.7% of patients at discharge and 52.5% at follow-up. Stroke patients managed by the Multidisciplinary Team (MDT) demonstrated significantly higher rates of survival at discharge compared to those not under Stroke MDT care (88.7% vs. 66.7%, p = 0.003).
Conclusions:
Perioperative stroke can be debilitating, both immediately and in the long term. The presence of specialist stroke teams plays a key role in reducing the long-term burden and mortality of this condition.
A137 A novel technique for surgical repair of chronic symptomatic sternal malunion combining a modified mini Robicsek and internal stabilization with titanium plates
Alessandro Tamburrini, Aiman Alzetani, Christopher Mitchell, Gabriel Hunduma
University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
Correspondence: Alessandro Tamburrini
Journal of Cardiothoracic Surgery 2024, 19(2):A137
Introduction: Sternal fractures are rare and-in-most cases conservative management yields very good outcomes. Failure of conservative management is very rare but can result in symptomatic malunion with chronic pain and disabling discomfort. Repair techniques are anecdotal and non-standardized. We present the results of our novel type of repair combining a limited modified mini-Robicsek and internal fixation with titanium plates.
Body: Four patients with simple and one patient with complex post traumatic sternal malunion were treated with this innovative technique. All patients had at least one risk factor for impaired bone healing (BMI, Osteoporosis, arthritis, diabetes or osteomyelitis). Demographic and operative data are summarised in Table 1. After exposure of the malunion, transverse osteotomies were performed to mobilize and refashion the fractured edges of the malunion. A modified mini-Robicsek was constructed by placing two vertical wires to approximate the gap and two horizontal wires tied over one or two vertical titanium plates which were fashioned over the fracture and fixed with bicortical screws. In the simple cases, the minimal residual gap was filled with Cerament® bone void filler. In the complex case presenting a 4 × 2 cm defect sternal defect post-osteomyelitis, the gap was filled with autologous bone graft from iliac crest. At 6 months follow-up all patients were pain-free, with CT showing normal sternal alignment and healed fracture.
Conclusion: Our novel technique for repair of transverse symptomatic sternal malunion combines 2 existing techniques and contrasts both vertical and horizontal forces providing multi-directional stability, with excellent results.
A138 Study to investigate the reasons for hospital stay more than 3 days after VATS lobectomy
Fatima Altayeb1, Mauin Uddin2, Bejoy Philip2, Michael Shackcloth2
1Liverpool heart and chest hospital, liverpool, United Kingdom. 2liverpool heart and chest hospital, liverpool, United Kingdom
Correspondence: Fatima Altayeb
Journal of Cardiothoracic Surgery 2024, 19(2):A138
Background: Video-assisted Thoracoscopic surgery (VATS) lobectomy has become the standard procedure for treatment of lung cancer. Potential benefit includes a reduced hospital stay and costs.
Objective: To investigate the causes contributing to delayed discharge (after 3 days) in patients undergoing VATS lobectomy.
Methods: Retrospective study from the electronic patient records of the 325 patients who had VATS lobectomy between January 2022 and August 2022 in a single centre.
Results: The study identified that 49.8% of patients stayed more than 3 days.
Causes of delayed discharges were multifactorial 40%, air leak 30%, infection 7%, pain 6%, arrhythmia 3%, respiratory causes 1%. Other non-common causes of delayed discharge were 13% of the total number (hyperglycaemia, delirium, stroke, surgical emphysema, vocal cord palsy, tension pneumothorax, myocardial infarction, chylothorax).
Conclusion: Air leak (alone or in combination with other causes) was the most common reason for prolonged hospital stay. Based on the findings, we recommend the implementation of a comprehensive plans to enhance pain management (use of liposomal bupivacaine), and early use of flutter bags to try and decrease the percentage of patients staying longer than 3 days. These findings have the potential to enhance the efficiency of the VATS lobectomy care pathway, ultimately improving patient satisfaction and resource utilization. Continued audit will be essential to ensure sustainability in the care pathway.

VATS lobectomy causes of delayed discharge
A139 A quality improvement initiative to safely reduce unnecessary chest X-rays after elective lung resection and mediastinal surgery
Jacie Jiaqi Law, William Kah Howe Lee, Michael Calderwood, Liana Montgomery, Ralitsa Baranowski, Niall McGonigle, Rory Beattie, Mark Jones, Peter Mhandu
Royal Victoria Hospital, Belfast, United Kingdom
Correspondence: Jacie Jiaqi Law
Journal of Cardiothoracic Surgery 2024, 19(2):A139
Objectives: Chest x rays (CXR) are empirically performed after elective thoracic surgery. There is no evidence base to this costly practise with existing literature demonstrating limited impact on patient care.
Methods: From June 2022 to October 2023, we performed a three-phase cycle quality improvement initiative using the “plan-do-study-act” (PDSA) methodology to reduce recovery and daily CXR utilisation. Each cycle duration was 4 months. Interventions included education within the MDT team, standardizing CXR ordering practises and feedback gathering. Patient demographics and postoperative outcomes were analysed to assess the safety of our initiative. Cost saving was estimated using NIHR Costing Tool (iCT).
Results: 269 elective thoracic surgery patients were monitored. Patient characteristics and operative data were similar between pre and post-intervention cohorts. Mean daily rate of CXR performed per patient reduced from 1.25 ± 0.8 to 0.8 ± 0.3(p < 0.001) while recovery CXRs reduced from 100%(269) to 80%(215) (p = 0.29). Each audit phase consistently demonstrated only 2%-3% of recovery CXRs led to clinical intervention. No difference was observed with postoperative complications (Clavien-Dindo Classification ≥ 3) (13% vs 14%,p = 0.53), hospital length of stay (7 ± 6 vs 7 ± 13 days,p = 0.65),return to theatre (7% vs 6%,p = 0.86), hospital readmission (6% vs 6%,p = 0.86) and death within 30 days (1% vs 1%,p = 0.85) before and after intervention. Conservative estimate of cost saved was GBP 76,908 per year.
Conclusion: Routine CXR utilisation after elective thoracic surgery can be reduced safely and systematically. Further PDSA cycles are undergoing within our institution to sustain this patient-benefiting and NHS cost saving initiative.
The legend for this figure is—Overview of events after routine recovery chest x ray in PDSA cycle 1 to 3.
Figure A: Overview of events after routine recovery chest x ray in PDSA cycle 1 to 3.

A140 Concomitant mitral valve repair and personalised external aortic root support: initial experience in two centres
Ahmed ElSherbini1,2, Ana Redondo3, Mohamed ElSaegh1, Shafi Mussa1, Andrew Parry1, Serban Stoica1,2, Conal Austin3, Massimo Caputo1,2
1University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom. 2University of Bristol, Bristol, United Kingdom. 3Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
Correspondence: Ahmed ElSherbini
Journal of Cardiothoracic Surgery 2024, 19(2):A140
Background: Marfan syndrome often leads to aortic root and mitral valve (MV) diseases, traditionally managed through simultaneous MV repair and valve-sparing aortic root replacement. The Personalised External Aortic Root Support (PEARS) procedure has emerged as a strategy for treating aortic root issues in connective tissue disorders.
Methods: We retrospectively reviewed patients from two centers who underwent MV repair and PEARS since 2015.
Results: Ten patients (median age 23 years, range 11–44 years) were included. Eight Marfan syndrome patients had MV repair and PEARS; one with endocarditis had Ross procedure, PEARS, and MV repair; and one had MV repair and PEARS 11 years after an arterial switch operation. The median largest aortic root diameter was 45 mm, with no significant aortic valve gradients observed. No immediate postoperative complications were noted.
Over a median follow-up of 2.8 years (1 month–5.4 years), eight patients had no significant complications. MV improved and remained stable; four patients had no regurgitation, and six had trivial/mild regurgitation. Aortic root diameter decreased to a median of 37 mm.
One patient, at 3 months post-op, developed a severe inflammatory reaction involving the PEARS, leading to severe coronary artery stenosis, requiring intervention. One patient died 2.25 years post-op due to non-cardiac causes.
Conclusion: PEARS is a promising alternative for connective tissue disorder patients needing MV repair, reducing cardiopulmonary bypass time and enabling early intervention for aortic root dilatation. However, larger studies are needed to assess its safety, particularly concerning coronary artery complications.
A141 Effect of lung cancer screening program on a thoracic surgical unit
Muhammad Nagi Abdulhakeem, Fady Bassily, Damian Cullen, Archie Samuels, Martin Ledson, Matthew Smith, Susannah Love, Steven Woolley, Julius Asante-Siaw, Michael Shackcloth
Liverpool Heart and Chest Hospital NHS Trust, Liverpool, United Kingdom
Correspondence: Muhammad Nagi Abdulhakeem
Journal of Cardiothoracic Surgery 2024, 19(2):A141
Objectives: To assess the impact of Target Lung Health Checks (TLHC) on a large thoracic surgery unit, compare patient characteristics to other lung cancer surgery patients.
Methods: Records retrospectively reviewed of patients who underwent lung resections for presumed cancer between 10/2021 and 08/2023 (99 weeks). Patient’s demographics, hospital stay, mortality and pathological staging were compared.
Results: In this period, screening was open to eligible patients from an area of approximately 1,000,000 people. 226 patients, referred from TLHC underwent lung resection for suspected/confirmed cancer (4 proven benign), 2 underwent VATS lung biopsies and 1 thymectomy (2.28 surgeries/week). These patients occupied 2.04 hospital beds daily, including 0.18 ITU beds on average. Compared to lung cancer resection patients not referred via TLHC during the same period, TLHC patients were significantly younger (68 ± 4.5 vs 69.4 ± 9.6, p-value 0.001), more likely to have a minimally invasive procedure (88.6% vs 82.9%, p-value 0.04), and less likely to be admitted to ITU (9.6% vs 22.1%, p-value < 0.001). TLHC patients more often had a stage I disease on pathological staging (82.9% vs 65.8%, p-value < 0.001). There was no significant difference in sex, length of hospital stay, or 30-day mortality. Over a mean follow up period of 13 months (2–25 months), TLHC patients had lower mortality (hazard ratio 0.46, 95% CI 0.22–0.96).
Conclusions: TLHC has increased the demand on our unit’s resources and work force. However, patients coming via TLHC do better and are treated at an earlier stage, predicting a better overall survival.
A142 Outcomes following colorectal metastasectomy: single centre retrospective analysis
Rana Mehdi, Alina-Maria Budacan, Amber Ahmed-Issap, Kajan Mahendran, Shilajit Ghosh, Lakshmi Srinivasan, Udo Abah
Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
Correspondence: Rana Mehdi
Journal of Cardiothoracic Surgery 2024, 19(2):A142
Background: The utility of pulmonary metastasectomy for colorectal cancer remains controversial. The only randomised data to date has shown no survival benefit, whilst large observational studies demonstrate prolonged survival. However, these series typically contain patients with favourable prognostic characteristics and the question remains; is the demonstrated benefit due to selection bias alone? We performed a retrospective analysis to examine the postoperative outcomes in the face of the current controversy and new alternatives therapies.
Methods: Patients were identified from a prospectively completed surgical dataset. Primary tumour, perioperative, recurrence and mortality data were collected.
Results: 176 patients were identified from Jan 2012-Dec 2021. 12 patients presented with liver metastases at the time of presentation, all but one of these patients underwent liver resection for colorectal metastases prior to thoracic surgery. Seven patients presented with synchronous metastases which were operated on in stages. Mortality at 90 days, 1 year and 2 years from resection was 1.1%, 8% and 14.8% respectively. Postoperative complications were 12% and average length of stay was 4.3 days. Median was survival 61.3 months (95% CI 52.1–70.5.) At the time of this analysis, 81 patients (45.7%) remain alive. 27.6% of cases (49 patients) had further recurrence within the lung, of those patients, 37 went on to have further surgery; including repeat metastasectomy, lymph node staging or rib resection.
Conclusion: Our series demonstrates prolonged survival with low postoperative morbidity and mortality. In the face of such uncertainty, surgical metastasectomy remains a valid option until more definitive randomised data is available.

A143 Device assisted pericardial harvest and preparation, a promising adjunct to neocuspidization? A preclinical evaluation study
Ayush Balaji1,2, Hammad Chishti1,2, Rishab Makam3, Adhya Mathrani1,2, Aman Sanghai1,2, Grace Ruggins1,2, Manish Chauhan4
1Hull York Medical School, Hull, United Kingdom. 2University of York, York, United Kingdom. 3Hull University Teaching Hospitals Trust, Hull, United Kingdom. 4School of Physics, Engineering and Technology, University of York, York, United Kingdom
Correspondence: Ayush Balaji
Journal of Cardiothoracic Surgery 2024, 19(2):A143
In this study, we introduce a device aimed at expediting the pericardial harvesting process, specifically for the Ozaki procedure and related neocuspidization procedures. This tool is designed to improve ergonomics, reduce operative time, and ensure uniform outcomes. It combines cutting and marking functions for the pericardium, aiding in suture placement and leaflet creation.
Traditional leaflet preparation methods, often manual and time-consuming, can extend overall surgery duration and affect outcomes. Our device aims to streamline this process. Utilizing 3D CAD modeling and adapting from original leaflet designs, the modularity allows for the handling of various leaflet sizes, increasing its adaptability for different surgical requirements. The device was printed using Poly-Lactic-Acid (PLA) and the blade was created using surgical steel molded to fit the leaflet templates.
We conducted initial tests on silicone pericardium models, later incorporating fiber-infused silicon to better replicate the pericardium's texture. The goal is to simulate actual surgical conditions, enhancing the device's accuracy and utility. Following prototyping and testing different iterations, we found that the device will likely reduce preparation time leading to reduced cross-clamp-time, improve uniformity of leaflets, and minimize tissue handling. The device production cost is low and will be further reduced with industrial 3D printing capability. Our next phase, pending ethics approval, involves testing on animal tissue, a vital step toward verifying its clinical applicability.
The device's development focuses on reducing harvest time while maintaining precision and consistency in leaflet production. This tool could significantly impact the workflow of neocuspidization procedures, improving overall efficiency and reproducibility.

A144 The service development of an advanced clinical practitioner led Intravenous access service. Enabling reduced patient waiting times and enhancing patient experience
Alister Morris1, Lisa Wood2
1LHCH, Liverpool, United Kingdom. 2LHCH, Liverpool, United Kingdom
Correspondence: Alister Morris
Journal of Cardiothoracic Surgery 2024, 19(2):A144
Working in an advanced clinical practitioner (ACP) role within in a stand-alone tertiary cardiothoracic Trust it was noticed that the patients referred with complex infections such as endocarditis had prolonged waiting times for a PICC or Midlines (long term IV access lines). Thus, often leading to multiple cannulations and patient dissatisfaction. This was due to due to limited availability of trained experts in long term line insertion.
In 2020, the Trust highlighted this as an issue and implemented expert training for the ACP’s to insert both midlines and PICC lines. This was led by the Trust IV access lead (a Consultant Anaesthetist) who organised the initial training of 2–3 ANP’s. Once established the service became ACP led.
Currently there are now 3 Cardiothoracic ACP’s, 3 Cardiology ACP’s, 1 microbiology nurse specialist and 10 ICU ACP’s competent. In addition to this almost all surgical ACP’s and outreach nurses are now trained in ultrasound venepuncture and cannula insertions, with the aim of upskilling more staff in the future.
The data extrapolated from the Trust electronic patient records both pre and post IV access team establishment has shown that there is reduction in the length of time a patient now has to wait for a long-term IV access line. This is calculated from the time it is requested to the time inserted. This aids an improved patient experience due to reduction in cannulations, venepunctures and reduces length of stay enabling patient discharge if clinically stable and a community IV service is available.
A145 The feasibility of using High Flow Nasal Oxygen (HFNO) on a thoracic surgery ward
Lisa Kenyon, Babu Naidu
University Hospitals Birmingham, Birmingham, United Kingdom
Correspondence: Lisa Kenyon
Journal of Cardiothoracic Surgery 2024, 19(2):A145
Objectives: There is little evidence for HFNO use in Thoracic surgery particularly post-operatively. The European Respiratory Society guidelines (2021) recommends using HFNO over COT in hypoxemic ARF and either HFNO or NIV for post-operative patients at high risk of pulmonary complications.
A quality improvement project on the feasibility of using HFNO was carried out. Previously there was no other respiratory support except conventional oxygen therapy (COT) and patients in acute respiratory failure (ARF) were admitted to ITU solely for HFNO. The aim was to reduce respiratory complications after surgery and reduce admissions to ITU.
Methods: A feasibility study and audit of elements of a new HFNO Standard Operating Procedure was performed retrospectively. Data was collected between February to July 2023 including all patients who used HFNO during their hospital stay.
Results: 14 patients used HFNO (Table 1). All were indicated due to hypoxemic ARF and secretion retention. No patient had a contraindication. For precautions: at risk of C02 retention secondary to oxygen use (1), facial deformity (1). 60% had an escalation plan at commencement (8) but only 2 had a valid Respect form.
Conclusions: The use of HFNO was feasible on the ward. There was a reduction of admission to ITU solely for HFNO (86%). 21% of patients still required emergency bronchoscopy but most were successfully treated for ARF with HFNO. Overall good adherence to the SOP for indications, precautions, and escalation plans. We will consider using prophylactic HFNO post-operatively in high-risk patients to reduce the need for emergency bronchoscopy.
A146 Primary sternal fixation with titanium plates in high-risk patients. Clinical results and ultrasound assessment at follow-up
Ammar Mustafa1, Jens Roggenbach2, Nicolas Nikolaidis1, Kumaresan Nagarajan1, Nikhil Patil1, Harisherjot Basran3, Giuseppe Rescigno1
1Department of Cardiothoracic Surgery, Wolverhampton, United Kingdom. 2Department of Cardiothoracic Anaesthesia, Wolverhampton, United Kingdom. 3College of MDS, University of Birmingham, Birmingham, United Kingdom
Correspondence: Ammar Mustafa
Journal of Cardiothoracic Surgery 2024, 19(2):A146
Median sternotomy closure is based on cerclage with sternal wires. This allows reduction of the iatrogenic fracture. However, micro-movements are still possible. In obese patients we have used titanium plates to improve sternal fixation. We assessed the clinical results and the presence of residual micro instability (RMI) by ultrasound imaging (2D-US).
In 12 obese patients (Table) the sternal closure was obtained by sternal wires and two Sternalock Blu X-plates fixed with screws to the sternal body (Zimmer Biomed, Jacksonville, FL, USA). The patients were issued with a questionnaire about their pain score at hospital discharge and 6 weeks after surgery. The median follow up was 292 days. The RMI of the sternal halves was assessed by 2D-US (SonoSite X-Porte, Fujifilm, USA).
One patient required sternal debridement after 4 weeks for instability. The sternotomy was paramedian and the plates were therefore screwed too close to one of the sternal edges. The remaining patients reported mean pain score (1–10 scale) 3.3 ± 2, 1.3 ± 1.7, 0.4 ± 0.7, at day 1, hospital discharge and 6 weeks, respectively. Time to full recovery was 3.3 ± 2.7 weeks. The 2D-US was not able to detect RMI at rest or while coughing, except in one patient who was assessed only three weeks after surgery (1.5 mm horizontal movement when coughing).
Titanium X-plates have shown excellent results in terms of postoperative pain and time to full recovery. The 2D-US showed stable healing of the fracture. A perfect median sternotomy is a prerequisite as shown by our single poor outcome.
Demographic features and risk factors for sternal complications (N patients = 12)
Mean ± SD or N (%) | |
---|---|
Age (years) | 53.1 ± 9.2 |
Gender (M/F) | 11/1 |
BMI | 36.0 ± 3.4 |
Diabetes | 4 (33.3%) |
COPD | 2 (16.5%) |
A147 First minimally invasive valve experience in the west of Ireland
Henri Bartolozzi
University Hospital Galway, Galway, Ireland
Correspondence: Henri Bartolozzi
Journal of Cardiothoracic Surgery 2024, 19(2):A147
Recent studies have highlighted the utility of minimally invasive cardiac surgery and the excellent outcomes that can be achieved. Here we present the outcomes of the introduction of a minimally invasive cardiac surgery program in the west of Ireland and in the smallest cardiac unit in the British Isles. The program commenced in August 2019, where a total of 35 patients have undergone surgery under the supervision of a proctor, despite pausing during the COVID-19 pandemic. The age range of the patients was 39 to 86 years of age, with 22 female patients and 13 male patients.
Successful outcomes include a 100% repair rate for degenerative mitral valve disease, 0% pacemaker insertion and paravalvular leak rate among 13 Aortic Valve and 11 Mitral Valve replacements.
Blood transfusion, length of stay and post op complication rates were comparable to contemporaneous open procedures in the unit demonstrating how, under correct proctorship, a minimally invasive programme can be started in any or all cardiac surgery units.
A148 10 years on from the ‘#Hello, My Name is…’ campaign: evaluating patient awareness of ward round members in cardiac surgery at two UK cardiac centres
Eteesha Rao1, Danai Karamanou2, Bil Kirmani3
1Newcastle University, Newcastle, United Kingdom. 2James Cook University Hospital, Middlesbrough, United Kingdom. 3Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
Correspondence: Eteesha Rao
Journal of Cardiothoracic Surgery 2024, 19(2):A148
Objectives: ‘#Hello, My Name is…’ is an international campaign launched in 2013 to improve patient-centered care. It recommends, firstly, that healthcare professionals should start by introducing themselves by name and role before every patient interaction, establishing an effective therapeutic relationship. 2023 marks ten years of this NHS-wide campaign, strongly backed by Care Quality Commission (CQC), Medical Defence Union (MDU) and multiple Trusts nationally.
The objective of this study was to ascertain whether UK cardiac centres are meeting these core values. We did this by comparing their performance against the campaign’s standards.
Methods: We performed a prospective, blinded review of consecutive ward rounds over two weeks in two UK cardiac centres. Selected patients were subsequently interviewed on the same day using a proforma.
Results: Please see attached results table.
Measure of quality | Centre 1: (n = 47) | Centre 2: (n = 32) | Patient quotes |
---|---|---|---|
1. Communication | |||
a) Effective communication? | 85.1% | 96.9% | • “not able to understand medical jargon” • “struggled with some of the terminology such as 'transfuse' and 'anaemic/low haemoglobin’” • “Better communication would help put me at ease” |
b) Introduced names and roles? | 78.7% | 81.3% | • “…don't know role or name of who I’m talking to so hard to build connection and don't know if directing questions at the right person” • “…don’t know roles when asking for help … everyone has same scrubs and lanyard colours” • “… have different colour uniforms but can't tell roles to uniforms link” • “…can tell roles from coloured uniform” |
2. Good bedside manner | |||
a) No medical jargon used | 87% | 93.8% | • “Sternum” • “beta-blocker” • “Anaemic” • “Mild peripheral oedema” • “Reduced air entry at the left” • “Crepitations” • “Arrhythmia” |
b) Asking patients if any questions/concerns | 77% | 78% | • “didn't know could ask questions” • “always felt safe” • “Still had a few questions to ask but tired from operation …Would be helpful if they could have a place to leave questions that doctors could answer as and when they have time” |
3. Patient autonomy | |||
a) “No decision about me without me” | 77% | 62.5% | • “Told going home but don't feel ready” • “… want to be more involved in the decision making as mostly just told what to do” • “Not entirely sure what all the tests he's having are for and not received any results for them yet” |
4. Patient seen as a person a) Personal touches? | 91% | 87.5% | • “Everyone's been fantastic from cleaners to surgeons. All very helpful” • “You all perform miracles every single day, thank you” |
Discussion: The results indicate three key opportunities for improving communication and compassion. Although communication is good, there's substantial room for improvement. 23% of encounters could have better accessible language and time for patients’ questions. 22% of patients may not know the roles of staff seeing them on ward rounds. Patient autonomy is the weakest domain, stressing the importance of prioritizing patient involvement in decision-making.
Conclusion: Ten years after the "Hello my name is…" campaign was launched, 1 in 5 healthcare professionals in cardiac surgical centres still do not introduce themselves. Up to 38% of patients were treated paternalistically and 1 in 10 consultations used medical jargon. Patient centred care could be substantially and easily improved.
A149 From operating room to court room—10 years of clinical negligence in a cardiothoracic unit
Samantha Pringle, Mylvaganam Jeyakanthan, Stephen Clark
Freeman Hospital, Newcastle, United Kingdom
Correspondence: Mylvaganam Jeyakanthan
Journal of Cardiothoracic Surgery 2024, 19(2):A149
Introduction: Surgeons usually know little about clinical negligence in their unit. We sought to analyse a decade of medicolegal claims to determine their value, incidence and themes.
Methods: 10 years of our Trusts cardiothoracic surgical data (2013 to April 2023) from the NHS Resolution Claims Management System was reviewed. Claims are indexed by incident date.
Results: The average post incident notification window for claims was 1.81 years, 0.3 years shorter than the Trust mean. 28 claims (total value of £8.5 M) were made over 10 years (4% of Trust total by volume, 3% by value). 6.5% of claims were high value, low volume and the remainder were low value, high volume. 25% remain open. The average claim was £275 k (73% of Trust mean). In closed claims, 33% had no damages paid and the rest were settled with mean damages of £86 k.
Causes of claims by injury were fatality after surgery (39%), unnecessary/additional procedures (19%), and bowel complications (6%). Average claim value in this cohort was £135 k. By claim volume the main causes were delayed treatment (26%), operator error (23%) and poor nursing care (10%). By claim value the most frequent were brain damage (£5 M), amputation (£1 M) and fatality (£75 k). Claims of low value (total £2 M) were caused by delays in treatment, operator error and inappropriate treatment.
Conclusions: Awareness of medicolegal claims is useful to highlight themes and areas for improvement. An appreciation of the value of claims provides useful insight and awareness for clinicians to reduce potential for liability.
A150 The effectiveness of 3D printing in pre-operative planning in patients with congenital heart disease
Shayan Soozandeh1, Amirhassan Parvizi1, Mylvaganam jeyakanthan2, David Nahabedian3, James Coey1, Stephen Clark2
1St George’s Medical School and Northumbria University, Newcastle, United Kingdom. 2Freeman Hospital, Newcastle, United Kingdom. 3St George’s Medical School, Grenada, Grenada
Correspondence: Shayan Soozandeh
Journal of Cardiothoracic Surgery 2024, 19(2):A150
Objective: Congenital heart disease (CHD) involves complex structural anatomy requiring meticulous surgical planning. Current surgical planning techniques rely heavily on interpretation of medical imaging with room for human error and cannot always be interpreted easily by the wider team. Leveraging 3D printing offers a promising solution to enhance preoperative planning for CHD surgery and share anatomical detail and technical operating intentions with the team. We created cost effective patient-specific 3D printed heart models based on CT scans and MRI data, with the intention of minimizing surgical risks, and sharing with team members, patients and carers.
Methods: We produced a series of 3D heart models using anonymized CT scans and MRI files from two pre-operative CHD patients. These models varied in size, materials, and representation. Data collection involved standardized surveys aimed at gathering feedback from surgeons and the wider team involved in the surgery.
Results: The data was analyzed using the Likert scale and categorized into three areas: Preoperative communication and planning (77% found the models useful), Risk aversion (70% found them useful), and Preoperative efficiency (64% found them useful). Graphical representations are shown in Figs. 1, 2, and 3.
Conclusion: Our data supports the efficacy of cost effective 3D printing from CT and MRI images to enhance preoperative planning and team education. This can potentially reduce error by providing surgeons with patient specific, tangible heart models to visualize and plan their procedures more effectively. Addressing limitations will advance the use of 3D printing as a valuable tool in surgical planning.

A151 Opening a bubbling drain to air: can you do that?
Ilecia Baboolal, David Waller
St. Bartholomew's Hospital, London, United Kingdom
Correspondence: Ilecia Baboolal
Journal of Cardiothoracic Surgery 2024, 19(2):A151
Background: Persistent air leak (PAL) after thoracic surgery presents a clinical challenge leading to extended hospital stay or reattending and risking pleural infection. We report the effectiveness of the controversial “opening a bubbling drain to air” manouevre to test lung expansion and expedite drain removal.
Methods: In a 3-year period we performed the open to air test in 15 consecutive patients (M: F 13:2, median age 70, range 57–79 years) with PAL after decortication in 11 and lung volume reduction in 4. Following opening to air, patients were closely monitored and had a portable xray after 2 h. Perioperative characteristics and clinical course were monitored with a median follow up of 6.6 (range 1–24 months).
Results: The duration of PAL was 17 (range 12–37 days). 5 patients had a digital drainage system with an air leak of (300–5500) ml/min and 10 patients on underwater seal drainage had grade 2 (range 1–3) leak (Robert David classification).
In 13 of 15 (86%) patients, we successfully removed their drain and discharged them 1–5 days later (median 1.1 days) with no further consequences The manoeuvre was unsuccessful in 2 patients: one immediate and one readmission 2 days later.
Conclusion: Opening a bubbling chest drain to air can expedite drain removal and discharge in those whose lung has become trapped with a fixed space. Severity of air leak does not appear to be predictive but future work is needed to identify how early this manoeuvre can be safely employed.
A152 Early experience with the ascyrus medical dissection stent use in acute type A aortic dissection
Firas Aljanadi, Jenna Doherty, Chris Austin, Pushpinder Sidhu, Reuben Jeganathan, Gwyn Beattie, Mark Jones, Alsir Ahmed
Royal Victoria Hospital, Belfast, United Kingdom
Correspondence: Firas Aljanadi
Journal of Cardiothoracic Surgery 2024, 19(2):A152
Objectives: Acute Type-A Aortic Dissection (ATAAD) repair carries a high surgical risk. Ascyrus Medical Dissection Stent (AMDS) insertion during the repair has been shown to enhance true lumen re-expansion, false lumen obliteration, and aortic remodelling. We describe our early experience with the AMDS use in our centre.
Methods: We retrospectively reviewed our experience with the AMDS usage, from Nov 2021 to February 2023. We examined the postoperative outcomes, namely the operative and short-term mortality, true lumen expansion, the fate of the false lumen, as well as aortic remodelling.
Results: Twenty consecutive patients undergoing repair of ATAAD were reviewed, of whom, nine patients (45%) received an AMDS. Median age was 53 years. All patients had a successful deployment of the device, with no operative or 30-day mortality. Median hospital stay was 21 days. Postoperatively, acute kidney injury occurred in two patients, bleeding requiring re-exploration in one patient, and two patients had a stroke. Malperfusion improved from 87% preoperatively to 29%, including in a patient with limb paralysis. There was no short-term mortality, or aortic injury related to device usage. Re-intervention occurred in two patients, and three patients were re-hospitalised. False lumen obliteration was achieved in six patients (67%) and a stable aortic diameter was observed in seven patients (78%).
Conclusion: Our results show that the use of the AMDS in ATAAD repair is safe and effective in promoting true lumen expansion, false lumen obliteration, aortic wall remodelling, and significantly reduces malperfusion. Further follow-up is required to assess its long-term benefits.
A153 Training junior surgeons in Off-Pump Coronary Artery Bypass Grafting (OPCABG): a 20-year experience
Marco Gemelli1,2, Ettorino Di Tommaso1, Lauren Dixon1, Roberto Natali1, Anil Sankanahalli Annaiah1, Vito Domenico Bruno1, Raimondo Ascione1
1University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom. 2University of Padova, Padova, Italy
Correspondence: Marco Gemelli
Journal of Cardiothoracic Surgery 2024, 19(2):A153
Objective: Training residents in advanced coronary surgery is a challenge. In our high-volume off-pump coronary surgery center, residents routinely perform this procedure supervised or unsupervised. We aim to evaluate perioperative and long-term outcomes of OPCABG performed by residents compared to consultant surgeons.
Methods: Prospectively collected data from the internal database registry were analysed from 7,310 consecutive patients undergone OPCAB surgery between January 2001 and December 2021 at our institution. OPCAB patients were split in 2 groups by main operator, including residents and consultants. Short-term outcomes and long-term survival follow-up were compared between the two groups.
Results: Overall, 2,269/7,310 (31%) OPCAB patients were operated by residents, and distribution of baseline risk factors was balanced between groups. In terms of postoperative outcomes, there were no difference in mortality (1.3% vs. 1.7%, p = 0.19), return to theatre for bleeding (1.9% vs. 2.2%, p = 0.40), postoperative cerebrovascular accident (0.2% vs. 0.4%, p = 0.08), post-operative dialysis (1.3% vs. 1.7%, p = 0.24) and hospital length of stay (8.3 days vs. 8.3 days, p = 0.83). The mean follow-up was 10.7 years and there was no significant difference in term of survival between the groups (70.1% vs. 72.1%, p = 0.13). Multivariate regression analysis indicated that being operated by a resident was not a predictor of long-term mortality.
Conclusions: Training junior surgeons in OPCAB surgery in a high-volume center is safe and effective with no difference in key early hospital outcome and long-term survival compared to senior surgeons.

A154 Return in theatre for bleeding after aortic valve replacement: a propensity-matched study comparing full sternotomy and minimal access
Vincenzo Caruso, Rajdeep Bilkhu, Paolo Bosco, Kamran Baig, Gianluca Lucchese
St Thomas' Hospital, London, United Kingdom
Correspondence: Vincenzo Caruso
Journal of Cardiothoracic Surgery 2024, 19(2):A154
Objectives: Aim is to compare the incidence of return to theatre for bleeding (RTT) between full sternotomy (FS) aortic valve replacement (AVR) and minimally invasive AVR (MIS-AVR).
Methods: Prospectively collected data for patients undergoing isolated, first-time AVR, was retrospectively reviewed. MIS was performed via upper hemi-sternotomy (M-S) or right anterior thoracotomy (RAT). Four-hundred-ninety-five MIS patients were matched to a control group (FS) using propensity score analysis through a nearest neighbor matching model, with MIS as the dependent variable. Age and baseline left ventricular ejection fraction were the two covariates in the matching model; patients with pre-existent risk factors for bleeding were excluded. Composite primary endpoint was the incidence of RTT and mortality.
Results: Overall, 1501 patients underwent isolated AVR via FS or MIS. Re-exploration for bleeding occurred in 72 (4.8%) patients (FS: n = 46, 5%; MIS; n = 26, 4.3%, OR: 0.8(85% CI:0.5, 1.3), p = 0.539.A total of 990 patients were matched (FS: n = 495; MIS: n = 495) to create a database with similar baseline characteristics. Incidence of RTT was 4.2% (n = 21) for MIS and 5.2% (n = 26) for FS, with no statistically significant difference: OR: 0.8 (95% CI:0.4, 1.4), p = 0.532. Also, in-hospital mortality was similar between the two groups (FS: n = 9, 1.8%; MIS: n = 5, 1%, Log-rank test: p = 0.904). At univariate analysis, no risk factors were associated with the incidence of RRT.
Conclusions: Our findings suggest that MIS have similar incidence of RRT and comparable mortality to FS. In a matched cohort, no significant risk factors were identified for RRT.
A155 CABG in two adult dextrocardia patients: single surgeon experience from leeds
Kalyana Javangula, Roshni Manoj, Rudolfo Paniagua
Leeds general Infirmary, Leeds, United Kingdom
Correspondence: Roshni Manoj
Journal of Cardiothoracic Surgery 2024, 19(2):A155
Dextrocardia présents unique challenge for cardiac surgeons due to mirror image anatomy. These patients need complete preoperative evaluation including imaging to assess the anatomical features which could help in planning the operation.
We present two adult patients with Dextrocardia and Situs inverses totals (one caucasian and one from Middle East) who presented to our centre with coronary artery disease. The standard preoperative evaluation include clinical examination, ECG, CXR, TTE, Coronary angiogram, CT chest and abdomen, MRI if venous drainage patterns demand further evaluation. The key surgical arrangements include Cannulation technique, exposure of surgical targets, choice of conduits and graft configuration and special venous drainage techniques based on venous system anomalies.
Both our patients received 3 grafts each including RIMA and Saphenous vein conduits on standard CPB with central cannulation (aorta and right atrium) technique. These procedures are performed by a single right handed surgeon who positioned himself on the left side of table to perform the operation. RIMA is used as peddled graft to the LAD and saphenous vein used for the CX/OM and RCA/PDA vessels. Both patients made an excellent recovery without any postoperative complications and were discharged home on 5th and 6th postoperative days. Both patients attended follow up clinics were they showed complete recovery from surgery and total relief from angina symptoms.
A156 A small number of JCOGs in a big segmentectomy wheel: how real-life historical practice compares to the JCOG0802/WJOG4607L trial
George Hudson, Igor Saftic, Douglas West, Eveline Internullo, Rakesh Krishnadas, Stylianos Gaitanakis, Periklis Perikleous
Bristol Royal Infirmary, Bristol, United Kingdom
Correspondence: George Hudson
Journal of Cardiothoracic Surgery 2024, 19(2):A156
Objectives: Recent trials have supported the use of segmentectomy in early-stage non-small cell lung cancer (NSCLC). We set to investigate how applicable the JCOG0802/WJOG4607L trial is to real-life experience by comparing current and previous practice.
Methods: A single-centre database was screened for segmentectomies between April 2012 and December 2022. From 255 segmentectomies, 163 were performed for NSCLC and these were retrospectively examined against JCOG’s inclusion/exclusion criteria.
Results: In 2022 we recorded the highest number of NSCLC segmentectomies (n = 43) and highest proportion of ‘complex’ segmentectomies, (n = 20/43,47%) compared to previous years. Across all years, only 20 (12%) patients would have fulfilled JCOG-criteria, the majority falling short due to pre-operative tumour size > 20 mm and/or non-peripheral location, co-morbidities, or resection margins not confirmed intra-operatively.
Segmentectomies not adhering to JCOG-criteria showed no significant difference in pre-operative WHO performance [median = 1 vs 1, p = 0.437], Clavien-Dindo scores [median = 1 vs 0, p = 0.222], length of stay [median = 4 vs 5-days, p = 0.371], or 30-day mortality [median = 1 vs 1 deaths, p = 0.581] compared to JCOG-adherent segmentectomies. Importantly, the non-adherent group had 4 (3%) incomplete (R1) resections and 20 (14%) recurrences, compared to 0 incomplete resections and 1 (5%) recurrence in the adherent group.
Conclusions: Segmentectomies are becoming more common and complex and surgeons should adhere to evidence-based practice. Although our JCOG-group was too small for survival analysis, we identified a higher proportion of incomplete resections and recurrences in historical segmentectomies not adhering to JCOG-criteria; we therefore suggest lobectomies should still be offered for larger tumours and when resection margins cannot be confirmed.

A157 Unveiling the heart of the matter: a comprehensive analysis of off-pump vs. on-pump CABG outcomes in a high-volume center
Marco Gemelli1,2, Ettorino Di Tommaso1, Lauren Dixon1, Roberto Natali1, Anil Sankanahalli Annaiah1, Vito Domenico Bruno1, Raimondo Ascione1
1University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom. 2University of Padova, Padova, Italy
Correspondence: Marco Gemelli
Journal of Cardiothoracic Surgery 2024, 19(2):A157
Objective: Safety and benefit of off pump coronary artery bypass grafting (CABG) remain debated. We compared short-term outcomes and long-term survival of patients undergoing off-pump vs. on-pump CABG in a high-volume center.
Methods: Prospective data were collected for 13,326 consecutive patients undergoing isolated CABG at our institution between January 2001 and December 2021. Long-term survival follow-up was performed, and outcomes were compared between off-pump (OPCABG) and on-pump surgery (OnCABG).
Results: 55% (n = 7324) of the isolated CABG were performed off-pump and there were no significative differences between the groups in terms of baseline characteristics. In terms of post-operative outcomes, OPCABG were less likely to return to theatre due to bleeding (2.1% vs. 2.9, p = 0.004) or have a CVA (0.8% vs. 1.8%, p < 0.001). Furthermore, OnCABG had a significatively longer length of stay (LOS) (8 vs. 9 days, p < 0.001) and a higher risk of in-hospital mortality (1.6% vs. 2.2%, p = 0.01). OnCABG was found to be an independent risk factor for perioperative mortality. The mean follow-up was 9.5 years and survival in OPCABG group was significantly better (73.3% vs. 71.3%, p = 0.02). OnCABG resulted an independent risk factor for increased long-term mortality at the univariate Cox regression, but not at the multivariate. At a subgroup analysis, lower rate of postoperative CVA favor OPCABG in patients > 75 years old and with prior CVA, while a significant advantage in terms of short-term mortality and long-term survival is evident for OPCABG in patients with CKD.
Conclusions: OPCABG is a safe procedure which offer excellent short- and long-term outcomes.

A159 Hybrid strategies employing device closure for ventricular septal defects: a multicentre experience
Ahmed ElSherbini1,2, Yoshi Kagiyama3, Andrew Tometzki1, Gareth Morgan4,5, Demetris Taliotis1,2, Damien Kenny3, Massimo Caputo1,2
1University Hospitals Bristol and Weston, Bristol, United Kingdom. 2University of Bristol, Bristol, United Kingdom. 3Children's Health Ireland (CHI) at Crumlin, Dublin, Ireland. 4Children's Hospital Colorado Anschutz Medical Campus, Aurora, Denver, USA. 5University of Colorado, Denver, USA
Correspondence: Ahmed ElSherbini
Journal of Cardiothoracic Surgery 2024, 19(2):A159
Background: Hybrid techniques employing device closure of ventricular septal defects (VSDs) enable the closure of challenging defects while eliminating the need for either a ventriculotomy or atriotomy and cardiopulmonary bypass.
Methods: A retrospective multicenter study was conducted on VSDs closure attempts using a hybrid approach from January 2005 to September 2023. Data from patient demographics, clinical records, and echocardiography were collected during the intervention, outcomes and follow-up included assessing device placement, residual shunting, complications, tricuspid valve regurgitation, clinical status, and any re-interventions.
Results: Sixty-five patients were included and divided into two groups based on the strategy used:
Group A: forty-five patients underwent hybrid perventricular device closure. The median age was 6.5 months (1 month-6.7 years), and weight was 6.25 kg (2.7–19.5 kg). Forty-four devices (size range: 6-20 mm) were successfully implanted in 41 (91.1%) patients, with three patients receiving two devices each.
Group B: twenty patients who underwent hybrid retrograde device closure via carotid cutdown. The median age was 7 months (3-16 months), and weight was 7.1 kg (4.6–9.5 kg). Seventeen devices (size range: 5-12 mm) were successfully implanted in 16 (80%) patients, with one patient receiving two devices.
Conclusion: Employing hybrid techniques for device closure of VSDs is a safe and effective strategy for patients whose size, cardiac anatomy, or comorbidities make them challenging candidates for either conventional surgical or transcatheter techniques. This approach may reduce the morbidity associated with conventional surgical repair and streamline the patient care pathway. The decision to convert to surgical repair should be made early if suboptimal device placement occurs.
A160 Post pneumonectomy syndrome treated with intrapleural breast implant
Federico Femia, Karen Harrison-Phipps
Guy's and St Thomas NHS Foundation Trust, London, United Kingdom
Correspondence: Federico Femia
Journal of Cardiothoracic Surgery 2024, 19(2):A160
Introduction: Postpneumonectomy syndrome is a rare, potentially lethal complication caused by extreme rotation and shift of the mediastinal organs after a pneumonectomy. Compression of the airway and distortion of major vessels result in dynamic obstruction. Diagnosis is usually based on clinical and radiological findings.
Patient and methods: Here we present a case of a 71-year-old lady who underwent 6 months earlier a left pneumonectomy for lung cancer, on a background of congenital lung hypoplasia. She represented with worsening dyspnea and stridor of new onset lasting one month. A CT scan showed severe mediastinum shift with critical obstruction of the right main bronchus (Fig. 1a) and stretching of the mediastinal vessels (Fig. 1b). She underwent a redo thoracotomy: after circumferential incision of the reflection of the mediastinal pleura, the mediastinal compartment was successfully medialised. To prevent re-shifting, an adjustable breast implant was placed into the pleural space. The final target volume of the implant was defined measuring the residual pleural space with sterile water. To limit the expansion of the implant towards the diaphragm, a tailored sling made from a biologic mesh was positioned at the base of the pleural space.
Results: After progressive inflation of the implant, reimaging on postoperative day 6 showed a successful medialisation of the mediastinum, with improved airway patency (Fig. 1c) and heart de-rotation (Fig. 1d).
Conclusions: Postpneumonectomy syndrome is a rare but life-threatening complication, which requires patient-tailored solutions. The risk might be increased in patients with pre-existing unfavorable conditions like lung hypoplasia.
Patient gave their written, informed consent to publish their information in an open access journal.

A161 Outcomes of early versus delayed repair of post-infarction ventricular septal defect
Vincenzo Caruso1, Rajdeep Bilkhu1, Antonio Bivona2, Paolo Bosco1, Kamran Baig1, Gianluca Lucchese1
1St Thomas' Hospital, London, United Kingdom. 2Basildon Hospital, Basildon, United Kingdom
Correspondence: Vincenzo Caruso
Journal of Cardiothoracic Surgery 2024, 19(2):A161
Objective: Our aim was to assess outcome after VSD repair and its relationship to timing of surgery.
Methods: Data for patients undergoing repair of post-infarction VSD between 2017 and 2020, was retrospectively reviewed. The primary endpoint was in hospital mortality. Secondary endpoints were predictors of mortality. Surgery was defined as emergency or urgent if performed the same day or within 3 days; semi-urgent if performed after 3 days.
Results: Twelve patients underwent surgery for post-infarction VSD. Six patients (50%) were in cardiogenic shock and median EuroSCORE II was 24.2% (12–50%). Intra-aortic balloon pump was used in all patients. Eight (65%) patients had posterior VSD and the remainder anterior. Isolated VSD repair was performed in 4 (33%) with 7 (58%) requiring CABG and 1 (8%) requiring valve surgery. Another patient required VSD repair, CABG and valve surgery. Surgery was performed urgently in 7 (58.3%) patients and semi-urgently in the remaining patients. Overall, in-hospital mortality was 41.7%. Mortality in those undergoing urgent surgery (40%) was lower compared to those undergoing semi-urgent surgery (60%); however, this did not reach statistical significance (p = 0.55). On univariate analysis, EuroSCORE II and concomitant surgery were predictive of mortality (p = 0.018 and p = 0.046, respectively).
Conclusion: We have demonstrated that surgery for post-infarction VSD carries high mortality, however, if promptly performed, survival of 60% can be achieved. Mortality was noted to be higher when surgery is delayed beyond 3 days, although this did not reach statistical significance. Higher EuroSCORE II and concomitant surgery were predictive of mortality in this cohort.
A162 Clinical outcomes in minimally invasive versus open thymectomy in patient with non-thymomatous myasthenia gravis
Federico Femia, Giulia Fabbri, Leanne Ashrafian
Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
Correspondence: Federico Femia
Journal of Cardiothoracic Surgery 2024, 19(2):A162
Introduction: Thymectomy has been a mainstay in the treatment of myasthenia gravis (MG), historically performed through median sternotomy. Minimally invasive approaches for thymectomy have increasingly been used. We conducted a retrospective study on our cohort of patients to assess clinical outcomes in MG patients according to surgical approaches.
Methods: All consecutive patients affected by MG without thymoma and who underwent thymectomy from 2012 to 2021 were recorded. These patients were divided into two groups according to surgical approach: open group and minimally invasive (MI) group. Rating of reduction in number and dosage of medications, downstaging in MGFA class, and number of hospitalizations were compared between the two groups.
Results: A total of 21 consecutive patients were included in the dataset, 17 who had minimally invasive thymectomy and 4 who had open thymectomy. MG downstaging was not significantly different between the two groups (82.4% MI vs 50% open, p = 0.172). Reduction in medication dosage or medication suspension was also not significantly different between MI and open groups (pyridostigmine: 78.6% vs 50%, p 0.26; prednisolone: 66.7% vs 100%, p 0.338). Rate of hospitalizations in MI group was 23.5% before surgery and 5.9% after, whereas for the open group was 25% both before and after surgery.
Conclusions: No differences were recorded in clinical outcomes after thymectomy for MG treatment in our patients comparing minimally invasive and open approach. The minimally invasive group showed good clinical results in MG treatment. Further studies are needed to confirm these results.
A163 An investigation of factors impacting on mortality in patients with extra-cardiac arteriopathy undergoing cardiac surgery
Nada Al Yasen1,2, Eduardo Urgesi2, Wael I Awad2,3
1Queen Mary, Barts and The London School of Medicine and Dentistry, London, United Kingdom. 2Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom. 3William Harvey Research Institute, QMUL, London, United Kingdom
Correspondence: Nada Al Yasen
Journal of Cardiothoracic Surgery 2024, 19(2):A163
Objective: To investigate specific factors impacting on mortality in patients with extra-cardiac arteriopathy (ECA) undergoing cardiac surgery.
Methods: Retrospective analysis of 13,531 consecutive patients who underwent cardiac surgery at our institute between Apr 2015 and Sept 2022. Patients were categorised into two groups: those with (ECA) and those without ECA (N). Groups were compared and multivariate logistic regression analysis adjusting for age, gender, type of operation and operative urgency was conducted to identify specific risk factors predicting mortality.
Results: 756 (5.6%) ECA and 12,775 (94.4%) N patients were studied. ECA vs N patients were older (68 years vs 64.7, p < 0.0001), had greater co-morbidity: LVEF < 50% (37.3% vs 25.4%, p < 0.0001), insulin dependent diabetes (15.2% vs 5.1%, p = 0.036), previous MI (45.1% vs 3888 31.2%, p < 0.0001), previous stroke (18.1% vs 6.2%, p < 0.0001) and severe renal impairment (23.4% vs 10.8%, p < 0.0001). ECA group vs N underwent more emergency operations (9.3% vs 5.1%, p < 0.0001), were more likely to require post-op haemodialysis (10.5% vs 4.8%, p < 0.0001), had higher risk of post-op stroke (3.9% vs 2.3%, p = 0.004) and in-hospital mortality (8.2% vs 3.2%, p < 0.0001); mortality in isolated CABG was (5.1% vs 1.4%, p < 0.0001), isolated valve replacement/repair (7.4% vs 2.9%, p = 0.0533), and CABG + valve replacement/repair (12.9% vs 4.5%, p = 0.001). Table 1 shows Logistic regression analysis for factors significantly impacting on in-hospital mortality in the ECA group.
Conclusions: Patients with ECA have worse outcomes following cardiac surgery. Identifying independent predictors of mortality may guide clinical decision-making in the management of these patients.
A164 Redefining the role of humans in MDTs: AI's emerging potential in clinical decision-making
Mylvaganam Jeyakanthan, Stephen Clark
Freeman Hospital, Newcastle, United Kingdom
Correspondence: Mylvaganam Jeyakanthan
Journal of Cardiothoracic Surgery 2024, 19(2):A164
Introduction: We compared the MDT decision-making abilities of humans and artificial intelligence using ChatGPT in deciding upon investigations and management planning for patients.
Methods: 124 patients were considered by humans in our weekly heart valve MDT. 53% were in house urgent cases and 18% had endocarditis. Patient details were also entered as prompts into ChatGPT to provide suggested patient management plans through artificial intelligence. The extent of consensus between humans and AI was evaluated to determine if humans were now unnecessary.
Results: There was remarkable similarity in decision-making between human surgeons and ChatGPT, with a concordance rate of 73.4%. The Pearson correlation coefficient was 0.74 (p < 0.001, 95% CI: 0.66–0.81) highlighting a strong positive association. However, unlike humans in no cases did AI make a definitive management decision nor give any technical support for operative strategy beyond basic options. AI though did suggest additional tests or investigations that were not considered by the human team in 18% with the potential for AI to enhance plans that human experts might overlook or feel unnecessary.
Conclusions: This underscores the promise of advanced AI models for decision synergy with surgeons. With higher-order models, such as ChatGPT 4.0, even greater accuracy and correlation with human decision-making can be anticipated, while always relying on human expertise for crucial insights into surgical technique. ChatGPT primarily served as an auxiliary tool, using only basic prompts without specific surgical knowledge. We therefore remain safe in our jobs. For now.
A165 Risk of invasive lung cancer in screen-detected and non-screen-detected pure ground glass nodules: a systematic review
Abdullah AlShammari1,2, Akshay Patel3,4, Chiara Proli1,2, Anuj Wali1, Jose Gallesio1, Mark Boyle1, Paulo De Sousa1, Eric Lim1,2
1Department of Thoracic Surgery, Royal Brompton Hospital, London, United Kingdom. 2National Heart and Lung Institute, Imperial College London, London, United Kingdom. 3Department of Thoracic Surgery, University Hospitals Birmingham, Birmingham, United Kingdom. 4Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
Correspondence: Abdullah AlShammari
Journal of Cardiothoracic Surgery 2024, 19(2):A165
Background: The IASLC TNM proposal suggests that pure Ground Glass Nodules (pGGNs) ≤ 30 mm should be classified as cTis or pathological AIS without any invasive malignancy potential. This study seeks to ascertain the true proportion of pGGNs that harbour pathological minimally invasive or invasive adenocarcinoma.
Methods: We analyzed 2633 pGGNs (≤ 30 mm), reported in 25 observational studies identified through a systematic search of electronic databases. The primary outcome was the prevalence rate of invasive malignancy in pGGNs nodules ≤ 30 mm in diameter (pooled random effects model). Meta-regression was performed to determine the impact of baseline risk, size, and country of investigation on overall effect size. The study was registered with PROSPERO (CRD42021286261).
Results: All studies were retrospective in design (n = 25), most of which were conducted in Asia (n = 23). Patient selection was either surgical series (n = 21) or as a result of lung cancer screening (n = 4). The proportion of minimally invasive and invasive cancer ranged from 3 to 76%. We found a pooled prevalence of 45.3% (95% CI 36–54%). Considerable heterogeneity was observed (I2 = 95%, p < 0.01) and meta-regression based on size selection and country of investigation revealed no significant contribution to effect size effect or indeed accounted for any heterogeneity. However patient selection accounted for 16% of the observed heterogeneity (p = 0.008).
Conclusions: pGGNs ≤ 30 mm harbour a high proportion of invasive malignancy in reported studies contrary to the IASLC proposals and opinions from numerous guidelines across the world. Further work is warranted to determine the features of pGGNs that contribute to their invasive potential.
A166 Heart transplantation for mitochondrial cardiomyopathy and associated metabolic syndromes: case series and systematic literature review
Halil Ibrahim Bulut, Andy Morley Smith, Fernando Riesgo Gil, Owais Dar, Graham Lennox, Zych Bartlomeij, Diana Garcia Saez, John Dunning, Espeed Khoshbin
Royal Brompton and Harefield Hospital part of Guys and St Thomas NHS Foundation Trust, London, United Kingdom
Correspondence: Halil Ibrahim Bulut
Journal of Cardiothoracic Surgery 2024, 19(2):A166
Introduction: Mitochondrial diseases, including cardiomyopathies, pose challenges for heart transplantation. This review explores feasibility and ethical considerations. We share experiences with transplantation in maternally inherited diabetes, deafness, and m4300 mutation syndromes, marking the first reported cases for these syndromes.
Methodology: A systematic review of the literature was performed. A Medline search was conducted under the terms “heart”, “Transplantation”, and "mitochondrial diseases”. Out of 186 papers 16 satisfied our criteria for inclusion. The majority were limited to case reports. We reviewed the literature and report our institutional experience with two cases.
Results: Current literature on heart transplantation in mitochondrial diseases consists of only a few of currently identified syndromes. Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes, Kearns–Sayre syndrome, Friedreich's ataxia, and respiratory chain defects are the only reported syndromes who have successfully received heart transplantation. A significant portion of the reports are in the paediatric population. Cardiac transplantation was successfully performed, immunosuppressive medications were tolerated, and cardiac functions remained stable in the short to medium term. However, in our experience systemic metabolic syndromes such as Stroke-Like Episodes should be born in mind and prevented in the perioperative period. Complex bridging to transplantation with mechanical circulatory support is also feasible.
Conclusion: Heart transplantation is a feasible option and when indicated will prevent major adverse cardiac events in patients with mitochondrial disease. Management of metabolic complications is a key to success in these patients. A multi-disciplinary approach with input from specialists in neuromuscular degenerative diseases in our cases was essential.

A167 Cardiac Enhanced Recovery After Surgery (ERAS): an interim report to patients’ perspectives
Evangelos Anastasakis, Krishna Mani, Alexander Smith, Chrysoula Nana, Philemon Gukop, Adnan Charaf, Pouya Youssefi, Justin Nowell, Robin Kanagasabay, Marjan Jahangiri
St George's Hospital, London, United Kingdom
Correspondence: Evangelos Anastasakis
Journal of Cardiothoracic Surgery 2024, 19(2):A167
Objectives: This study aims to (1) evaluate the effectiveness of patient education and prehabilitation, (2) compare expectations for recovery to post-operative experience and 3) compare quality of life pre-operatively and post-operatively, in patients undergoing cardiac surgery with a full enhanced recovery after surgery (ERAS) protocol.
Methods: Single-centre, prospective cohort study of patients undergoing elective or urgent cardiac surgery between November 2022 and October 2023. Participants completed a pre-operative (after consenting to surgery) and post-operative (6 weeks to 6 months) survey. Domains assessed were concerns, education, recovery, quality of life, and satisfaction. The cardiac ERAS protocol was implemented in all phases of care.
Results: 193 patients completed the pre-operative survey. 87 (45%) have completed the early post-operative survey to date. Patients over-estimated the incidence of post-operative mortality (9%), myocardial infarction (12%), stroke (11%), wound infection (14%) and bleeding (12%). Expectations of pain in the first post-operative week, were significantly higher than actual evaluations (7/10 vs 6/10; p < 0.05). The timespan to independence with activities of daily living was under-appreciated: 47% predicted independence at 1 week post-operatively but only 18% reported this. Exercise tolerance improved significantly post-operatively (2 vs 3 flights of stairs before breathlessness; p < 0.05). Complete symptom resolution was achieved in 43% with shortness of breath, 60% with chest pain, 50% with dizziness, 61% with palpitations, 85% with loss of consciousness, 60% with excessive sweating and 60% with leg swelling.
Conclusion: Cardiac surgery has early benefits to quality of life and symptom control. However, patient education needs to be optimised to enhance recovery.
A168 Assessing compliance to the pre-operative Cardiac Enhanced Recovery After Surgery (ERAS) protocol
Evangelos Anastasakis, Krishna Mani, Alexander Smith, Chrysoula Nana, Philemon Gukop, Adnan Charaf, Pouya Youssefi, Justin Nowell, Robin Kanagasabay, Marjan Jahangiri
St George's Hospital, London, United Kingdom
Correspondence: Evangelos Anastasakis
Journal of Cardiothoracic Surgery 2024, 19(2):A168
Objectives: Increased compliance to Enhanced Recovery After Surgery (ERAS) protocols decreases peri-operative complications and length of hospital stay and improves post-operative outcomes. This study aims to assess compliance to the pre-operative cardiac ERAS protocol.
Methods: Retrospective analysis of the pre-operative cardiac ERAS protocol at a single institution, for patients undergoing cardiac surgery. Each recommendation within the protocol was analysed individually with a complete audit cycle (audit July 2023 and re-audit October 2023). Domains assessed in urgent and elective patients, were consumption of clear fluids before general anaesthesia; and oral carbohydrate loading. Domains assessed in elective patients, were measurement of HbA1c; measurement of albumin and correction of nutritional deficiency; smoking and hazardous alcohol consumption; and pre-operative patient education. Compliance was defined as low < 70%; acceptable ≥ 70% or excellent ≥ 80%.
Results: 24 elective and 35 urgent and elective patients were analysed on initial audit. On re-audit 22 elective and 32 urgent and elective patients were analysed. All elective patients were educated at pre-assessment clinic; had their HbA1c and albumin levels measured; and were screened for alcohol and cigarette use. Consumption of clear fluids before general anaesthesia was encouraged up to 2 h pre-operatively in 80% and 88% on audit and re-audit respectively. Oral carbohydrate loading was administered in 71% and 75% on audit and re-audit respectively.
Conclusion: We report excellent compliance to pre-operative cardiac ERAS in 5 domains and acceptable compliance in 1 domain. To ensure standards remain high leading to optimal patient outcomes, continuous re-auditing and staff education are indicated.
A169 Real life experience of neoadjuvant chemotherapy and immunotherapy in non-small cell lung cancer
Fady Bassily, Muhammad Abdulhakeem, Annemarie Brunswicker, Richard Page, Susannah Love, Steven Woolley, Julius Asante-Siaw, Matthew Smith, Michael Shackcloth
Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
Correspondence: Fady Bassily
Journal of Cardiothoracic Surgery 2024, 19(2):A168
Introduction: Checkmate 816 trial showed that patients with resectable NSCLC who were given neoadjuvant nivolumab plus chemotherapy had a significantly longer event-free survival and a higher percentage of patients with a pathological complete response, than chemotherapy alone. The addition of nivolumab to neoadjuvant chemotherapy did not increase the incidence of adverse events or impede the feasibility of surgery. We present our real-life experience of neo-adjuvant chemo-immunotherapy.
Methods: Of the patients who underwent surgery at a single centre between April and September 2023, 47 patients were referred for neoadjuvant therapy. 8 patients did not undergo neoadjuvant treatment (1 EGFR mutation, 2 declined, 5 were deemed not fit).
Results: Median time between surgical clinic and Oncology clinic was 8 days, oncology clinic and start of neoadjuvant treatment 11 days, completion of neoadjuvant treatment and surgery 44 days.
15/20 patients completed neoadjuvant treatment. 3 stopped after one cycle, one after two cycles, one had nivolumab alone for 3rd cycle.
15 patients have undergone surgery (5 awaiting surgery). 13 underwent a VATS lobectomy (1 converted to open middle and lower lobectomy due to lymph node invading pulmonary artery). 2 open operation (1 sleeve).
Histology is available on 15 patients. A complete pathological response was seen in 5/15 patients and Major Pathological response in 2/15 patients. 9 patients were down staged.
Conclusions: Our results suggest that in real-life, similar results can be achieved to the Checkmate 816 study in terms of side-effect to chemoimmunotherapy and complete pathological response. Our VATS resection rate was higher.
A170 Trends and outcomes in mechanical vs bioprosthetic aortic valve replacement: analysis of UK database
Marjan Jahangiri1, Krishna Mani1, Evangelos Anastasakis1, Andrew Embleton-Thirsk2, Rajdeep Bilkhu1, Dehbi Hakim-Moulay3, Vassilios Avlonitis4, Max Baghai5, Karen Booth6
1St Georges NHS Trust, London, United Kingdom. 2University College London, london, United Kingdom. 3University College London, London, United Kingdom. 4Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom. 5Kings College, London, United Kingdom. 6Freeman Hospital, London, United Kingdom
Correspondence: Krishna Mani
Journal of Cardiothoracic Surgery 2024, 19(2):A170
Objective: To date the trend in use of mechanical versus bioprosthetic aortic valves and their outcomes in the era of transcatheter aortic valve replacement (TAVR) in the UK is not reported. We set out to examine trends.
Methods: We analysed consecutive patients who underwent surgical aortic valve replacement (SAVR) ± coronary artery bypass graft (CABG) surgery between 2013 and 2020. This included elective, urgent and emergency operations, operative data, in-hospital mortality and postoperative complications, comparing mechanical with bio-prosthetic valves.
Results: 45,426 patients were identified. 35,874 (79.0%) had bioprosthetic and 7,734 (17.0%) had mechanical valve. The mean age was 71, those receiving a mechanical valve being younger at 57 compared with tissue valve 74. Mortality for the cohort was 2.5% and for the SAVR and SAVR + CABG subgroups was 2.0% and 3.5% respectively. There was a significant increase in use of bioprosthetic valves in patients ≥ 75 years and a decrease in their use in patients ≤ 60 years. Those receiving bioprosthesis were more likely to be urgent (26.4%) than those receiving mechanical valves (18.7%). Despite the patients with bioprosthesis being of higher risk, length of hospital stay was shorter (6.2 vs 8.3 days, p < 0.0001).
Conclusions: We have shown a decrease in use of bioprosthetic valves in patients less than 60, but an increase in their use in patients older than 75 years. SAVR + CABG has low mortality and a low level of complications in the UK in people of all ages.
A171 Permanent pacemaker implantation following conventional aortic root and valve sparing surgery
Krishna Mani1, Evangelos Anastasakis1, Adnan Charaf2, Marjan Jahangiri1
1St Georges NHS Trust, London, United Kingdom. 2St Georges NHS Trust, London, United Kingdom
Correspondence: Krishna Mani
Journal of Cardiothoracic Surgery 2024, 19(2):A171
Objective: Conventional aortic root and valve sparing surgery are the preferred treatment for aortic root pathologies. However, concerns persist regarding the potential need for permanent pacemaker implantation (PPI) post-surgery. We aim to describe the incidence of PPI following aortic root replacement.
Methodology: We conducted a retrospective analysis of 642 consecutive patients who underwent conventional aortic root replacement (ARR) and valve sparing root replacement (VSRR) between 2006 and 2022. The primary endpoint was the incidence of PPI implantation.
Results: Of the 641 patients, 498 (78%) underwent ARR and 143 (22%) underwent VSRR. 18 (2.8%) underwent redo ARR. Median cross-clamp time was 88 (range, 54–208) minutes with cardiopulmonary bypass of 107 (range, 75–296) minutes. 6 (1%) patients required PPI. 4 pacemakers were implanted post first time bioprosthetic ARR, 1 after mechanical ARR and 1 after VSRR. In the bioprosthetic ARR, 3 patients required pacemaker for atrial fibrillation and 1 for complete heart block. 3 of these were implanted before hospital discharge with a median implantation of 6 days post-operatively. One patient had pacemaker three weeks after discharge.
In the mechanical ARR, PPI was performed for complete heart block on day 6 after surgery. In the VSRR patient, pacemaker was implanted for atrial fibrillation at 6 days.
Conclusion: Conventional ARR and AAR carry a low risk of risk of PPI.
A172 Early and long-term outcomes of conventional and valve-sparing aortic root replacement
Krishna Mani, Alexander Smith, Evangelos Anastasakis, Adnan Charaf, Robert Morgan, Mark Edsell, Maria Teresa Tome Esteban, Frank Schroeder, Marjan Jahangiri
St Georges NHS Trust, London, United Kingdom
Correspondence: Krishna Mani
Journal of Cardiothoracic Surgery 2024, 19(2):A172
Objective: We aim to determine the early and long-term outcomes of conventional aortic root (ARR) and valve sparing root replacement (VSRR) using a standard perioperative approach.
Methods: We present prospectively collected data of 641 consecutive patients undergoing elective and urgent aortic root surgery (498 ARR, 143 VSRR) between 2006 and 2022. Patients with aortic diameters of > 4.5 cm were referred for surgery. Primary outcomes were operative mortality and incidence of postoperative complications. Secondary outcomes were long-term survival and requirement for re-intervention. Median follow-up was 7.8 years (range, 0.5–14.5).
Results: 203 (32%) patients had bicuspid aortic valves and 18 (2.8%) underwent redo procedures. Median cross-clamp time was 88 (range 54–208) min with cardiopulmonary bypass of 107 (range, 75–296) min. In-hospital mortality was 11 (1.7%) (ARR [2.0%]; VSRR [0.7%]), with transient ischaemic attacks/strokes occurring in 1.1%. 13 (2.0%) required a re-sternotomy for bleeding and 14 (2%) received haemofiltration. ICU and hospital stays were 1.7 and 7.0 days respectively. During follow-up, redo surgery for native aortic valve replacement was required in 2 (1.4%) of the VSRR group.
Conclusions: ARR and VSRR can be performed with low mortality and morbidity as well as a low rate of re-intervention during long-term follow-up, if performed by an experienced team with a consistent perioperative approach. This series provides contemporary evidence of how to balance the risks of aortic aneurysms and the risk of rupture at diameters of 4.5 cm against the risks and benefits of surgery.
A173 Pulmonary valve replacement amongst congenital cardiac surgeons in the UK & Ireland: current practice & attitudes towards a randomised controlled trial
Chris Bond1, Timothy Jones2, Mark Danton3, Andreas Hoschtitzky4, Nicola Viola5, Nigel Drury2
1Queen Elizabeth Hospital, Birmingham, United Kingdom. 2Birmingham Children's Hospital, Birmingham, United Kingdom. 3Royal Hospital for Children, Glasgow, United Kingdom. 4Royal Brompton Hospital, London, United Kingdom. 5Southampton Children's Hospital, Southampton, United Kingdom
Correspondence: Chris Bond
Journal of Cardiothoracic Surgery 2024, 19(2):A173
Introduction: Data regarding the optimal prosthesis for pulmonary valve replacement in patients with congenital heart disease is sparse. Recent retrospective studies demonstrate higher incidence of structural valve degeneration and reintervention with Edwards Perimount and Resilia valves compared with Medtronic Hancock II. We surveyed adult congenital cardiac surgeons to delineated current practice and willingness to randomise patients between prostheses in a clinical trial.
Methods: An online survey was sent to all Consultant adult congenital cardiac surgeons in UK and Ireland. Information was sought on preferred prosthesis, factors influencing this decision, implantation technique, postoperative anticoagulation, and willingness to randomise adults and adolescents to different prostheses in a clinical trial.
Results: 27 (69%) surgeons responded, representing ≥ two responses from each level 1 ACHD centre. 19 (70%) of surgeons reported their preferred prosthesis was an Edwards bovine pericardial valve, most commonly the Inspiris Resilia (n = 7, 26%). Only 2 (7%) surgeons favoured the Hancock II valve, the remaining 6 (22%) prefer pulmonary homografts. Data regarding long term freedom from reintervention (23, 85%) was the most common factor influencing prosthesis choice. 22 (81%) surgeons across 11 (92%) centres were willing to randomise adult patients to either Perimount Magna-Ease or Hancock II in a clinical trial, dropping to 11 (41%) surgeons for adolescent patients.
Conclusion: Edwards pericardial valves are the most commonly implanted prostheses in the pulmonary position for congenital heart disease. Most surgeons are open to randomising adult patients to different bioprostheses, suggesting a pragmatic, multi-centre, randomised controlled trial comparing outcomes is feasible.
A174 A feasibility study of rehabilitation for cardiac patients aided by an Artificial Intelligence-web based Programme: a randomised controlled trial (RECAP trial)
Pasan Witharana1,2, Lisa Chang1, Rebecca Maier1, Emmanuel Ogundimu3, Christopher Wilkinson1,4, Thanos Athanasiou2, Enoch Akowuah1
1Academic Cardiovascular Unit, South Tees NHS Foundation Trust, Middlesbrough, United Kingdom. 2Imperial College London, London, United Kingdom. 3Durham University, Durham, United Kingdom. 4Hull York Medical School, University of York, York, United Kingdom
Correspondence: Pasan Witharana
Journal of Cardiothoracic Surgery 2024, 19(2):A174
Objectives: RECAP trial assesses the feasibility of a home-based Cardiac Rehabilitation (CR) programme delivered using a mobile app powered by artificial intelligence to prescribe exercise goals.
Methods: The trial is being conducted in two stages: Phase I and Phase II. Phase I was a usability study aimed at assessing the functioning of the technology including the app. Using consecutive sampling, data was collected for 15 patients in Phase I.
Phase II is a prospective feasibility randomised controlled trial, in which 70 patients will be allocated in a 1:1 ratio to a home-based CR programme delivered using a mobile app with accelerometers or standard hospital-based rehabilitation classes.
Results: We have completed Phase I of the study, with 15 patients, aged 49 to 77. Three were female and 12 were male. Two patients were post coronary artery bypass grafting surgery and 13 were post ACS. Six-minute walk test (6MWT) distance data was available for ten patients. The patients improved their mean 6MWT distance from 393.5 m (initial visit) to 550.0 m (final visit). The average System Usability Scale score for the app was 82/100, receiving an overall rating of “Excellent”.
During the qualitative interviews following Phase I, patients stated they felt motivated to do more every day as the accelerometers monitored their daily physical activity levels.
Conclusions: We are currently recruiting to Phase II of the study. This work is novel: we are not aware of any previous studies that have used AI based mobile apps to deliver home-based CR in the NHS.
A175 Cardiothoracic training in the United Kingdom: a comprehensive survey-based analysis
Sunil Bhudia1, Mohamed Elshalkamy1, Ahmed Shazly2, Mohamed Osman1, Mohammad Salmasi1
1Royal Brompton and Harefield Trust, London, United Kingdom. 2Basildon and Thurrock niversity Hospital, London, United Kingdom
Correspondence: Mohamed Elshalkamy
Journal of Cardiothoracic Surgery 2024, 19(2):A175
Objective: The survey targeted both National Trainees and SAS doctors in the field of Cardiothoracic Surgery in UK. The aim of the survey is to evaluate the level of satisfaction of surgeons in training, challenges facing them and gathering suggestions and ideas about improving the training.
Methods: The survey collected data from 65 participants. Questions included level of training, their satisfaction with the training, competencies, research, publications, challenging they are facing and their suggestions to improve the quality of training.
Results: Survey included 51 males and 14 females, categorised as 39 NTNs and 26 SAS. Participants possessed various experience levels, with 41% having > 10 years of experience and 49% holding 4–10 years.
Among SAS, 14% reported unsuccessful applications for NTN, while 16% encountered difficulties in portfolio preparation.
Participants’ satisfaction with both pathways revealed that 23% were dissatisfied, 48% neutral, and 29% satisfied.
Most of participants were competent in chest drain insertion, opening and closing of sternotomy and thoracotomy, and central cannulation. Decent numbers are competent in performing CABG, AVR and lung resections while small percentage are capable to perform redo sternotomy and mitral surgery.
Challenges included lack of mentorship (52.3%), concerns about work-life balance (58%), heavy workloads (44.6%) and limited clinical exposure (43%).
Conclusion: These findings offer valuable insights into the cardiothoracic training in the UK, highlighting challenges, and areas of potential improvement. According to the results, we recommend encouraging the mentorship program by SCTS for SAS and arranging meetings for both NTN and SAS surgeons to follow-up the training.

A176 Virtual reality for enhanced preoperative planning and intracardiac baffle design for double outlet right ventricle
Mehar Bijral1, Endrit Pajaziti2, Mannat Rana3, Claudio Capelli2, Tony-Harshan Linton-Jude3, Martin Kostolny4,2, Georgios Belitsis2
11. University College London Medical School, London, United Kingdom. 2University College London, Research Department of Children's Cardiovascular Disease, London, United Kingdom. 3University College London Medical School, London, United Kingdom. 4Great Ormond Street Hospital, London, United Kingdom
Correspondence: Mehar Bijral
Journal of Cardiothoracic Surgery 2024, 19(2):A176
Objectives: Surgical repair of Double Outlet Right Ventricle (DORV) is a complex procedure involving intricate rerouting of the Left Ventricle (LV) to either the aorta or pulmonary root, depending on the location of the interventricular communication (IVC). The study aims to leverage the power of virtual reality (VR) to enhance preoperative planning for DORV procedures and tailor treatment while minimising documented complications including heart block, residual small right ventricle and intracardiac channel narrowing.
Methods: Utilising an in-house developed VR platform, intracardiac morphology of DORV was reconstructed from computed tomography (CT) images. This enabled us to precisely map the conduction system and identify optimal baffle suture lines. Virtual surgical simulations were conducted; focusing on designing and sizing of intracardiac baffles.
Results: In the immersive VR environment, we successfully engineered two precisely designed baffles for a DORV heart. One baffle facilitated the connection between the LV and the pulmonary root, while the other connected the LV to the aorta. They were optimised in terms of size and surface area, as evidenced by an unobstructed left ventricular outflow tract. Furthermore, we applied 3D printing technology to create physical models of the DORV heart and the customised baffles, which can serve as invaluable templates for fashioning patches.
Conclusions: VR has revolutionised our understanding of intracardiac anatomy, highlighting its critical role as an indispensable clinical tool. It has advanced surgical planning, the design of intracardiac repairs, and the comparative analysis of complex congenital heart disease procedures.

A177 Remote monitoring in a virtual ward safely facilitates conversion of urgent to elective cardiac surgery (the WATCH pathway)
Arun Kirupananthavel, Kerrie Webb, Jason Radley, Gordon Ferguson, Debashish Das, Dan Jones, Martin Yates, Kulvinder Lall, Stephen Edmondson
St Bartholomew's Hospital, London, United Kingdom
Correspondence: Arun Kirupananthavel
Journal of Cardiothoracic Surgery 2024, 19(2):A177
Objectives: Inpatient wait for urgent coronary artery bypass graft surgery (CABG) can be up to 3 weeks. The aim of this project is to assess the feasibility and outcomes of remote monitoring in a virtual ward to facilitate hospital discharge and conversion from inpatient urgent to early elective CABG.
Methods: All patients referred for urgent inpatient CABG were assessed for suitability using a pre-set criteria (Pain free for 48 h, non-critical coronary disease, all investigations completed and accepted and listed for surgery on specific date within 14 days). They were monitored via the Ortus iHealth platform with daily symptomatic questionnaires. Feedback was obtained by a standard questionnaire.
Results: From December 2022 and October 2023, 38 patients were recruited onto the pathway. Mean age was 52 years and 35(92%) were Male. Median time from discharge to surgery was 8 days with 327 symptom questionnaires. Two patients flagged on the system with symptoms, both were admitted and underwent expedited elective surgery. In hospital mortality was 0% and one patient had resternotomy for bleeding.
Patient feedback showed 95% of patients felt safe going home and 89% found the Ortus ihealth application easy to use. 95% of patients rated their overall experience good, very good or excellent.
We saved 380 bed nights and converted all patients from urgent to elective with potential savings of £817 k.
Conclusion: Selected patients requiring urgent CABG can be safely monitored via a virtual ward with high patient satisfaction and significant reduction in hospital stay and costs.
A178 Endoscopic vs open vein harvest: patient satisfaction, learning curve & new devices
Lesley Scott, Lesley Anne Davies
Golden Jubilee University National Hospital, Glasgow, United Kingdom
Correspondence: Lesley Scott
Journal of Cardiothoracic Surgery 2024, 19(2):A178
Objective: Endoscopic vein harvesting (EVH) is rapidly gaining popularity owing to reduced wound complications and increased patient satisfaction. We started doing EVH using a unique combination of devices, CoreVista from CardioPrecision and HemoPro2 from Getinge, and reviewed our results six months after commencing the programme.
Methods: Patients were selected for EVH based upon obesity, vein quality on ultrasound examination and operator availability. CoreVista technology has been developed to bring the monitor screen into the operative field to ensure better operating posture for operators and improve hand–eye coordination for faster learning (CardioPrecision, UK). The Vasoview Hemopro 2 endoscopic vessel harvesting system was used with carbon dioxide insufflation (Getinge, UK). Only thigh veins were harvested initially. Training in use of the devices was provided by Getinge and CardioPrecision.
Length of stay (LOS) and PROMs responses were generated as representative of patient outcomes. Time to independence was recorded as a measure of the learning curve.
Results: We have so far attempted EVH on 74 patients. Average LOS was 7.3 days for EVH and 7.7 days for OVH. Operators were operating independently within 2–3 weeks of commencing training. Patients in the EVH group reported significantly fewer wound-related mobility issues (8.35 vs. 9.71, p = 0.01) and higher satisfaction with the appearance of their scars (9.14 vs. 5.92, p = 0.01).
Conclusion: EVH is effective in improving patient outcomes within six months of commencing a programme. With the latest new devices and training, independence can be achieved within 2–3 weeks.

A179 Post-cardiotomy VA-ECMO: a retrospective cohort study
Daniella Ricchiuti1, Gillian Hardman2, Nicola Rogerson2, Antony H Walker2, David Rose2, Mohamad Nidal Bittar2
1St George's, University of London, London, United Kingdom. 2Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, United Kingdom
Correspondence: Daniella Ricchiuti
Journal of Cardiothoracic Surgery 2024, 19(2):A179
Objectives: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is indicated for patients with post-cardiotomy cardiogenic shock. In our centre, VA-ECMO use is infrequent, therefore we sought to review its use and outcomes in our institution.
Methods: A retrospective cohort study was performed of all patients undergoing cardiac surgery between 1 June 2010 and 31 October 2023. Those supported with post-cardiotomy ECMO were identified, with inpatient survival reviewed, and comparison made between those who died and those who survived. Statistical analysis was performed using SPSS v. 29.0 (IBM Corporation, Armonk, NY, USA) with a p value of < 0.05 set for statistical significance.
Results: A total of 15,524 patients underwent cardiac surgery during the study period with 7 patients supported with VA-ECMO (0.05%). Median (IQR) age was 44 (30.5–64.5) and 71% of patients were male. Median EuroSCORE II (IQR) was 8.01% (4.8–16.4). 57% of patients had coronary artery bypass grafts (CABG), 57% valve surgery, and 57% aortic surgery. 43% were successfully weaned off ECMO and 2/7 patients (29%) survived to hospital discharge (Table 1). There was a significant difference in the incidence of renal dysfunction in those who died (100% versus 0%, p = 0.05).
Conclusion: Survival to discharge in patients supported with post-cardiotomy VA-ECMO in our institution is in line with published series. With small numbers and infrequent use, further analysis is required to understand the indications and to optimise outcomes within our patient population.
A180 Approaches to mobile app-based cardiac rehabilitation: a systematic review
Pasan Witharana1,2, Mohamed Sherif3, Christopher Wilkinson1,4, Thanos Athanasiou2, Enoch Akowuah1
1Academic Cardiovascular Unit, South Tees NHS Foundation Trust, Middlesbrough, United Kingdom. 2Imperial College London, London, United Kingdom. 3Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom. 4Hull York Medical School, University of York, York, United Kingdom
Correspondence: Pasan Witharana
Journal of Cardiothoracic Surgery 2024, 19(2):A180
Objectives: Home-based cardiac rehabilitation programmes may use mobile apps to facilitate their delivery, using various approaches including goal setting. This study aims to review the current literature on the use of mobile apps in cardiac rehabilitation with a particular emphasis on goal setting based on real-time physical activity data.
Methods: We searched the databases Embase, Medline, CINAHL and SportsDiscus. Articles published from the databases’ inception until the 1st of June 2022 were included in this review. Each article was assessed by two independent assessors for eligibility. Data were extracted and the risk of bias was assessed.
Results: Our initial search returned a total of 212 papers. 18 articles were eligible to be included in the review. Five randomised controlled trials, one non-randomised control trial, three observational studies, two qualitative, and seven single-group studies were included in the review, with a total of 1371 participants.
Four out of the five randomised controlled trials (RCT’s) reported an increase in physical activity in the app-based groups. Two of them reported 6-min walk test (6MWT) distance as an outcome measure. One RCT reported the mean 6MWT distance in the app group as 347.26 m and in the control group as 289.69 m, 12 weeks after intervention. Another reported a mean increase of 60 m in the app group compared to 47 m in the standard care group. Ten articles reported the use of physical activity monitoring devices.
Conclusions: Mobile apps can help create personalised cardiac rehabilitation programmes using strategies including physical activity tracking and custom goal setting.
A181 National variation in the utilisation and implementation of high-risk MDTs in thoracic surgery- is there scope for national guidelines?
Charlotte Holmes1, Nicole Asemota2,3, Joshil Lodhia1, Vasileios Kouritas2, Peter Tcherveniakov1
1St James University Hospital, Leeds, United Kingdom. 2Norfolk and Norwich Hospital, Norwich, United Kingdom. 3Royal Papworth Hospital, Cambridge, United Kingdom
Correspondence: Charlotte Holmes
Journal of Cardiothoracic Surgery 2024, 19(2):A181
Objective: Cardiothoracic surgery High risk MDTs (HRMDTs) were recommended after a 2007 UK Healthcare Commission report. The literature suggests that more patients are offered radical resection and have comparable outcomes to low risk patients after implementation of an HRMDT. There are no established guidelines for the formation of a Thoracic surgical HRMDT. Our objective was to survey UK thoracic surgical units to better understand the current national practice.
Methods: An electronic survey was sent to all thoracic surgical units in the UK. Endpoints included the number of units with a HRMDT, specialty representation, frequency, governance, criteria, and case distribution.
Results: 16 of 35 Units are represented. 62% have a HRMDT. Specialties in attendance by percentage of units: 100% surgeons, 80% anaesthetists, 50% radiologists, 20% oncologists, 10% respiratory, 30% specialist nurses and 30% physiotherapists. 40% of units meet fortnightly, 30% weekly, 20% as required and 1 unit twice weekly. 60% of units record the HRMDT in patient records and 40% informally. 40% have a HRMDT criteria; which varied between units. 50% of units distribute high-risk cases evenly, 50% by the consultant referred to. Dual consultant operating for high-risk cases occasionally utilised in 75% of units and not utilised in 25%.
Conclusion: Nationally there is significant variability in adoption, organisation and governance of the HRMDT. Established criteria is used in very few centres; with a variation between units. Further work is planned to establish consensus criteria for high- risk and to establish national guidance for the implementation of the thoracic surgical HRMDT.
Legend is Map of responding units.

I confirm the map is not under copyright and can be published open access CCBY 4.0.
A182 Ultrasound mapping -paramount step prior EVH and ERAH
Jasmina Ttofi, Michael Turton, Jyothi Nair, Iakovos Ttofi, George Krasopoulos
Oxford University Hospitals, Oxford, United Kingdom
Correspondence: Jasmina Ttofi
Journal of Cardiothoracic Surgery 2024, 19(2):A182
Objective: This study sought to assess the accuracy of preoperative conduit mapping using bedside ultrasonography (US) to determine the suitability of conduits for coronary artery bypass grafting (CABG). The primary objective was to reduce conduit harvesting-associated morbidity and improve the quality of conduits, especially in the context of endoscopic vein harvesting (EVH) and endoscopic radial harvesting (ERAH).
Method: Prospectively collected data from patients undergoing EVH and ERAH for CABG were retrospectively analysed. A subgroup of 50 patients participated in preoperative conduit assessments conducted at the bedside or in an aesthetic room, with a focus on evaluating conduit competency post-training for surgical care practitioners.
Results: Out of 3,058 CABG patients, a significant majority (87.7%) opted for EVH and/or ERAH as their conduit harvesting technique of choice. All patients underwent preoperative assessment with ultrasonography (US), consistently yielding high accuracy during incisions. Diameter discrepancies in the greater saphenous vein, ranging from 0.5 to 0.8 mm, assessed in a standing position. This preoperative mapping allowed for precise diagnosis of conduit quality and anatomical abnormalities. 93% of cases successfully made the appropriate right conduit selection, with the remaining 7% determined perioperatively.
Conclusion: Bedside ultrasonographic vein mapping serves as an accurate and non-invasive preoperative assessment method for determining the suitability of the greater saphenous vein as a bypass conduit. It significantly contributes to enhancing the quality of conduits, reducing morbidity associated with conduit harvesting, and optimizing conduit selection in CABG procedures. This approach presents improvement in overall patient care quality and surgical outcomes.
A183 Relationship between treatment strategies and hospital resource utilization in patients undergoing tetralogy of Fallot repair: results from a national dataset
Shubhra Sinha1,2, Dan-Mihai Dorobantu3, Ferran Espuny Pujol4, Qi Huang4, Christina Pagel4, Sonya Crowe4, Katherine Brown1, Trevor Richens5, Rodney Franklin6, Serban Stoica7
1Great Ormond Street Hospital, London, United Kingdom. 2University of Bristol, Bristol, United Kingdom. 3University of Exeter, Exeter, United Kingdom. 4Clinical Operational Research Unit, UCL, London, United Kingdom. 5University Hospitals Southampton, Southampton, United Kingdom. 6Royal Brompton Hospital, London, United Kingdom. 7Bristol Royal Hospital For Children, Bristol, United Kingdom
Correspondence: Shubhra Sinha
Journal of Cardiothoracic Surgery 2024, 19(2):A183
Objectives: To report health resources utilisation (HRU) following primary surgical repair (PrS), surgical (SPS) or transcatheter palliation (RVOTd) in children with tetralogy of Fallot (ToF).
Methods: All ToF patients treated between 2000 and 2016 in England and Wales were linked to national hospital, intensive care and outpatient records using data from the Linking AUdit and National datasets in Congenital HEart Services (LAUNCHES) project. Hospital stay was described in yearly age intervals, and associated risk factors were explored using median regression.
Results: Patients underwent PrR (n = 2,421), SPS (n = 304) or RVOTd (n = 144). Marked variation in proportion of pre-repair palliations per centre (Panel A). The median age was 0.7 years (95% CI 0.5–1.1). The median post-repair length of stay (post-LoS) was 8 days (IQR: 6–12). Pre-repair RVOTd was associated with longer post-LOS (p < = 0.05). During the first 3 years of life, the average cardiac-HRU was 9.3 episodes/year for the whole cohort. Pre-repair palliation resulted in higher average cardiac HRU (11.5 episodes/year) and longer (median) days in hospital during this time (+ 29 days, p < 0.01), with differences between SPS (+ 39 days, p < 0.001) and RVOTd (+ 22 days, p < 0.01). After year 3, HRU decreased to 1 annual out-patient episode (Panel B).
Conclusions: In ToF, HRU is greatest in the first 3 years of life, and beyond that, remains low on average. There was an association between pre-repair palliation and greater episodes/year and days in hospital in the first 3 years of life, compared to primary repair.

A184 Remote monitoring of over 4000 patients awaiting cardiac surgery across London
Cathy Walters1, Martin Yates2, Sunil Bhudia3, Mario Petrou4, Roberto Casula5, Justin Nowell6, Kamran Baig7, Max Baghai8, Debashish Das2, Stephen Edmondson2
1Royal Brompton and Harefield NHS Trust, London, United Kingdom. 2St Bartholomews Hospital, London, United Kingdom. 3Harefield Hospital, London, United Kingdom. 4Royal Brompton Hospital, London, United Kingdom. 5Hammersmith Hospital, London, United Kingdom. 6St Georges Hospital, London, United Kingdom. 7St Thomas Hospital, London, United Kingdom. 8Kings College Hospital, London, United Kingdom
Correspondence: Cathy Walters
Journal of Cardiothoracic Surgery 2024, 19(2):A184
Objectives: The number of patients awaiting cardiac surgery and length of time waited are both increasing. Undetected deterioration can result in unplanned admission, morbidity or mortality. Remote monitoring provides a method of real time prioritisation based on clinical deterioration at home. The aim of this project is to the review the outcomes of regional remote monitoring, 1 year after it was launched.
Methods: All patients waiting for cardiac surgery across London are invited to take part in remote monitoring using the Ortus iHealth platform. Symptom questionnaires were completed every two weeks. Any symptom deterioration is flagged to the responsible consultant. Those with significant symptoms have their treatment expedited.
Results: From September 2022 to September 2023, across seven cardiac surgery centres, 4142 patients were recruited to remote monitoring of whom 3572 (85%) activated their account. A total of 22,086 questionnaires were completed of which 2095 (9.5%) were flagged by the system. Following clinical review 432(12%) patients had their case escalated to the consultant surgeon for expedited surgery.
Conclusion: We have successfully implemented remote monitoring of patients awaiting cardiac surgery across London. Around 12% of patients have their care escalated based on this process maintaining elective activity and potentially preventing unplanned admissions.
A185 Our 12 consecutive years of totally endoscopic conduit harvesting practice
Jasmina Ttofi, Michael Turton, Jyothi Nair, Iakovos Ttofi, George Krasopoulos
Oxford University Hospitals, Oxford, United Kingdom
Correspondence: Jasmina Ttofi
Journal of Cardiothoracic Surgery 2024, 19(2):A185
Objective: This 12-year retrospective study evaluates the effectiveness of endoscopic vein harvesting (EVH) and endoscopic radial harvesting (ERAH) as the primary harvesting techniques in coronary artery bypass grafting (CABG) procedures.
Method: The study involved the retrospective analysis of prospectively collected data. The analysis encompassed a subgroup of 27 patients who completed a postoperative satisfaction questionnaire, as well as 680 patients assessed for surgical site infection (SSI) rates within six weeks following surgery.
Results: Out of 3,058 CABG patients, 87.7% chose EVH and/or ERAH, underscoring their popularity. Only 15.3% underwent open vein harvesting (OVH), with minimal conversions to OVH (0.5%). EVH and ERAH demonstrated short harvesting times (averaging < 15 min per vein) and minimal blood loss. ERAH, while taking slightly longer at 25 min on average, showcased promise with the use of a pneumatic tourniquet. Notably, endoscopic techniques achieved an impressive 0% SSI rate over the last five years, in stark contrast to the 3% SSI rate associated with OVH. The study emphasized that ongoing training for surgical care practitioners had no detrimental effect on overall performance or SSI rates.
Conclusion: Endoscopic conduit harvesting, especially EVH and ERAH, stands as a safe and efficient method for CABG procedures. Patients undergoing these techniques experienced rapid postoperative recovery, minimal complications, and heightened satisfaction. Furthermore, these approaches decreased postoperative pain and reduced the need for wound-management resources. The study underscores the importance of standardized training for surgical care practitioners to maintain these positive outcomes and sustain consistently low SSI rates.
A186 Introduction of endoscopic saphenous vein harvesting service for coronary artery bypass grafting. A single unit experience
Shincy Joseph, Anil Sankanahalli Annaiah, Chandrashekar Chowdappa, Rony Alan, Jeremy Chan, Luke Rogers, Cha Rajakaruna
Bristol Heart Institute, Bristol, United Kingdom
Correspondence: Shincy Joseph
Journal of Cardiothoracic Surgery 2024, 19(2):A186
Introduction: Endoscopic saphenous vein harvesting (EVH) provides an alternative harvesting technique in addition to the traditional open technique for coronary artery bypass grafting (CABG). The EVH technique is particularly beneficial in patients with a high risk of donor site infection, such as patients with diabetes, poor LV, and emergency surgery. We aim to share our experience and learning curve in introducing the EVH service.
Method: Since 2015, all surgical care practitioners (n = 4) in our units have started the EVH training. Two (50%) have completed the training and perform EVH regularly, while the others remain in training. The learning curve was evaluated including the procedure time, drain insertion, and post-operative wound infection.
Results: A total of 564 patients underwent EVH for CABG between 2015 and 2023, with 531 (94.15%) performed by the two trained operators. Overall, the mean operative time for operators 1 and 2 were 56 (SD: 15.85) and 55.57 (SD18.10) minutes, respectively. The mean harvesting time per length for operators 1 and 2 were 31.30 (SD:14.34) and 37.12 (SD 15.19) minutes, respectively. The learning curve showed approximately 50–100 cases are required to reach to average of 30 min per length.
The incidence of drain insertion rate, conversion to open rate, and wound infection was 9.75%, 0.53%, and 0.35%, respectively.
Conclusion: EVH can be introduced with a reasonable learning curve and satisfactory short-term clinical outcomes.

A187 Multidisciplinary perioperative management of patients undergoing septal myectomy: outcomes of a high volume team in the United Kingdom
Martin Yates, Lauren Tully, Stephanie Hampson, Evgeny Raevsky, Andre Navarro, Angela Gallagher, Kostas Savvatis, Perry Elliot, Claire Rathwell, Alex Shipolini
St Bartholomews Hospital, London, United Kingdom
Correspondence: Martin Yates
Journal of Cardiothoracic Surgery 2024, 19(2):A187
Objectives: Septal Myectomy is the gold standard treatment for patients with severe symptomatic left ventricular outflow obstruction, secondary to hypertrophic cardiomyopathy, despite optimal medical therapy. Patient selection and operative decision making is complex and we believe best carried out by a specialist multidisciplinary team. We aim to update the surgical experience of a septal myectomy program in the United Kingdom.
Methods: Single centre experience of septal myectomy as part of a specialist hypertrophic cardiomyopathy team. All patients are discussed in MDT pre-operatively and managed in theatre by a specialist team of two surgeons, anaesthetists and cardiologists. Data from a prospective database was reviewed retrospectively for physiological and clinical outcomes.
Results: From September 2016 to October 2023, 219 patients underwent septal myectomy. Mean age was 52 years and 151 (69%) were male. All patients underwent Septal Myectomy with additional Mitral Valve Repair (167: 76%), 145 Left atrial appendage occlusion (145:66%), CABG (18:8%), planned AVR (25:11%). Mean bypass and cross clamp times were 138 and 105 min respectively. Mean weight of muscle resection was 6.5 g (1.5–15). Forty nine (22%) patients had a second bypass run for further muscle resection (39:18%) or MV intervention (8:3.6%). Complications were VSD (1:0.45%), resternotomy (3:1.4%), Mortality (1:0.45%). 217 (99%) patients had a resting gradient less than 15 mmHg and 210 (96%) had a provoked gradient < 15 mmHg. Symptomatic improvement was seen in more than 90% of patients.
Conclusion: Surgical management of hypertrophic cardiomyopathy can be performed safely with good outcomes as part of a high volume specialist multidisciplinary team.
A188 Audit on chest drain clinic: are we utilising the service?
Nur Binti Yusri
City Hospital, Nottingham, United Kingdom
Correspondence: Nur Binti Yusri
Journal of Cardiothoracic Surgery 2024, 19(2):A188
The chest drain clinic service under the department of Cardiothoracic Surgery designed to provide post-discharge follow-up for patients with chest drains, has proven to be an efficient and cost-effective resource. This study assessed the clinic's effectiveness in ensuring safety, regular reviews, and its impact on costs and bed utilization.
A retrospective analysis of a one-year period identified 97 patients discharged home with chest drains. The study found that 64% of these patients required only one clinic visit before chest drain removal. This approach led to a 60% reduction in inpatient stays, resulting in a remarkable total of 1,038 saved bed days and making space for additional admissions and care.
The study also highlighted the cost savings from inpatient beds minus clinic visits, totalling approximately £361,200 over the study period. These savings allowed the service to care for an additional 173 patients, generating potential income of £1,038,000 for the trust from further admissions and operations.
Furthermore, the audit revealed that only 7.2% of patients required re-admission due to complications such as pain, infection, or worsening surgical emphysema. Importantly, these patients could re-enter care directly from the chest drain clinic, bypassing the emergency department, thereby saving time and resources.
In summary, the chest drain follow-up clinic has demonstrated its effectiveness not only in patient safety and regular reviews but also in substantial cost savings, increased bed availability, and efficient re-admission procedures. This study highlights the significance of expanding and optimizing such services within healthcare institutions, ultimately benefiting both patients and healthcare providers.
A189 Surgical site infection after endoscopic and open saphenous vein harvesting for coronary artery bypass grafting
Anil Sankanahalli Annaiah, Shincy Joseph, Chandrashekar Chowdappa, Rony Alan, Jeremy Chan, Luke Rogers, Cha Rajakaruna
Bristol Heart Institute, Bristol, United Kingdom
Correspondence: Anil Sankanahalli Annaiah
Journal of Cardiothoracic Surgery 2024, 19(2):A189
Introduction: The benefit of endoscopic vein harvesting (EVH) is to limit the incision length with an aim to reduce the incidence of surgical site infection. We aim to compare the incidence of surgical site infection (SSI) after EVH and open saphenous vein harvesting (OVH).
Method: All patients who underwent coronary artery bypass grafting requiring a venous conduit from 2021 in our centre are included in this study. EVH is performed by 4 trained SCPs while OVH is performed by SCPs as well as the surgical team, in particular out-of-hour cases.
Incidences of in-hospital SSI in patients undergoing EVH were audited by the SCP team while OVH was reviewed by the wound care specialist team.
Results: A total of 1042 patients were included, of which 342 (32.8%) of patients underwent EVH. Ten patients (2.92%) had post-operative haematoma and no patients had confirmed surgical site infection after EVH. Sixteen patients (2.29%) were diagnosed with surgical site infection by the wound care specialist after open vein harvesting. In addition, 20 patients (2.86%) had haematoma after OVH that was managed conservatively.
Conclusion: Endoscopic vein harvesting is associated with a low incidence of postoperative haematoma and surgical site infection. EVH could be considered in patients with a high risk of surgical site infection.
A190 Successful application of endoscopic conduit harvesting to neurovascular surgical procedures: SCPs embarking on new frontiers
Jasmina Ttofi, Michael Turton, Jyothi Nair, Iakovos Ttofi, Jash Patel, Rana Sayeed
Oxford University Hospitals, Oxford, United Kingdom
Correspondence: Jasmina Ttofi
Journal of Cardiothoracic Surgery 2024, 19(2):A190
Objectives: This study aims to review the initial experience and evaluate the efficacy of endoscopically harvested radial arteries (ERAH) in neurovascular cerebral high and low flow bypass surgery. It promotes minimally invasive surgery and expands the role of surgical care practitioners (SCPs) across surgical specialties.
Methods: Prospective data collection for all patients in the ERAH-cerebral bypass programme that started in 2019. Experienced Cardiothoracic SCPs harvested the radial artery using a standardised technique including pre-operative ultrasonography and an intra-operative endoscopic approach with a pneumatic tourniquet and 2,500 iU systemic heparin administration. Post-operative cerebral angiography was used to assess ERAH graft patency.
Results: Ten patients had a radial artery as their chosen conduit harvested by a standardised technique with ultrasonography and an endoscopic approach; heparin was used in eight patients. All ERAH grafts were of suitable length without signs of spasm. All grafts were patent on post-operative cerebral angiography.
Conclusion: The study demonstrates that high-flow cerebral bypass with an ERAH interposition graft followed by cervical internal carotid artery ligation is an effective surgical procedure and is facilitated by collaboration with experienced Cardiothoracic SCPs. The study highlights the potential for expanding the role of SCPs across different surgical specialties to enhance patient outcomes.
A191 Early results from an emphysema MDT without local access to treatments
Mohammad Diab1, James Ackah1, Phil Hughes2, Thomas Nicholson2,1, David Waller3, Timothy Batchelor3, Adrian Marchbank1
1Derriford, Plymouth, United Kingdom. 2Derriford, Hospital, United Kingdom. 3BARTS HEALTH NHS TRUST, London, United Kingdom
Correspondence: Mohammad Diab
Journal of Cardiothoracic Surgery 2024, 19(2):A191
Introduction: Lung volume reduction surgery (LVRS) and endobronchial valves (EBVs) improve lung function, exercise capacity and quality of life in appropriately selected patients with severe emphysema. In 2020/21 NHS Digital estimated 1.17 million people in England were diagnosed with COPD, 1.9% of the population, yet < 400 procedures were performed in 2022.
Aim: To compare the local patient cohort referred to external sites for treatment with a national cohort.
Methods:
-
Data extraction from the local MDT data collection tool (Nov 19-June 2023)
-
Aggregated data from a national cohort (LV Register)
-
Retrospective analysis of age, gender, FEV1, DLco, RV, TLC, BMI, Glenfield score, intervention and complications
Results:
-
114 patients discussed at MDT
-
13 patients underwent LVR remotely (7EBV:6 LVRS)
-
14 patients died on waiting list.
-
2 declined to travel
-
12 awaiting further work-up.
-
73 unsuitable.
Table 1: (a) local cohort vs (b) UK LVR register characteristics (c) outcomes and complications.
Conclusions:
-
Remote LVR service has provided excellent QOL for the small cohort referred with no 90-day mortality.
-
There was no statistical difference between the local cohort with respect to BMI, RV, compared to the national cohort
-
FEV1% in the local cohort was significantly better than the national cohort (p < 0.03)
-
Local MDT with remote attendance from a distant LVRS provider allows an appropriate cohort of patients to be referred for treatment, but there may be some selection bias.
-
Local provision of LVRS should be considered, as there is a group of patients who decline to travel for treatment.

A192 Demographic factors affecting utilisation of remote monitoring in patients waiting elective cardiac surgery
Matyl Kassouf1, Arun Kirunpananthavel1, Damian Balmforth2, Lianne Bello1, Debashish Das1, Martin Yates1, Stephen Edmondson1
1St Bartholomews Hospital, London, United Kingdom. 2Royal Sussex County Hospital, Brighton, United Kingdom
Correspondence: Matyl Kassouf
Journal of Cardiothoracic Surgery 2024, 19(2):A192
Objectives: Remote patient monitoring can detect deterioration in patients awaiting cardiac surgery. However, some studies suggest certain patient populations are less able to use such technology. The aim of this project is to determine demographic factors affecting utilisation of remote monitoring.
Methods: All patients at a single centre are offered remote monitoring using the Ortus iHealth platform. We compare two groups of patients; ‘inactive’ who did not interact with the application, and those whose operations had been ‘expedited’ as a result of monitoring. We used univariate compare demographic factors including age, sex, ethnicity, primary language and indices of socioeconomic deprivation. Significant factors on univariate analysis were entered into multivariate analysis using binary logistic regression.
Results: From September2022 to June2023, n = 76 patients were inactive whilst n = 122 had expedited surgery. No significant difference between the expedited and inactive populations were seen for mean age (63.9 years vs 64.5 years (p 0.74)), Female gender (67% vs 75% (p 0.22)), English as Primary Language (74% vs 80%(p 0.29)), or Ethnicity (p = 0.095). On univariate analysis, significantly lower Index of Multiple Deprivation (p = 0.039), Living Environment Rank (p = 0.006), Barriers to Housing Rank and Income Deprivation Affecting Older People Index (p = 0.018) were seen inthe inactive population. On multivariate analysis Barriers to Housing Rank remained as an independent predictor of being an inactive user.
Conclusions: Major demographics including age and language do not influence the utilisation of remote monitoring, however there is a suggestion of reduced use in patients from areas of social deprivation.
A193 Early and mid term outcomes of endoscopic mitral repair using ChordX™ premeasured chordal loop suture system
Mukesh Karuppannan, Rashmi Tamang, Jakia Sultana, Khalid Ajbna, Ibrahim Alawady, Grzegorz Laskawski, Joseph Zacharias
Blackpool Victoria Hospital, Blackpool, United Kingdom
Correspondence: Mukesh Karuppannan
Journal of Cardiothoracic Surgery 2024, 19(2):A193.
Objective: Chordal replacement has become a well established technique of mitral repair. Premeasured chordal loop system has simplified mitral repairs by the minimally invasive endoscopic approach. This study sought to evaluate our experience with Endoscopic mitral repair using the ChordX ™ premeasured chordal loop system.
Methods: Hospital data from all patients who underwent endoscopic mitral repair using the ChordX ™ premeasured chordal loop system between January 2015 and August 2023 were analysed.Primary outcomes were 30-day mortality and morbidity and secondary outcome was one & 8-year survival.
Results: Out of the 302 patients who underwent mitral repair by endoscopic approach, ChordX™system was used in 134 (44.3%) patients (mean age 64.8 ± 12.3 years, Males-73.9%).The mean logistic EuroSCORE was 4.9 ± 4.1.Concomitant atrial fibrillation ablation was performed in 24.6%.The mean aortic occlusion time was 105.6 ± 32.7 min.The median length of ICU stay was 1 day (IQR-0) and median post operative hospital stay was 6 days (IQR-3.5). There was no in- hospital deaths. Post operative morbidity included new onset atrial fibrillation (12.6%), reopening for bleeding/tamponade (2.9%),stroke (2.2%), pneumonia(1.4%),complete heart block requiring permanent pacemaker (0.7%).There were no instances of reoperation for repair failure.The 1 year,5 year and 8 year survival was 99.1%,92.5% and 85.7% respectively.
Conclusions: This study confirms the favourable early and mid term outcomes of endoscopic mitral repair using the ChordX™pre measured chordal loop suture system.Echocardiographic analysis of the integrity of the repair in this patient group will be evaluated to add onto the promising outcomes.
Outcomes of Endoscopic mitral repair using Chord X™ premeasured chordal loop suture system
Characteristic | Outcome |
---|---|
Age (mean) | 64.8 ± 12.3 |
Preop NYHA Class I | 15.6% |
Class II | 39.5% |
Class III | 40.2% |
Class IV | 4.4% |
Logistic EUROSCORE | 4.9 ± 4.1 |
Mean Aortic occlusion time(mins) | 105.6 ± 32.7 |
Median post op hospital stay (days) | 6 (IQR 3.5) |
Morbidity | |
New onset atrial fibrillation | 12.6% |
Reopening for bleeding/tamponade | 2.9% |
Stroke | 2.2% |
Pneumonia | 1.4% |
PPM implantation | 0.7% |
Survival | |
30 day | 100% |
1 year | 99.1% |
5 year | 92.5% |
8 year | 85.7% |
A194 Early outcomes of using the CMR versius surgical robot in thoracic surgery for oncological resections
Ahmed Osman1, Patrick Hurley2, Giuseppe Aresu2, Aman Coonar2, Adam Peryt2
1Nottingham University Hospital, Nottingham, United Kingdom. 2Royal Papworth Hospital, Cambridge, United Kingdom
Correspondence: Ahmed Osman
Journal of Cardiothoracic Surgery 2024, 19(2):A194
Objectives: Minimally Invasive Thoracic Surgery (MITS) is a widely used approach in thoracic surgery. Here, we present our early outcomes of the CMR Versius Surgical Robot in Thoracic surgery.
Methodology: Retrospective-prospective data collection from the institute’s database. Patients undergoing MITS using the CMR Versius-Surgical-Robot for known or suspected oncological disease, between April 2023 and October 2023, were included. Primary outcomes evaluated were post-operative Length of Stay (LOS), and 30-day mortality. Multiple secondary outcomes were evaluated.
Results: Forty-seven patients included in this study (28-females;19-males). Thirty-day mortality is 0%. Median post operative length-of-stay was 3 days (range 1–40, mean 5.3 days).
Age ranged between 21 and 84 (mean 67.4). Performance status 0 (n = 23), PS 1 (n = 17), PS 2 (n = 8).
Preoperative diagnoses were anterior mediastinal mass (n = 10), posterior mediastinal nodule (n = 1), LLL adenocarcinoma (n = 4), LLL nodule (n = 3), LUL adenocarcinoma (n = 2), LUL metastasis (n = 1), LUL nodule (n = 2), RLL adenocarcinoma (n = 7), RLL nodule (n = 2), RML nodule (n = 2), RUL adenocarcinoma (n = 5), RUL nodule (n = 7), RUL squamous cell carcinoma (n = 1).
Two approaches were utilised: Subxiphoid (n = 10), standard lateral (n = 37). Conversion rate was low (4%, 2 patients) as well as the return to theatre during the same admission (4%). The mean procedure time from “skin-to-skin” was 04 h 00 min (median 03 h 47 min).
Immediate post-operative air-leak measurements: 0 ml (n = 33); > 10 ml but < 250 ml (n = 11); > 250 ml (n = 3). Histological Resection margin status post op: R0 (n = 44); uncertain (n = 2); pending (n = 1).
Conclusion: Utilising the CMR Versius Surgical Robot for oncological resections in thoracic surgery is safe and effective, with a low complication rate.

A195 Efficiency dissected: a biennial analysis of cardiac surgery theatre operations at a singular tertiary care centre
Gabriel Hunduma, Suvitesh Luthra, Davorin Sef, Theodore Velissaris, Scabolcz Miskolckzi
University Hospital Southampton NNS Foundation Trust, Southampton, United Kingdom
Correspondence: Gabriel Hunduma
Journal of Cardiothoracic Surgery 2024, 19(2):A195
Objectives: The current bed pressures have escalated to new heights in this post-pandemic era. This demands further stringent measures for optimising surgical operational efficiency. Variables including transfer times involved in the cardiac surgery pathway leading up towards knife to skin time, significantly impacts the overall surgical efficiency and theatre utilisation. To date, no published analysis exists of cardiac theatre operational performance in the United Kingdom. The aim of our study was to perform a comprehensive analysis of the department’s operational efficiencies throughout the cardiac surgery pathway.
Methods: A retrospective analysis of 1979 procedures were conducted between December 2019 and March 2022. We collected transfer time, surgeon idling time, knife to skin time, ‘procedure time’, and total operation time. These variables were correlated with predefined indices of operational efficiency (Surgical Index of operational Efficiency–sInOE, and Index of Operational Efficiency–InOE). Goodness of fit regression curves were performed for InOE comparative to times on the Operational Pathway.
Results: The mean ‘procedure time’ was 246 ± 73 min (78% of total OR time). Utilisation efficiencies were highest for AVR (71.8%) and CABG (73.1%) and least for complex aortic procedures (60.8%). No significant differences were found for procedure specific or team specific differences for standard procedures. Procedure times correlated the strongest with InOE (r = − 0.96, p < 0.01) indicating stronger signs of efficiency. A statistically significant linear dependence on InOE was observed with Procedure times only.
Conclusion: Approaches towards providing excellent theatre utilisation and efficiencies could be achieved by directing attention to pre-operative variables.
Procedure specific mean times | ||||||
---|---|---|---|---|---|---|
Procedure | N | Transfer times (mins) | Preparation time (mins) | Knife to skin time (mins) | Procedure times (mins) | Total OR times (mins) |
CABG | 622 | 55.2 ± 22.1 | 55.4 ± 21.9 | 67.6 ± 22.6 | 236.9 ± 65.9 | 304.5 ± 72.8 |
AVR | 588 | 55.7 ± 21.5 | 56.2 ± 21.2 | 67.7 ± 20.9 | 236.8 ± 69.8 | 304.5 ± 74.2 |
MVR | 190 | 57.1 ± 18.9 | 57.2 ± 18.8 | 69.6 ± 18.4 | 243.3 ± 67.9 | 312.9 ± 70.0 |
AORTIC | 189 | 54.8 ± 25.8 | 55.2 ± 25.6 | 68 ± 27.3 | 265.9 ± 85.7 | 333.9 ± 96.3 |
Other cardiac | 398 | 56.2 ± 22.7 | 56.4 ± 22.7 | 69.1 ± 23.8 | 251 ± 76.3 | 320.5 ± 82 |
Table: Isolated procedure specific mean times across the cardiac surgery pathway.
A196 Factors affecting structural valve deterioration in tissue aortic valve replacement: a systematic review
Asveny Ranjananthanan1, Sahil Kakar2, Abeeraam Ranjananthanan3, Meera Shankar1, Sundas Butt4, Amer Harky5, Mohamed Zeinah6
1School of Medicine, University of Liverpool, Liverpool, United Kingdom. 2Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom. 3Faculty of Medicine, Queens Medical Center, Nottingham, United Kingdom. 4Department of Plastic Surgery, City Hospital, Nottingham, United Kingdom. 5Department of Cardiothoracic Surgery, Liverpool, Liverpool, United Kingdom. 6Faculty of Medicine, Ain Shams University, Cairo, Egypt
Correspondence: Sahil Kakar
Journal of Cardiothoracic Surgery 2024, 19(2):A196
Objectives: Tissue aortic valve replacement is preferred in selected patient cohorts as it does not require lifelong anticoagulation, unlike mechanical valve replacement. However, structural valve deterioration (SVD) is a complication that should be considered. Multiple factors can determine the incidence of SVD—which we aimed to investigate.
Methods: A literature search was conducted on PubMed, Scopus, EMBASE and Google Scholar, April 2023. The primary outcome was to identify factors that contribute towards SVD in tissue AVR. Articles were included if they discussed factors affecting SVD in tissue AVR. Expert opinions, editorials and reviews were excluded.
Results: A literature search yielded 22 studies and 28,079 patients, with a mean age of 55.9–83.6 years included in the analysis. Of these, 11 factors were identified to be influencing SVD of tissue AVR. Factors identified were age, sex, COPD, haemodialysis, hypercholesterolemia, Previous history of coronary artery bypass graft or percutaneous coronary intervention, raised post-procedural mean pressure gradient (MPG), prosthetic size, type of valve, surgical approach and length of hospital stay.
Age, a well-known factor where in a younger population SVD was more likely. It was also found that those with a MPG < 10 mmHg did not develop SVD. 18% of patients who are on haemodialysis were found to develop SVD, whereas those without had a 5% incidence. Stentless valves were free from SVD, however small valve sizes were prone to SVD.
Conclusion: Due to the varying definitions of SVD used, it was difficult to isolate factors. Ideally, a standardised definition for SVD should be used.
A197 Does predetermined MV replacement afford risk mitigation in high-risk patients with complex degenerative MV disease?
Rashad Abdelrahman, Giulia Apicella, Jacob Chacko, Adam Szafranek, Niki Nicou, Anas Boulemden, Umar Hamid, Saqib Qureshi
Nottingham City Hospital, Nottingham, United Kingdom
Correspondence: Rashad Abdelrahman
Journal of Cardiothoracic Surgery 2024, 19(2):A197
Objectives: We sought to explore factors that dictated ultimate implantation of MV prosthesis in degenerative pathology with or without an initial adoption of repair strategy.
Methods: This was an observation exploratory analysis of surgical database, perioperative echo assessments and operative records.
Results: Between September 1995 and August 2021, we identified N = 71 patients that underwent MV replacement for degenerate pathology. The replacement group was divided into Group 1 (n = 24) where an initial repair was attempted but subsequently failed and Group 2 (n = 47), where attempt was not considered, and replacement was carried out from outset. There were no significant differences in the spectrum and character of MV pathology between two groups. Myxomatous degeneration, Chordal elongation, Chordal rupture predominantly associated with Barlow’s type, bileaflet prolapse with significant tissue fragility. However, Group 2 patients were older, had more concomitant procedures, had a higher operative risk (Table). Management of surgical risk by adopting replacement from outset strategy resulted in controlled CPB and cross clamp times which translated into similar length of stays between the two groups (table).
Conclusions: Given the complexities of current surgical practice, a judicious pre-determined MVR is a safer method of managing surgical risk compared to undertaking an initial failed attempted MV repair and then subsequent replacement.
Table:
Variable | Group1 (n = 24) | Group 2 (n = 47) | P value |
---|---|---|---|
Age (mean ± SD) | 67 ± 17 | 75 ± 9.5 | 0.024 |
CPB time (min) | 156 ± 57 | 133 ± 51 | 0.078 |
Cross Clamp time (min) | 118 ± 39 | 99 ± 41 | 0.05 |
Concomitant procedures | N = 3 (Tricuspid repair) (12%) | N = 24 (CABG, AVR, TVR, Pericardectomy) (51%) | 0.002 |
EuroSCORE (mean ± SD) | 1.8 ± 1.5 | 5.3 ± 5.4 | 0.003 |
Length of stay (days) mean ± SD | 16.7 ± 9.5 | 17.4 ± 13.5 | 0.80 |
A198 Anticoagulation following mitral valve repair: a snapshot survey of UK practice
Jason Trevis1, Rebecca Maier1, Luke Rogers2, Enoch Akowuah1, Cardiothoracic Interdisciplinary Research Network (CIRN)3
1James Cook University Hospital Academic Cardiovascular Unit, Middlesbrough, United Kingdom. 2Bristol Royal Infirmary, Bristol, United Kingdom. 3CIRN, London, United Kingdom
Correspondence: Jason Trevis
Journal of Cardiothoracic Surgery 2024, 19(2):A198
Current national and international guidelines for anticoagulation after mitral valve repair (MVr) are based on retrospective data or expert opinion alone and cite varying recommendations. This survey aimed to assess feasibility of the delivery of a randomised controlled trial to determine optimal management to prevent thromboembolic complications after MVr.
Lead MVr surgeons in cardiothoracic centres in the UK were contacted along with a member of the CIRN. Data was collected prospectively on consecutive MVr’s over two four-week periods (November 2022(P1) and February 2023(P2)). Data included pre- and post-operative rhythm, trial eligibility, willingness of patient and surgeon to randomise to the trial, post-operative oral anticoagulant (OAC)/antiplatelet.
18 separate sites provided data (n = 17 in P1, n = 13 in P2). 151 eligible patients were identified (median per site n = 4(± 3)). Data regarding cardiac rhythm and willingness to randomise is presented in Table 1. Patients in AF were put on warfarin (20%) or novel/direct oral anticoagulant (DOAC) (58%) alone or in combination with an antiplatelet (12%). Those in SR were typically placed on a single agent (antiplatelet (49%), warfarin (22%) or DOAC (19%)).
This UK survey highlights the variation in practice regarding anticoagulation following MVr. The majority of patients and surgeons were willing to randomise to a proposed trial controlling for post-operative cardiac rhythm within this area. An NIHR application is planned.
A199 The impact of NSAID use on pleurodesis following thoracic surgery
Akolade Habib, Kudzayi Kutywayo, Edward Caruana
Glenfield Hospital, Leicester, United Kingdom
Correspondence: Akolade Habib
Journal of Cardiothoracic Surgery 2024, 19(2):A199
Objectives: Achieving pleural symphysis following thoracic surgical procedures is an essential part of the postoperative period. A post-operative pain-free period is also crucial to reducing post-op. complications. We wrote a best-evidence topic on the effect of NSAIDs on pleurodesis.
Methods: We performed a comprehensive literature search across Pubmed and Cochrane libraries for articles between 1983 and 2022 using the MeSH terms and keywords, NSAIDs, pleurodesis, and other related synonyms.
Results: None of the studies reviewed showed an increased failure rate of pleurodesis following NSAID administration.
Conclusions: There is a need for a more robust study into the subject matter, however, preliminary results suggest that NSAID administration does not reduce the efficacy of pleurodesis. Pain management and pleural symphysis are two important aspects of the post-operative management of thoracic surgical patients.
A200 A review of 64 cases of diaphragmatic hernia repair in a single institution
Jamal Khan, Ralitsa Baranowski, Niall McGonigle, Harry Parissis
Royal Victoria Hospital, Belfast, United Kingdom
Correspondence: Jamal Khan
Journal of Cardiothoracic Surgery 2024, 19(2):A200
Objectives: Association of surgical method with pain management and length of stay.
Methods: Retrospective review of 64 cases. Patients with a diaphragmatic hernia; congenital and traumatic. Hiatus hernia repair was excluded. Data reviewed for demographic information, type of surgery, post-operative pain management, surgery outcomes, hospital stay and recurrence of hernia.
Results: The mean age was 45.2 years.
49 were traumatic and 15 congenital.
Traumatic hernias were repaired mostly via thoracotomy (84%). 50% of congenital hernias were repaired via thoracotomy, 37.5% via laparotomy and 12.5% via laparoscopy.
Hospital stay for the entire group was 12.3 days. Average stay for the traumatic hernias via thoracotomy was 11.2 days and 18.6 days for laparotomy.
The length of stay with a traumatic hernia was grossly skewed due to concomitant head and chest injuries.
In congenital hernias, the average stay was 13.1 days. The shortest stay was 4 days for a laparoscopic procedure and the longest stay was 37 days for a thoraco-laparotomy, complicated by an infected mesh. The average length of stays for repairs via thoracotomy was 16.8, laparotomy 9.16 and laparoscopy 10 days.
19% of the trauma patients were managed in ICU post operatively. One patient died in the intensive care unit (2.3%).
Thoracotomy approach required more postoperative pain relief than others.
Average follow-up was 8 years with no evidence of recurrence.
Conclusion: The most common surgical repair route seen was via thoracotomy.
No approach to repair was better than others and an understanding of all options was vital to achieving good results.
A201 Does the initial amount of pulmonary blood flow affect outcomes in patients with Tricuspid Atresia/VSD and normally related great arteries?
Natasha Bocchetta1,2, Betul Cinar3, John Stickley3, Adrian Crucean3, Chetan Mehta3
1University of Birmingham, Birmingham, United Kingdom. 2Hull York Medical School, Hull, United Kingdom. 3Birmingham Children's Hospital, Birmingham, United Kingdom
Correspondence: Natasha Bocchetta
Journal of Cardiothoracic Surgery 2024, 19(2):A201
Background: Patients with Tricuspid atresia, normally related great arteries (TA/NRVA) Stage I palliation is dictated by initial amount of pulmonary blood flow (PBF): reduced, balanced, increased. Reduced and increased PBF patients require PBF augmentation and pulmonary artery banding respectively at Stage I. Balanced PBF patients progress straight to Stage II palliation. The relationship of initial PBF on outcomes has scarce research. Therefore, we investigated the effect of initial PBF on survival and reintervention rates in TA/NRGA patients; secondary aim, investigating the timings across palliation between PBF groups.
Methods: Single-institution retrospective review of TA/NRGA patients, 2000–2023. Patients grouped into low, balanced, and high PBF based on their first stage of palliation. Survival and reintervention rates were reported by Kaplan–Meier survival analysis and Cox-proportional hazards model. Palliation timings as medians and interquartile range.
Results: Overall 55 patients were included, with a median follow-up of 6.41 years (IQR = 3.68, 12.88). All 5 deaths were in the low PBF group. There was no statistically significant difference in survival or reintervention rates between the low and high PBF groups (p = 0.16, p = 0.34 respectively). The low PBF group had a hazard ratio of 3.09 (95%CI = 0, infinity) for survival and 1.85 (95%CI = 0.51,6.68) for reintervention. Across palliation the low PBF group had earlier interventions.
Conclusions: Although patients with low PBF didn’t have statistically significantly higher death or reintervention rates, they appear to be at increased risk for both, compared to the high PBF group. Patients with low PBF also received interventions at an earlier time than the high PBF group.

A202 Does the robotic approach further improve long term outcomes in segmentectomies?
Giulia Fabbri, Federico Femia, Savvas Lampridis, Akshay Patel, Karen Harrison-Phipps, Andrea Bille
Guy's Hospital, London, United Kingdom
Correspondence: Giulia Fabbri
Journal of Cardiothoracic Surgery 2024, 19(2):A202
Objective: To investigate the impact of video-assisted thoracic surgery (VATS) versus robotic-assisted thoracic surgery (RATS) on oncologic outcomes in patients undergoing segmentectomy for non-small cell lung cancer (NSCLC).
Methods: We conducted a single-center prospective study, enrolling consecutive patients who underwent RATS or VATS segmentectomy for NSCLC between July 2015 and December 2021. Primary outcomes were overall survival (OS), disease-free survival (DFS), and recurrence rate. Secondary outcomes included lymph node yield, length of stay (LOS), duration of chest tubes (LOD), and complication rates.
Results: A total of 144 patients were included in the study, 86 undergoing RATS and 58 VATS segmentectomies. The median follow-up was 30 months. RATS demonstrated superior OS (3-year: 86.4% vs. 72.3%; 5-year: 86.4% vs. 56.6%; P = 0.042) and DFS (3-year: 86.4% vs. 66.9%; 5-year: 86.4% vs. 54.5%; P = 0.028) [Fig. 1a–b]. On multivariable analysis, RATS was associated with improved OS (HR, 0.41; 95% CI, 0.16–0.95; P = 0.048) and DFS (HR, 0.43; 95% CI, 0.19–0.91; P = 0.032) [Fig. 1c–d]. VATS was linked to a higher recurrence rate than RATS (17.2% vs. 5.8%; P = 0.048); RATS was associated with a higher median number of harvested lymph node stations compared to VATS (7 [IQR, 2] vs. 5 [IQR, 2]; P < 0.001), including mediastinal (4 vs. 3, P < 0.001) and hilar (3 vs. 2, P < 0.001) stations. Median LOS, LOD, and complication rates were similar between groups.
Conclusions: For NSCLC segmentectomies, RATS was associated with superior long-term survival and lower recurrence compared to VATS. The enhanced nodal dissection capabilities of RATS may contribute to these favorable oncologic outcomes.

A203 Establishing the sex-specific genetic profile of the long saphenous vein at baseline and in response to flow: preliminary results from a first-in-human experimental study
Georgia R. Layton1,2, Shameem Ladak1, Liam McQueen1, Lathishia Joel David1, Gavin Murphy1,2, Mustafa Zakkar1,2
1University of Leicester, Leicester, United Kingdom. 2University Hospitals of Leicester, Leicester, United Kingdom
Correspondence: Georgia R. Layton
Journal of Cardiothoracic Surgery 2024, 19(2):A203
Introduction: Vein graft disease (VGD) compromises the long-term patency of venous conduits and may contribute to the worse outcomes in women compared to men after CABG. This study set out to explore whether there are identifiable differences between the genetic profile of LSV sections from male and female patients undergoing CABG.
Methods: Applied bioinformatics analysis of bulk-RNA data from spatially sequenced sections of LSV from men and women undergoing CABG. Expression differences were validated using RT-qPCR and immunofluorescence in ex-vivo samples exposed to arterial shear.
Results: 3.9% of genes were differentially expressed at baseline with unique profiles of expression within male and female samples in whole tissue as well as endothelial and smooth muscle cell groups. Initial pathway enrichment has shown very high rates of angiogenesis pathway activation in females, as well as log fold change expression of VEGFA increased by up to 4.7 times (p = 0.00325) in females compared to males. We have also demonstrated clear differential VEGFA expression responses to flow between sexes.
Conclusion: Our data suggests that sex-differences equate not only in baseline gene expressions but also in the cell populations demonstrating these altered expressions. There are also differing sex-specific responses to arterial shear. We hypothesise that these transcriptomic differences result in a varied propensity for VGD between male and female patients, and this is being further explored.
A205 Temporary centrimag BiVAD support as a bridge to heart transplantation: the last decade of experience at Royal Papworth Hospital
Sri Aurovind, Ahmad Shafi, Zameer Abdul Aziz, Pradeep Kaul, Muhammad Rafiq, Stephen Petit, Marius Berman, David Jenkins, Stephen Tsui, Hssiba Smail
Royal Papworth Hospital, Cambridge, United Kingdom
Correspondence: Sri Aurovind
Journal of Cardiothoracic Surgery 2024, 19(2):A205
Background: The Centrimag ventricular assist device (VAD) is a versatile and reliable method of temporary mechanical circulatory support for patients in refractory cardiogenic shock. Patients with biventricular disease who are unsuitable for implantable LVAD support may be bridged directly to heart transplantation with Centrimag BiVAD support. We report our institutional experience with this strategy over the last decade.
Methods: We reviewed consecutive patients who were supported with Centrimag BiVAD as a bridge to heart transplantation. Baseline characteristics, adverse events during support, duration of support and clinical outcomes were recorded.
Results: 109 patients received Centrimag BiVAD support from January 2012 to September 2023, including 89 men and 20 women. The mean age was 42 years (range 15–65 years). Indications included dilated, ischemic, hypertrophic and arrhythmogenic cardiomyopathies. Mean BiVAD support time was 48 days with a maximum support time of 293 days. Re-exploration for post-operative bleeding occurred in 23 (21%) patients. Competing outcomes were transplantation (66%), death during support (31%), recovery (2%) and conversion to implantable LVAD (1%). Mean time to heart transplantation was 57 days. Uncensored survival from the onset of Centrimag BiVAD support was 61% at one year, 57% at five years and 45% at ten years.
Conclusion: Our institutional experience supports the utility of temporary mechanical circulatory support with Centrimag BiVAD as a bridge to urgent heart transplantation. Five and ten-year survival from the onset of Centrimag BiVAD support compares favorably with published case series of implantable BiVAD support with the HVAD or Heartmate 3 device.
A205 Two decades of coronary bypass grafting in the UK; a propensity-matched analysis of conduit choice in a complete national series
Georgia R. Layton1,2, Shubhra Sinha3, Daniel P. Fudulu3, Gianni D. Angelini3, Mustafa Zakkar1,2
1University of Leicester, Leicester, United Kingdom. 2University Hospitals of Leicester NHS Trust, Leicester, United Kingdom. 3University of Bristol, Bristol, United Kingdom
Correspondence: Georgia R. Layton
Journal of Cardiothoracic Surgery 2024, 19(2):A205
Objectives: There is well-proven long-term patency advantage of arterial grafts for CABG, and more than 90% of patients in the UK will receive at least one arterial graft during this procedure. However, a significant proportion of patients will still receive total venous revascularisation. This patient group is poorly defined, and their outcomes are seldom reported. This large, multi-centre study aims to define the outcomes of patients receiving CABG using only venous conduits.
Methods: Retrospective, propensity matched, analysis of all consecutive patients undergoing CABG, in the UK between 1996 and 2019 using data from the prospectively managed National Adult Cardiac Surgery Audit obtained from the National Institute of Cardiovascular Outcomes Research central cardiac database.
Results: 380,293 patients were included in this study with 7.52% receiving venous conduits only; propensity matched outcomes are reported for 55, 808 patients. Patients receiving at least a single arterial graft had significantly lower mortality (1.5% versus 5.1%, risk difference -3.5% [95% C.I -3.8–3.3%], p < 0.001), need for post-operative dialysis (2.0% versus 3.9%, p < 0.001) and shorter length of hospital admission (7 days versus 6 days, p < 0.001). Rates of stroke were similar across groups.
Conclusions: This analysis has identified an elevated mortality risk after CABG when a venous-only conduit strategy is used, even when accounting for elevated peri-operative risk profiles. Total venous revascularisation retains a critical, unavoidable role for certain patients and so there remains a need to optimise the long-term patency of venous grafts and perioperative morbidity and mortality for the benefit of this niche patient cohort.
A206 A comparison of the measurements of incidental aortic aneurysms detected via lung cancer screening programme low dose computed tomography versus subsequent cardiac gated computed tomography. Can low dose computed tomography be used and the baseline for aortic follow up?
James Ackah, Alessia Marigliano, Sanjay Asopa
Derriford Hospital, Plymouth, United Kingdom
Correspondence: James Ackah
Journal of Cardiothoracic Surgery 2024, 19(2):A206
Introduction: Lung cancer screening programs, using low dose non-contrast CT scans (LDCTs), are gaining national adoption due to reduced all-cause mortality. However, incidental intra-thoracic aortic aneurysms > 40 mm are increasingly referred for further assessment with cardiac gated CT (CGCT) scans. This study aims to compare aneurysmal diameter measurements between LDCTs and CGCTs to assess LDCT suitability as a baseline for aortic follow-up.
Methods: We conducted a retrospective analysis from October 2022 to October 2023, focusing on patients with aortic aneurysms initially detected by LDCTs and subsequently re-evaluated with CGCTs. The mean time interval between scans was 93.6 days.
Results: We compared measurements from 13 aneurysms, including 12 ascending aortic aneurysms and 1 aortic arch aneurysm. The mean diameter for LDCT was 51.31 mm, for CGCT was 52.07 mm, with a mean difference of 0.77 mm. Welch’s t-test showed a t-statistic of 0.2735 (t-critical = 2.0639, p = 0.7868), indicating no statistically significant difference in aneurysmal diameter between LDCT and CGCT (Fig. 1).
Conclusions: Cardiothoracic centres receiving aortic referrals from lung cancer screening programs may consider using LDCT scans as the baseline for aortic follow-up. This approach potentially reduces healthcare burden, cost, and patient radiation exposure. Further adoption of LDCTs in this context could streamline clinical practice and enhance patient care.

A207 The patient experience of undergoing and recovering from coronary artery bypass graft (CABG) surgery: thematic analysis of patient interviews from the "Heart of the Matter" study
Francesca Leone1,2,3, Maureen Twiddy3, Azar Hussain1, Mahmoud Loubani1,3
1Castle Hill Hospital, Cottingham, United Kingdom. 2Sheffield Teaching Hospitals, Sheffield, United Kingdom. 3Hull York Medical School, Hull, United Kingdom
Correspondence: Francesca Leone
Journal of Cardiothoracic Surgery 2024, 19(2):A207
Objective: We undertook the “Heart of the Matter” study to better understand the experience of undergoing coronary artery bypass graft (CABG) surgery from the patient perspective, and how this differs as an urgent patient in comparison to the elective population.
Method: This is a prospective qualitative study comprising semi structured interviews in patients 6 months post CABG. Transcripts underwent thematic analysis on NVivo Version 14.
Results: Seven elective patients and 13 urgent patients took part in the study. 30% of participants were female. Major themes included (1) uncertainty or anxiety in the post-operative period around recovery independent of whether the patient originated on the elective or urgent pathway. Patient’s expectations included a more immediate degree of follow up from specialist services and a faster rate of recovery. (2) An external locus of control was either a source of comfort or anxiety around diagnosis and/or operative management. (3) The urgent population more than the elective population expressed shock at their sudden need for surgery, contrary to their previous self-perception as a healthy individual.
Conclusion: Coronary artery bypass surgery is a major life event for patients undergoing the procedure. This can bring uncertainty as well as anxiousness for patients as they undergo the procedure and recover in the community. There is a role for education and pre-habilitation in both elective and urgent patient pathways to manage patient expectations and prepare patients for their surgical recovery.
A208 Surgical technique for removal of renal cell carcinoma with IVC tumour thrombus using normothermic CPB
Antanas Macys1, Riccardo Abbasciano1, Jae Yun1, Jonathan Afoke1, Archie Hughes-Hallett1, David Nicol2
1Imperial College Healthcare NHS Trust, London, United Kingdom. 2Royal Marsden Hospital, London, United Kingdom
Correspondence: Antanas Macys
Journal of Cardiothoracic Surgery 2024, 19(2):A208
Background: Advanced renal cell carcinoma (RCC) spreads locally through renal veins, occasionally reaching the IVC (IVC) and the right intra-cardiac chambers. The most common technique for radical nephrectomy and IVC tumour thrombus removal employs cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest, but this can be associated with increased morbidity and mortality, and five-year survival ranges from 40 to 60%. We present our experience with normothermic, beating-heart, CPB for patients with RCC and IVC tumor-thrombus.
Methods: We conducted a single centre review of patients requiring nephrectomy of stage IIIb, IIIc, IIId and IV RCC, operated from 2015 to 2023.
Results: A total of 38 patients were included. Median age was 66 (interquartile range, 60.25–71). Twenty-five patients (66%) were male, most of them (68%) in ASA class 3. Seven patients (18%) had a previous history of cardiovascular disease. Median Body Mass Index (BMI) was 26.9 (23–29.5). Twelve patients (32%) had diabetes, and 7 patients (8%) hypercholesterolemia.
Twenty-one patients underwent normothermic CPB. One patient (5%) died in the post-operative period. Median cardiopulmonary bypass time was 44 min (31–53). Median post-operative Intensive Therapy Unit stay was 3 days (3–8). The incidence of reoperation for bleeding 5%, wound infection 18%. Seventy-four percent of the patients were alive at 8 years.
Conclusions: Surgical excision for RCC and IVC tumor-thrombus remains a complex procedure with severe impact on outcomes. Normothermic CPB-assisted IVC tumour thrombus removal with beating heart technique is simple, reproducible and safe, avoiding deep hypothermic circulatory arrest-related complications.
A209 Congenital cardiac surgery training in the UK: the role of wet-labs in teaching surgical skills
Francesca Gatta1, Nabil Hussein2, Joseph George2, Shafi Mussa3, Attilio Lotto4
1Liverpool Heart and Chest Hospital, Liverpool, United Kingdom. 2Castle Hill Hospital, Cottingham, United Kingdom. 3University Hospitals Bristol, Bristol, United Kingdom. 4Alder Hey Children Hospital, Liverpool, United Kingdom
Correspondence: Francesca Gatta
Journal of Cardiothoracic Surgery 2024, 19(2):A209
Objectives: Training in congenital cardiac surgery is extremely complex, with limited opportunities for hands-on experience in clinical posts. This study aims to evaluate the impact of the yearly SCTS Congenital Wet-Lab on trainees’ aspirations to succeed in congenital cardiac surgery (CCS) in the United Kingdom.
Methods: A retrospective survey was circulated to 2022 and 2023 attendees. The results were collated with the official SCTS post-course questionnaire. Data was analysed and processed using descriptive statistics.
Results: A total of 37 responses were analysed. Most delegates were male (77.8%), in the age groups 25–28 (33.3%) and 31–34 (33.3%). 55.6% of candidates were Cardiothoracic NTN ST3-ST6, 11.1% pursuing a CESR root, and 88.9% SCTS members. Attendance was uniform across 11 Deaneries. The course improved both theoretical knowledge and technical skills for all attendees (100%). Simulation included operations on pig/piglet hearts for: Ross, Ross-Konno, Konno, Hypoplastic arch reconstruction, Aortic annular enlargement and Norwood. Subjective self-evaluated competencies for these increased significantly (from 5.4 ± 2.1 to 8.3 ± 1.4, p < 0.01). 100% of the cohort agreed the course provided insight into CCS, which was not available in their current job role. 89% of delegates benefited from networking and felt more incorporated into the CCS community.
Conclusions: In 2022, the SCTS Education Group established the Congenital Cardiac Wet-Lab. The course attracts fellows and trainees across the country and has received excellent feedback. It improved delegates understanding and performance of complex congenital operations, increased motivation to continue in the specialty, and created a feeling of community across the UK.
A210 Thoracoscopic first rib resection for thoracic outlet syndrome: a single centre retrospective cohort study assessing safety and efficacy relative to conservative management and open surgery
Jean-Luc Duval, Fernanda Binati, Tenisha Joseph, Dominic PJ Howard, Francesco Di Chiara
Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
Correspondence: Jean-Luc Duval
Journal of Cardiothoracic Surgery 2024, 19(2):A210
Objectives: Thoracoscopic first rib resection (FRR) is an emerging option for minimally invasive surgical management of thoracic outlet syndrome (TOS), particularly in venous TOS, as an inferior approach to the rib allows preservation of collateralised veins. Despite this, its safety and efficacy relative to existing treatment options have not previously been reported in the literature. As one of three centres in the UK offering this service, we sought to compare these modalities in terms of inpatient course, complications and symptom resolution.
Methods: Case notes of all patients with confirmed TOS at our centre between January 2017 and August 2023 were retrospectively analysed. Phone interviews were performed to quantify residual symptoms objectively using the validated QuickDASH Questionnaire (0 = no symptoms, 100 = complete disability).
Results: Twenty-two (22) patients underwent thoracoscopic FRR, 26 underwent open FRR and 26 were managed conservatively during the period studied. Demographics were comparable and venous TOS was the most common presentation across all three cohorts. There was no significant difference in average length of stay (3.2 vs 2.2 days, p = 0.751), postoperative analgesic requirements or major post-operative complications between thoracoscopic and open FRR. There was over 75% response rate to QuickDASH Questionnaire in all three cohorts. The average QuickDASH score was 13.07 for thoracoscopic FRR vs. 11.98 for open (p = 0.752) and 16.94 for conservative (p = 0.441).
Conclusions: Thoracoscopic FRR is a safe and efficacious option in the surgical management of TOS and has been demonstrated to be non-inferior to the open approach.
A211 The current status of minimally invasive cardiac surgery in the United Kingdom
Chris Bayliss1, Enoch Akowuah2, Stuart Grant2, Narain Moorjani3, Joseph Zacharias4, Hunaid Vohra5, Jiaqiu Wang6, Andrew Goodwin1
1James Cook University Hospital, Middlesbrough, United Kingdom. 2South Tees Academic Cardiovascular Unit, Middlesbrough, United Kingdom. 3Royal Papworth Hospital, Cambridge, United Kingdom. 4Blackpool Teaching Hospitals, Blackpool, United Kingdom. 5Bristol Heart Institute, Bristol, United Kingdom. 6NHS Arden and Greater East Midlands Commissioning Support Unit, Arden and Greater East Midlands, United Kingdom
Correspondence: Chris Bayliss
Journal of Cardiothoracic Surgery 2024, 19(2):A211
Objectives: Minimally invasive cardiac surgery continues to evolve. We aimed to establish the current status of minimally invasive cardiac surgery in the United Kingdom.
Methods: Data for all adult cardiac surgery procedures performed in the UK (excluding Scotland) during 2021/22 financial year were extracted from the UK National Adult Cardiac Surgery Audit database.
Results: For isolated coronary surgery, 2.9% (305/10539) of procedures were performed without a full sternotomy, the majority (68.5%, 209/305), via mini-thoracotomy. 40% (15/35) of UK centres performed at least one isolated CABG without full sternotomy.
For isolated aortic valve surgery, 13.4% (445/3313) of procedures were performed without a full sternotomy, with the majority (80.7%, 359/445) performed via partial sternotomy. Most UK centres (71%, 25/35) performed at least one isolated AVR without a full sternotomy.
For isolated mitral valve surgery, 13.9% (231/1667) of procedures were performed without a full sternotomy, the majority of these (77.9%, 180/231) performed via a mini-thoracotomy. Just under half of UK centres (48%, 17/35) performed at least one mitral operation without full sternotomy.
There were 28 robotically assisted procedures performed across all operative groups (23 isolated CABG and 5 mitral procedures).
Minimally invasive mitral procedures had longer mean bypass (140 vs 104 min) and cross-clamp times (92 vs 78 min). Mean bypass and cross-clamp time was similar between full sternotomy and minimally invasive aortic valve replacement (bypass 90 vs 91 min, cross-clamp 68 vs 67 min).
Conclusions: This study outlines the current status of minimally invasive cardiac surgery in the UK.
A212 A systematic review and meta-analysis of dual versus single antiplatelet therapy in coronary artery bypass surgery
Emmanouil Verigos1, Eduardo Urgesi2, Nicole Makariou3, Wael Awad2,4
1Barts and The London, London, United Kingdom. 2Barts Heart Centre, London, United Kingdom. 3Barts Health NHS Trust, London, United Kingdom. 4William Harvey Research Institute, London, United Kingdom
Correspondence: Emmanouil Verigos
Journal of Cardiothoracic Surgery 2024, 19(2):A212
Background: There is a lack of consensus in the literature as to whether dual antiplatelet therapy (DAPT) demonstrates benefits over single therapy following coronary artery bypass surgery. The aim of this meta-analysis was to assess the impact of dual antiplatelet therapy on patient outcomes after coronary artery bypass grafting (CABG).
Methods: A meta-analysis was performed according to the PRISMA guidelines. PubMed, Embase and Cochrane databases were searched for observational and randomised controlled studies investigating the effect of dual antiplatelet therapy following CABG on mortality, myocardial infarction, stroke, graft patency, repeat revascularisation and bleeding. Risk ratios for each outcome were calculated and subgroup analyses were conducted to ascertain the differences between different DAPT regimens versus aspirin alone, on outcomes.
Results: Twenty-three studies with a total of 56,032 patients were pooled for analysis. Compared to single antiplatelet therapy (SAPT), DAPT significantly reduced all-cause mortality (RR: 0.60; 95% CI: [0.46, 0.79]; p: 0.002; I2: 60%), cardiovascular death (RR: 0.53; 95% CI: [0.32,0.87]; p: 0.010; I2: 34%) and vein graft occlusion (RR: 0.71; 95% CI: [0.60,0.84]; p < 0.001; I2: 27%). These findings only applied to patients receiving aspirin and clopidogrel as the DAPT combination. There was no significant difference in the risk of myocardial infarction, bleeding, stroke/thromboembolic events or repeat revascularisation in patients receiving DAPT versus SAPT (Table 1).
Conclusions: DAPT reduces the risk of mortality and graft failure in CABG patients compared to SAPT without an increase in bleeding. These findings suggest that DAPT is a useful post-operative treatment strategy following CABG.
A213 Robotic assisted MIDCAB vs sternotomy LIMA-LAD: can potential be realised during the learning curve?
John Massey, Selvaraj Shanmuganathan, Ken Palmer, Omar Al-Rawi, Gopal Soppa, Tim Ridgway, Paul Modi
Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
Correspondence: John Massey
Journal of Cardiothoracic Surgery 2024, 19(2):A213
Introduction: Minimally invasive direct coronary artery bypass (MIDCAB), particularly the robot-assisted option, offers potential advantages compared to conventional sternotomy, including reduced surgical trauma and blood loss, shorter hospital stay, and improved cosmesis. There is a learning curve associated with robotic surgery, during which benefits may not be realised. This study presents a comparative analysis of robotic-assisted MIDCAB to the sternotomy approach for isolated LIMA-LAD grafting.
Methods: Robot-assisted coronary surgery commenced in 2019 as a single surgeon practice, expanding to two surgeons in 2021. Data were collected prospectively for all patients (n = 162) undergoing isolated LIMA-LAD between 2019 and 2023 (Group 1 = Robotic LIMA-LAD, n = 69; Group 2 = Sternotomy LIMA-LAD, n = 93). The primary end point was length of stay < 3 days. Secondary end points were conversion to sternotomy, post-op blood loss, ICU stay and length of stay > 5 days.
Results: There was no statistical difference in pre-operative characteristics between groups. Six patients (9%) were converted to sternotomy. Significantly more patients in Group 1 were discharged within 3 days (39% vs 3% p < 0.001). Group 1 were extubated earlier than Group 2 (ventilation time 4 h vs 6 h p < 0.001) and had lower post-operative blood loss (350mls vs 455mls p < 0.006) but this did not translate into shorter ICU stay. More patients in group 2 stayed longer than 5 days (33% vs 71% p < 0.001).
Conclusion: Robot-assisted MIDCAB is associated with earlier extubation, less blood loss and shorter post-operative hospital stay compared to sternotomy even during the learning curve.

A214 Long-term diagnostic yield for navigational bronchoscopy: analysis of over 600 procedures
Arvind Muthirevula, Joshil Lodhia, Elaine Teh, Marco Nardini, Richard Milton, Alessandro Brunelli, Peter Tcherveniakov, Nilanjan Chaudhuri
St James University Hospitals, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
Correspondence: Arvind Muthirevula
Journal of Cardiothoracic Surgery 2024, 19(2):A214
Objective: This study set out to investigate the effectiveness of navigational bronchoscopy in diagnosing lung lesions, particularly in cases where standard diagnostic methods failed or were not feasible. The primary focus was to evaluate its accuracy in diagnosis, with secondary goals assessing complications such as pneumothorax rates, the need for drain insertion, and the duration of hospital stays.
Methods: We conducted a detailed analysis of navigational bronchoscopy procedures carried out by multiple surgeons from 2018 to 2022. The evaluation of diagnostic accuracy relied on pathology results obtained from biopsies taken per lesion. We confirmed the long-term accuracy by examining follow-up CT scans and treatments provided for at least one year post-procedure. Additionally, we evaluated post-procedural complications and the duration of hospital stays.
Results: Throughout the study period, 603 procedures were performed, achieving a diagnostic accuracy of 59% per lesion biopsied. When considering different surgeons with a minimum experience of 30 procedures, the diagnostic accuracy ranged between 54 and 67%. True positive identifications were found in 38% of cases, while true negatives accounted for 21%. The incidence of pneumothorax was 7%, requiring drain insertion in 3% of cases. The average hospital stay was 0.51 days, with 399 patients discharged on the day of the procedure.
Conclusion: Our comprehensive analysis demonstrated the substantial diagnostic accuracy of navigational bronchoscopy in identifying lung lesions, particularly in cases where standard diagnostic methods may not suffice. Despite the occurrence of pneumothorax, the procedure showcased effectiveness by ensuring notably short post-procedural hospital stays.
A215 Are surgeons good at documenting their operations? Adherence of patient operation notes to the Royal College of Surgeons of England GUIDELINES IN THORACIC SURGERY
Aishah Mughal1, Zuhaib Ehsan2, Abdulaziz Alshamlan1, Elisha Warner1, Ahmed El-Zeki1, Patrick Yiu1, Ahmed Oliemy1, Ahmed Habib1
1New Cross Hospital, Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom. 2University of Birmingham, Birmingham, United Kingdom
Correspondence: Aishah Mughal
Journal of Cardiothoracic Surgery 2024, 19(2):A214
Objectives: All surgeons are required to document operative details following each procedure in the medical notes. Operation notes must meet a standard as outlined by the Royal College of Surgeons of England (RCEng) ‘Good Surgical Practice’ Guidelines. We aim to evaluate the adequacy and adherence of patient operation notes following thoracic surgery against the RCSEng guidelines.
Method: A clinical audit was performed on all patients undergoing thoracic surgery between 04/01/2023 and 28/07/2023. Data was collected from electronic health records on adherence to 17 parameters outlined by RCSEng Guidelines. Data analysis was performed using SPSS V.29.
Results: 173 patients undergoing thoracic surgery with complete data were included. The median age of patients at operation was 65 years (IQR 51–74). Type of operation performed included: anatomical lung resection (31.2%), wedge resection (10.4%), bronchoscopy and/or mediastinoscopy (9.8%), decortication (9.8%) and other thoracic procedures (30.6%).
Adherence to RCSEng guidelines are outlined in Fig. 1. Adherence was excellent for the documentation of operation date (98.8%), name of operating surgeon (100.0%) and operative procedure (98.8%). However, documentation was poor for anticipated blood loss (0.6%), antibiotic prophylaxis (1.73%) and DVT prophylaxis (10.1%). Detailed post-operative care instructions were documented in 56.6% of all operation notes.
Conclusion: Surgeons are adequately documenting operation notes in accordance with guidelines, however, improvement is needed to ensure post-operative instructions including DVT and antibiotic prophylaxis are more frequently reported. Recommendations should involve emphasising the importance of guideline adherence amongst surgeons, and creating software proforma to facilitate completion of operative notes using a template.

A216 Financial implications of publication and conference attendance in cardiothoracic surgery
Matyl Kassouf, Arun Kirupananthavel, Stephanie Hampson, Ana Lopez-Marco, Martin Yates
St Bartholomew's Hospital, London, United Kingdom
Correspondence: Matyl Kassouf
Journal of Cardiothoracic Surgery 2024, 19(2):A216
Objectives: Attendance at academic conferences and publication in peer reviewed journals are essential for career progression in cardiothoracic surgery. The speciality must encourage medical students and trainees whilst consultants must be supported for continuing education and sharing of research. The aim of this project is to assess the current costs of conference attendance and publication in cardiothoracic surgery.
Methods: We compiled a list of the most common cardiothoracic journals and scientific meetings. We recorded the cost of publication of a paper in each journal from their author guidelines. For each conference we recorded the cost of attendance for student, trainee and consultant. Data is presented as mean with range.
Results: We reviewed n = 12 cardiothoracic journals. Mean cost of publication was £2231 (£0-£3090). The cost of two was not immediately available. Only one of the twelve journals was free for publication.
We reviewed n = 10 cardiothoracic conferences. Mean cost of attendance for medical students £127 (£0-£445), trainees £203 (£50-£445) and consultants £664 (£150-£1111). Only two conferences offer attendances for free to medical students.
Conclusions: The significant cost of conference attendance and publication in cardiothoracic surgery is becoming prohibitive for students, trainees and consultants in the United Kingdom.
A217 Implementation of AFACS prevention care bundle reduces atrial fibrillation after cardiac surgery in a single centre in England
Jean-Paul Evangelista1, Rosalie Magboo2, Joanna Murfin1, Dimitrios Pousios1, David Thirukumaran1
1University Hospital Southampton NHS FT, Southampton, United Kingdom. 2St Bartholomew’s Hospital, London, United Kingdom
Correspondence: Jean-Paul Evangelista
Journal of Cardiothoracic Surgery 2024, 19(2):A217
Objective: Atrial fibrillation (AF) poses significant burden to patients, healthcare practitioners, and healthcare systems. Atrial Fibrillation after Cardiac Surgery (AFACS) prevention care bundle was found to be a useful tool in reducing this common adverse event. We adopted and implemented the care bundle with an emphasis on early β-blocker (re)administration postoperatively to help reduce our local AF incidence.
Methods: Data from previous audit was utilised as baseline. Using the plan-do-study-act (PDSA) cycle, we introduced a care bundle in May 2023 across the cardiac intensive care, high dependency units and wards through repeated multidisciplinary team teachings and poster/email reminders. A weekly snapshot audits were done to identify implementation barriers and facilitators. Run chart was produced to analyse trends. Post-implementation data were prospectively collected in September 2023. Descriptive and inferential statistical analysis were conducted.
Results: Overall, 70 patients (60% male, mean age 69 years, 50% undergone coronary artery bypass grafts (CABG)) and 93 patients (70.9% male, mean age 67 years, 51.6% undergone CABG) were included in the baseline and post-implementation audit, respectively. After the care bundle implementation, we found a 13% increase in the early postoperative β-blocker administration and 9% reduction in the incidence of AFACS (pre-implementation = 40% vs post-implementation = 31%), although this was not statistically significant (χ2 = 1.365, p = 0.242). Challenges identified include poor documentation and staff engagement.
Conclusion: AFACS prevention care bundle has improved our β-blocker administration practice and AF incidence, indicating successful uptake of the project. Barriers and facilitators identified will be addressed in future PDSA cycles.
A218 Determinants of trans-prosthetic gradients after isolated surgical aortic valve replacement and effect on survival: a UK study
Mohamed Shoeib1, Rebecca Gosling1,2, Elena Wolodimeroff2, Charlotte Pickavance2, Sam Jenkins2, Bara Kubanova2, Norman Briffa1,2
1Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom. 2Department of infection, immunity and cardiovascular disease, University of Sheffield, Sheffield, United Kingdom
Correspondence: Mohamed Shoeib
Journal of Cardiothoracic Surgery 2024, 19(2):A218
Objectives: Patient-prosthetic mismatch (PPM), when severe, can be associated with adverse outcomes following surgical aortic valve replacement (sAVR). PPM occurs when the implanted valve is too small for the patient, with a small orifice area and elevated trans-valvular pressure gradient. We sought to determine the impact of patient & operative variables on post-operative peak trans-valvular pressure gradient (PG), and identify its influence on survival.
Methods: Large single centre retrospective study of 1790 patients who underwent isolated sAVR between June 2003 and February 2017, of which 604 patients satisfied the inclusion criteria. TTE was performed between six and 12 months post-operatively. Independent predictors of PG were determined using a cox-proportional hazards model. Survival analysis was evaluated by KM curves and log-rank test.
Results: Mean age was 69.5(± 11.4) years and 346(59%) were male. Mean PG was 29.96(± 12.4) mmHg. Independent predictors of increased PG were: smaller valve size, postoperative diuretic use, age, gender and operating surgeon (p < 0.001). Seventy-two patients (12%) died during follow-up. Mean survival was 12.1 years. PG was identified as a significant predictor of mortality (HR 1.02, p = 0.001) with a 12% increase per 5 mmHg gradient. Other predictors included age and diabetes mellitus.
Conclusion: In a large cohort of patients undergoing sAVR at a single centre in the UK, valve size was the biggest determinant of postoperative PG. Postoperative pressure gradient was a significant predictor of all-cause mortality. Implanting the largest possible valve size should be considered the single most effective way of reducing the post-operative gradient and long-term mortality.
The legend for the figure is—Post-operative pressure gradient was identified as a significant predictor of mortality (HR 1.02, p = 0.001).

A219 Unveiling the cardiovascular consequences of cannabis consumption: a up-to-date systemic review
Vanessa J. Chow1, Muhummad Hamza Shah2, Meera Shankar3, Fadi Al-Zubaidi4, Arwa Khashkhusha3, Bea Duric5, Amer Harky6
1Buckinghamshire NHS Trust, Thames Valley, United Kingdom. 2University of Edinburgh, Edinburgh, United Kingdom. 3University of Liverpool, Liverpool, United Kingdom. 4Bristol Heart Institute, Bristol, United Kingdom. 5Kings College of London, London, United Kingdom. 6Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
Correspondence: Vanessa J. Chow
Journal of Cardiothoracic Surgery 2024, 19(2):A219
Objective: Cannabis is the most widely used illicit substance globally. With its escalating use following broader legalization, there has been a concomitant increase in cardiovascular complications among users, raising significant public health concerns. Such a trend mandates a critical examination of cannabis-related risks, particularly their significance for public health.
Methodology: A systematic review was conducted to explore the relationship between cannabis consumption and cardiovascular health in adults aged ≥ 18. Three databases (PUBMED, EMBASE, and CENTRAL) were reviewed up to October 2023 using the PRISMA guidelines.
Results: 58 studies, including 56 observational and 2 clinical trials, revealed a complex yet increasingly substantiated connection between cannabis use and cardiovascular health. Literature indicates an increased risk of acute coronary syndromes (17 studies), arrhythmias (10 studies), cerebrovascular events (8 studies), transient hemodynamic fluctuations (5 studies), and thrombotic occurrences (2 studies). Furthermore, post-percutaneous coronary intervention complications have been reported, alongside structural cardiac changes such as myocardial injury, heightened aortic stiffness, and atherosclerosis.
The primary demographic impacted consisted of males with relatively fewer traditional cardiovascular risk factors. The review found no direct link between cumulative or average cannabis use and cardiovascular disease, emphasizing the need for discerning cannabis's cardiovascular effects amid changing demographics and usage patterns.
Conclusion: This review underscores an association between cannabis consumption and heightened cardiovascular risk. The use of marijuana should be carefully reviewed and considered by healthcare professionals given the reported cardiovascular adverse events. Strict guidelines should be in place to ensure public safety and minimise hospital admissions related to marijuana use.
A220 Airway stenting in patients with advanced inoperable oesophageal cancer using self-expanding carinal Y-stents
Caoimhe McNamara, Rachel Brown, Mohammad Aladaileh, Donna Eaton
Mater Misericordiae University Hospital, Dublin, Ireland
Correspondence: Caoimhe McNamara
Journal of Cardiothoracic Surgery 2024, 19(2):A220
Objectives: To assess the indications and outcomes of patients with oesophageal cancer undergoing central airway stenting using a carinal Y-stent. Central airway stenosis and/or trachea-oesophageal fistula are potentially life-threatening complications presenting in up to 4.79% to 9.4% of these patients. We reviewed the indications and outcomes of patients with advanced oesophageal cancer who underwent airway stenting in our unit using carinal Y-stents.
Methods: A retrospective review was performed of consecutive oesophageal cancer patients who underwent central airway stenting between 2014 and 2023 using a carinal Y-stent. We used the carinal Aerstent (Leufen Medical) which is a pre-loaded self-expanding covered Y-stent, inserted via a rigid bronchoscope and sited using either bronchoscopic and/or fluoroscopic guidance. Patients were assessed for dyspnoea using a modified Borg scale score before and after stenting.
Results: During the 9 year period study period 12 patients underwent carinal Y-stent insertion to manage central airway stenosis and/or trachea-oesophageal fistula. There were no immediate complications (no patient had pneumothorax, haemorrhage or tracheal rupture) and all patients were extubated in recovery. Mean dyspnoea grade was 6.4 ± 1.34 and significantly reduced 1.6 ± 0.69(p = 0.005) following stent insertion.
Conclusions: Airway stenting can offer excellent palliation in those oesophageal cancer patients with airway stenosis and/or trachea-oesophageal fistula. In our experience the preloaded carinal Aerstent (Leufen Medical) was easily deployed, well tolerated and had with minimal complications, making it an attractive therapy for improving quality of life in this patient group.
A222 Stand-alone surgical ablation for atrial fibrillation: a UK single-centre experience
Mark Anthony Sammut1,2, Justin Lee1, Robert Storey1,2, Chai Jin Lim2, Manwi Singh2, Sxe Chang Cheong2, Steven Hunter1
1Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom. 2The University of Sheffield, Sheffield, United Kingdom
Correspondence: Mark Anthony Sammut
Journal of Cardiothoracic Surgery 2024, 19(2):A222
Objectives: Stand-alone surgical ablation is an effective procedure for symptomatic atrial fibrillation (AF) refractory to first-line therapy but widespread adoption is limited. We report on the safety and efficacy of this procedure utilising the Cox-Maze IV technique and its variations, predominantly via a thoracoscopic approach.
Methods: This was a retrospective observational study on 94 consecutive patients who underwent stand-alone surgical ablation for refractory AF at our centre between January 2014 and March 2022. Complications were recorded up to hospital discharge and/or 30 days post-procedure. Freedom from atrial tachyarrhythmias (ATA) was determined by electrocardiography, Holter monitoring and pacemaker interrogation at various time points with or without additional therapies for AF.
Results: The median duration of AF was 4.7 years (interquartile range 2.6–8.2) and persistent in 82% of patients. 35% of patients had ≥ 1 previous catheter ablation and another 55% had been deemed unsuitable for one. The mean left atrium volume index was 40 ± 13 ml/m2. Video-assisted thoracoscopic surgery (VATS) was the initial approach in 94% of cases with 4% requiring conversion to sternotomy. The major complication rate was 8.5% with no deaths within 30 days. 70% of patients had no documented ATAs at their first follow-up (median 57 days from surgery). Freedom from ATAs was 74% (53/72), 59% (27/46) and 30% (7/23) at 1, 3 and 5 years, respectively.
Conclusion: In an experienced centre, stand-alone surgical ablation for symptomatic refractory AF has good early and acceptable mid-term efficacy for maintaining sinus rhythm.

A223 Pre-operative left ventricular mass in patients with aortic stenosis undergoing aortic valve replacement: anticipating incomplete regression for timely intervention
Fatemeh Habibi Nameghi1, Diego Perez De Arenaza2, Marcus Flather1
1Norwich Medical School, Norwich, United Kingdom. 2Hospital Italiano Department of Cardiology, Buenos Aires, Argentina
Correspondence: Fatemeh Habibi Nameghi
Journal of Cardiothoracic Surgery 2024, 19(2):A223
Objectives: Incomplete regression of left ventricular mass index (IR-LVMI) is an adverse prognostic marker in patients with aortic stenosis (AS) undergoing aortic valve replacement (AVR). Optimal timing of AVR remains a grey area for clinicians. We retrospectively analysed data from the ASSERT trial to investigate the determinants of IR-LVMI to refine optimal intervention windows for AVR based on pre-operative LVMI.
Methods: 190 patients with severe AS undergoing AVR were enrolled from ASSERT. Abnormal LVMI was defined using the Mayo Clinic thresholds: > 132 g/m2 for women and > 144 g/m2 for men. LVMI was measured before AVR and at 6 and 12 months. Patients with LVMI exceeding these thresholds at 12 months were considered to have IR-LVMI. Predictors of IR-LVMI were determined using logistic regression analyses.
Results: Of the variables associated with post-AVR IR-LVMI (baseline LVMI, systolic blood pressure and prior stroke), baseline LVMI had the strongest association. Patients with LVMI above the median had higher post-operative mortality at 12 months compared to those below (9.8% vs 2.9%). The 2nd tertile (28% regression) was the only group with abnormal pre-operative LVMI who achieved normal LVMI at follow up.
Conclusions: Though higher baseline LVMI was associated with greater LVMI regression, patients with midrange LVMI achieved regression to the norm. This suggests that AS patients should have AVR prior to LVMI exceeding 257 g/m2 which would improve the probability of achieving normal post-operative levels, and reduce risk of mortality and other adverse effects.
A224 Surgical management of advanced stage thymoma: 10 year experience
Rhona Taberham1, Vanessa Chow2, Dionisios Stavroulias1
1Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom. 2Buckinghamshire NHS Trust, Aylesbury, United Kingdom
Correspondence: Rhona Taberham
Journal of Cardiothoracic Surgery 2024, 19(2):A224
Objectives: Less than 30% of thymoma diagnoses are made at TNM stage III or IV. As per ITMIG recommendations, surgery is utilised as part of multimodality treatment. We aimed to review our 10 year experience in surgical management of advanced thymoma.
Methods: We retrospectively reviewed a single surgeon experience of 15 patients undergoing resection for stage III or IV thymoma between November 2013 and November 2023. The primary outcome assessed was 30-day mortality. Additional outcomes included completeness of resection, disease recurrence and further treatment.
Results: 9 male and 6 female patients with a median age of 63 [range 39–83] were included. Median follow-up was 30 months [range 6–117]. 5/15 (33.3%) patients had stage IV disease. There was no 30-, 60- or 90-day mortality. One patient in the series died, 18 months post-operatively from an unrelated cause. 12/15 patients had upfront resection, 3/15 underwent induction chemotherapy. An open approach was required in 66.6% of cases (10/15). 6/15 were R0 resections, 6/15 were R1 and 3/15 were R2. 6 patients had adjuvant treatment. 6 patients developed recurrence; 3 underwent further surgery, 2 underwent chemotherapy and 1 opted for surveillance.
Conclusion: Surgery plays a role in the management of advanced thymomas in combination with radiotherapy and systemic treatments. In our series, there was no mortality related to the operation, with good medium-term survival. For patients in whom a complete resection is not possible, debulking can be considered, balancing the morbidity of surgery with potential survival benefits.
A225 Radiological surveillance post aortic dissection repair: adherence to ACC/AHA guidelines
Shashi Kumar Kallikere Lakshmana, Alessia Marigliano, Shawn Britto, Sanjay Asopa
University hospital Plymouth, Plymouth, United Kingdom
Correspondence: Shashi Kumar Kallikere Lakshmana
Journal of Cardiothoracic Surgery 2024, 19(2):A225
All patients who survive an acute aortic dissection necessitate lifelong, ongoing surveillance of their aortic pathology.
Objectives: The main objective is to assess the adherence to the 2022 ACC/AHA guidelines by evaluating the utilization of post-aortic dissection repair radiological surveillance.
Methods: A retrospective study was designed to collect and analyze data of patients who underwent aortic dissection repair between 2018 and 2020. Data from 54 patients who underwent aortic dissection repair was analyzed. We investigated the proportion of patients undergoing CT scans at various post-discharge intervals, including 1 month, 6 months, 12 months, and annually.
Results: Among the surviving patients (n = 44), the utilization of pre-discharge CT scans was 31.8%, 1-month post-discharge was 18.1%, 6-month post-discharge was 18.1%, 12-month post-discharge was 36.36%, and annual post-discharge was 27.2%. These findings provide insights into the compliance with recommended radiological surveillance intervals.
Conclusions: Survivors of aortic dissection repair remain at risk for long-term complications. Guidelines recommend postoperative imaging surveillance, but from our study we can clearly notice the need for improved adherence to the ACC/AHA guidelines for post-aortic dissection repair radiological surveillance. The suboptimal radiological surveillance while long-term mortality and re-interventions remain substantially high, suggests a potential area for enhancing patient care and long-term monitoring. Further research and initiatives may be necessary to promote better compliance with these guidelines and improve patient outcomes.
A226 Comparative analysis of different perfusion strategies for thoraco-abdominal aorta repair
Ali Shan1, Victoria Rizzo1, Jason Kho1, Franziska Gorke1, Muhammad Ashraf1, Sunaina Mathapati2, Roxanne Noaces1, Amit Chawla1, Morad Sallam1, Michael Sabetai1
1Guy's and St Thomas' Hospital NHS Trust, London, United Kingdom. 2King's College London, London, United Kingdom
Correspondence: Ali Shan
Journal of Cardiothoracic Surgery 2024, 19(2):A226
Objective: We compare outcomes of using Left Heart Bypass (LHB) or full Cardio-Pulmonary Bypass—Deep Hypothermic Circulatory Arrest (CPB-DHCA) in our experience for thoracoabdominal aortic aneurysm repair.
Methods: Retrospective study of patients who underwent repair from 2013 to 2023. Analysed data includes demographics, perfusion strategy and post-procedure complications. Those analysed were 30-day mortality, stroke, permanent neurologic deficit, dialysis requirement and bowel ischemia. Parametric statistics were used for comparisons.
Results: 120 patients were included with average age of 60 years and male predominance (80.8%, 127). 20 (14.4%) patients had connective tissue disorder. Average aneurysm size was 6.8 cm. 25% (30) required LHB whereas 50% (60) of patients required CPB-DHCA. Average LHB time was 187.79 min. Average CPB and DHCA times were 185.02 and 26 min respectively. Overall 30-day survival rate was 93.3% (112). Complication rate was (25, 20.8%), most common being stroke (11, 9.2%), paraplegia (9, 7.5%), post-operative dialysis (5, 4.2%) and bowel ischaemia (4, 3.3%). There was no significant difference between 30-day mortality (p = 0.627, CI 95%) or complication rates (p = 0.899, CI 95%) between LHB and CPB-DHCA cohorts. Prolonged DHCA time was associated with increased complications (p = 0.038, CI 95%). Most significant association of 30-day mortality was with poor pre-operative kidney function (Stage 3 or worse) (rank correlation, p = 0.032, CI95%, ρ(118) = 0.195).
Conclusions: 30-day mortality and complications between these groups was similar. Pre-operative kidney dysfunction is a key risk factor when assessing risk for surgery. Prolonged DHCA time increased risk of complications. However, it had no effect on 30-day mortality.
A227 Using artificial intelligence to predict the progression of ascending thoracic aortic aneurysms: a proof of concept
M Yousuf Salmasi1,2, Maria Comanici2,1, Declan O'Regan1, Sunil Bhudia2
1Imperial College London, London, United Kingdom. 2Harefield Hospital, London, United Kingdom
Correspondence: Maria Comanici
Journal of Cardiothoracic Surgery 2024, 19(2):A227
Background: Guidelines for the intervention on ascending thoracic aortic aneurysms (ATAA) are based only on aortic size as measured from cross-sectional imaging. However, > 40% of type A aortic dissections (TAAD) occur below diameter thresholds. Due to the vast heterogeneity in the pathoanatomy of ATAA, image-based predictive algorithms for risk of TAAD are challenging to produce. Artificial intelligence (AI) has the ability to analyse vast numbers of scans and generate predictive models for aortic dilatation and wall failure.
Methods: Ten patients with serial retrospective cross-sectional images of the aorta (> 3 images) spanning a range of 5–10 years were analysed. Computerised-tomography scans with ECG-gating were used. A standardised pipeline of image-processing and manual identification of the aortic wall slice-by-slice was performed. This allowed for aortic wall segmentation in 3D, followed by surface mesh generation to represent the 3D geometry (software used: DeepVessel® Cardisight, Keyamedical).
Results: Through mesh sequence generation, a basic algorithm predicting future aortic growth over time (ΔT) was executed for each patient. This preliminary study has shown with early deep learning models, there is promise for the generation of convolutional neural networks (CNNs) to automate image segmentation and predict the progression of aortic disease from baseline imaging. When combined with finite element analysis, patient-specific accurate models areas of wall stress maps can also be incorporated.
Conclusion: This study holds promise for the incorporation of thousands of CT aortic images to generate an automated tool for predicting aortic wall shape and mechanical failure (TAAD) in the near future.

A228 Thoracoabdominal aortic surgery: our surgical odyssey
Ali Shan1, Victoria Rizzo1, Franziska Gorke1, Muhammad Ashraf1, Jason Kho1, Sunaina Mathapati2, Roxanne Noaces1, Morad Sallam1, Amit Chawla1, Michael Sabetai1
1Guy's and St Thomas' Hospital NHS Trust, London, United Kingdom. 2King's College London, London, United Kingdom
Correspondence: Ali Shan
Journal of Cardiothoracic Surgery 2024, 19(2):A228
Objective: To describe and analyse our experience as an aortic referral centre for thoracoabdominal aortic aneurysm repairs, of more than a decade.
Methods: Retrospective analysis of prospectively collected data was carried out to include all consecutive adult patients undergoing thoraco-abdominal aneurysm repair (TAAR) operated at a single centre from 2006 to September 2023. Data extracted included demographic data, pre-morbid clinical state, degree of aortic disease, perfusion strategy used, and post-operative complications. Patients who had infected aetiology or TEVAR explants were excluded from the study. Primary measured outcomes were 30-day mortality and major complications including stroke, permanent neurological deficit, renal dysfunction requiring dialysis, and bowel ischemia. All outcomes were measured for patients combined and then further analysed according to their Crawford types.
Results: The total number of patients included in the study was 147 who underwent thoracic aorta or thoracoabdominal aorta repair. The average age was 59.1 years with a male predominance (108, 72.9%). Out of all patients, 29 (19.7%) patients were known to have connective tissue disorder. The majority (84, 57%) of patients had aneurysm without dissection as their pathology. Over all 30-day mortality was 10.2% and the complication rate was 20.4%. The highest mortality and morbidity was associated with Crawford type II (12.1% and 39.3% respectively).
Conclusions: Our results are comparable to other dedicated aortic centres. Mortality and morbidity remain significant, however pathology and surgery is complex. Referral of such cases in specialized centres may improve outcomes.
A229 Avidity of AtriClip device on FDG-PET scans: incidental or infective?
Ashiq Abdul Khader1, Leon Menezes1,2, Christopher Primus1, Neil Roberts1
1Bart's Heart Centre, St Bartholomew's Hospital, London, United Kingdom. 2University College London, London, United Kingdom
Correspondence: Ashiq Abdul Khader
Journal of Cardiothoracic Surgery 2024, 19(2):A229
Objectives: Atriclip left atrial appendage closure devices are important for the prevention of cardioembolic stroke, however their removal for suspected infection is associated with a high risk of circumflex artery injury. FDG positron emission tomography/computed tomography (PET-CT) forms part of the diagnostic work up for infective endocarditis. Avidity of Atriclip on PET-CT is of uncertain clinical significance, therefore we investigated the potential incidental avidity to ascertain if there was false positivity.
Methods: A retrospective analysis of all patients who underwent Atriclip insertion and subsequently had an FDG-PET scan any time postoperatively, in a single institution. Any avidity of Atriclip devices were noted and correlated with any device infection and subsequent removal of Atriclip.
Results: Between 2017 and 2023, 459 patients underwent Atriclip insertion at a single institution, with 8 cases of post-operative FDG-PET scans. Indication for PET included diagnostic work up for suspected cancer or infective endocarditis. There were 4 cases of Atriclip avidity on PET scans, with no cases of proven device infection or removal of device required.
Conclusions: Removal of Atriclip devices for suspected infection is a high risk procedure, which can be dictated by FDG-PET avidity on diagnostic work up. Our retrospective analysis shows possible incidental false positivity of Atriclip avidity, therefore a diagnosis of Atriclip infection due to PET avidity should be interpreted with caution.
A230 Four year follow-up of transbronchial microwave ablation for early lung cancers and lung oligometastases
Joyce Chan1, Aliss Chang1, Ivan Siu1, Rainbow Lau1, CM Chu2, Tony Mok3, Calvin Ng1
1Division of Cardiothoracic Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, Hong Kong. 2Department of Imaging and Interventional Radiology, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong, Hong Kong. 3State Key Laboratory of Translational Oncology, Department of Clinical Oncology, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong, Hong Kong
Correspondence: Joyce Chan
Journal of Cardiothoracic Surgery 2024, 19(2):A230
Objectives: Transbronchial microwave lung ablation has been a novel local therapy for early lung cancers and lung oligometastases in selected patients, who typically has high surgical risks or suffers from multifocal cancers. This is a single institute retrospective review of the 4-year result of transbronchial microwave ablation using electromagnetic navigation bronchoscopy guidance in the hybrid operating room.
Methods: Between March 2019 and September 2023, 194 nodules in 128 patients were treated. Eligible lung nodules were either proven lung cancers, metastases, or radiologically suspicious. Safety and mid-term control rate of the technique were assessed.
Results: Mean maximal diameter of lung nodules was 12 mm (range 6-29 mm), and bronchus sign was positive in 28.4% of them. Technical success rate was 100%, although 85 (43.8%) nodules required double ablation and 22 (11.3%) required triple or more ablation for adequate coverage. Mean minimal ablation margin was 6.2 mm. Mean hospital stay was 1.55 days, 150 cases (77.3%) and 186 cases (95.9%) were discharged by post-ablation day 1 and 3 respectively. Complications included mild pain which did not require hospitalization (8.7%), pneumothorax requiring drainage (4.1%), post-ablation reaction (3.1%), pleural effusion (2.1%) and hemoptysis (2.1%). Mean follow up for all cases is 24.6 months. For the 131 nodules which had completed at least 1-year follow up computer tomography scan, 7 had complete response, 82 had partial response, 30 had stable disease, and 12 (9.2%) had local recurrence.
Conclusions: Transbronchial microwave ablation is a safe and novel ablative technique, and has encouraging mid-term local control rate.

A231 High intensity statin therapy as secondary prevention post coronary artery bypass graft (CABG) surgery
Gentjan Jakaj, Alice Mines, Alia Noorani
King's College Hospital, London, United Kingdom
Correspondence: Alice Mines
Journal of Cardiothoracic Surgery 2024, 19(2):A231
Objectives: To audit the prescription of high-intensity statin therapy in patients with coronary artery disease undergoing surgical revascularisation, as well as ensuring pre-operative and post-operative cholesterol monitoring, in line with the national standards of practice described in NICE guidelines.
Methods: A retrospective audit of 100 consecutive patients undergoing coronary artery bypass grafting surgery was undertaken. Standards audited were prescription of high-intensity statin, pre-operative cholesterol check and post-operative discharge instructions to primary care for follow up of lipid profile. Data was collected from electronic ward notes, drug charts and discharge letters.
Results: The first cycle of this audit revealed poor compliance against the audit standards. Only 33% of patients were prescribed appropriately aggressive lipid-lowering therapy. Similar levels of compliance (34%) were found with the number of patients discharged with instructions for primary care lipid profile follow-up. An electronic prescribing bundle, pre-operative blood screening panel and discharge proforma were created and disseminated to the clinical ward team. A prospective re-audit cycle of 100 patients occurred 3 months later, revealing improvement in all three categories—appropriate statin prescribing rose from 33 to 96%, pre-operative lipid screening occurred in 92% (increased from 80%), and follow-up lipid profile instructions were sent to the GP in 94% (increased from 34%).
Concluions: Such stark improvements in compliance are a testament to the available benefits of online electronic patient records and the innovative use of automated templates and proformas to ensure guidelines are executed successfully for enhanced patient care, with minimised room for human error.
A232 Pharmacotherapy surveillance post aortic dissection repair: adherence to ACC/AHA guidelines
Shashi Kumar Kallikere Lakshmana, Alessia Marigliano, Shawn Britto, Sanjay Asopa
University Hospital Plymouth, Plymouth, United Kingdom
Correspondence: Alessia Marigliano
Journal of Cardiothoracic Surgery 2024, 19(2):A232
Objectives: The objective of this study is to review the compliance of pharmacotherapy management in patients with post Aortic Dissection Repair, as outlined in the 2022 ACC/AHA Guidelines.
Methods: We analyzed a dataset of 42 patients with aortic dissection to assess the prescription rates of different medications and the subsequent patient outcomes. Among these patients, 95% were discharged on beta-blockers (BB), 36% were prescribed ACE inhibitors (ACEi) and/or angiotensin receptor blockers (ARBs), with 26% on ACEi and 9.5% on ARBs. Statins were prescribed to 32% of the patients. Only 2% received medical advice regarding blood pressure (BP) and lifestyle management, while 2% had no documentation of pharmacotherapy. There were 10 recorded deaths.
Results: The data indicates that beta-blockers are the most commonly prescribed medication for aortic dissection, with a high utilization rate of 95%. ACE inhibitors and ARBs are less frequently used, with 36% of patients receiving these medications, and a notable discrepancy between ACEi (26%) and ARB (9.5%) prescriptions. Statins were prescribed to 32% of the patients, potentially indicating their role in the management of aortic dissection. A mere 2% of patients received medical advice for BP and lifestyle management, highlighting the need for increased attention in this area. Furthermore, 10 documented deaths emphasize the severity and complexity of aortic dissection cases.
Conclusions: The data suggests that beta-blockers are the primary pharmacotherapy for aortic dissection, with a relatively lower utilization of ACE inhibitors, ARBs, and statins.
A233 Understanding patient’s experiences and their involvement in treatment decision-making for early-stage non-small cell lung cancer
Hemangi Chavan1,2, Janelle Yorke2, Sorrell Burden2
1Royal Brompton Hospital, London, United Kingdom. 2University of Manchester, Manchester, United Kingdom
Correspondence: Hemangi Chavan
Journal of Cardiothoracic Surgery 2024, 19(2):A233
Background: Surgical treatment remains the gold standard in early-stage non-small cell lung cancer. It offers overall survival benefits, either on its own or as a part of multimodality treatment. Managing early-stage non-small cell lung cancer requires increasingly complex decision-making by healthcare professionals. This study aimed to explore patients' experiences and involvement in treatment decision-making for early-stage non-small cell lung cancer using a qualitative pragmatic approach.
Methods: Total twenty-four participants, 47 transcripts were included for data analysis, from patients and their healthcare professionals. Participants were recruited from two centres- surgical and oncology. Reflexive thematic analysis methods were used to analyse the data.
Results: The synthesis of the key findings is discussed in three overarching themes. These are ‘Dilemmas in treatment options and treatment decision-making process’, 'Information sources and systemic barriers to treatment decision-making', and 'Deliberation and strategies to improve treatment decision-making'. The study shows the complexity of treatment decision-making in early-stage non-small cell lung cancer. Currently, shared decision making is not often used in practice. Instead, consultations focused on informing MDT recommendations, gathering information, and consenting to the procedure. Patients' preferences, values, alternative options, and long-term treatment outcomes were not explicitly discussed. Patients preferred professionals to facilitate treatment decisions by presenting the information clearly and comprehensively.
Conclusion: Findings highlight the need to adopt a patient-centred approach, provide emotional support throughout the treatment process, and acknowledge their values in treatment decision-making.
A234 Surgical access for TAVI- ten year experience from a specialist centre
Anan Daqa1, Ricky Vaja1,2, Simon Davies1, Mark Boyle1, Joanne Shannon1, Alison Duncan1, Mario Petrou1, Ulrich Rosendahl1, Rashmi Yadav1, Cesare Quarto1
1Royal Brompton Hospital, London, United Kingdom. 2National Heart & Lung Institute, London, United Kingdom
Correspondence: Anan Daqa
Journal of Cardiothoracic Surgery 2024, 19(2):A234
Introduction: Percutaneous femoral access for TAVI is now routinely used by most centres and is associated with low morbidity and mortality. However, patients who are not anatomically suitable for this approach may require alternative invasive surgical access. Here we present our 10 year experience from a single centre.
Methods: Data was retrospectively analysed from prospectively collected data from a single centre between March 2013 and September 2023. All patients were discussed in an MDT and the procedure was performed by both a cardiologist and cardiac surgeon.
Results: In total 112 patients requiring planned surgical access were identified of which 70 (62.5%) were male. The mean age was 78.3 years with a mean logistic Euroscore of 21.7. Surgical access routes included: femoral n:21 (18.8%), axillary/subclavian n:27 (24.1%), transapical n:31 (27.7%), direct aortic n:22 (19.7%) and carotid n:22 (19.7%). The valve was successfully deployed in 109 patients (97.3%). Elective cardiopulmonary bypass was used in 8 patients (7.1%) and 4 (3.6%) required emergency use. Major bleeding occurred in 3 (2.7%) patients and the mean number of red cells transfused was 2.3 units. Two patients required full sternotomy, 1 for major bleeding and 1 needed bypass grafting due to coronary obstruction. Six patients (5.4%) died in hospital and 3 patients had a stroke (2.7%). Seventeen patients (15.2%) required a permanent pacemaker and 5 patients (4.5%) required renal replacement therapy.
Conclusion: In this extremely high risk population, alternative surgical access routes for TAVI can safely be performed with low morbidity and mortality.
A235 Total endovascular aortic arch repair: is it for everyone and where is its evidence?
Mariam Hussain1, Matti Jubouri1, Mohammed Al-Tawil2, Sven Z Tan3, Mohamed Bashir4, Alexander Georgotellis5, Bashi Velayudhan6, Idress Mohammed6
1Hull York Medical School, York, United Kingdom. 2Al Quds Univerisity, Jerusalem, Palestine. 3Barts and London School of Medicine, Queen Mary University, United Kingdom. 4Velindre University Trust, Cardiff, United Kingdom. 5University of Cape Town, Cape Town, South Africa. 6SRM Insitutes for medical sciences, Chennai, India
Correspondence: Mariam Hussain
Journal of Cardiothoracic Surgery 2024, 19(2):A235
Background: Open total arch replacement (TAR) remains the mainstay management strategy for thoracic aortic arch pathologies. TAR evolved from the 2-stage conventional elephant trunk (CET) technique to the hybrid frozen elephant trunk (FET) which combined open surgical repair (OSR) with thoracic endovascular aortic repair (TEVAR) into a 1-stage procedure. Although FET has been able to achieve better outcomes than CET, it is still associated with complications requiring secondary reintervention. Consequently, FET is being overtaken by new generations of TEVAR devices for endoarch repair. Total endoarch repair (TER) is currently indicated in patients deemed high-risk for open surgery; however, it has shown strong potential for becoming the gold standard treatment for aortic arch pathologies. Therefore, this review aimed to highlight the evolution of aortic arch repair, focusing on TER device development, intervention criteria, and clinical outcomes.
Methods: A comprehensive literature search of various databases (PubMed, Google Scholar, EMBASE, Scopus, and ResearchGate) was conducted and papers published as of July 2023 were included.
Results: Upon comprehensively searching the literature, the technical success of TER ranged from 91%-100%, mortality 0%-19%, stroke 0%-16.7%, and reintervention 0%-30.3%, using different commercially available endografts.
Conclusion: TER represents the future of aortic arch repair with comparable clinical outcomes to FET. Given its novelty, further studies with larger cohorts and longer follow-up periods are necessary. Additionally, studies directly comparing arch OSR to TER are warranted to determine superiority.
A236 Minimally invasive aortic valve replacement: preoperative factors predicting technical difficulty
Alexandru Visan1, Andrew Goodwin1, Enoch Akowuah2
1James Cook University Hospital, Middlesbrough, United Kingdom. 2South Tees Hospitals NHS Foundation Trust, Middlesbrough, United Kingdom
Correspondence: Alexandru Visan
Journal of Cardiothoracic Surgery 2024, 19(2):A236
Objectives: Minimally invasive aortic valve replacement (AVR) continues to be an efficient treatment option in isolated aortic valve lesions. Our objective was to establish factors predicting the rate of conversion to conventional sternotomy and the technical difficulty of the procedure.
Methods: This was a single-centre and retrospective study. Data was collected from one operator in order to minimise performance bias. All procedures were performed through a mini-sternotomy to the 2nd intercostal space. CT measurements were collected in accordance with previously published preoperative CT planning tools (aortic diameter, depth, distance of valve from incision). Cross-clamp times and need for conversion to sternotomy were used as surrogate markers for the operative technical difficulty.
Results: 314 procedures were performed between September 2012 and September 2023. 33 cases (10.5%) were converted to sternotomy. There were five in-hospital deaths (1.6%). The median follow-up time was 6.9 years [IQR 4.4–9.8]. Median cardiopulmonary bypass time was 72.0 min [IQR 64–85] and median cross-clamp time 55.5 min [IQR 49–64]. In simple linear regressions, BMI, and both components of the BMI independently were found to be strong predictors for an increase in the cross-clamp times (β 0.46, p < 0.001), but were not associated with an increase in the rate of conversion. CT measurements were not shown to be predictive of conversion.
Conclusions: Minimally invasive AVR is a safe procedure with a relatively short learning curve. Although BMI was associated with an increase in cross-clamp times, higher BMI did not lead to a higher risk of conversion in our study.

A237 Surgical resection following neoadjuvant chemoimmunotherapy: an early single-centre experience
Akshay Patel, Eleni Josephides, Eleni Karapanagiotou, Harman Saman, Alex Georgiou, Andrea Bille
Guy's Hospital, London, United Kingdom
Correspondence: Akshay Patel
Journal of Cardiothoracic Surgery 2024, 19(2):A237
Objective: Checkpoint blockade treatment has transformed the paradigm of managing resectable stage III non-small cell lung cancer (NSCLC). Randomised controlled data has demonstrated efficacy in the neoadjuvant setting both in terms of overall and event-free survival.
Methods: We conducted a single-centre retrospective case-series analysis over a 4-year period. We collected all demographic, histopathological and outcome data in the short-term period.
Results: Twenty-seven patients underwent induction treatment prior to surgical intervention during the study period (10 were salvage surgery (pre-2022) and 17 were following downstaging neoadjuvant immunotherapy). Twenty-five patients underwent combination chemoimmunotherapy and 2 underwent anti-PD-1 monotherapy. The median age of the cohort was 66 with a strong male preponderance (67%). The majority of these cases were for primary lung cancer (NSCLC) (n = 23). Resection strategy was primarily minimally invasive (robotic assisted (n = 19), VATS (n = 3)) and 5 cases were performed open. There were 3 elective conversions in the robotic subgroup due to invasion of the pulmonary artery mandating vascular sleeve. Bronchial sleeve was required in 4 cases. Median operating time and length of in-hospital stay was 112 min (40–300) and 4 days (4–18) respectively. All cases except one were R0 resections [AP1]. There were no recorded in-hospital deaths in this cohort.
Conclusions: Lung cancer resection post-chemoimmunotherapy is technically demanding surgery owing to adhesions, increased vascularity, and friable native tissues. We have demonstrated safety and feasibility of the minimally invasive robotic approach in this complex group of patients, however long-term follow-up data is still awaited.
A238 Advanced thymic epithelial tumour resection: single centre experience
Akshay Patel1, Eleni Josephides1, Eleni Karapanagiotou1, Daniel Smith1, Paolo Bosco2, Gianluca Lucchese2, Rajdeep Bilkhu2, Andrea Bille1
1Guy's Hospital, London, United Kingdom. 2St Thomas' Hospital, London, United Kingdom
Correspondence: Akshay Patel
Journal of Cardiothoracic Surgery 2024, 19(2):A238
Objective: Complete surgical resection of Thymic epithelial tumours (TET) is a key factor in determining long-term overall survival and recurrence. In advanced stage disease however, a multi-modality approach is requisite for achieving long-term disease control. Herein, we present our experience of dealing with stage IV TETs.
Methods: We conducted a single-centre retrospective case-series analysis over a 10-year period (2012–2022). We collected all demographic, histopathological and outcome data at long-term follow-up.
Results: We identified 198 patients who had undergone resection for TET, this cohort had a slight male preponderance (53%), with a median age of 63 (19–86). Thirteen patients (7%) of our cohort were thymic carcinomas. Within the entire cohort, 25 patients were advanced stage TET (TNM 3 and above), all of whom underwent induction treatment followed by surgical resection. All underwent open procedures, employing extrapleural pneumonectomy (EPP) in 5 cases. Major vessel reconstruction was required in 13 cases (SVC and innominate vein), chest wall resection in 5 cases and diaphragm resection in 12 cases. Median operating time was 200 min (120–600). Post-operative histology confirmed thymoma (B2/B3) (n = 23) and thymic carcinoma (n = 2). Long-term follow-up at 4 years has demonstrated an 83% overall survival rate in the entire cohort.
Conclusions: Our experience with stage IV TETs over ten years reveals that an integrated treatment strategy, combining induction therapy with surgery, leads to notable long-term survival rates, despite the surgical complexity of extensive reconstructions required. Further prospective data is warranted to evaluate the outcomes of surgical techniques in this complex and heterogeneous pathology.
A239 Exploring risk factors for acute kidney injury in patients undergoing cardiac surgery
Megha Bhandari, Esther Abelian, Rushmi Purmessur, Jason Ali
Royal Papworth Hospital, Cambridge, United Kingdom
Correspondence: Megha Bhandari
Journal of Cardiothoracic Surgery 2024, 19(2):A239
Background: Acute Kidney Injury (AKI) is an important complication following cardiac surgery that has been associated with adverse outcomes. The aim of this work was to investigate the incidence and risk factors for AKI in patients undergoing cardiac surgery at our centre.
Methods: This is a retrospective analysis of 1441 patients who underwent elective or urgent (but not emergency) cardiovascular surgery with use of cardiopulmonary bypass over a 1-year period. Our exclusion criteria were heart transplant, single CABG, congenital repairs or patients on dialysis or renal transplant pre-operatively. Data analysis was performed in R studio.
Results: The mean age of the patients was 67.7 years. Mean creatinine from a 7-day period before surgery was 90 µmol/L compared with the mean peak post operative creatinine of 127 µmol/L (95% CI 33–42, p-value < 0.05). As defined by the KDIGO AKI stages, 27% developed a AKI stage 1, 11% developed AKI stage2 and 1% AKI stage3.
The following variables correlated strongly (P-value < 0.001) with post-operative risk of AKI: The comorbidities of diabetes, smoking, and peripheral vascular disease; pre-operative medications: diuretics, calcium channel blockers and SGLT-2 inhibitors and receiving FFP or RBC transfusion postoperatively.
Conclusion: AKI is a common complication following cardiac surgery. Having an insight into the risk factors for AKI allows an opportunity for intervention preoperatively and can also highlight patients that may require extra vigilance in the perioperative period to reduce its incidence, which may lead to an improvement in outcomes following surgery.
A240 Reoperative mitral valve surgery in the UK: 20-year trends and outcomes
Luke J Rogers1, Tim Dong2, Rahul Kota2, Jeremy Chan2, Saifullah Mohamed1, Franco Ciulli1, Gianna Angelini2,1, Daniel Fudulu2,1
1Bristol Heart Institute, Bristol, United Kingdom. 2University of Bristol, Bristol, United Kingdom
Correspondence: Luke J Rogers
Journal of Cardiothoracic Surgery 2024, 19(2):A240
Introduction: The incidence of reoperative mitral valve (RMV) surgery appears to be increasing alongside the comorbidity of patients undergoing surgery. This study reports UK trends and outcomes following RMV surgery.
Methods: We retrospectively analysed consecutive patients who underwent primary MV surgery (PMV) (n = 46,385) and RMV surgery (n = 1206) between 1/11/1996 and 30/03/2019 using data from the National Adult Cardiac Surgery Audit (NACSA). We compared clinical and procedural characteristics between PMV and RMV surgery and used mixed effects models to investigate several outcome predictors and the effect of re-do mitral valve surgery on outcomes. Youden’s index was used to calculate the threshold of risk factors associated with mortality.
Results: There was a steady, yearly increase in the number of PMV and RMV coupled with a decreased operative mortality. Redo-MV operations accounted for 1,206 (2.5%), and the majority of these procedures were replacements 1,167 (97%). RMV was associated with significantly increased mortality (13% vs 5.2%), dialysis (14% vs 5.2%), cerebrovascular event (2.4% vs 1.2%), return to theatre for bleeding (8.3% vs 5.3%) and increased median length of stay (15 va 11 days) compared to primary MV repair (all P < 0.001). Age > 70 years (OR 2.0), kidney disease (Cr > 110) (OR 2.3), peripheral vascular disease (OR 2.0) and prolonged cross-clamp time (> 115 min) (OR 2.7) were associated with increased mortality (all P < 0.005) in RMV.
Conclusion: Mitral valve surgery is increasing in the UK. Reoperative mitral valve surgery is associated with increased in-hospital mortality and morbidity; however, we noted trends in decreased yearly mortality.

A241 Using Edwards Sapien 3 transcatheter aortic valve for mitral valve replacement; a safe alternative in high risk patients
Mahmud Yusuf, Ricky Vaja, Marina Cannoletta, Ahmed Elfadil, Sameer Thakur, Shashi Lakshmana, Anthony De Souza, Mario Petrou, Ulrich Rosendahl, Cesare Quarto
Royal Brompton Hospital, London, United Kingdom
Correspondence: Mahmud Yusuf
Journal of Cardiothoracic Surgery 2024, 19(2):A241
Introduction: Mitral annular calcification (MAC) constitutes a challenge during mitral surgery. Various techniques have been described and yet there is no standard surgical consensus. Furthermore, patients requiring re-do mitral surgery who are deemed high risk also pose a clinical challenge. We provide our experience of using an alternative approach.
Method: We present a case series between February 2019 to June 2023 using Edwards Sapien 3 Transcatheter Aortic Valves in the mitral position for patients with severe MAC via median sternotomy (n:4), (3 of these patients underwent concomitant AVR) or patients requiring re-do mitral surgery who were deemed unfit for re-do surgery using a trans-apical approach (n:3). All patients were discussed in a heart valve MDT prior to operation and data was prospectively collected.
Results: In total there were 3 male patients (42.9%) and the average age was 63.1 years. Mean Euroscore was 5.1. The procedure was successful in all patients with no 30-day mortality. During a mean follow up duration 12.9 months (range 3 to 46 months), there was 1 death at 20 months. There were no post-operative neurological complications and no need for mechanical support. Two patients had mild paravalvular leak and 1 patient required a permanent pacemaker. The mean length of hospital stay was 10 days.
Conclusion: Using Edwards Sapien 3 Transcatheter Aortic Valves for mitral valve replacement offers a feasible alternative strategy for patients with MAC as well as patients who are high risk for redo surgery with favourable short- and medium-term outcomes.
A242 Long- and mid-term experience with one-and-a-half ventricle repair for ebstein anomalies of the tricuspid valve
Ahmed ElSherbini1,2, Francesca Bartoli-Leonard2, Muhammad Mustafa3, Andrew Tometzki1, Shafi Mussa1, Serban Stoica1,2, Conal Austin3, Andrew Parry1, Massimo Caputo1,2
1University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom. 2University of Bristol, Bristol, United Kingdom. 3Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
Correspondence: Ahmed ElSherbini
Journal of Cardiothoracic Surgery 2024, 19(2):A242
Background: Ebstein Anomaly (EA) management lacks established guidelines. This study explores the mid and long-term outcomes of one-and-a-half ventricle repair (1.5VR) at two medical centres.
Methods: The study identified all patients who underwent 1.5VR for EA, excluding those with concomitant heart defects except atrial septal defects (ASD).
Results: Out of 344 EA patients, 18 underwent 1.5VR. Their mean age at surgery was 12.1 years (range, 3.6 month–64.4 years), with a mean weight of 26.1 kg (range, 4.10–100 kg). Fifteen patients had 1.5VR as their initial procedure, while three required Blalock-Taussig Shunts due to desaturation at neonatal period. Six patients needed concomitant Tricuspid Valve Repair (TVR), and five later. ASD closure was performed in six patients during 1.5VR and in three patients at the time of TVR. The average intensive care stay was three days (ranging from 1 to 9 days), with one patient experiencing jugular vein thrombosis requiring readmission at day 8 post-operatively. No early or late mortalities were observed during a median follow-up of 15.1 years (ranging from 3 to 34 years).
Post-operatively and during long-term follow-up, MRI and echocardiography showed significant improvements in right and left ventricle dimensions, volumes, and functions. These improvements were also reflected in improved functional status based on the NYHA class and reduced VEVCO2 in cardiopulmonary exercise tests.
Conclusion: 1.5VR is associated with symptom improvement and increased exercise capacity in EA patients. More comprehensive studies are needed to deepen our understanding of ventricular dynamics and pathophysiology, enabling more precise surgical strategy selection.
A243 Impact of in-hospital smoking cessation program implementation on hospital stay duration and post-discharge follow-up outcomes; two centres study
Mohamed Elshalkamy, M Yousuf Salmasi, Anikin Vladimir, Finch Jonathan, Emma Beddow, Nizar Asadi
Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
Correspondence: Mohamed Elshalkamy
Journal of Cardiothoracic Surgery 2024, 19(2):A243
Objective: Current smokers who undergo thoracic surgery, including lung cancer patients, pose a significant challenge to perioperative management as well as long-term outcomes. We have recently implemented a nurse-led service to identify, advise, and prescribe nicotine replacement (NRT) for current smokers undergoing thoracic procedures.
Methods: A retrospective analysis was conducted on a cohort of patients who underwent thoracic surgery over a six-month period comparing results before and after implementation of in-hospital smoking cessation program (IHSCP) (Aug-Nov 2022 vs. May-Aug 2023).Patient smoking status was documented, and outcomes of the program on hospital stay were measured.
Results: 1210 patients underwent thoracic procedures, 549 patient before implementation (Group A) and 661 patient after implementation (Group B) of IHSCP.
From Group B, 75% of smoking patients were identified in time prior to surgery and advised on smoking cessation. 10 refused NRT (6 of whom refused to cease smoking altogether). 4 patients agreed to smoking cessation but never received NRT.
From Group B, 50% of smokers successfully received NRT. Regarding hospital stay, patients in Group A had an average of 7.4 ± 9 days, whilst Group B had an average of 6.1 ± 7 days, although this difference was non-significant (p > 0.05).
Conclusion: IHSCP is effective among thoracic surgery patients. This outcome holds promise for reducing smoking prevalence across the UK and aligns with the NHS's commitment to cut down the number of smokers in the country. Future study needs to be conducted on a larger number of patients to confirm potentiality to reduce hospital stay.
A244 A new multidisciplinary lung cancer One Stop Clinic (OSC) in a large tertiary referral centre has led to a strongly positive impact on treatment pathways for high-risk patients
Linda Kimani, Hanan Hemead, Florentina Popescu, Marcus Taylor, Paula Ellacuria, Jonathan Hiu, Siobhan Keegan, Felice Granato, Matthew Evison, Kandadai Rammohan
Manchester University NHS Foundation Trust, Manchester, United Kingdom
Correspondence: Linda Kimani
Journal of Cardiothoracic Surgery 2024, 19(2):A244
Objectives: Only 50% of patients with lung cancer began treatment within the 62-day target in 2022 (Q4) (Office of National Statistics). Our ‘one stop clinic’ (OSC) was developed in conjunction with the Regional Cancer Network. It brings together surgeons, oncologists, respiratory physicians, anaesthetists, oncogeriatricians, Prehab4Cancer, Macmillan and smoking cessation teams to aid decision making for high risk patients in one appointment. The referral criteria include PPO FEV1/DLCO < 40%,PS > / = 2,frailty > 5, pneumonectomy, interstitial lung disease.
Methods: OSC patients between July 2022 and October 2023 were reviewed. The median time (IQR, Range) from referral acceptance to decision to treat (DTT), treatment outcome, median time from DTT to treatment and on day decisions were reported. 30 and 90 day mortality were compared by treatment.
Results: 86% of 331 clinic patients decided on treatment on the day. Median time from referral to DTT was 5 days (IQR 4, 0–39) a time saving of 30 days when compared to our pre-one stop cohort (35 days). The median time to commencing treatment from DTT was 28 days (IQR 13, 0–161). 100% of patients were screened for tobacco dependency, frailty, prehab and nutrition.
40% (133/331) of patients had surgery. 30 day survival was 96% and 94.4% at 90 days. In the nonsurgical cohort, 85.4% had radiotherapy, 1.5% chemoradiotherapy and 13.1% best supportive care/surveillance. All the non-surgical cohort survived 30 days, 90 day survival was 99.3%.
Conclusion: The centralized OSC has significantly improved treatment pathways for high risk lung cancer patients while offering a holistic approach.
A245 Preoperative high-risk anaesthetic review pathway: is it necessary and does it prolong patient waiting times in elective surgery?
Chiemezie Okorocha, Shaun Stone, Shahida Liaqat, Ashvini Menon, Vanessa Rogers, Hazem Fallouh, Robin Wotton, Maninder Kalkat, Sajith Kumar, Babu Naidu
Queen Elizabeth Hospital, Birmingham, United Kingdom
Correspondence: Chiemezie Okorocha
Journal of Cardiothoracic Surgery 2024, 19(2):A245
Objectives: With NHS waiting times reaching record highs since 2016 [1], and cancer treatment targets hitting record lows [2], innovation is favourable in reducing NHS waiting lists and on-the-day cancellations [3, 4].
Preoperative high-risk anaesthetic review pathways (HRA) are the norm but are they essential and do they unnecessarily prolong waiting times in elective surgery?
Methods: 40 patients who attended consultant-led HRA clinic over 3 months in 2023 were analysed. Patient characteristics were mapped against local published criteria for referrals. The outcome of the review from proceeding to surgery to cancellations were recorded.
Results: The median age of the patients was 72.5 years (IQR 16).
The procedures included airway interventions, lung cancer resections, lung volume reduction surgery, tracheal and chest wall resections with reconstruction.
Of the patients referred on to the HRA pathway 36/40 had clear indications for referral.
34 patients proceeded with surgery, 4 required further investigations prior, 1 patient was deemed too high risk for surgery and 1 patient declined surgery. No patients underwent further optimisation.
Table 1 highlights the median time intervals of all patients seen and referred onto HRA clinic.
Conclusions: The HRA review is useful in the shared decision-making process of patients’ care; evidenced by the significant number (15%) who avoided surgery altogether.
For cancer patients, HRA review was feasible without significantly extending the patient pathway; but further improvements are required to consistently achieve 28-day targets to treatment.
References
- [1]
https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/
- [2]
https://www.england.nhs.uk/statistics/statistical-work-areas/cancer-waiting-times/
- [3]
O’Dowd, A. (2023) BMJ: 381, p1083.
- [4]
Limb M. BMJ. (2023) bmj.o2455

A246 Impact of the introduction of a multi-disciplinary clinic (“One-Stop Clinic”) on the outcomes of high risk patients with resectable Non-Small Cell Lung Cancer (NSCLC): a single centre experience
Hanan Hemead, Florentina Popescu, Linda Kimani, Matthew Evinson, Kandadai Rammohan, Siobhan Keegan, Marcus Taylor, Felice Granato
University Hospital of Manchester, Manchester, United Kingdom
Correspondence: Hanan Hemead
Journal of Cardiothoracic Surgery 2024, 19(2):A246
Introduction: The last National Lung Cancer Audit (NLCA) report shows worsening performance status (PS) of patients with resectable NSCLC. Longer life expectancy with subsequent increased frailty and comorbidities have increased surgical referrals of high-risk patients. Several studies showed higher mortality and morbidity in this cohort. One-stop clinic (OSC) is a comprehensive service aiming to improve outcomes of high-risk patients with NSCLC (Fig. 1).
Methods: We conducted a retrospective comparative analysis of the post-operative outcomes (90-day mortality and length of hospital stay, LOS) of patients operated from 01/07/22 to 14/7/2023. Patients were divided in: high-risk (HR) group and non-high risk (NHR). Groups were matched for age and stage. Criteria for HR included: BMI < 20, postoperative predicted FEV1/DLCO < 40, interstitial lung disease, frailty score > 5, PS 2, and proposed pneumonectomy.
Results: 271 patients were identified in HR group and 92(34%) underwent surgery. A matched cohort (n = 92) for age and stage were identified in the NHR group. The mean LOS was 6.7 days in HR compared to 6 days in NHR (p = 0.99). Three patients died in the HR compared to two in NHR cohort (p = 0.98).
Conclusion: The implementation of OSC resulted in insignificant difference of LOS and mortality in HR compared to NHR group despite higher surgical and physiological complexity of the HR group. These results demonstrate the importance of selection and optimisation of HR patients within a multidisciplinary clinical environment to ensure optimal outcomes. Further research is needed to compare long-term outcomes of HR patients undergoing surgical and non-surgical management.

A247 Validation of days alive and out of hospital as an outcome measure after coronary artery bypass graft surgery and acute coronary syndrome
Robert Grant1,2, Weiqi Liao1, Joanne Miksza1, Marius Roman1,2, Gavin Murphy1,2
1University of Leicester, Leicester, United Kingdom. 2Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
Correspondence: Robert Grant
Journal of Cardiothoracic Surgery 2024, 19(2):A247
Objectives: ‘Days alive and out of hospital’ (DAOH) is a composite outcome measure that integrates death, hospital length-of-stay, and hospital readmission.
We determined the median DAOH at 90 days (DAOH90), 180 days (DAOH180), and 365 days (DAOH365) for patients admitted with acute coronary syndrome (ACS) and coronary artery bypass graft (CABG) surgery.
Methods: Retrospective cohort study. In total 565,378 ACS and 95,299 CABG patients in England were identified between 01/04/2010 – 31/03/2015 from HES data.
Results: The median DAOH90, DAOH180, DAOH365 for ACS was 84 (75 – 87), 171 (142 – 176), and 353 days (295– 361) respectively, with corresponding one-year MACE rates of 18.6%, 11.3%, and 9.39%. A range of ± 2 days from the median ACS DAOH90 resulted in a range of MACE from 14.8 – 22.5%. Similarly a range of ± 4 days in ACS DAOH180 resulted in a range from 6.24 – 15.3%. A range of ± 8 days in ACS DOAH365 resulted in a range from 2.30 – 13.4%.
The median DAOH90, DAOH180, DAOH365 for CABG was 81 (74 – 83), 171 (163 – 173) and 355 days (346 – 358) respectively, with corresponding one-year MACE rates of 4.39%, 3.62%, and 2.92%. A range of ± 2 days from the median CABG DAOH90 resulted in a range of MACE from 2.35%—6.62%. Similarly, a range of ± 4 days CABG DAOH180 resulted in a range from 1.31%—8.20%. A range of ± 8 days CABG DAOH365 resulted in a range from 0 – 11.49%.
Conclusion: This descriptive data should aid trialists considering DAOH as an outcome in ACS and CABG populations.
A248 A stitch in time saves more than nine: a quality improvement project reducing the burden on community care without impacting patient safety
Sophie Majoe, Stylianos Gaitanakis, Douglas Miller, Thomas Sullivan, Rakesh Krishnadas, Igor Saftic, Doug West, Eveline Internullo
Bristol Royal Infirmary, Bristol, United Kingdom
Correspondence: Sophie Majoe
Journal of Cardiothoracic Surgery 2024, 19(2):A248
Objectives: Chest drains are standard practice after Thoracic procedures. Currently, removal of the non-absorbable “purse-string” suture is required 7–10 days after drain removal, typically performed at a GP practice, incurring time and costs to the healthcare system. Use of barbed sutures allow for removal and closure of drain sites without requiring this subsequent appointment. This quality improvement project aims to compare our current standard technique of closing and securing the chest drain site after thoracic procedures with a barbed sutures technique.
Methods: Patients undergoing VATS procedures were non-randomly distributed to use of standard practice with non-absorbable purse-string or barbed suture. We collected information regarding wound complications after drain removal. Subjective data with regards to ease of removal and education was collected via questionnaire from nursing staff involved in drain removal. Costs were estimated using National Health Service tariffs and procurement cost.
Results: There were 44 patients in the standard care group with 39 in the barbed suture group. There were no statistically significant differences regarding wound complication after drain removal (Table 1). Feedback from nursing staff showed that the barbed technique is easier for drain removal and requires one nurse vs two for the standard technique. Despite being more expensive at £20 each, the barbed suture group proved more cost effective due to lack of requiring GP practice nurse appointments at £160.
Conclusion: The use of barbed sutures after thoracic surgery is a technique that utilises less resources without compromising patient safety, proving advantageous for follow up and community care.
A249 Cold Hemagglutinin Disease (CHAD) manifesting during cardiac surgery: a case report
Andrea D'alessio, Ali Ansaripour, Joshua Oliver, Charles Chan, Vivek Srivastava
Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
Correspondence: Andrea D'alessio
Journal of Cardiothoracic Surgery 2024, 19(2):A249
A 74-year-old male presented for elective mitral and tricuspid valve with a background of staged PCI to LAD and LCx. On preoperative assessments, there was only minor non-specific anaemia (haemoglobin 113 g/L) with no evidence of bleeding or clotting abnormalities or other cause for anaemia. Following initiation of cardiopulmonary bypass, systemic cooling was commenced targeting 34℃. And cold blood cardioplegia at 4℃ was delivered. Standard left atriotomy was performed and clumps of blood were noted in the left atrium and left ventricle. ACT was confirmed to be in range. A sample of blood from the CPB was collected and exposed to ice demonstrating clumps and raising a suspicion of cold agglutinins. The patient was rewarmed to 37℃, subsequent doses of cardioplegia were used as warm and the heart chambers were washed out. MV repair and TV repair were carried out uneventfully. And the patient made an uncomplicated recovery with discharge on the 5th post operative day. Formal haematology consultation and positive direct antiglobulin test confirmed CHAD. CHAD is a form of autoimmune haemolytic anaemia where IgM autoantibodies against red blood cells, triggered by low-temperature, lead to their agglutination and lysis. CHAD can have severe consequences during cardiac surgery and, modification of surgical techniques should be adopted. However preoperative testing for CHAD is not routine due to low incidence (0.3%) in cardiac surgery, In this patient, keen vigilance for abnormal findings led to identification of CHAD intraoperatively and prompt modification of operative techniques averted potential complications of CHAD.
Patient gave their written, informed consent to publish their information in an open access journal.

A250 Chest wall resection and reconstruction for chest wall sarcomas: an analysis of survival, predictors of outcome and long-term functional status
Alina-Maria Budacan, Akshay Patel1, Pavithra Babu2, Haitham Khalil1, Vaiyapuri Sumathi2, Michael Parry2, Maninder Kalkat1
1University Hospitals Birmingham, Birmingham, United Kingdom. 2Royal Orthopaedic Hospital, Birmingham, United Kingdom
Correspondence: Alina-Maria Budacan
Journal of Cardiothoracic Surgery 2024, 19(2):A250
Objective: We aimed to analyze survival, predictors of outcome and the long-term functional status of patients with a diagnosis of chest wall sarcoma undergoing chest wall resection and reconstruction.
Methods: Retrospective analysis of a prospectively maintained database of all patients who underwent chest wall resection and reconstruction for chest wall sarcomas between January 2008 and December 2021. The primary outcome measure was overall survival and univariate and multivariate analyses were employed to determine the risk factors for poor survival.
Results: One hundred and thirty-eight patients were included. Table 1 shows the pre-operative characteristics of our cohort. Median number of ribs removed was 3 (1–4). Other structures removed included part of sternum, clavicle, spine, and intrathoracic structures (diaphragm, lung, pericardium). Ninety-six percent had an R0 resection (n = 131) and 75.1% had no post-operative complications up to 30 days post procedure; median length of hospital stay was 7 days. Median overall and disease-free survival was 1631 and 1331 days respectively. For those alive, at long-term follow-up, 80% had an MRC of 0 and Karnofsky index > 80%. Univariate analysis identified pre-operative neoadjuvant treatment, larger tumor size, non-chondrosarcomatous pathology, adjuvant treatment, R1 resection and need for further surgery as significant predictive factors of recurrence. Advanced age, low BMI (< 25), low pre-operative albumin were significant predictive factors for post-operative death.
Conclusions: Careful patient selection and multi-disciplinary decision-making is crucial. Surgical treatment should be focused on en-bloc R0 resection in functionally robust patients. In more aggressive sub-types, pre-operative induction treatment must be undertaken prior to resection.
A251 Surgical outcomes and quality of life after aortic surgery in octogenarians
Mohamed Shoeib, Susmit Das, Olaniran Omodara, Syed Sadeque, Govind Chetty, Stefano Forlani, Graham Cooper, Renata Greco
Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
Correspondence: Mohamed Shoeib
Journal of Cardiothoracic Surgery 2024, 19(2):A251
Objectives: Aortic surgery in elderly patients is associated with high rates of postoperative morbidity and mortality. Considering the current pressure on the national health system and the limited hospital resources, offering major aortic surgery to this group of patients remains controversial. One of the main preconceptions is the expected poor quality of life after surgery.
Methods: We prospectively collected data of 800 consecutive patients who underwent major aortic surgery between 2011 and 2023. Forty-five patients (5.6%) were octogenarians. The median age was 82 years (80–87 years). Preoperative, operative, & postoperative data, including hospital mortality, survival, as well as QOL following surgery are reported in the table.
Results: Twenty-two patients (48.9%) required emergency surgery. The main indications for aortic surgery were ascending aortic aneurysm in 48.9%, acute aortic syndrome in 22.2% and chronic aortic syndrome in 6.7%. Five patients (11.1%) had surgery of the aortic root, 37 (82.2%) of the ascending aorta and 9 (20%) of the arch. In-hospital mortality was 26.6%, incidence of stroke 11% and average length of hospital stay 21 days (7–139 days). Overall survival at 1 and 3 years was 64.4% and 51.1%. 80% of survivors reported good QOL following surgery and none of the patients regreted choosing to have aortic surgery.
Conclusion: Octogenarians undergoing aortic surgery have a relatively high risk of post-operative complications (mortality 26.6%, stroke 11%). Despite general perception, the patients who survived aortic surgery maintain a good quality of life.
A252 The Surgical Management of Kommerell's Diverticulum: a hybrid, multidisciplinary approach
Tharun Rajasekar1, Jakub Marczak2, Omar Nawaytou2, Ahmed Othman2, Ayman Kenawy2, Manoj Kuduvalli2, Deborah Harrington3, Mark Field3
1Liverpool Medical School, Liverpool, United Kingdom. 2Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom. 3Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom
Correspondence: Tharun Rajasekar
Journal of Cardiothoracic Surgery 2024, 19(2):A252
Objectives and Aims: Kommerell’s diverticulum (KD) is a rare congenital defect involving the development of an abnormal subclavian artery (SCA) alongside a left or right aortic arch due to aberrant regression of the 4th pharyngeal arch artery. This often causes oesophageal and tracheal compression. Studies report a variety of open and endovascular management strategies with varying success. This case series aims to elucidate our institution’s approaches and outcomes when managing these patients.
Methodology: A single-centre retrospective analysis identified six patients presenting with an aberrant subclavian artery with KD between January 2022 and September 2023. Data collected included the patient demographics, presentation, management and post operative complications. The demographic and intraoperative data was collected using the electronic health database.
Results: The mean age of patients was 54.5 years, evenly split between males and females. Four patients presented with compressive symptoms whilst the remaining were asymptomatic. Three patients had KD with an aberrant left SCA and right sided arch whilst the others presented with an aberrant right SCA. Two patients also presented with an acute aortic dissection. Currently, four patients have received intervention through a hybrid two stage endovascular and open approach whilst the other two still await treatment. This included a subclavian-carotid bypass followed by an aortic replacement.
Conclusion: This study highlights the importance of a multidisciplinary, hybrid approach to managing these patients and emphasizes the lack of a one size fits all strategy.
345
A253 Assessing outcomes and quality of life in octogenarians following type A aortic dissection repair
Harry Smith, Daniel Sitaranjan, Shakil Farid, Ravi De Silva, Jason Ali
Royal Papworth Hospital, Cambridge, United Kingdom
Correspondence: Harry Smith
Journal of Cardiothoracic Surgery 2024, 19(2):A253
Objectives: Assess perioperative outcomes and postoperative quality of life (QOL) of octogenarians undergoing acute type A aortic dissection (TAAD) repair.
Method: We performed a retrospective analysis of prospectively collected operative and outcome data between 2011 and 2022. Baseline patient characteristics, intraoperative variables, and postoperative outcomes were reported. Follow up was conducted with SF-36 questionnaire to assess QOL (median follow 58 months).
Results: 56 octogenarians underwent TAAD repair. 23 patients underwent isolated ascending aorta repair. 16 underwent aortic arch surgery (including 3 frozen elephant trunks), 6 underwent ascending aorta replacement and valve replacement, 11 underwent aortic root surgery and 6 patients underwent concomitant CABG and 19 underwent concomitant valve replacement or repair. 16 patients underwent deep hypothermic circulatory arrest (DHCA), of this group 12 underwent DHCA and had cerebral antegrade perfusion, 4 underwent DHCA alone.
51 patients were discharged, 5 died prior to discharge representing 8.9% in house mortality. 30-day mortality was 19.6%, 6-month mortality was 26.7%- and 1-year mortality was 32.1%.
Of the 24 patients who were alive during 24th September 2023, 17 responded to the SF-36 questionnaire. For the physical functioning domain (10 items) the average score was 48.1% ± 9.8%, for social functioning (2 domains), 62.1% ± 3.19 pain (2 domains) 86.7% ± 3.3%, general health (5 domains) 60.1% ± 17.2% and for the emotional well-being domain (5 domains) 75.5% ± 19.2%.
Conclusion: At our centre between 2011 and 2022, octogenarians operated on for type A aortic dissection who survived past a period of 6 months have SF36 scores indicating a good QOL.
A254 A simple method to identify left common pulmonary venous (PV) trunk on computed tomography (CT) scans to reduce the impact of venous anatomical variation on minimally invasive lung resection
Hanan Hemead1, Islam Elgamal1, Ashvini Menon2, Vanessa Rogers2, Maninder Kalkat2, Babu Naidu1, Hazem Fallouh1
1University hospital of Birmingham, Birmingham, United Kingdom. 2University Hospital of Birmingham, Birmingham, United Kingdom
Correspondence: Hanan Hemead
Journal of Cardiothoracic Surgery 2024, 19(2):A254
Introduction: The incidence of left common PV in is reported to be around 20%. There are multiple reports of inadvertent injury or transection of the inferior PV during left upper lobectomy. A radiological method to identify this anomaly has been developed by Polaczekand, relying on accurate measurements of the length between the left atrium and the bifurcation, however, is rarely used, perhaps due to complexity. We hypothesize that using the bronchial division as a landmark can offer a simpler method to detect left common PV.
Methods: The schematic (Fig. 1:A,C)) highlights the relationship between the left bronchial bifurcation and venous anatomy and its application on CT scans. On sagittal enhanced CT chest views, the PV branching corresponds to the left main bronchus (LMB) bifurcation to upper and lower lobar bronchi. If two veins are visible at the point of LMB division, this means the left PV has divided extra-pericardially into two veins with two separate ostia.
Results: This method was validated on control normal anatomy CT scans and four cases proved to have conjoined left venous trunk intra-operatively (Fig. 1:B,D). One patient had inadvertent division of the inferior vein as a result.
Conclusion: Interrogating the left venous anatomy at the secondary carina on the sagittal view of CT scans provides pre-operative identification of common venous trunk. The detection of this anomaly preoperatively using this technique increases the safety of minimally invasive lobectomies by avoiding injury or inadvertent division of the inferior vein.

A255 Rib fixation: far more than just plates and screws
Jennifer Williams1,2, Stamatina Koskolou1,2, Tom Combellack1,2, Malgorzata Kornaszewska1,2, Ainis Pirtnieks1,2, Vasileios Valtzoglou1,2
1University Hospital of Wales, Cardiff, United Kingdom. 2Llandough University Hospital, Cardiff, United Kingdom
Correspondence: Jennifer Williams
Journal of Cardiothoracic Surgery 2024, 19(2):A255
Management of multiple rib fractures varies across the UK, however evidence for surgical fixation (SSRF) is growing. There is a discrepancy on whom performs the SSRF; trauma, orthopaedics or thoracic surgeons. It is agreed, treatment for rib-fractures is multi-modal; including physiotherapy, regional anaesthesia and rehabilitation.
We outline our approach and rationale. Patients with multiple fractures are reviewed by the thoracic surgeons, as part of a multi-specialty approach under the Major Trauma Centre (MTC). Patients are triaged with a rib-injury-score and receive regional anaesthesia within 6-h of admission. SSRF considerations include clinical flail, significant displacement, pain or failed extubation. Secondly when concomitant injuries require intervention; air-leak, haemothorax or diaphragmatic injury.
Pre-operatively we perform 3D CT-Chest reconstruction. Flexible bronchoscopy, secretion lavage and a double-lumen is placed for single-lung ventilation. Muscle-sparing incisions and Synthes-MatrixRib are used. Diaphragmatic VATS inspection is performed, with paravertebral and intercostal blocks placed under direct-vision. Aims include secretion clearance, occult injury treatment, improved analgesia and chest wall stabilisation. Most patients have their SSRF within 48 h from surgical decision.
Figure-1 demonstrates increased referrals to the acute pain-team since the MTC opened, consequently improving analgesia control and enhancing-recovery. In 2022, 325 blunt chest traumas were referred to the MTC; 50 patients required thoracic surgery and 37 had SSRF. It is challenging to quantify multi-modal benefits from non-randomised registry data.
Historically Thoracic Surgeons performed fewer SSRF, however our chest-wall anatomy and VATS skills convey additional benefits. SSRF competance is an important adjunct to thoracic surgeon's skillset; offering chest-wall stabilisation and enhanced-recovery.

A256 An insight into theatre perioperative practitioners' learning experience and concerns when assisting heart and lung organ procurement and transplantation. A local service improvement project
Yi Wang1, Espeed Khoshbin1,2
1Harefield Hospital, Royal Brompton and Harefield Hospital as part of Guys and St Thomas NHS Trust, Harefield, United Kingdom. 2National Heart and Lung Institute, Imperial College London, London, United Kingdom
Correspondence: Yi Wang
Journal of Cardiothoracic Surgery 2024, 19(2):A256
Objectives:or
- 1.
We explore theatre perioperative practitioners' (TPP) learning experience during organ procurement.
- 2.
Understand the concern faced by TPPs when assisting.
- 3.
Find out how TPPs deal with stress.
- 4.
Identify TPPs' stress coping strategies.
- 5.
Make recommendations for changes.
Methods: A mixed methodology approach was applied using quantitative questionnaires and qualitative focus group discussions. Firstly, quantitative data were collected through a survey. Then, a qualitative method was conducted through focused group discussions using open questions, and themes were then developed.
Results: The study was conducted in early 2023. A total of 19 TPPs took part, and 16% of TPP believed that they lacked training before starting their independent practice. 21% rated education and training in transplantation and retrieval as being inadequate. 31% felt psychologically unsupported. However, 95% believed that they were best supported by their fellow TPP colleagues when they encountered stress. Just under half the TPPs expressed stress levels reaching 7–10/10. The most shared concerns during the focus group discussion included being overworked, lack of sleep, poorly protected rest periods, and emotional upset during some DCD organ procurement. These were mainly due to interpersonal conflict during procedures, but occasionally, ethical dilemmas such as personal beliefs and cultural backgrounds have played a part.
Conclusions: There is a need for educational programmes and psychological support, as there is a lack of training and lack of psychological support. However, this study has demonstrated good team spirit and peer support amongst the TPPs. We recommend developing relevant educational and psychological support.
A257 The commando procedure: the good, the bad and the ugly
Agni Leila Salem, Jakub Marczak, Ayman Kenawy, Ahmed Othman, Omay Nawaytou, Deborah Harrington, Manoj Kuduvalli, Mark Field
Liverpool Heart and Chest, Liverpool, United Kingdom
Correspondence: Agni Leila Salem
Journal of Cardiothoracic Surgery 2024, 19(2):A257
Objective: Tirone David described the first series of patients to undergo reconstruction of the aorto-mitral continuity (David et al., 1997), latterly called the “Commando Procedure” or “UFO Procedure” (Misfield et al., 2019). There has been increasing interest in the approach over recent years especially with the presentation of complex and advanced root abscess and prosthetic valve endocarditis. This abstract sets out our initial learning from the first 14 cases.
Methods: We conducted a retrospective analysis of all patients undergoing reconstruction of the aorto-mitral continuity between 2017 and 2023.
Results: All 14 patients were classified as Urgent. 13 patients had active infection as the underlying pathology and 1 had severe symptomatic heart failure from structural aortic valve degeneration and severe mitral stenosis. All underwent MV replacement and pericardial patch reconstruction of the roof of the left atrium, intervalvular fibrose body and aortic annulus. The root was repaired with a range of techniques including homograft, Dacron prosthetic valve conduits and pericardial root reconstruction with AVR.
Discussion: Given the literature documented operative mortality risk we have restricted the procedure to patients who present with aggressive organisms and advanced tissue destruction who leave little choice but extensive resection and reconstructive approach. In-hospital mortality was 2/14 (14.3%). We have found poor outcomes appear to be related to increasing age and impaired LV function. Our experience is that homograft’s prove the best technical option for the aortic root replacement, followed by prosthetic Dacron root conduits followed by pericardial patch root reconstruction and aortic valve replacement.
A258 Altmetric vs bibliometric trends in the top 100 cited Thoracic Surgery articles: the efficacy of web-based platforms and social media in advancing the propagation of scientific literature
Alana Atkinson1, William Cartlidge1, Rickesh Karsan2, Gwyn Beattie2
1Queen's University Belfast, Belfast, United Kingdom. 2Department of Cardiothoracic Surgery, Royal Victoria Hospital, Belfast, United Kingdom
Correspondence: Alana Atkinson
Journal of Cardiothoracic Surgery 2024, 19(2):A258
The number of citations that publications accrue is the gold standard measure of scientific impact. However, altmetric data could forecast areas of new research that have the potential to shape the field of thoracic surgery. Our intent was to explore if there was a correlation between research impact and dissemination via web-based platforms, by analysis of citation and altmetric scores (AS) respectively.
The Clarivate Web of Science query included the terms ‘thoracic AND surg*’. Results were sorted by highest citations first, obtaining the top 100 English-language articles; AS was retrieved using ‘Altmetric it!’. Statistical analysis of altmetric and citation data was performed using regression and ANOVA methods. 5-year trend projections for altmetric and citation parameters were generated employing forecast models (IBM SPSS v23.0).
Eligible articles totalled 179,930. ‘Molina et al.; 2008,’ achieved both the highest number of citations (2,775) and AS (796). Mean number of citations was 657.75 ± 0.478 and mean AS was 46.11 ± 0.483. Twitter/X had the highest mean score (31.73 ± 0.724). A significant relationship was established between altmetric and citation score (p = < 0.001), and rate (p = < 0.001) respectively. By regression analyses, 5-year impact factor had a positive correlation with citation score (p = 0.019) but no correlation with AS (p = 0.246). Over the next 5-years altmetrics are predicted to increase significantly more than citations, demonstrated using forecast models (p = 0.0021).
Scientific research dissemination has changed with the growing influence and use of social media and web-based platforms. This has been demonstrated by altmetric data possessing utility in forecasting the prospective impact of research within thoracic surgery.
A regression to demonstrate the relationship between citations and altmetric score for the top 100 cited research papers in thoracic surgery.

A259 Epithelial-to-mesenchymal transition in malignant pleural mesothelioma is a harbinger of poor prognosis following surgical resection
Kudzayi Kutywayo1, Dean Fennell2, Apostolos Nakas1
1Glenfield Hospital, University Hospital of Leicester NHS Trust, Leicester, United Kingdom. 2University of Leicester, Leicester, United Kingdom
Correspondence: Kudzayi Kutywayo
Journal of Cardiothoracic Surgery 2024, 19(2):A259
Objectives: Malignant pleural mesothelioma has a low survival rate. Multimodality treatment is the mainstay of radical intent treatment. It remains uncertain how patients with similar stage and histologic subtype have a wide variance in outcome. The epithelial-mesenchymal transition (EMT) enables dissociation of tumour cells from the primary tumour mass, invasion through the extracellular matrix, intravasation into blood vessels and colonisation of distant organs. We investigated factors affecting the prognosis of patients who had undergone surgery.
Methods: Pleural tissue from 100 malignant pleural mesothelioma consecutive patients who underwent extended pleurectomy/decortication was collected. Tissue cores were stained in tissue microarray panels. Multiplex immunofluorescence was performed. Automated quantitative pathology and machine learning were used to analyse the microimmunofluorescence images. Gene set encrichment analysis was used for genetic feature selection.
Results: The median age was 70.50, M:F = (3.8:1). The majority of the patients had epithelioid subtype (89.58%). 91.67% had microscopic residual tumour (R1). Median PFS and OS were 162.50 and 387.50 days respectively. PFS and OS had a moderate correlation (0.68). Pancytokeratin loss and high Ki67 were associated with much worse outcomes when compared to tumors which retained pancytokeratin (p = 0.0005). Gene set enrichment analysis showed strong EMT scores in pancytokeratin-negative, high Ki67 tumours (p = 0,0047). A significant difference was also noted in signalling pathways such as TGF = beta (0,0012350, hypoxia (0,00946) and angiogenesis (0,000781).
Conclusion: Epithelial-to-mesenchymal transition and signalling pathways associated appear to have a prognostic factor in malignant mesothelioma. Investigation of chromosomal deletions with EMT is underway.
A260 The female experience of Coronary Artery Bypass Grafting over twenty years
Lauren Kari Dixon1, Ettorino Di Tommaso1, Marco Gemelli2,1, Vito Domenico Bruno3, Roberto Natali1, Raimondo Ascione1
1Bristol Heart Institute, Bristol, United Kingdom. 2University of Padova, Padova, Italy. 3I.R.C.C.S. Ospedale Galeazzi Sant'Ambrogio, Milan, Italy
Correspondence: Lauren Kari Dixon
Journal of Cardiothoracic Surgery 2024, 19(2):A260
Objective: Female sex is a known risk factor for poor outcomes after coronary artery bypass grafting (CABG). The aim of our study was to evaluate the outcomes of female patients who underwent CABG at our centre during the last twenty years.
Methods: Between January 2001 and December 2021, 14,433 patients (11,780 male and 2,653 female) underwent CABG at our centre. Baseline and outcome data were compared between males and females using Wilcoxon rank sum; Pearson’s Chi-squared or Fisher’s exact test. Multivariable logistic regression models were used to compare outcomes.
Results: Female patients were older (71vs68, p < 0.001) with more co-morbidities, like diabetes (26% vs 22%; p < 0.001) and hypertension (77% vs 73%, p < 0.001). Females had more urgent/emergency surgery (52.9% vs 48.7%, p < 0.001). There were no significant differences regarding the use of cardiopulmonary by-pass (56% vs 55%, p = 0.6). Females received less grafts on average (2 vs 3, p < 0.001) and less left internal mammary grafts (84% vs 90%, p < 0.001).
In-hospital mortality was higher in females (2.7% vs 1.5%, p < 0.001) and length of hospital stay was longer (7 vs 6 days, p < 0.001).
Median follow-up was 10.7 years. Long-term mortality was also higher in females (42% vs 36%, p < 0.001).
On multivariable analysis, female sex remained a risk factor for both in-hospital mortality (OR 1.81, 95% CI 1.40–2.38, p < 0.001) and long-term mortality (HR 1.21, 95% CI 1.09, 1.34, p < 0.001).
Conclusions: Female sex has been a significant risk factor for poor outcomes after CABG over the last twenty years at our centre, including short-term and long-term mortality.

A261 In patients requiring Concomitant Aortic Arch and Root Surgery; is Valve sparing root replacement an effort worth taking?
Muhammad Usman Shah, Mauin Uddin, Azamal Mulla, Sivaraj Govindasamy, Ayman Kenawy, Ahmed Othman, Deborah Harrington, Manoj Kuduvalli, Mark Field, Omar Nawaytou
Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
Correspondence: Muhammad Usman Shah
Journal of Cardiothoracic Surgery 2024, 19(2):A261
Objectives: To assess feasibility and safety of valve sparing aortic root replacement(VSRR) with concomitant Aortic Arch surgery and whether increasing complexity of surgery may impact immediate post-operative survival in a high-volume aortic centre.
Methods: Retrospective observational study: we looked at institutional VSRR cohort of 261 patients since 2017 and identified 48 patients underwent VSRR with concomitant Aortic Arch surgery to assess feasibility and intra hospital outcomes.
Results: Out of the 48 patients (mean age 53.8): 26 had VSRR with Arch surgery for emergent type-A acute aortic syndromes (mean Euroscore II 6.9) whereas 22 had non-emergent surgeries for chronic dissections, syndromic patients, bicuspid aortic valves and aneurysms (mean Euroscore II 5.1). In the emergency surgery group: Hemiarch replacements 18 and total arch with frozen elephant trunk in 8. The Arch procedures in non-emergent patients: Hemiarch replacements 14, total arch with elephant trunk 6 and total arch in 2. All patients had trivial to minimal Aortic Regurgitation (AR) post-operatively with no salvage valve replacement. In hospital and 30-day mortality for all patients was 0%. Complications: 7 had neurological complications 5 of which were in the emergent group and 1 patient needed permanent pacemaker in the whole cohort. Discharge echo showed 0 to trace AR in all patients. Follow up echo showed no change in the AR.
Conclusion: We believe in high volume centres with expertise: doing Valve sparing root replacement with Concomitant Aortic Arch Surgery for patients in both emergent and non-emergent scenarios is feasible, safe with good valve repair outcomes.

A262 Ten year experience of an Enhanced Recovery After Surgery (ERAS) pathway following primary lung cancer resection
Lauren Kari Dixon1,2, David Messenger1, Vito Domenico Bruno3, Douglas West1, Luke Rogers1, David Bleetman1, Lesley Wood1, Neil Rasburn1, Timothy Batchelor4, Natasha Joshi1
1University Hospitals Bristol and Weston, Bristol, United Kingdom. 2Royal College of Surgeons of England, London, United Kingdom. 3I.R.C.C.S Osperdale Galeazzi—Sant'Ambrogio, Milan, Italy. 4The Thorax Centre, St Bartholomew's Hospital, Bristol, United Kingdom
Correspondence: Lauren Kari Dixon
Journal of Cardiothoracic Surgery 2024, 19(2):A262
Objective: The Enhanced Recovery After Surgery (ERAS) pathway in our Thoracic Surgery department is design to reduced post-operative length of stay and improve patient recovery following surgery. After using the ERAS pathway for 10 years, the aim of this study was to evaluate the effectiveness of the pathway on reducing post-operative length of stay (LOS).
Methods: All consecutive primary lung cancer resections from August 2013 to July 2023 were included. Each patient followed our 15 step ERAS pathway and their compliance to each step was recorded giving an overall score out of 15. Linear and logistic regression models were used to analyses the relationship between ERAS compliance scores and LOS.
Result: Over 10 years, 2192 primary lung cancer resection have been performed. 61% lobectomy, 23% wedge resection, 10% segmentectomy, 4% pneumonectomy and 3% bi-lobectomy. Surgeries were performed VATS in 80%, open in 13% and were converted in 6%.
Our median length of hospital stay was 4 days (IQR 3–7), 30 day mortality was 1.2%, 30-day re-admission rate was 7%. One-year mortality was 23% and median survival was 784 days (IQR 386–1,481). The median ERAS compliance score was 12/15 (80%).
Using linear regression modelling, increased ERAS compliance was significantly correlated with a reduced LOS R2 = -0.48, p = 0.002.
On univariable regression analysis, increasing compliance to the ERAS pathway was protective against a prolonged LOS (> 4 days) (OR: 0.91, 95% confidence intervals (0.84, 0.99), p = 0.031).
Conclusion: Increased compliance with our ERAS pathway is associated with shorter length of hospital stay.

A263 Multidisciplinary team meetings for lung volume reduction: long term trends on functioning and service provision across the UK
Azhar Syed Thanveer, Helen Weaver, Sridhar Rathinam
Glenfield Hospital, UHL, Leicester, United Kingdom
Correspondence: Azhar Syed Thanveer
Journal of Cardiothoracic Surgery 2024, 19(2):A263
Background: The NHS Guidelines recommend that all patients considered for Lung Volume Reduction should be assessed on set criteria by a specialist multi-disciplinary team (MDT).
Objectives: This study was done with the objective of evaluating the functioning LVR MDTs across the UK and check their compliance with national recommendations given by NHS England as well as Society of Cardio-Thoracic Surgeons (SCTS). Practise was compared between 2019 (when commissioning policy was first published) and 2023 to assess the impact of commissioning policy by the NHS.
Methodology: Cross-sectional analytical study comparing LVR MDT functions between 2019 and 2023. Data was gathered in 2019 contemporaneously and again in 2023 using online survey questionnaires with inclusion of questions on perception among surgeons on MDT impact.
Results: Table 1 shows the trends in LVR MDT between 2019 and 2023. Three-fifths of the units without a dedicated LVR MDT were outside England. Two MDTs (9%) did not offer any endobronchial interventions. Radiologist representation at MDTs has reduced by 20%. Two thirds of the responders felt that the use of MDTs had led to an increase in total number of patients undergoing interventions.
Conclusions: Access to LVR MDTs is still not 100% across the UK, with only 80% of them being quorate. Half the MDTs still do not carry out risk-assessment. A majority of surgeons opine that the introduction of the MDT and endobronchial interventions has had a positive impact on both the number of patients discussed as well as those treated.
A264 How does frailty affect recovery after thoracic surgery
Lauren Kari Dixon1,2, Douglas Miller1, Igor Saftic1, Stylianos Gaitanakis1, David Luther1, Kajan Kamalanathan1, Lesley Wood1, Neil Rasburn1, Timothy Batchelor3, Natasha Joshi1
1University Hospitals Bristol and Weston, Bristol, United Kingdom. 2Royal College of Surgeons of England, London, United Kingdom. 3The Thorax Centre, St Bartholomew's Hospital, London, United Kingdom
Correspondence: Lauren Kari Dixon
Journal of Cardiothoracic Surgery 2024, 19(2):A264
Objective: Frailty is often considered a risk factor for poor recovery after surgery. In our thoracic surgery department, all patients follow an Enhanced Recovery After Surgery (ERAS) protocol. This study aimed to determine how well frail patients comply with the ERAS programme and how well they recover following thoracic surgery.
Methods: All consecutive patients who underwent lung cancer resection between 2019 and 2023 were included. Patients were assessed using the Clinical Frailty Scale; we defined frailty as a CFS of 4 or above. Differences between groups were compared with Pearson’s Chi-squared; Wilcoxon rank sum or Fisher’s exact test. Logistic regression models were used to compare outcomes.
Results: Of the 798 patients (128 frail, 669 control), there were no differences in age (median 70 years, p = 0.9), surgical approach (VATS in 83% vs 84%, p = 0.7) or ERAS protocol compliance (median score 12/15, p = 0.06). Frail patients were more likely to have sub-lobar resection (46% vs 34%, p = 0.001), ASA 3–4 (80% vs 53%, p < 0.001) and ITU/HDU admission (27% vs 19%, p = 0.043).
There were no significant differences in length of hospital stay (median 4 days, p = 0.078), 30-day mortality (0%, p > 0.9) or 30-day readmission (6.3% vs 7.9%, p = 0.5).
On multivariable regression analysis, frailty was not an independent predictor of poor ERAS protocol compliance (OR 0.9, CI 0.52, 1.68, p = 0.4), prolonged LOS (OR 1.05, CI 0.64, 1.71, p = 0.8) or 30-day readmission (OR 0.54, CI 0.15, 1.41, p = 0.3).
Conclusion: Overall our ERAS protocol is safe and effective for frail patients and leads to outcomes comparable to non-frail patients.
A265 A study of the influence of posterior pericardiectomy on the development of post-operative atrial fibrillation in cardiac surgical patients
Tara Chan-A-Sue1, Rickesh Karsan2, Gwyn Beattie2
1Queens University Belfast, Belfast, United Kingdom. 2Department of Cardiothoracic Surgery, Royal Victoria Hospital, Belfast, United Kingdom
Correspondence: Tara Chan-A-Sue
Journal of Cardiothoracic Surgery 2024, 19(2):A265
Objectives: Post-operative atrial fibrillation (POAF) is a surgical complication occurring in 20–55% of cardiac surgical cases and is associated with increased adverse outcomes, including extended in-hospital stay and mortality. Performing a posterior left pericardiotomy, a surgical manoeuvre that drains the pericardial space into the left pleural cavity, has been shown to reduce POAF in cardiac surgical patients without additional risk of postoperative complications such as pericardial effusion. This study investigated whether posterior pericardiotomy influenced the incidence of POAF in patients undergoing isolated coronary artery bypass (CABG).
Methods: Conducted retrospective analysis of a single surgeon's data of the incidence of POAF and pleural effusion in isolated CABG cases (on and off cardiopulmonary bypass) with a posterior pericardiectomy from January 2010 to October 2023 from a single centre: excluding any patient with pre-existing AF. Independent-Samples Mann–Whitney U analysis was performed to determine statistical significance using SPSS statistical software.
Results: 193 patients had isolated CABG, 48 (25%) had a posterior pericardiectomy (Table 1). POAF occurred in 9 (29%) of the pericardiotomy group and in 2 of the 9 cases atrial fibrillation was persistent at discharge. There were 14 cases of pleural effusion, 4 (29%) occurred in the posterior pericardiectomy group with 1 (25%) requiring chest drain insertion. At p = 0.05 these results were not shown to be statistically significant.
Conclusion: Our study identified that performing a posterior pericardiectomy in isolated CABG cases did not reduce the incidences of POAF or pleural effusion. Further investigation in a larger cohort is recommended to explore this trend.

A266 The surgeons edge in community health engagement: lung cancer screening
Faisal Jawad1, Babu Naidu1, Madava Djearaman1, Rachel Avery2, Benjamin Aribisala3, Shahida Liaqat1, Sonia Ashraf3, Patricia Glynn1, Dan Craddock3
1Queen Elizabeth Hospital, Birmingham, United Kingdom. 2Roy Castle, Birmingham, United Kingdom. 3BSol ICB, Birmingham, United Kingdom
Correspondence: Faisal Jawad
Journal of Cardiothoracic Surgery 2024, 19(2):A266
Objective: The Targeted Lung Health Check (TLHC) pilot, launched in October 2022 in Birmingham & Solihull, targets lung cancer screening for smokers aged 55–74 under the leadership of a Thoracic Surgeon with a multidisciplinary approach. To enhance effectiveness(1), a Community Engagement Program (CEP) was setup to improve uptake and detect more resectable lung cancers at earlier stages. Historically, only 27% of non-small cell lung cancers were initially amenable to curative resection(2).
Method: The CEP initiatives included;
-
Targeted social media campaigns
-
Community engagement events, addressing misconceptions, confusion, anxiety, and apathy to prompt action.
-
Outdoor advertising, constantly drip-feeding messages.
-
Primary care toolkits
-
Video Ad productions
-
Literature design, clear and accessible information in a variety of languages
-
Visiting places of worship, faith events, sports venues, independent cancer support centres
-
Adopting local community champions
Results:
-
Uptake rates improved from 65 to 76%
-
Missed appointment reduced from 52% in October 2022 to 26% by June 2023
-
70 + patients accessed the lung cancer pathway at an earlier stage
-
69% of cancers detected stage 1/2
-
958 (38.7%) incidental findings referred for further investigation and management.
Conclusion: The early initiatives adopted by the CEP are associated with an improved uptake, surpassing more established screening programmes, such as bowel cancer screening (69%)(2). Furthermore, we have seen a rise in the incidence of earlier stage resectable lung cancers. The involvement of CEP initiatives and the inclusion of a surgeon have proven pivotal in the effectiveness of the programme highlighting Surgeons should be involved in all future screening initiatives.
A267 Optimal diuretic dosing strategies following cardiac surgery: a retrospective cohort study
Nicola Edwards1, Elizabeth O'Connell1, Bilal Kirmani1, Matthew O'Connell2
1Liverpool Heart and Chest Hospital, Liverpool, United Kingdom. 2Association of Professional Healthcare Analysts, Liverpool, United Kingdom
Correspondence: Nicola Edwards
Journal of Cardiothoracic Surgery 2024, 19(2):A267
Background: Diuretics are drugs used to treat oedema and fluid overload. Loop diuretics are the most frequently prescribed. Furosemide is used following cardiac surgery to re-establish euvolaemia following peri operative fluid administration, however its threshold response is not often appreciated, potentially affecting the diuretic response and can lead to prolonged hospitalisation. The limited literature relates to prescribing in healthy volunteers, renal or heart failure.
Methods: A single-centre retrospective cohort study of 101 consecutive post-operative cardiac surgery patients was undertaken. The primary outcome measured was the number of dose escalations required in the post-operative period. Secondary outcome measures included hospital length of stay.
Results: In 101 patients who underwent cardiac surgery 92.5% (N = 86) were prescribed postoperative diuretics. The most common starting dose was 40 mg daily, with 76.3% (N = 71) receiving this. Of those, 47.9% (N = 46) required no adjustment to their diuretic dose, while 50.5% (N = 47) required at least 1 dose adjustment. Of this group, 42.3% (N = 20) required 1 change to furosemide prescription, and many needed further subsequent dose escalations to achieve adequate diuresis and fluid balance. All patients that were off pump (N = 14) required postoperative diuretic, but fewer dose escalations than those who had cardiopulmonary bypass.
Conclusion: Loop diuretics play a vital role in post-operative fluid management, and establishing euvolaemia efficiently in patients can lead to fewer associated compilations, and a reduced hospital stay. Further research is required reviewing furosemide dosage regimes, in relation to the dose response curve.
Differences between patients requiring dose escalation versus no escalation (univariable analysis). (BMI—Body mass index, CCF—congestive cardiac failure, CKD—Chronic kidney disease, CPB—Cardio-pulmonary bypass, N—number, SD—standard deviation)
A268 Diversity at the heart of the specialty: a national initiative for widening participation in cardiothoracic surgery
Kirstie Kirkley1,2, Georgia Layton1,3, Javeria Tariq1,4, Karen Booth1,5, Farah Bhatti1,6
1Society for Cardiothoracic Surgery in Great Britain and Ireland, London, United Kingdom. 2University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom. 3University Hospitals of Leicester NHS Trust, Leicester, United Kingdom. 4Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom. 5Freeman Hospital, Newcastle, United Kingdom. 6Morriston Hospital, Swansea, United Kingdom
Correspondence: Kirstie Kirkley
Journal of Cardiothoracic Surgery 2024, 19(2):A268
Students from widening participation (WP) backgrounds are less likely to apply for and obtain places to study medicine. This compromises the long-term diversity of the applicant pool for cardiothoracic surgery (CTS). It is well established that patient care is adversely affected by a lack of diversity within healthcare professionals. As such, this national initiative set out to promote CTS amongst senior school students in the UK with a focus upon those from WP backgrounds.
Students were invited via the Medical Schools Council to six online lectures, and to submit a competitive application to undertake work experience within a CTS unit. Twelve students were selected to participate in a clinical placement and were provided with an online, interactive coaching resource to aid cross-centre standardisation of experience. All attendees were invited to complete electronic questionnaires before and after their experiences.
482 students attended lectures, with 100% providing feedback afterward. Attendees were most frequently female (77%), from ethnic minority groups (80%) and WP backgrounds (42%). Perceived barriers to pursuing this career included inability to gain work experience (71%), financial restrictions (45%) and lack of application mentoring (41%).
100% of students recommend the work experience scheme as helpful. Students reported improved confidence with the hospital environment, the role of a doctor and the specialty. All were more likely to consider a career in surgery following this exposure.
Low cost interventions utilising pre-existing cardiothoracic surgical networks can successfully engage a large, diverse population of students who feel restricted from accessing our specialty.
A269 A single centre experience and the clinical outcome of VATS diaphragm plication; the importance of selecting the correct patient
Zoe Langham, Ashvini Menon, Vanessa Rogers, Babu Naidu, Ehab Bishay, Maninder Singh Kalkat, Richard Steyn, Hazem Fallouh
University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
Correspondence: Zoe Langham
Journal of Cardiothoracic Surgery 2024, 19(2):A269
Background: Diaphragm plication improves breathlessness in phrenic nerve palsy. However, patients often have other comorbidities which can cause breathlessness making patient selection challenging. We hypothesise that careful selection of patients with set criteria results in maximal symptom improvement and good overall patient satisfaction.
Objective: To study the effect of selecting patients with the criteria below for VATS plication on breathlessness, PFTs and patient satisfaction post operatively. The primary outcome is achieving significant improvement of Medical Research Council (MRC) dyspnea score. The secondary outcome is significant improvement in PFTs, patient satisfaction and any adverse events.
Methods: Clinical criteria: Breathlessness MRC > 1 with or without postural dyspnea. BMI < 35. No severe heart failure or COPD. Radiological criteria: Ultrasound/fluoroscopy evidence of paradoxical or no movement of diaphragm. PFTs criteria: Restrictive pattern with postural drop in FVC or FEV1 > 10%. Of the included 15 patients, 9 patients responded with further responses expected. Change in MRC, PFTs and adverse events were collected. An in-house designed QOL questionnaire was completed and recorded.
Results: There was a significant decrease in MRC dyspnea score (-0.80, P = 0.022, n = 10), a trend toward improvement in FVC (16.7% P = 0.182) and FEV1 (12.6% P = 0.159, n = 5) There was no correlation between BMI and symptom improvement. 84.6% would recommend the surgery. 69.2% experienced some level of neuropathic pain.
Conclusions: Minimally invasive Diaphragm plication in patients with the selected criteria offers significant improvement in breathlessness and high satisfaction, despite high rate of neuropathic pain.
A270 Uniportal VATS simple and complex anatomical segmentectomies: a single centre experience
Veena Surendrakumar, Mostafa Ahmed, Maria Kolokotroni, Antonio Martin-Ucar, Luis Hernandez
University Hospital Coventry & Warwickshire, Coventry, United Kingdom
Correspondence: Veena Surendrakumar
Journal of Cardiothoracic Surgery 2024, 19(2):A270
Objectives: The evidence behind anatomical segmental resection in the treatment of lung lesions has been growing over recent years. Anatomical segmentectomies can be considered simple or complex; the latter involving the dissection of multiple intersegmental planes and thereby increasing both the intricacy of the surgery and potentially the risk of complications. We compare the early postoperative outcomes of simple and complex uniportal VATS segmentectomies in our single centre institution over a six-year period.
Methods: All anatomical segmentectomies performed between November 2016 and December 2022 were retrospectively reviewed using a prospectively maintained database. Patient details, operative factors and postoperative data were collected and compared between the two groups. Qualitative data was analysed using the chi-squared test and quantitative data with the Mann–Whitney U Test. Statistical significance was defined as p < 0.05 throughout.
Results: A total of 251 patients (115 male and 136 female, median age of 70 [range 36 to 93] years) underwent uniportal VATS anatomical segmentectomy over a six-year period. There were no significant differences in age, gender or pre-operative lung function between the two groups. There was one postoperative mortality following simple segmentectomy.
Conclusion: Uniportal VATS complex anatomical segmentectomy can be effectively performed with a similar experience and early outcomes to that of simple segmentectomies. We have confirmed in our practice that complex segmentectomies are associated with longer air leaks leading to a slightly increased intercostal drain duration and, probably, a limited increase in hospital stay. This is likely explained by the dissection of more intersegmental planes.
A271 Co-design utilising a health psychology evidence-based framework (COM-B) in non-participants of pre-rehabilitation trial targets effective strategies to enhance recruitment
Salma Kadiri1, Rosemary Kyle2, Janette Rawlinson2, Matar Alzahrani2, Joan Duda2, Babu Naidu2, Louisa Stonehewer2, Krishna Kholia1, Thomas Pinkney1, Fang Gao Smith2
1UHB, Birmingham, United Kingdom. 2UOB, Birmingham, United Kingdom
Correspondence: Salma Kadiri
Journal of Cardiothoracic Surgery 2024, 19(2):A271
Objectives: Recruitment and participation in pre-rehabilitation clinical trials in some patient groups remains low. Reasons for refusing to take part, are multi-dimensional and poorly understood. Behaviour change models such as COM-B have been used as a framework to understand poor participation in other areas e.g.screening programmes. In this Study within a trial (SWAT) of the ongoing Fit 4 Surgery trial, we aim to co-design a short survey with patients using the COM-B framework to better understand barriers and facilitators to participation.
Methods: Feedback from PPI members, using focus group questions and the SWAT registry list, was examined by the PPI representatives and qualitative researcher on the trial management groups to understand what information is important to collect for this SWAT.
Results: A mixed method survey consisting of 6 sections of questions has been created to understand how and why patients who decline to participate in Fit4surgery 2 RCT make this decision. Socio-demographic, ethnicity and physical activity level data is collected. This includes open and closed-ended questions. To reduce the health literacy skill burden and avoid low completion rates, photo-elicitation has been used to convey concerns. These visual mediums can be used to elicit further comments in free text boxes. Descriptive statistics and qualitative methods will be used to analyse the feedback from the first 20 participants and will be presented at the meeting.
Conclusions: Data from the SWAT may guide future improvements in the study design and help develop strategies to increase participation in trials, especially from hard-to-reach groups.
A272 Different cardiac imaging techniques combined to 3D-print a mitral valve model: a literature review
Tara Chan-A-Sue1, Panagiotis Kyriazis2,3, Prakash Punjabi2,3
1Queens University Belfast, Belfast, United Kingdom. 2National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom. 3Hammersmith Hospital, London, United Kingdom
Correspondence: Tara Chan-A-Sue
Journal of Cardiothoracic Surgery 2024, 19(2):A272
Objectives: Three-dimensional (3D) imaging enabled new insights into the mitral valve (MV) pathology mechanisms and enhanced surgical interventions. The review aims to explore the different 3D imaging techniques used in producing 3D-printed MV models and their clinical implications.
Methods: Review of literature evaluating 3D imagining modalities assessing MV pathology and methods to create 3D models available from Clarivate Web of Science search engine and National Institute of Health: National Centre for Biotechnology online database.
Results: The transoesophageal approach is the highest accuracy echocardiography technique providing a real-time 3D panoramic view of the MV and adjacent anatomy (Fig. 1)1. Multidetector row computed tomography (MDCT) has enabled image acquisition throughout the cardiac cycle and has been utilised to create patient-specific 3D models having a higher spatial resolution and short acquisition time compared to cardiac magnetic resonance imaging (CMR). 3D printing is a rapid prototyping process with the current generation of MV models utilising a range of flexible materials to replicate sub-valvular functional elements which have been used to facilitate the device positioning and predict interaction with native tissue allowing performance review of MV repair/replacement during benchtop simulations. The main limitation of the available models is their ability to mimic the behaviour of biological tissues to reflect the deformable nature of the cardiac structures throughout the cardiac cycle.
Conclusions: Advances in 3D imaging and modelling of the MV have improved the general understanding of anatomical pathogenesis and surgical planning improving patient selection, treatment pathways and clinical outcomes.

A273 UK experience of direct procurement of lungs with ongoing abdominal normothermic regional perfusion from controlled DCD donors
Luke Williams1,2, Rachel Hogg1, Sarah Beale1, Pradeep Kaul2, Phil Curry3, Simon Messer3, Prashant Mohite3, Rajamiyer Venkateswaran4, Vipin Mehta4, Gerard Meachery5, Jerome Jungschleger5, Jorge Mascaro6, David Quinn6, John Dunning7, Bart Zych7, Anand Jothidasan7, Mubassher Hussain7, Chris Johnston8, Gavin Pettigrew9, Anne Olland10, Andrew Butler9, Gillian Hardman5, Chris Watson9, Ian Currie1,8, Marius Berman2
1NHS Blood and Transplant, Bristol, United Kingdom. 2Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom. 3Golden Jubilee University National Hospital, Glasgow, United Kingdom. 4Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom. 5Freeman Hospital, Newcastle Hospitals NHS Foundation Trust, Newcastle, United Kingdom. 6University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom. 7Harefield Hospital, London, United Kingdom. 8Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, United Kingdom. 9Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom. 10Hôpital Civil Strasbourg, Strasbourg, France
Correspondence: Luke Williams
Journal of Cardiothoracic Surgery 2024, 19(2):A273
Objectives: Describe the UK experience of direct procurement (DRP) of lungs for transplantation alongside abdominal normothermic regional perfusion (A-NRP).
Methods: Lung utilisation and 90-data survival data from DCD lung transplants between 1 January 2015 and 31 December 2022 were obtained from the NHSBT registry. Case notes from all DCD lung recipients in this cohort were analysed to define primary graft dysfunction (PGD) grade using ISHLT criteria. 90-day survival rates were compared for standard DCD retrieval and DRP with A-NRP using the log-rank test. Grade 3 PGD rates at 72 h after transplant were compared using Fisher’s exact test.
Results: There were 307 DCD lung donors in this cohort (3 TA-NRP, 18 DRP with A-NRP and 289 standard DCD retrieval). 13 (72%) A-NRP donors and 236 (82%) standard DCD donors resulted in lung transplants. There was no difference in utilisation (p = 0.50).
90-day survival rate for standard DCD lung recipients was 87.3% (95% CI: 82.3–91.0%). 90-day survival rate for recipients of lungs procured with concomitant A-NRP was 92.3% (95% CI: 56.6–98.9%, log-rank p-value = 0.59).
After excluding transplants with key data missing, 238 transplants were included in the PGD analysis (12 A-NRP with DRP, 223 standard DCD). Grade 3 PGD rate at 72 h after transplant for standard DCD lungs was 24.2% (95% CI: 18.7–30.4%) versus 25.0% (95% CI: 5.5–57.2%) with concomitant A-NRP (Fisher’s exact test p-value > 0.99).
Conclusions: Direct procurement of lungs with A-NRP is feasible and has comparable organ utilisation, 90-day mortality and severe PGD rates to standard DCD retrieval.

A274 Comparative analysis of LVOT/annulus measurement using echocardiogram and TAVI CT in predicting prosthesis size in surgical aortic valve replacement
Yama Haqzad1, Mohamed Sherif2, Hamzaur Rehman1, Javeria Tariq1, Pankaj Kaul1, Betsy Evans1, Kalyana Javangula1, Sotiris Papaspyros1, Antonella Ferrara1, Ali Al-Sarraf1, Walid Elmahdy1
1Leeds General Infirmary, Leeds, United Kingdom. 2Castle Hill Hospital, Hull, United Kingdom
Correspondence: Mohamed Sherif
Journal of Cardiothoracic Surgery 2024, 19(2):A274
Objective: This study aims to compare the accuracy of measurement of left ventricular outflow tract (LVOT) using echocardiogram and annulus using Transcatheter Aortic Valve Implantation (TAVI) Computed Tomography (CT) in predicting prosthesis size for surgical aortic valve replacement (SAVR).
Methods: A single-centre retrospective analysis of patients undergoing isolated SAVRs between January 2019 and January 2023. Patient demographics, echo measurements and TAVI CT results were obtained from electronic health records. IBM SPSS version 27 was used for data analysis. The correlation coefficient was calculated using Pearson equation.
Results: Preoperative LVOT measurements were available for 211 (57%) patients (out of 371). 132 (63%) male and 79 (37%) female, with mean age of 67 years (Standard deviation SD 9.7, range 36–82).
Mean LVOT measurement was 21.5 mm (SD 2.3, range 16–30 mm) and mean implanted SAVR size was 22.8 (SD 2.1, range 19–29 mm). A moderate positive correlation (r = 0.37, p < 0.001) was observed between LVOT measurement and valve size.
60 patients (28%) had TAVI CT scans. Mean annular size was 25 mm (SD 2.5, range 20–31) and the mean SAVR prosthesis size was 23 mm (SD 2.6, range 19-27 mm). Annulus measurement using TAVI CT exhibited strong positive correlation with the implanted prosthesis size (r = 0.75, p < 0.001).
Conclusions: Our study shows that pre-operative measurement of LVOT and annulus using echo and TAVI CT are reliable predictors of aortic prosthesis size. TAVI CT has stronger correlation with the prosthesis size implanted. We suggest that smaller LVOT measurements on echo should warrant a TAVI CT for optimum pre-operative planning.
A275 Effect of intraoperative oxygen consumption on acute kidney injury after paediatric cardiac bypass surgery: a causal machine learning analysis
Yadav Srinivasan1, Mansour T. A. Sharabiani2, Alireza S. Mahani3, Richard Issitt1, Serban Stoica4
1Great Ormond Street Hospital for Children, London, United Kingdom. 2School of Public Health, Imperial College, London, United Kingdom. 3Davidson Kempner Capital Management, New York, USA. 4Bristol Royal Children’s Hospital, Bristol, United Kingdom
Correspondence: Yadav Srinivasan
Journal of Cardiothoracic Surgery 2024, 19(2):A275
Objective: Identify the relationship between granular intraoperative perfusion data and occurrence of postoperative acute kidney injury (AKI).
Methodology: Single-centre retrospective study of 762 consecutive patients. The explanatory variables were preoperative laboratory and demographic data, and minute-by-minute intraoperative perfusion data. AKI was reported on ordinal KDIGO scale. Large language models were used to extract data from textual fields. Causal analysis of impact of oxygen delivery on AKI used serum creatinine ratio (postop to preop) and duration with urine output below 0.5 ml/kg/hr (within 48 h post-surgery). Oxygen delivery impact was quantified by comparing the difference between Oxygen Extraction Ratio (OER) and a target value of 22% (global median of the combined data from all patients). Total positive differences and negative differences between OER and the target value (OER plus and minus respectively) were computed. Causal inference of their impact on the above two components of AKI was performed using causal random forests.
Results: OER-plus is found to be a significant risk factor for serum creatinine ratio, i.e., larger and longer-lasting positive deviations of OER from 22% increase the risk of high serum creatinine ratios. Similarly, we find OER-minus is a significant risk factor for patients’ postoperative urine output. If both OER-plus and OER-minus were fully eliminated from our dataset, the number of patients with severe AKI (2 or 3) would reduce from 206 to 140.
Conclusion: The shift in focus from oxygen delivery to consumption combined with advanced ML algorithms may help refine goal-directed perfusion and reduce end-organ injury further.
Figure
Overview of data preparation and modelling steps. (Dark blue: important data files; light blue: data preparation step; green: modelling step.) The ‘patient file’ consists of one record per patient, while the ‘perfusion file’ consists of multiple records per patient, arranged in a time-series format. Perfusion file used for calculating oxygen consumption (using Fick’s equation) and computing residuals via Arrhenius regression. The file features are merged, adding KDIGO score and its two constituents to produce the ‘consolidated file’. Analysis consists of variable importance analysis using a random forest model, and causal machine learning using a causal forest model
A280 Importance of preoperative albumin as a predictor of mortality: patients undergoing surgery for infective endocarditis
Tara Chan-A-Sue1, David Varghese2, Rickesh Karsan3, Gwyn Beattie3
1Queens University Belfast, Belfast, United Kingdom. 2Glasgow Cardiovascular Research Centre, British Heart Foundation Centre of Research Excellence, Glasgow, United Kingdom. 3Department of Cardiothoracic Surgery, Royal Victoria Hospital, Belfast, United Kingdom
Correspondence: Tara Chan-A-Sue
Journal of Cardiothoracic Surgery 2024, 19(2):A280
Objective: Surgery for infective endocarditis (IE) is an effective solution which provides good results when it is coupled with optimum medical care. The aim of this study was to identify any modifiable preoperative risk factors associated with adverse outcomes after surgery.
Methods: A retrospective analysis of the pre-operative demographics, albumin (Alb), intraoperative details, and postoperative complications of patients (n = 209: 160 males and 49 females) undergoing surgical management for IE from October 2011 to May 2022 from a single centre. Our primary outcome was in-hospital or 30-day mortality. Logistic regression was used to identify if preoperative albumin levels were associated with mortality. Data was analysed in Unistat statistical software packages.
Results: In terms of operative urgency 26 elective, 152 urgent, 26 emergencies and 5 salvage. There were 20 deaths (9.6%), 1 was elective, 9 urgent, 6 emergencies and 4 salvage (Fig. 1). The median Euroscore-2 was 4.4% (2.3 to 11.0) and it was strongly correlated with mortality. The preoperative albumin in the survivors was 36 (32 to 40) vs 33 (30.5 to 35.5) in the non-survivors, p = 0.04 this was shown to be a statistically significant mortality predictor using univariate logistic regression (OR 1.0872 [1.00–1.16], p = 0.0487).
Conclusion: Our study identified low albumin level as a predictive factor for adverse outcomes after surgery for IE. We suggest that it becomes standard practice to refer all patients with IE to the dieticians on referral.

A281 Bridging the gap in aortic care: the experience of clinical nurse specialist in establishing a nurse-led aortic surveillance clinic
Roxanne Noces
St. Thomas' Hospital, London, United Kingdom
Correspondence: Roxanne Noces
Journal of Cardiothoracic Surgery 2024, 19(2):A281
Aortic surgery is performed to treat a variety of aortic pathologies. Surgery can effectively treat these conditions but comes with peri and post-operative risk. Surveillance of patients to decide the optimum time to intervene is necessary. It is also crucial to recognise the importance of postoperative surveillance to ensure optimal patient outcomes and long-term success.
Aortic surveillance involves the systematic monitoring of patients following surgery, family members of patients with a genetic component to their aortic pathology and those with incidental abnormal findings that do not reach threshold for surgery but are at increased risk of an adverse event. Early detection enables timely intervention and management, which can prevent catastrophic events and preserve life. Moreover, surveillance can help identify modifiable risk factors and guide implementation of preventative measures to reduce the risk of future aortic events.
Despite being a relatively new there are almost 500 patients under the Aortic Surveillance Clinic at St Thomas’ Hospital. These patients were previously seen in individual consultant clinics. The clinical nurse specialist is responsible for managing this clinic: streamlining this follow up process, allowing for standardisation of practice and providing a defined point of contact for patients, family and health professionals. They ensure the patients undergo regular imaging, they conduct telephone consultations to establish patient wellbeing, discuss results and provide education. The role enables the effective triage, prioritisation and escalation of patient findings. They collaborate closely with the wider multi-disciplinary team to develop appropriate care plans and improve communication between all stakeholder groups.
A282 A screening process to identify prehabilitation needs for patient awaiting in-house urgent (IHU) cardiac surgery
Michael Rice
Royal Papworth Hospital, Cambridge, United Kingdom
Correspondence: Michael Rice
Journal of Cardiothoracic Surgery 2024, 19(2):A282
Objectives: To optimise the patient journey though cardiac surgery by highlighting those patients who may require enhanced physiotherapy input whilst awaiting IHU surgery. Does optimising a patient’s physical and mental condition pre-surgery affect their post operative outcomes?
Methods: From April to September 2022, 58 patients awaiting IHU cardiac surgery were screened using a novel tool focusing on musculoskeletal, neurological and respiratory diagnoses. Diagnosis codes were obtained from a database based on the electronic patient record, selected from a full list and separated into the above specialities. IHU patient notes were reviewed as able to provide prehabilitation or advice, to those with comorbidities that may affect their post-operative outcomes.
Results: 14 patients screened in for physiotherapy intervention due to having comorbidities and were reviewed for a range of inputs including sternal precaution advice, active cycle of breathing techniques, sit to stand practice and chair exercises. Assessing outcomes for these patients compared to their peers has not yet been reviewed.
Conclusions: It has not yet been established if prehabilitation is of benefit to IHU patients despite being a focus of cardiac surgeons to improve outcomes, especially in the context of increased surgical wait times, although suitability needs clarification with the cardiology team. Novel ideas to specify those patients who would get most benefit from physiotherapy input by using a screening tool would streamline resources.
A283 Prediction and control of oxygen extraction for goal-directed perfusion during paediatric cardiopulmonary bypass
Yadav Srinivasan1, Mansour T A Sharabiani2, Alireza S Mahani3, Richard Issitt1, Serban Stoica4
1Great Ormond Street Hospital for Children, London, United Kingdom. 2School of Public Health, Imperial College, London, United Kingdom. 3Davidson Kempner Capital Management, New York, USA. 4Bristol Royal Children’s Hospital, Bristol, United Kingdom
Correspondence: Yadav Srinivasan
Journal of Cardiothoracic Surgery 2024, 19(2):A283
Objective: The creation of a model for use during cardiopulmonary bypass that can predict oxygen extraction based upon real-world data of temperature and oxygen demand.
Methodology: Intraoperative minute by minute oxygen extraction data from 616 consecutive paediatric patients were analysed for autocorrelation and a predictive model created using an AutoRegressive Integrated Moving Average with eXogenous variables (SaO2, cardiac index, haematocrit, temperature)—(ArimaX) method. Lagged coefficients were examined to determine impact on oxygen extraction ratio (OER). Steady-state analysis was undertaken to understand impact of time-independence for comparison with established Q10 and Arrhenius models of temperature-dependent metabolism.
Results: OER displayed significant autocorrelation that could be negated with differencing. The dynamic model demonstrated significant system memory with past actions taking 10–15 min to wane. Past values of OER also have significant and slowly decaying impact on system evolution. Direct regression of oxygen extraction on temperature with data used for building the ARIMAX model produced a Q10 of ~ 3. However, the dynamic model indicated a Q10 of 1.75, below the currently accepted range of 2–3. Sign of lagged coefficients were consistent with an adaptive body mechanism to maintain oxygen extraction in line with a temperature-dictated metabolic rate (and hence oxygen demand).
Conclusion: The dynamic model suggests that there is systematic under-oxygenation of the patients at low temperatures, and systematic over-oxygenation of patients at high temperatures, contrary to the accepted Q10 temperature-dependent metabolism, with a transition point at ~ 32 °C. These findings can assist general and goal-directed perfusion practice.
Figure:

Figure: Calculated oxygen extraction vs. temperature for a random subsample of the intraoperative data (black dots), along with Q10 model fits (to the full data). The red line shows the result of the steady-state analysis of the dynamic model, while the green line shows the fit from a static model.
A284 Introducing the ReSPECT process in elective cardiac surgery
Rushmi Purmessur, Saur Hajiev, Lana Shirley, Jason Ali
Royal Papworth Hospital, Cambridge, United Kingdom
Correspondence: Rushmi Purmessur
Journal of Cardiothoracic Surgery 2024, 19(2):A284
The ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) process creates personalised recommendations for a persons clinical care and treatment in a future emergency in which they are unable to make their own choices. This has replaced DNACPR forms and is increasingly used routinely in the hospital setting. Following cardiac surgery, unexpected emergencies and complications can arise, where knowing the patients wishes may aide decision making.
Having ReSPECT conversations and completing the form can be challenging, particularly when patients are simultaneously being consented to embark on surgery.
We are developing a procedure to implement the ReSPECT process at our centre:
When a patient attends their first appointment with the surgeon, they are given a patient information leaflet describing ReSPECT and its importance.
They currently receive a booklet called “all about me” which they are required to complete. We plan to insert questions that will encourage patients to think about emergencies and their wishes.
When patients attend their pre-operative assessment appointments, cardiac support nurses will initiate the ReSPECT form, guided by what the patient has already written and further discussion.
The ReSPECT form and clinical recommendation will be completed by the surgical consultant or registrar on admission for surgery.
We propose that this method of implementation allows patients the opportunity to really think about what they would want in an emergency and discuss with their family, ensuring that this does not simply become a ‘tick-box exercise’.
A285 Long-term results after aortic valve replacement using a novel tissue bioprosthesis: best available evidence
Davorin Sef1, Myat Soe Thet2, Tomislav Klokocovnik3, Suvitesh Luthra1
1University Hospital Southampton, Southampton, United Kingdom. 2Imperial College London & Imperial College Healthcare NHS Trust, London, United Kingdom. 3General Hospital Celje, Celje, Slovenia
Correspondence: Davorin Sef
Journal of Cardiothoracic Surgery 2024, 19(2):A285
Objectives: While current data shows a clear trend towards the use of bioprosthetic valves during aortic valve replacement (AVR), particularly in younger patients, durability of bioprosthetic valves remains the most important concern. We conducted a first systematic review of all available evidence that analysed early and long-term outcomes after AVR using the Inspiris RESILIA™ bioprosthesis.
Methods: A systematic literature search was performed to identify all relevant studies evaluating early and long-term outcomes after AVR using the Inspiris RESILIA™ bioprosthesis and including at least 20 patients with no restriction on the publication date.
Results: A total of 416 studies were identified, of which 15 studies met the eligibility criteria. The studies included a total of 3166 patients with an average follow-up of up to 5.3 years. The average age of patients across the studies was 52.2–75.1 years. Isolated AVR was performed in 39.0–86.4% of patients. In-hospital or 30-day postoperative mortality was 0–2.8%. At the longest follow-up of 7 years, freedom from all-cause mortality was 85.4%. Among studies with mid- and long-term follow-up, trace/mild paravalvular leak (PVL) was detected in 0–3.0%, while major PVL was found only in up to 2.0% of patients. Structural valve degeneration was reported in total among 3 patients.
Conclusions: AVR using the Inspiris RESILIA™ bioprosthesis demonstrated excellent postoperative long-term outcomes. Further large randomized trials with a longer follow-up are required to establish durability of this new tissue bioprosthesis.
A286 Pericardiectomy preoperative characteristics and postoperative outcomes: a retrospective study
Shashi Kumar Kallikere Lakshmana, Alessia marigliano, Sanjay Asopa
University Hospital Plymouth, Plymouth, United Kingdom
Correspondence: Shashi Kumar Kallikere Lakshmana
Journal of Cardiothoracic Surgery 2024, 19(2):A286
Objectives: This retrospective study aimed to investigate the relationship between preoperative patient characteristics and their postoperative outcomes in a cohort of cardiac surgery patients. Specifically, we examined how preoperative factors may influence postoperative recovery and overall health.
Methods: Data from a comprehensive database of cardiac surgery patients were analyzed. The study cohort included patients who underwent excision of the pericardium. We assessed various preoperative variables, including the presence of angina, dyspnoea, comorbidities like diabetes and hypertension, and surgical urgency. We also examined demographic data, smoking history, and cardiac vessel disease severity. Postoperative outcomes were assessed, including New York Heart Association (NYHA) score post-op improvement, mortality, and length of hospital stay. Statistical analysis, including logistic regression and descriptive statistics, was employed to uncover significant associations and trends.
Results: Our analysis revealed that patients with a higher preoperative NYHA score, preexisting diabetes, and urgent surgical procedures were more likely to have adverse postoperative outcomes. Patients with a history of smoking also exhibited a higher risk. The study found that preoperative variables are significant predictors of postoperative outcomes, particularly in relation to NYHA score improvement.
Conclusions: The findings from this study emphasize the importance of preoperative patient assessment and risk stratification in cardiac surgery. Identifying patients at higher risk based on preoperative characteristics can aid in tailoring treatment plans, optimizing postoperative care, and potentially improving patient outcomes. This research provides valuable insights for healthcare practitioners in managing cardiac surgery patients, ultimately contributing to better postoperative recovery and enhanced patient care.
A287 Anti-thrombotic therapy after tissue surgical aortic valve replacement
Saima Azam, Prashant Mohite, Karim Morcos, David Varghese, Philip Curry
Golden Jubilee National Hospital, Glasgow, United Kingdom
Correspondence: Saima Azam
Journal of Cardiothoracic Surgery 2024, 19(2):A287
Objectives: The choice of anti-thrombotic therapy following tissue surgical aortic valve replacement (tSAVR), has been a subject of considerable variation among cardiothoracic surgeons. This diversity in clinical practice is exacerbated by discrepancies between surgical preferences and guidelines. The aim was to assess anti-thrombotic therapy after tSAVR ± coronary artery bypass graft (CABG) in our tertiary cardiothoracic hospital compared with 2021 ESC/EACTS guidelines.
Methods: This was a retrospective observational study. All patients data who underwent primary isolated tSAVR ± CABG for a six month period (01/10/2022 to 31/03/2023) was collected. Long term anticoagulation was recorded, as well as baseline indications for oral anticoagulation (OAC). CHA2DS2VASc scores were calculated and stratified into low, intermediate and high risk.
Results: 90 patients underwent primary isolated tSAVR ± CABG. 55.6% (n = 50) underwent tSAVR only, and 44.4% (n = 40) underwent tSAVR and CABG. 16% had a baseline indication for oral anticoagulation (OAC) and received OAC. 83% of patients (n = 75) had no baseline indication for OAC. In this cohort, patients with a low CHA2DS2VASc (4%, n = 4) score 3 received aspirin, and 1 received aspirin + OAC. In patients with intermediate CHA2DS2VASc (17%, n = 15), 11 received aspirin alone, 2 received dual anti-platelet therapy (DAPT), and 2 received aspirin + OAC. Finally, 62% (n = 56) had a high CHA2DS2VASc score. 13 received aspirin + OAC, 5 received DAPT, and 38 patients received SAPT.
Conclusion: There is significant variation in practice in anticoagulation post tSAVR. Calculating the CHA2DS2VASc score in patients helps to stratify treatment strategy according to risk in patients that have no indication of OAC.
A288 10 years of valve-sparing aortic root replacement: outcomes from a tertiary cardiac surgery centre
Olaniran Omodara, Sana Khan, Mohamed Shoeib, Syed Sadeque, Renata Greco, Stefano Forlani, Govind Chetty
Northern General Hospital, Sheffield Teaching Hospitals Foundation NHS Trust, Sheffield, United Kingdom
Correspondence: Olaniran Omodara
Journal of Cardiothoracic Surgery 2024, 19(2):A288
Objectives: Valve-sparing aortic root replacement (VSRR) is a management option for aortic aneurysms in patients with structurally normal aortic leaflets. This circumvents lifelong anticoagulation with its associated risks, including complexities for women of child-bearing age, young/active patients, and is associated with a lower rate of re-do surgery. We investigated outcomes of VSRR in our centre.
Methods: We prospectively collected data on 48 patients between 2012 and 2023. Three patients required aortic valve replacement for residual moderate regurgitation (AR) on their intraoperative trans-oesophageal echocardiogram. Of the remaining 45, 93.3% (n = 42) were elective cases. Surgeries were performed using David’s procedure; 35.6% (n = 16) required leaflet repair; 95.6% (n = 43) were performed jointly by two consultants. Our primary outcome was in-hospital mortality; secondary outcomes were freedom from new significant AR, left ventricular systolic dysfunction (LVSD), and long-term survival.
Results: There were no in-hospital deaths; median length of stay was 9 days (IQR = 6–13). Median duration of trans-thoracic echocardiographic follow-up was 37 months (IQR = 15–83); one patient developed new AR and two new LVSDs; none of these three had undergone leaflet repair. Redo surgery for further valve repair/replacement was not required in any patient. One patient died of an aortic-related complication (pseudoaneurysm) within six months of surgery, and four died of non-aortic-related comorbidities during follow-up. Echocardiographic and survival data are shown in table 1.
Conclusions: VSRR had low in-hospital mortality, low incidence of new significant AR and LVSD, and good long-term survival. VSRR can be safely and successfully performed in a tertiary centre with a dedicated aortic team.
A289 Partial replacement of tricuspid valve using cryopreserved tricuspid homograft: 20-year outcomes
Samad Raza, Bishwo Shrestha, Fiona Doig, Douglas Bell, Peter Pohlner, Homayoun Jalali, Rishendran Naidoo
Department of Cardiothoracic Surgery, The Prince Charles Hospital, Brisbane, Australia
Correspondence: Samad Raza
Journal of Cardiothoracic Surgery 2024, 19(2):A289
Objectives: Use of homograft tissue for tricuspid valve repair is a rare but useful technique to salvage a severely deformed valve, however limited data exists about its long-term viability. At our institution, we have implemented a unique technique of using a tricuspid homograft with its supporting apparatus for partial replacement of the native tricuspid valve. We now present the long-term outcomes of these patients.
Methods: Since 1992, 14 patients underwent tricuspid valve repair using tricuspid homograft. The patients’ age ranged from 15 days to 73 years at time of surgery. Indications for repair were congenital anomalies (n = 9) and bacterial endocarditis (n = 5). Kaplan–Meier methods and Log-Rank Chi-Square test were used to estimate freedom from re-intervention, and overall survival.
Results: The mean follow-up was 147 ± 87 months (maximum 278 months). There were 3 deaths unrelated to the primary tricuspid valve surgery, and 3 redo tricuspid valve operations. In the remaining cohort, 6 were asymptomatic and 2 reported class II dyspnoea, whilst none had severe tricuspid regurgitation on echocardiogram. Estimated freedom from death and reoperation at 10, 15 and 20 years was 61%. No patients with greater than 10 years of follow-up have required reintervention.
Conclusions: Partial replacement of the tricuspid valve using tricuspid homograft tissue effectively restores the anatomical conformity of the native tricuspid valve and has durable long-term survival and freedom from severe tricuspid regurgitation in patients with congenital anomalies and infective endocarditis. This cohort represents the longest term follow up for homograft repair of the tricuspid valve in the literature.
A290 Comparison of open, robotic, and videothoracoscopic surgery in obese patients for lung cancer. A multicenter retrospective series
Giulia Fabbri, Federico Femia, Akshay Patel, Eleonora Farinelli, Karen Harrison-Phipps, Andrea Bille
Guy's Hospital, London, United Kingdom
Correspondence: Giulia Fabbri
Journal of Cardiothoracic Surgery 2024, 19(2):A290
Objective: to compare Robotic-assisted (RATS), Video-assisted (VATS), and open (OA) approaches in terms of morbidity and mortality rate and technical feasibility in obese patients undergoing anatomical lung resection for early stages Lung Cancer (NSCLC).
Methods: We conducted a prospective study enrolling consecutive patients with Body Mass Index (BMI) ≥ 30 kg/m2 undergoing anatomical lung resection for stages I-II NSCLC between 2015 and 2022. Primary outcomes were: complication rate, length of hospital stay (LOS), length of chest drain (LOD), in hospital, 30- and 90-days mortality, and intraoperative blood loss (IBL). Secondary outcomes were conversion rate, lymphnode yield, and operating time.
Results: We collected a total of 259 patients, 142 in the RATS group, 79 in the VATS group and 38 in the OA group. The results are shown in Table 1. RATS and VATS had a significantly lower complication rate, LOS, and LOD compared with OA. IBL was significantly lower in the RATS group compared to VATS and OA. The median number of lymphnode stations harvested was significantly higher in the RATS group. Finally, RATS was associated with a significantly lower operating time than VATS and OA.
Conclusion: In our series, VATS and RATS were associated with significantly better clinical outcomes compared to open approach in obese patients after anatomic lung resection for Stage I-II NSCLC. Moreover, RATS appears to be more efficient compared to VATS and open as it was associated with a significantly fewer IBL, a significantly higher lymph node yield and shorter operative time.
A291 Coronary ischemia following congenital cardiac surgery has high mortality and often requires multiple imaging modalities for diagnosis
Simran Kundan, Preeti Kathel, Martin Kostolny, Branko Mimic, Nagarajan Muthialu, Victor Tsang, Anusha Jegatheeswaran
Great Ormond Street Hospital, London, United Kingdom
Correspondence: Anusha Jegatheeswaran
Journal of Cardiothoracic Surgery 2024, 19(2):A291
Objectives: Coronary ischemia after paediatric cardiac surgery is rare, primarily occurring in patients undergoing coronary artery/aortic root surgery, requiring prompt evaluation/treatment. Our objectives were to: 1) evaluate index diagnoses, 2) assess timeline to diagnosis, and 3) understand the spectrum of reinterventions.
Methods: A quaternary paediatric hospital’s cardiac database was queried for patients undergoing coronary artery/aortic root surgery (1/4/2004–31/3/2022). This returned 923 patients who underwent retrospective chart review. Inclusion criteria: reintervention(s) (≥ 2 pump runs, or subsequent procedures) addressing coronary ischemia.
Results: N = 41/923 (4.4%) patients, who underwent 49 reinterventions [(median follow-up 7.7y (2.1y-11.8y)] (Fig. 1-Flowsheet of diagnoses/reinterventions). Coronary ischemia diagnosis occurred in the: OR = 23, ICU = 20, post discharge (asymptomatic) = 4, outside hospital postoperatively = 2. At diagnosis 31 pts = normal LV function, 1 = mild dysfunction, 2 = moderate dysfunction, and 7 = severe dysfunction. Pre reintervention #1: 14 patients were diagnosed intraoperatively without imaging, and 27 had a postoperative echocardiogram, (10 of whom underwent additional investigations*). Pre reintervention #2: 7 patients had echocardiography, but also additional investigations*. *Investigations = catheterization, CTA/CPET, and MRA/CPET. Systemic ventricular dysfunction was the cause of death in 3/41 (7.3%) patients, all diagnosed intraoperatively after index repair. Of the 36 survivors with known LV function at last follow-up, 35 = normal function and 1 = mild dysfunction.
Conclusions: Multiple imaging modalities were required to diagnose ischemia. Ischemia correction allows for ventricular recovery with maintenance in the medium-term. Reintervention for coronary ischemia has high mortality, potentially related to an ischemic insult immediately following bypass, as those who died were diagnosed intraoperatively.

A292 An unusual case of chylothorax secondary to a paravertebral cyst resection
Sarah Alzetani1, Aiman Alzetani2
1Salisbury District Hospital, Salisbury, United Kingdom. 2University Hospital Southampton, Southampton, United Kingdom
Correspondence: Sarah Alzetani
Journal of Cardiothoracic Surgery 2024, 19(2):A292
Background: Paravertebral cysts are lesions which can be encountered incidentally through imaging and are managed by surgical resection. Post-operative chylothorax is uncommon in such locations. This case describes a rare occurrence of this complication following a Müllerian cyst resection and it's multi-disciplinary team management.
Case summary: A 40 year old female presented with back pain. A CT scan confirmed a left paravertebral cystic lesion above the level of the aortic arch. She was referred to thoracic surgery and underwent a successful resection with a chest drain insertion on completion. A high output drainage was noted on day 1 and fluid analysis confirmed chyle. She was initially managed with a fat-free diet and octreotide for two-weeks with no resolution. A right thoracoscopy and ligation of her thoracic duct as well as a left thoracoscopic talc pleurodesis was then performed and total parenteral nutrition was commenced for a further week. With no apparent reduction in drainage, an upper body radio-labelled lymphangiogram was negative for anomalous lymphatic drainage. However, a subsequent lower body lymphangiogram demonstrated two trans-diaphragmatic anomalous lymph channels that fed into the base of the resected cyst. These were successfully embolised (Fig. 1) with complete resolution of the chyle leak within 24-h.
Discussion: This case demonstrates the unusual presence of anomalous lymphatic channels feeding into a paravertebral Müllerian cyst that can be a cause of chylothorax upon resection. Awareness of this anatomical variance and a multi-disciplinary approach is necessary for successful management of such cases.
Patient gave their written, informed consent to publish their information in an open access journal.

A293 Endoscopic vein harvesting in CABG: initial experience in a single centre
Ashwini Chandiramani, Nisha Nair, Muslim Mustaev, Kamran Baig, Michael Sabetai
St Thomas' Hospital, London, United Kingdom
Correspondence: Ashwini Chandiramani
Journal of Cardiothoracic Surgery 2024, 19(2):A293
Background: Endoscopic vein harvesting (EVH) is one of the high-technology and modern techniques for conduit-harvesting in CABG. The long-saphenous-vein graft (SVG) is harvested using an endoscope system inserted through two small, 1–3 cm incisions. The major advantages of EVH include minimal trauma to donor sites, faster healing and excellent patient-satisfaction. The aim of this study was to evaluate our initial experience and patient-outcomes post EVH.
Methods: A dedicated questionnaire was designed to assess patient symptoms, wound healing, analgesia requirements, infection rates and quality-of-life post-operatively. Thirty-consecutive-patients were followed-up in 8–28 weeks after CABG with EVH. The questionnaire was conducted via telephone-interview and responses were analysed by two independent-assessors.
Results: In the patient cohort, 25 (83.3%) were male. The total number of grafts was 2.93 ± 0.78 and the SVG number was 1.87 ± 0.73. Most patients (53%) had 2 SVG harvested, followed by 1 graft (30%), 3 grafts (13.3%) and 4 grafts (3.3%). In 22 (73%), SVG harvest was performed by EVH on the left leg and in 7 (23%) patients on the right leg. After discharge, 50% patients did not experience leg pain or erythema, 70% patients did not take any painkillers. Seven (23.3%) patients had discharge from the wounds requiring antibiotics. Notably, none of the patients required readmission for leg wound infection.
Conclusion: EVH technique is well-established in many institutions. It results in fast healing of the donor sites and good quality-of-life post CABG. Our pilot series shows that EVH can be successfully implemented with good clinical outcomes and patient satisfaction.
A294 Left anterior descending artery to pulmonary artery: a case report
Yunxi Guan1, Rushmi Purmessur2, Jason Ali2
1Norwich Medical School, Norwich, United Kingdom. 2Royal Papworth Hospital, Cambridge, United Kingdom
Correspondence: Yunxi Guan
Journal of Cardiothoracic Surgery 2024, 19(2):A294
Anomalous Left Coronary Artery from Pulmonary Artery (ALCAPA) is a rare congenital anomaly, typically diagnosed in infancy, with untreated cases carrying high mortality risk. However, we present an interesting case of ALCAPA in a 67-year-old patient who experienced unstable angina disproportionate to observed coronary artery stenosis.
Upon coronary angiography, the left main stem (LMS) was found to be originating from the left coronary sinus of Valsalva as normal, but most of its blood supply was being diverted into the pulmonary artery (PA), creating a left to right shunt. The proximal left anterior descending artery (LAD) was severely stenosed. Subsequent 3D reconstruction from a computed tomography coronary angiography unveiled a complex network of fistulae formed between the LMS and the pulmonary arterial trunk.
What makes this case unusual is that ALCAPA generally presents in early childhood with symptoms like failure to thrive or chronic ischemic complications. However, this patient remained asymptomatic for decades. The left coronary arterial system successfully maintained adequate oxygenation, with only a very small left-to-right shunt into the PA.
It was only with the development of stenosis in the proximal LAS that the left-to-right shunt into the PA worsened, leading to disproportionately severe angina.
In this case report, we describe the surgical procedure employed to address this complex anomaly. The intervention included an incision into the PA and direct closure of the LMS-PA fistula, followed by coronary artery bypass grafting. This case underscores the significance of timely diagnosis and intervention for congenital cardiac anomalies, even in late adulthood.

A295 Raphe realignment technique in Siever’s type 1 BAV repair improves leaflet motion and transvalvular gradients
Agni Leila Salem, Jakub Marczak, Ayman Kenawy, Ahmed Othman, Deborah Harrington, Mark Field, Manoj Kuduvalli, Omar Nawaytou
Liverpool Heart and Chest, Liverpool, United Kingdom
Correspondence: Agni Leila Salem
Journal of Cardiothoracic Surgery 2024, 19(2):A295
Objective: Bicuspid aortic valve (BAV) repair often leads to higher postoperative valve gradients compared to tricuspid aortic valves (TAV), which may lead to earlier valve degeneration.
We have altered our repair technique in these patients by implanting the raphe at the annular level rather than at its original anatomical level during David’s procedure. We hypothesise that this may improve leaflet mobility, coaptation height and flow patterns. The aim of this study is to compare our results pre and post refinement.
Methods: From November 2017 to March 2022, 170 patients underwent valve-sparing aortic root replacement with re-implantation technique. 51 patients had a BAV. Patients’ operative data and discharge echocardiograms were assessed. Patients were subdivided into: Group S; with a standard re-implantation of the raphe and Group R; with the raphe realigned and implanted at the annular level.
Results: 43 patients had L-R configuration and 1 R-N. (Group S: 12 patients, Group R: 32 patients). Preoperative mean aortic annular and root diameter, and preoperative AR were equal among groups. Valsalva grafts of same size, were used in all patients. Postoperatively, patients in group R had significantly lower peak transvalvular gradients and lower mean gradients. Postoperative aortic annular diameter did not differ among groups, all patients had grade 0 residual AR and equal coaptation length and height.
Conclusion: Realignment of the raphe at the level of the aortic annulus during type 1 BAV repair is associated with better flow characteristics and lower peak transvalvular gradients for the same aortic annulus and graft size.
A296 Could lung low attenuation areas on pre-operative CT scans be a non-invasive biomarker for postoperative dyspnoea in lung cancer surgery
Saffana Algaeed1,2, Salma Kadiri3, Helen Shackleford4, Hazem Fallouh4, Ehab Bishay3, Richard Steyn3, Vanessa Rogers4, Ashvini Menon4, Maninder Kalkat4, David Thickett4,5, Babu Naidu4,5
1University of Birmingham, Birmingham, United Kingdom. 2King Saud University, Riyadh, Saudi Arabia. 3University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom. 4University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom. 5University of Birmingham, Birmingham, United Kingdom
Correspondence: Saffana Algaeed
Journal of Cardiothoracic Surgery 2024, 19(2):A296
Background: We have previously presented (SCTS 2023) the significant long-term persistent breathlessness in half of the patients undergoing lung cancer resection in a large cohort of patients. A significant proportion of lung cancer patients have concurrent emphysema with low attenuation areas (LAA)/density on CT scans, the significance of which is unknown. This study aims to define the relationship between LAA, and postoperative dyspnoea measured by patients' reported outcomes.
Methods: Review of a subset of patients enrolled in a prospective observational study undergoing lung cancer surgery. The European Organisation for Research and Treatment of Cancer (EORTC QLQ-C30) survey was introduced pre-surgery, eight weeks and six months post-surgery. Quantitative analysis of CT scans using 3D Slicer software was performed to assess %LAA below 950 Hounsfield units. Multivariate ordinal logistic regression analysis investigated the relationship between %LAA-950, other peri-operative factors and postoperative dyspnoea six months post-surgery.
Results: A total of 60 unenhanced CT scans were analysed. EORTC QLQ-C30 dyspnoea scores at baseline and six months post-surgery were (0 ± 33.3) and (33.3 ± 66.6), respectively, (p = 0.00).
In the multivariable analysis, %LAA-950, baseline dyspnoea, smoking status, American Society of Anaesthesiologists physical status classification (ASA score), and length of hospital stay (LOS) were all significantly associated with the increase of dyspnoea after surgery (p < 0.05).
Conclusion: %LAA-950 emerges as a significant risk factor for postoperative dyspnoea in patients undergoing lung cancer surgery providing a promising avenue for better predicting breathlessness post-surgery and focusing on enhanced recovery with personalised care and targeted interventions.
A297 Predicting 30-day readmission after bilateral lung transplantation, insights from the nationwide readmission database
Madhivanan Elango
Houston Methodist Hospital, Houston, USA
Correspondence: Madhivanan Elango
Journal of Cardiothoracic Surgery 2024, 19(2):A297
Objectives: Lung transplantation is the definitve treatment for end-stage lung disease but can carry significant morbidity associated with high length of stay and readmission rate, which in itself is a predictor of long-term survival. We sought to identify the predictors of readmission in this population.
Methods: The Nationwide Readmissions Database was used to identify all bilateral lung transplant recipients (age > = 18) from 2016 to 2018. Primary outcomes include death during index admission, prolonged length of stay (> 30 days) and non-elective readmission within 30 days.
Results: 2431 patients who underwent bilateral lung transplantation from 2016 to 2018 were identified. There was 2.3% mortality rate on index admission, median length of stay was 22 days (IQR 15–43 days) and 30-day readmission rate was 27%. Diagnosis of sepsis (OR 7.53, 95% CI 4.26–13.0) and AKI were associated with increased mortality during index admission. Sepsis, AKI, tracheostomy, lung transplantion for pulmonary fibrosis, acute lung transplant rejection, and transfer to rehabilitation facility were all associated with prolonged length of stay. Age > 40 and elective admission for lung transplantation (OR 0.64, 95% CI 0.46- 0.88) were associated with decreased readmission rate while underlying lung disease, sepsis, transplant rejection, socio-economic status and tracheostomy were not associated with redmission.
Conclusions: More than one quarter of bilateral lung transplant recipients had a non-elective readmission within 30 days of discharge.The only significant predictor of readmission in our study was whether the patient was electively admitted for transplantation suggesting the health of patient prior to transplant is most predictive of need for readmission.
A298 Frozen elephant trunk: an overview of hybrid prostheses
Mariam Hussain1, Ihsan Abhbacker2, Aya Hammad1, Matti Jubouri1, Mohamad Bashir3
1Hull York Medical School, York, United Kingdom. 2St George’s University, London, United Kingdom. 3Vascular and Endovascular Surgery, Health Education and improvement Wales (HEIW), Cardiff, United Kingdom
Correspondence: Mariam Hussain
Journal of Cardiothoracic Surgery 2024, 19(2):A298
Background: Thoracic aortic pathologies are usually managed with different surgical and hybrid procedures, with total aortic arch replacement (TAR) being the main treatment for the disease implicating the aortic arch and the descending thoracic aorta (DTA). This can be performed in a single-procedure hybrid fashion using the frozen elephant trunk technique which utilises a hybrid aortic prosthesis (HP). This narrative review aims to provide an overview of the four major FET HPs, highlighting their design features, mechanical properties, configurations, and variants, and evaluating their clinical outcomes in the literature.
Methods: A comprehensive literature search was conducted using multiple electronic databases to identify and extract relevant data and information.
Results: Four FET devices were identified that can be considered the main option on the global market; Thoraflex Hybrid Plexus (THP), E-Vita, Cronus, and Frozenix J Graft. Each hybrid prosthesis (HP) features a unique design and features resulting in varying clinical outcomes. THP and E-Vita are the most widely used and investigated HPs, however, THP’s innovative design has translated to superior clinical outcomes. The use of Cronus and Frozenix is geographically confined to mainly manufacturers’ countries and therefore has not been thoroughly studied.
Conclusion: The FET technique for TAR can be considered an evolutionary step in the field of aortovascular surgery, allowing optimal treatment for complex aortic arch pathologies with favorable clinical outcomes. However, large studies directly comparing these four main FET HPs are required.
A299 Patients’ expectations of postoperative course and satisfaction following cardiac surgery
Krishna Mani1, Jack Luttman2, Justin Nowell1, Adrian Carrol3, Marjan Jahangiri1
1St Georges NHS Trust, London, United Kingdom. 2Brunswick Group LLP, London, United Kingdom. 3Edwards Lifesciences, London, United Kingdom
Correspondence: Krishna Mani
Journal of Cardiothoracic Surgery 2024, 19(2):A299
Objectives: We analyzed the preoperative concerns, expectations of surgery, anticipated recovery timelines, and pre- and post-operative education which impact recovery and quality-of-life in cardiac surgery patients.
Methods: We conducted a survey of 80 patients who underwent cardiac surgery between 2016 and 2019. This survey assessed patients’ preoperative concerns, allowed patients to evaluate the usefulness of information provided by the National Health Services, assessed the use of digital channels, for patients’ satisfaction with surgery, and for the impact of treatment on resumption of daily physical activity and overall quality-of-life.
Results: In our patient cohort, there was a high rate of overall post-surgical satisfaction (86%): 71% of respondents reported an improvement in physical health, 45% in mental health, and 70% in overall quality-of-life. Furthermore, 79% of respondents reported feeling prepared for their operation. The usefulness of information provided by the NHS varied across different stages of patients’ experiences. Although approximately 90% of respondents found information provided at each stage at least 'somewhat' helpful, the proportion who found the information 'very' helpful decreased following cardiac surgery (68% pre-procedure versus 55% post-discharge).
Conclusions: We report high levels of positive health outcomes and patient satisfaction among our cohort. However, survey responses highlighted areas of lower patient understanding, such as survival rates, post-operative pain, length of hospital stay, and time to resumption of physical activity. Our findings suggest room for improvement in addressing patients' understanding of expectations from surgery, and demonstrate a desire among patients for more surgical team-based, face-to-face consultation for cardiac surgery.
A300 The impact of donor age on long-term outcome after lung transplantation: a single-centre 22-year analysis
M Yousuf Salmasi1, Mahmoud Al Shiekh2, Charlotte Zeschky2, Tobin Mangel2, Mohamed Elshalkamy2, Diana Garcia Saez2, Bartlomeij Zych2, Espeed Khoshbin2
1Imperial College London, London, United Kingdom. 2Harefield Hospital, London, United Kingdom
Correspondence: M Yousuf Salmasi
Journal of Cardiothoracic Surgery 2024, 19(2):A300
Background: Given the shortage of donor organs for lung transplantation, extended criteria for donors aged > 60 years have been routinely considered to expand the donor pool. However, the impact of older donors, in terms of primary graft dysfunction and survival of recipients, is not clear.
Methods: We retrospectively analysed patients who underwent lung transplantation at a single centre. Consecutive patients were reviewed over a 22-year period (2000 to 2022) with up to 10-year follow-up data. Recipient patients were categorised based on lung-donor age: Group A (< 60 years) (n = 1,423) and Group B (> 60 years) (n = 144). Primary outcome was freedom from graft failure, whilst the secondary outcome was patient survival.
Results: Spearman-rank coefficient and scatterplot analysis confirmed no correlation between donor and recipient ages. There was no significant mean age difference between the two recipient groups A and B (43.2 ± 14 vs. 50 ± 12 years respectively, p = 0.458). Primary outcomes: 5- and 10-year freedom from graft failure was 68% and 49% for group A, and 53% and 38% for group B, respectively (logrank test, p = 0.041). Multivariate cox proportional hazards models found younger donor age to be a predictor of freedom from graft failure independently of recipient age (HR 1.01, 95% CI 1.01–1.02, p < 0.001). Secondary outcome: 5- and 10-year survival was 61% and 42% for group A, and 38% and 27% for group B, with donor age > 60 years being a significant predictor of worse survival (p < 0.001).
Conclusion: This study provides a cautionary recommendation to acceptance of lung donors > 60 year of age.

A301 Surgical smoke extraction devices within cardiac surgery: promoting utilisation in line with current health and safety recommendations (a primary research study)
Lauren Cody Guy
Barts Health NHS Trust, London, United Kingdom
Correspondence: Lauren Cody Guy
Journal of Cardiothoracic Surgery 2024, 19(2):A301
Aim: To identify the barriers to surgical smoke extraction device (SSED) utilisation within cardiac surgery, and to establish how such barriers could be overcome. Ultimately, this research aims to prevent ill-health and promote surgical staff and patient safety.
Methods: A questionnaire was distributed via a secure online survey platform to 29 eligible senior cardiac surgeons working within one department of the National Health Service. A quantitative research approach was adopted, and comprehensive descriptive statistical analysis of data was performed.
Results: Evidentially, there is an overall lack of awareness of the potential hazards associated with exposure to surgical smoke and paucity in familiarity with current recommendations from governing bodies. A shortfall in access to SSEDs and reluctance in adoption has prevented cardiac surgeons from utilising them. However, their level of concern, desire to access and eagerness to trial SSEDs is unequivocal.
Conclusions: In a surgical specialty whereby team members’ exposure to surgical smoke is both regular and longstanding but their risk of potential harm is avoidable, it seems indisputably ethically important to proactively reduce the risk of ill-health. Until the link between chronic exposure and occupational disease has been clinically disproven or safe workplace exposure limits have been identified, equipping cardiac surgery teams with valuable knowledge may help them to make wise, informed decisions regarding instrument selection/SSED adoption. Should a definitive link be proven, the physical, psychological and financial cost to healthcare organisations and staff could be detrimental if there is failure to prevent ill-health due to inactivity or passivity.
A302 Sustainability in cardiothoracic surgery: current trends in practice and views amongst surgeons
Catherine Simister1, Shahzad Raja2
1Imperial College School of Medicine, London, United Kingdom. 2Royal Brompton and Harefield NHS Trust, London, United Kingdom
Correspondence: Catherine Simister
Journal of Cardiothoracic Surgery 2024, 19(2):A302
Objectives: This study aimed to understand current trends in practice and perspectives amongst cardiothoracic surgeons in the UK regarding sustainable surgical practice.
Methods: A questionnaire was designed following immersion in literature regarding sustainable surgical practice. The RCS Intercollegiate Green Theatre Checklist was also used to structure the questionnaire. Google Forms software was used to create the questionnaire, which was distributed by email to all consultants and specialty registrars in cardiothoracic surgery in the UK. Multiple choice and free text question types were used. Reminders were sent twice within the one-month data collection period.
Results: Forty consultants and eight specialty registrars completed the questionnaire. A need to improve sustainability in cardiothoracic surgery was perceived by 83.3% of participants, with 87.5% believing the greatest contributor to emissions was disposable surgical products. The use of reusable surgical equipment was supported by over 90% of participants, but this was not available to 40.4% of participants. 87.5% of participants had an instrument preference list for at least one of their procedures. Disposable textile use was less prevalent. Availability of sensor-controlled taps was reported by 46.4% of participants and over 90% used water for every scrub. One third of participants were aware of sustainability initiatives within their trust.
Conclusions: The need to improve sustainability in cardiothoracic surgery is supported by cardiothoracic surgeons. Measures to reduce the waste and energy output of surgery are already in limited use, but a focus should be placed on national initiatives to increase adoption of sustainable practices in surgery.
A303 Sharing learning from the creation of a heart and lung transplant digital learning resource
Hazel Muse1, Kirstie Wallace1, Jamie Steane2, Stephen Clark1
1Freeman Hospital, Newcastle, United Kingdom. 2Northumbria University, Newcastle, United Kingdom
Correspondence: Hazel Muse
Journal of Cardiothoracic Surgery 2024, 19(2):A303
In 2022 we developed and launched an innovative web-based digital learning resource to help patients better understand the transplant process. The concept delivered state of the art educational content including text, video, staff and patient interviews and animation. Before formal assessment, patients were expected to log in and work through the resource chapters so that on physical hospital attendance verbal basic information giving was not needed freeing time for specific questions/areas to reinforce and releasing transplant co-ordinator time.
In the presentation we will share this project's encouraging initial quantitative and qualitative results.
In the first full year, 316 patients were invited to access the digital resource. 261 (82.6%) engaged with it online. 86 carers/family members created their own accounts to access the learning. 2 patients, unable to access the resource, were given a laptop to review material onsite. The uptake in digital access allowed clinicians to monitor an individuals engagement with the material and inform their conversations with patients. We will present patient engagement figures for the sections and least understood areas.
28 h/week was saved and repurposed by co-ordinators. Benefits also included consistency of education, ability for patients to repeat sections and absence of distractions. Added familiarity with the hospital environment and team and video content were most commonly praised by patients.
Early qualitative feedback suggests this has been transformative for patients, carers and clinicians. It has streamlined patient assessment from four to two days. We will discuss development plans and broader applications of the design.
A304 Audit closure: management of post-operative atrial fibrillation after lung resection
Aaliyah Ahmed1, Syed Faisal Hashmi2
1Royal Preston Hospital, Preston, United Kingdom. 2Royal Stoke University Hospital, Preston, United Kingdom
Correspondence: Aaliyah Ahmed
Journal of Cardiothoracic Surgery 2024, 19(2):A304
Objectives: Post operative atrial fibrillation (POAF) is a common complication following thoracic surgery. This study aims to optimise the management of POAF following thoracic surgery according to national guidelines.
Methods: This was a retrospective study consisting of patients (n = 631) who underwent segmentectomy, lobectomy or pneumonectomy between July 2021 and March 2022. 3.6% of these developed POAF, equalling 23 patients. For each patient, gender, age, previous history, procedure specifics, treatment, and length of stay (LOS) were identified as well as a CHADSVASC score calculated for each patient.
Results: Several medications and combinations were used. The most common combination was bisoprolol and amiodarone (35%), followed by bisoprolol alone (26%). No patient was treated with digoxin as first line. All patients who were previously on a beta blocker were continued on it post operatively. The mean LOS was 3.1 days longer in patients with POAF compared to those without POAF (Fig. 1). The average longest LOS was found with amiodarone alone, followed by bisoprolol. The CHADSVASC tool predicted 87% of the patients who developed POAF.
Conclusion: In summary, this study found a variety of medications used for treatment of POAF following thoracic surgery. Digoxin is no longer used as first line medication and adherence to beta blocker continuation was seen in all (100%) cases, in line with national and international guidelines (NICE, EATCS). The CHADSVASC was found to be a reliable tool to predict POAF, however there is a need to develop a risk prediction tool exclusively for POAF after thoracic surgery.
Average Length of Stay for POAF vs Non POAF Patients
A305 New Risk Prediction Model (RAAFTS) for post operative atrial fibrillation following thoracic surgery
Aaliyah Ahmed1, Hamzah Roker1, Felice Granato2, Syed Faisal Hashmi3
1Royal Preston Hospital, Preston, United Kingdom. 2Wythenshawe Teaching Hospital, Manchester, United Kingdom. 3Royal Stoke University Hospital, Stoke, United Kingdom
Correspondence: Aaliyah Ahmed
Journal of Cardiothoracic Surgery 2024, 19(2):A305
Objectives: Post operative atrial fibrillation (POAF) is a common complication following thoracic surgery. The aim of the study is to evaluate an additive risk prediction tool (RAAFTS—Risk Assessment for Atrial Fibrillation after Thoracic Surgery) for new onset POAF after lung resection, so it can be pre-emptively calculated & treated.
Methods: This was a retrospective study consisting of patients (n = 2643) who underwent segmentectomy, lobectomy or pneumonectomy between January 2012 and December 2019. 7.43% (n = 183) of this group developed POAF. For each patient, their age, gender, age, past medical history, and procedure type were used to calculate a score according to our proposed risk prediction model (Table 1) for POAF. (Minimum score 0, Maximum score 9).
Results: The risk prediction tool predicted 95% of the patients who developed POAF (a score of 2 or more). 75% of patients who developed atrial fibrillation were in in high-risk category scoring a 3 or more. There was a substantial difference between the POAF and non POAF patient scores. With the non POAF patients having just over 60% in the high-risk category compared to the 75% with the POAF patients.
Conclusion: In summary, the new risk prediction tool (RAAFTS) we trialled is a reliable method to quantify atrial fibrillation in thoracic surgery patients. A larger sample size is required to check the robustness of this tool to be widely utilised.
A306 Endoscopic conduit harvest in coronary artery bypass graft surgery; a histological analysis of radial artery and saphenous vein grafts
Machaela Miskell1, Gráinne Keehan2, Jack Whooley2, Sadiq Siddiqui2, Anne Maire Quinn3, Alan Soo4
1School of Medicine, University Galway, Galway, Ireland. 2Department of Cardiothoracic Surgery, Galway Univeristy Hospital, Galway, Ireland. 3Department of Anatomic Pathology, Galway University Hospital, Galway, Ireland. 4Department of Cardiothoracic Surgery, Galway University Hospital, Galway, Ireland
Correspondence: Machaela Miskell
Journal of Cardiothoracic Surgery 2024, 19(2):A306
Objectives: The aim of this study was to assess the effect of endoscopic harvest technique on vessel structural integrity, and to assess whether storing conduits in graft preservation solutions demonstrates any benefit in preservation of cellular integrity over heparinised saline.
Methods: This was a single-centre prospective observational study. Patients with coronary artery disease in whom coronary artery bypass grafting (CABG) was selected as the method of revascularisation, were asked to participate. Two tubular cuts ranging from 3 to 7 mm were taken from each conduit after ensuring sufficient remaining conduit length.
One specimen was stored in heparinised saline and the other in Duragraft for 60 min. Histological structure of the specimens was subsequently analysed using a series of specialised staining methods.
Results: 12 patients were included in this pilot study.
8 of these underwent radial artery endoscopic harvesting. 1 sample was insufficient for examination. Of the 7 remaining, 6 underwent endoscopic harvest, with structural integrity of the radial artery remaining intact in 5 of these.
1 specimen showed disruption of the tunica media, with a preserved endothelial lining.
No evidence of structural damage was seen in any of the 9 great saphenous vein specimens that were harvested endoscopically.
No morphological differences were seen between vessels stored in duragraft or heparinised saline.
Conclusion: This pilot study did not demonstrate any histological damage in the conduits harvested endoscopically; that could be solely attributed to harvest technique, suggesting that this technique may be non-inferior to the traditional open technique of conduit harvest used in CABG.
A307 Can an education session improve thoracic surgery and oncology healthcare professionals' views of health literacy, health-related barriers and their understanding of patient-centred communications?
Salma Kadiri1, Shareen Juwle2, Sam Govier1, Rachel Tarling3, Charlotte Krahe3, Babu Naidu4
1UHB, Birmingham, United Kingdom. 2UHB, Birmingham, United Kingdom. 3LJMU, Liverpool, United Kingdom. 4UOB, Birmingham, United Kingdom
Correspondence: Salma Kadiri
Journal of Cardiothoracic Surgery 2024, 19(2):A307
Background: Low health literacy is adversely associated with health outcomes. NICE guidelines state that health inequalities could be reduced by promoting health literacy and supporting effective, shared decision-making. Research has shown that healthcare professionals' knowledge of health literacy and the impact of patient health outcomes is limited, thus affecting patient-centred communication. Studies show that patients find it difficult to understand what healthcare professionals are informing them, even though healthcare professionals feel they explained clearly. This shows there is a need for professional development.
Method: Healthcare professionals who work along the cancer pathway at a tertiary centre were asked to fill out a survey with tick boxes and open-ended comment boxes asking their views on health literacy and health-related barriers that patients may face and how this may affect consultation communication. They then attended a professional development education session delivered by a trainee health psychologist, which covered topics ranging from understanding the differences between Equality, Diversity and Equity to defining patient-based communication strategies to consider health literacy.
Results: 12 HCPs have participated, including dietitians, specialist nurses, nurse educators, radiographers, and support workers. The pre-teaching survey has shown there is a need for further learning across the speciality. Further feedback is being gathered on how the teaching sessions have affected their understanding, confidence in using various communication strategies and their clinical practice. This will be presented at the meeting.
Conclusion: The audit highlights the importance of the simple strategy of considering health literacy to improve patient experience and reduce healthcare access barriers.
A308 The application of Electromagnetic Navigational Bronchoscopy (ENB) in diagnosis of pulmonary lesions: our experience
Hannah Jesani, Hanan Hemead, Josephine Cahill, Vanessa Rogers, Ehab Bishay, Maninder Kalkat, Hazem Fallouh, Babu Naidu, Ashvini Menon
Queen Elizabeth Hospital, Birmingham, United Kingdom
Correspondence: Hannah Jesani
Journal of Cardiothoracic Surgery 2024, 19(2):A308
Objectives: Electromagnetic navigational bronchoscopy (ENB) is a minimally invasive diagnostic and therapeutic technique, utilising endobronchial mapping to target pulmonary lesions. We analysed our departmental ENB diagnostic yield and patient management.
Method: We utilised the Medtronic ILLUMISTE system for diagnostic biopsy of lung lesions. We established a referral pathway and pre-operative assessment led by thoracic advanced care practitioners. We retrospectively analysed all patients who had undergone ENB from November 2021 until September 2023.
Results: Seventy patients in total underwent ENB procedures, with mean age of 69 years, 36 female and 34 males. Average lesion size was 28.6 mm (range 9-112 mm). Malignant histology was achieved in 36 patients (51%) of which 15 patients underwent surgical resection. Eighteen patients were referred for oncological treatment with either stereotactic ablative radiotherapy (2), chemotherapy (5), radical radiotherapy (2) or palliative radiotherapy (4). Three patients underwent surveillance for carcinoid.
Sixteen (47%) patients with non-malignant histology underwent surgery, 6 patients had a frozen section and lobectomy. Ten patients proceeded straight to surgical resection of which 7 patients had malignant histology. Following non-malignant ENB result 4 patients had further diagnostic procedures with CT biopsy (2), EBUS (1) or thoracoscopic lymph node sampling (1).
One patient developed a complication with pneumothorax requiring chest drain insertion.
Conclusion: Our experience of diagnostic ENB procedures shows this to be a safe and effective tool in diagnosing pulmonary lesions which are challenging via alternative techniques. Diagnosis of these lesions with ENB influences and guides further management for lung cancer.

A309 Innovative management of antenatally diagnosed congenital pulmonary airway malformation with invasive mucinous adenocarcinoma: a case report and literature review
Abdullah AlShammari1,2, Silviu Buderi1, Thomas Semple3, Yu Zhi Zhang4, Andrew Nicholson4, Simon Jordan1
1Department of Thoracic Surgery, Royal Brompton Hospital, London, United Kingdom. 2National Heart and Lung Institute, Imperial College London, London, United Kingdom. 3Department of Radiology, Royal Brompton Hospital, London, United Kingdom. 4Department of Histopathology, Royal Brompton Hospital, London, United Kingdom
Correspondence: Abdullah AlShammari
Journal of Cardiothoracic Surgery 2024, 19(2):A309
Congenital pulmonary airway malformations (CPAMs) are a spectrum of rare lung anomalies characterized by multicystic masses in the fetal lungs, typically detected through prenatal imaging. In a noteworthy case, a pre-term female infant with a prenatal diagnosis of CPAM underwent pleuro-amniotic shunting at 22 weeks gestation to alleviate fetal lung compression. Despite this intervention, she was born with a right-sided pneumothorax, necessitating immediate respiratory support and mechanical ventilation. On her first day, her condition deteriorated, leading to the use of extracorporeal membrane oxygenation (ECMO) and a subsequent CT scan. This confirmed the CPAM, revealing multiple cystic lesions and a significant shift of the mediastinum.
Urgent surgical intervention via posterolateral thoracotomy allowed for a lobectomy under ECMO. Postoperatively, a cardiac CT identified a narrowed left pulmonary artery, yet perfusion was unimpaired. Histopathology revealed CPAM type 1 with an invasive mucinous adenocarcinoma, stage 1 (pT1b), characterized by low-to-intermediate cellularity and the presence of KRAS G12D mutations.
Following a lengthy hospital stay marked by multiple extubation attempts, the infant was finally weaned to room air and discharged with a comprehensive follow-up strategy. The potential for malignant cell transmission to the mother through the shunt was deemed minimal by gynae-oncologists; however, vigilance was advised for both mother and child.
At four months post-operation, the infant showed no respiratory distress and exhibited healthy weight gain. This unique case of CPAM with associated mucinous adenocarcinoma treated with second-trimester pleuro-amniotic shunting signals a need for further study on the risk of malignancy transmission and long-term maternal health.
A311 Reintervention following isolated aortic valve replacement
Luke J. Rogers1, Jeremy Chan2, Daniel Fudulu2, Eltayeb Mohamed Ahmed1, Cha Rajakaruna1
1Bristol Heart Institute, Bristol, United Kingdom. 2University of Bristol, Bristol, United Kingdom
Correspondence: Luke J. Rogers
Journal of Cardiothoracic Surgery 2024, 19(2):A311
Introduction: The use of bioprostheses to treat aortic valve disease has increased worldwide, primarily due to the expansion of transcatheter techniques and patient desire to avoid lifelong anticoagulation. The longevity of these prostheses is however a concern. This study presents a single institutions real world data on aortic valve reintervention whether via redo-sternotomy or TAVI valve in valve (ViV).
Method: We retrospectively analysed consecutive patients who underwent first-time, elective or urgent isolated AVR between 1996 and 2023 at a single institution. Patients with infective endocarditis were excluded. Repeat valve intervention was defined as patients requiring redo surgical AVR or TAVI ViV.
Results: A total of 3751 patients were included, of which 118 (3.15%) patients required repeat intervention during the study period. The mean age at reintervention was 67 years (SD 12.7) for biological valves and 60 years (SD 12.7) for mechanical valves. Ninety-seven (77.96%) individuals had a biological valve implanted at first operation. The 1-, 3-, 5- and 10-year survival is 96.2%, 91.1%, 85% and 63.8%, respectively. The mean time from index operation to repeat intervention was 7.13 years (SD: 5.01 years), however in bioprostheses it was 6.1 years (SD 4.7) versus 10.7 years (SD 4.8) in mechanical.
Conclusion: The use of a biological prosthesis is associated with an earlier requirement for reintervention. Furthermore, this is significantly earlier than the often quoted "10–15 years". The lifetime management of aortic valve disease should be discussed at the index operation, especially in the context of the expanded scope of TAVI.

A312 Moments in time: an evaluation of procedural timings in the development of a cardiac DCD programme
Nicole Asemota1, John Louca1, Simon Messer2, Marius Berman1, Stephen Large1
1Royal Papworth Hospital, Cambridge, United Kingdom. 2Golden Jubilee National Hospital, Glasgow, United Kingdom
Correspondence: Nicole Asemota
Journal of Cardiothoracic Surgery 2024, 19(2):A312
Objectives: The importance of ischaemic and reperfusion timings towards success of DCD transplantation is clear. As one of the pioneering DCD heart transplant centres in the world, we reviewed our local transplantation procedural times and related these to survival.
Methods: Retrospective analysis of our local DCD Database from inception (01/03/2015 – 06/07/2023) was performed. Time periods and abbreviations are described in Image 1. Descriptive statistics, changes over time and survival were statistically reviewed.
Results: Ninety-five transplants were performed using direct procurement and perfusion. Mean Functional Warm Ischaemic Time (FWIT) was 25.2 ± 9.7 min. Mean Implant Time (IMT) was 47.9 ± 21 min, supported with retrograde cardioplegia. Mean OCS Reperfusion Time (OCS) was 266 ± 60.6 min. Trend analysis reviewed timings over time. All timings had an upward trend over time, with the steepest increase in IMT, (statistically moderate increase, Kendall Tau(τ) = 0.249). FWIT remained < 30 min since 2016. All trends were statistically significant (p < 0.05). Survival odds only fell slightly with increases in all times, with OCS time having the greatest impact (OR = 0.997 (OCS), 0.993 (FWIT), 0.992 (IMT)). However, these was not statistically significant, and wider review is required. Furthermore, actual overall survival remained high at 83.8% overall (13 deaths, Mean survival = 2527.9 days) (77% for those with FWIT > 30 min), despite these upward trends.
Conclusions: With increasing experience in DCD cardiac transplantation, our procedural times have increased, whilst maintaining a high survival rate. This suggests that, with experience, timings can potentially increase without impacting survival, potentially supporting longer transplantation distances. Multi-centre analysis is required to support these results.

A313 Sex and gender reflections in cardiac transplantation: a heart-to-heart discourse
Vanessa J. Chow
Buckinghamshire NHS Trust, Thames Valley, United Kingdom
Correspondence: Vanessa J. Chow
Journal of Cardiothoracic Surgery 2024, 19(2):A313
Aim: Cardiac transplantation is a quintessential remediation, offering a prognosticative amelioration for individuals grappling with terminal cardiac pathologies. Despite procedural evolutions, persistent gender-based discrepancies prevail, markedly marginalizing women across spectrums of access, evaluation, and procedural inclusivity within transplantation protocols. The aim of this review is make healthcare professionals aware of this issue and to challenge the persistent gender imbalances in the realm of heart transplant procedures, spotlighting the complex interrelationship between gender distinctions and the differential engagement with transplant-related healthcare services.
Method: An analysis encompassed literature spanning a decade, incorporating 34 studies—33 observational and one clinical—dedicated to examining gender and sex disparities in adult heart transplantation.
Results: The study revealed that nuanced disparities in cardiac structure and illness manifestation in females significantly impact their candidacy for heart transplant procedures. These inequalities can also originate from broad systemic structures down to individual biases, presenting as late referrals, more frequent removal from transplant lists, and suboptimal outcomes.
Conclusion: Addressing these issues requires dedicated time for a thorough evaluation of the transplantation process and a broader scrutiny of inequalities throughout cardiovascular treatment since they are interconnected. Increasing our consciousness of these problems and our inherent prejudices, along with a pledge to deepen research into gender and sex differences, is crucial for profound change. Furthermore, we must adapt to the changing global demographic, ensuring that all groups receive visibility and equitable opportunities in healthcare access.
A314 “Heart of the Matter: Family”—a mixed method study focusing on the family perspective of a relative’s coronary artery bypass graft (CABG) surgery
Charlene Marie Müller1,2, Francesca Leone3,2,4, Maureen Twiddy4, Azar Hussain2, Mahmoud Loubani2,4
1University Hospitals Bristol and Weston, Bristol, United Kingdom. 2Hull University Teaching Hospitals, Hull/Cottingham, United Kingdom. 3Sheffield Teaching Hospitals, Sheffield, United Kingdom. 4Hull York Medical School, Hull, United Kingdom
Correspondence: Charlene Marie Müller
Journal of Cardiothoracic Surgery 2024, 19(2):A314
Objectives: To determine the experiences of families of patients undergoing CABG surgery and whether support is needed for the family unit to facilitate recovery.
Methods: This is a prospective mixed methods cohort study. Patients completed a bespoke questionnaire 6–8 weeks post-operatively to explore their appraisal of care received by family members using likert-scales, analysed using descriptive statistics and Fisher’s exact test on SPSS. Family members underwent semi-structured interviews 2–4 months post-operatively, which were thematically analysed.
Results: 15 patient/family member units (6 urgent, 9 elective) participated. Patients post-CABG surgery felt supported by their family members (93%), but worried about the effect their condition would have on the family (73%). There was no significant difference between the urgent and elective cohort.
The main theme elucidated that family members often adopt a new role in caring for their loved one post-operatively. They expressed a desire for better direct communication with healthcare professionals and for care instructions upon discharge. Frequently highlighted was the stress of dealing with patients low mood and the mental strength required to take on a motivational role in the recovery phase.
Conclusions: Family members become carers for complex patients needing support through a protracted rehabilitation period after CABG surgery. Involving family in patient care and education can be both beneficial to the patient and their families, improve overall satisfaction and manage expectations. There is a potential role for family members in cardiac prehabilitation service design to promote patient engagement and assist the family unit with recovery in the community.
A315 Mild hypothermia versus normothermia in patients undergoing cardiac surgery: a propensity matched analysis
Ramanish Ravishankar, Azar Hussain, Mahmoud Loubani, Mubarak Chaudhry
Castle Hill Hospital, Hull, United Kingdom
Correspondence: Ramanish Ravishankar
Journal of Cardiothoracic Surgery 2024, 19(2):A315
Objectives: Currently there are no strict guidelines in cardiopulmonary bypass temperature management in cardiac surgery not involving the aortic arch. The aim of this study was to compare patient outcomes between mild hypothermia and normothermia undergoing on-pump cardiac surgery not involving the aortic arch.
Methods: This was a retrospective cohort study from January 2015 until May 2023. Patients who underwent cardiac surgery with cardiopulmonary bypass temperatures ≥ 32 °C were included and stratified into mild hypothermia (32–35 °C) and normothermia (> 35 °C) cohorts. Propensity matching was applied through the nearest neighbour method (1:1) using the risk factors detailed in the EuroScore using RStudio. The primary outcome was mortality. Secondary outcomes included post-op stay, intensive care unit readmission re-admission, stroke, and renal complications. Patients who had major aortic surgery and off-pump operations were excluded.
Results: Each cohort had 1675 patients. There was a significant increase in overall mortality with the mild hypothermia cohort (3.59% vs. 2.32%; p = 0.04912). There was also a greater stroke incidence (2.09% vs. 1.13%; p = 0.0396) and transient ischaemic attack (TIA) risk (3.1% vs. 1.49%; p = 0.0027). There was no significant difference in renal complications (9.13% vs. 7.88%; p = 0.2155).
Conclusions: Patient’s who underwent mild hypothermia during cardiopulmonary bypass have a significantly greater mortality, stroke, and transient ischaemic attack incidence. Mild hypothermia does not appear to provide any benefit over normothermia and does not appear to provide any neuroprotective benefits. This shows different results to that of other major studies; further trials and studies need to be conducted to reach a consensus.

A317 Surgery for rheumatic mitral valve disease: epidemiology and outcomes in the West of Scotland
George Gradinariu, Saima Azam, Sukumaran Nair, Zahid Mahmood, Kasra Shaikhrezai
Golden Jubilee National Hospital, Glasgow, United Kingdom
Correspondence: George Gradinariu
Journal of Cardiothoracic Surgery 2024, 19(2):A317
Objectives: Rheumatic mitral valve disease (RMVD) remains a clinical challenge. We investigated the epidemiology and outcomes following surgery for RMVD.
Methods: All consecutive patients undergoing mitral valve (MV) surgery for RMVD in a large centre between 2012 and 2022 were included. We defined early (2012–2016) and recent (2017–2022) eras. The primary outcome was long-term survival. Secondary outcomes were in-hospital mortality, reintervention rates and yearly incidence.
Results: 258 patients were included. The majority, 217 [84%], were females. Age at surgery was 63 years [IQR:52–73]. 52%(133/258) of patients had mixed MV disease, while 24%(62 and 63 respectively) had regurgitation or stenosis. 125(48%) had isolated MV surgery, 52%(133/258) concomitant valve or CABG surgery. 29%(75/258) of patients received a biological valve, 65%(168/258) mechanical valve and 6%(15/258) had MV repair. Median Euroscore II was 2.73% [IQR: 1.48–4.90%]. In-hospital mortality was 7%(18/258). 173 patients (67%) were alive after median follow-up of 5 years. Univariate Cox regression identified pulmonary hypertension [OR 1.61; 95%CI: 1.05–2.48, p = 0.03], age [OR 1.04; 95%CI: 1.02–1.06, p < 0.001], Euroscore II [OR 1.09;9 5%CI: 1.04–1.15,p = 0.01] and MV regurgitation [OR 2.05; 95%CI: 1.26–3.36, p = 0.04] as long-term mortality predictors. 9 reinterventions (3.8%) occurred after an average 42 months: 3 repair failure, 4 valve dysfunction, 2 endocarditis. More surgeries were performed in the early vs.recent era [yearly-mean 27 vs 20, p = 0.09]. The mean yearly incidence was 0.91 ± 0.19/100.000 people. This decreased from the early to the recent era [1.07 vs.0.78, p = 0.009].
Conclusion: The yearly incidence of surgery for RMVD has decreased in the recent era. Long-term results are affected by valve and patient-related factors.

A318 Images in cardiothoracic surgery: iatrogenic tracheal laceration before triple coronary artery bypass graft surgery
Katie Abraham, Soumik Pal, Tim Batchelor, Elizabeth Ashley, Shyam Kolvekar
St. Bartholowmew's Hospital, London, United Kingdom
Correspondence: Katie Abraham
Journal of Cardiothoracic Surgery 2024, 19(2):A318
Coronary artery bypass graft (CABG) surgery is a gold standard treatment for coronary revascularisation in multivessel disease. Median sternotomy is a frequently used surgical approach for cardiac surgery. However, the risk of working near the trachea is often overlooked.
We present a case of iatrogenic diathermy tracheal injury during interclavicular ligament dissection before CABG surgery. The injury was a 2 cm slit in the anterior tracheal ring 5 cm above the carina, which was sustained early in operation and repaired, before cannulation for cardiopulmonary bypass and use of heparin, using interrupted vicryl sutures, then buttressed with strap muscles. Due to the injury, the patient was given sugammadex and extubated early to relieve positive pressure on the repair. The patient had a good recovery with no complications due to the tracheal injury sustained.
Iatrogenic tracheal injuries are rare and can stem from multiple causes, including trauma, bronchoscopy and mediastinoscopy. This case highlights the risks of working in close proximity to the trachea. It also demonstrates the clinical presentation, diagnostic assessment and management of such a complication.
Preventative measures such as improved communication and continuing training could help reduce the risk of such incidents.
A319 Patient outcomes following mitral valve repair between consultant and registrars: a propensity matched analysis
Samuel Burton, Jeremy Chan, Gianni Angelini, Massimo Caputo, Hunaid Vohra
Bristol Heart Institute, Bristol, United Kingdom
Correspondence: Samuel Burton
Journal of Cardiothoracic Surgery 2024, 19(2):A319
Background: As mitral valve repair surgery continues to sub-specialise, the importance of producing proficient surgical trainees and patient safety must be considered. This study evaluates the clinical outcomes of patients who receive mitral valve repair for degenerative mitral regurgitation by consultant versus registrar-grade surgeons.
Methods: Data was collected for all patients who received mitral valve repair for degenerative regurgitation between April 2011 and March 2023. Patients were propensity score matched by lead surgeon grade to account for selection bias. Statistical inference was calculated via the Wilcoxon Rank-Sum and Chi2 tests, with a significance-determined p-value of < 0.05. Cox proportional hazards and multivariate regression models were employed to calculate survival analysis and adjust for confounding variables.
Results: A total of 951 patients who received mitral valve repair (865 consultant, 86 registrar) were matched 1:1, producing 86 pairs based on demographic and pre-operative data.
Matched groups demonstrated no statistically significant difference in in-hospital mortality (p = 0.31), postoperative length of stay (p = 0.36) and rates of returning to theatre for bleeding/tamponade/cardiac problems (p = 0.31).
Cox regression reported no significant difference in long-term survival (p = 0.88) with a mean time-to-event period of 6.2 years.
Cardiopulmonary bypass time was not significant (p = 0.57), while total cross-clamp time was increased in the registrar study group (p = 0.01). When adjusted for concomitant surgery, cardiopulmonary bypass and cross-clamp times were comparable between operator grades (p = 0.71 and 0.82).
Conclusions: Registrar-grade surgeons can safely perform mitral valve repair in patients with degenerative mitral regurgitation, yielding comparable short and long-term outcomes to consultant surgeons.
A320 Chest support for prevention of cardiac surgery complications: A, B or C?
Cheryl Uy1, Criscini Canga1, Kristia Basilio1, Randolph Antolin1, Bev Blair1, Rosalie Magboo1,2
1St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom. 2William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
Correspondence: Cheryl Uy
Journal of Cardiothoracic Surgery 2024, 19(2):A320
Objective: The use of chest support has been recommended as a wound support adjunct particularly in high-risk patients to potentially prevent surgical site infection after cardiac surgery. However, we observed a high rate of non-compliance in our patients cohort. This project aims to evaluate the available chest support and compare it with a newly developed CATS vest (CUI International Ltd).
Methods: Using the Plan-Do-Study-Act cycle, we evaluated the available chest supports (products A and B) in a single centre and compared it with CATS vest (product C) in high-risk patients (BSIR score > / = 8 ± body mass index (BMI) > / = 30) undergoing cardiac surgery. A five-point Likert scale was used to assess level of comfort, feeling of support/security and ease of use. Qualitative feedback was sought by independent reviewer to identify reasons for compliance/non-compliance. Subsequently, we approached five surgeons to try the new vests to their high-risk patients for comparison. Descriptive statistics was used in the analysis and compliance rate was determined.
Results: A total of 43 patients (60.5% male, average BMI = 35.6) were included in the analysis. Score comparison is shown in Table 1. Overall, identified reasons for compliance include: feeling secure/supported, helps with pain management, and enhanced mobility. However, the high rate of non-compliance for products A and B were due to: difficulty in breathing and discomfort related to the quality of material (non-breathable and cause skin irritation) and design (scratches skin/armpit).
Conclusion: The results gave us new insight on the reasons for non-compliance, suggesting local change in procurement.
A321 The role of NAHP in enabling innovation/new procedures within the NHS
Sarah Rennox, Elena Cifarelli, Alistair Gamble, David O'sullivan, Sophie Nicholls, Eltayeb Mohamed-Ahmed, Cha Rajakaruna, Anil Sankanahalli-Annaiah
Bristol Heart Institute, Bristol, United Kingdom
Correspondence: Sarah Rennox
Journal of Cardiothoracic Surgery 2024, 19(2):A321
Background: The aim of innovating in surgery is to find ways to improve patient outcomes and experience. There are huge financial constraints that form barriers against innovation in the NHS. Surgeons find it difficult to innovate in isolation as contemporary business cases require a multidisciplinary (MDT) approach. Business cases are turned down due to lack of practical approaches and associated cost.
Method: Since 2013 we have introduced a number of new procedures using a MDT. Theatre manager, theatre practitioners/SCP, anaesthetists and Surgeons, general manager, finance and clinical procurement. The process takes 6–8 meetings over a 6 months period. The clinical evidence is made by the surgeon. NAHP members outline the practical aspects (appointment of team to deliver innovation, facility/equipment required-what is available what is not—generating shopping lists). The manager/finance develop the business case and liaise with industry.
Results: In the past 10 years the following innovations have been introduced in our institution. EVH, Sutureless and deployment AVR, Frozen Elephant trunk programme, MIDCAB, Atriclip, Convergent procedure for lone AF, AMDS, Thorocoscopic clip, Sternal rigid fixation, open Thoracoabdominal programme and CALS programme. This approach gives managers and procurement confidence and motivation to deliver when the practical approach is delivered up front by NAHPs. This also delivers the SOP and new procedures applications.
Conclusions: NAHPs plays a vital role in the efficient delivery of healthcare innovations and brings confidence to the applications. Involving the NAHP team from the start of the process makes practical implementation safe and effective.
A322 Outcomes of custodiol versus blood cardioplegic agents in patients undergoing major aortic surgery: a large centre experience
Samuel Burton1,2, Vinci Naruka2, Selina Tsai2, Danielle Blackie2, Ana Lopez-Marco2, Benjamin Adams2, Aungye Oo2
1Bristol Heart Institute, Bristol, United Kingdom. 2Barts Heart Centre, London, United Kingdom
Correspondence: Samuel Burton
Journal of Cardiothoracic Surgery 2024, 19(2):A322
Objectives: Custodiol cardioplegia is well-established in routine cardiac surgery with the advantage of prolonged myocardial protection with single infusion. We aim to compare Custodiol versus blood cardioplegia efficacy in major aortic surgery.
Methods: Retrospectively analysed prospectively collated data of patients who underwent major aortic surgery by two experienced aortic surgeons at a large specialist centre. Patients were 1:1 propensity score matched by age, gender and EuroScoreII (35 Custodiol, 35 blood). All aortic operations were included, except for isolated aortic valve replacements. The Mann–Whitney U test was utilised to calculate statistical significance (p < 0.05), and multivariable regression was employed to adjust for covariates.
Results: Patients had a high mean EuroscoreII (7.9% and 7.6%). No significant change in preoperative to postoperative haemoglobin (p = 0.18) and sodium (p = 0.34) was noted between cardioplegic agents.
Similar outcomes were reported, including return to theatre for bleeding (p = 0.2), postoperative stroke (p = 0.6), acute kidney injury (p = 0.28), new pacemaker (p = 0.07) or 30-day mortality (p = 0.64).
Cardiopulmonary bypass (p = 0.41), cross-clamp (p = 0.88) and circulatory arrests (p = 0.46) times were not statistically significant between study groups and remained non-significant following adjustment for EuroscoreII, urgency, redo surgery and operation type.
Sub-analysis demonstrated a 30-min significantly shorter cross-clamp time in aortic root replacement receiving Custodiol (p = 0.015). Following covariates adjustment mechanical ventilation duration (p = 0.42), ICU length of stay (p = 0.49), and hospital stay (p = 0.25) were comparable.
Conclusions: Custodiol is a safe and effective myocardial protective agent in major aortic surgery. The reduced cross-clamp time was most noticeable in patients receiving Custodiol during aortic root replacements without affecting postoperative outcomes.
A323 A single centre early experience of donation after circulatory death (DCD) heart transplantation
David Varghese1, Amy Tang2, Sylvia Yew2, Sukumaran Nair1, Simon Messer1, Hari Doshi1, Prashant Mohite1, Karim Morcos1, Yasser Hegazy1, Lorraine Jerrett1, Philip Curry1
1GJNH, Glasgow, United Kingdom. 2University of Glasgow, Glasgow, United Kingdom
Correspondence: Amy Tang
Journal of Cardiothoracic Surgery 2024, 19(2):A323
Background: Donor organ shortage remains a major limiting factor and until recently only donation after brain death (DBD) was deemed suitable. However, the use of organs from donation after circulatory death (DCD) has increased the donor pool considerably in the UK.
Methods: A single-centre retrospective review on all patients that underwent orthotopic heart transplantation from DCD donors at our institution between November 2019 and Oct 2023. The primary outcomes were 30-day, 1-year survival, post-transplant primary graft dysfunction (PGD) and mechanical circulatory support (MCS) usage.
Results: 16 patients (14 male, 2 female) underwent DCD heart transplantation. Median age at transplantation was 57 (15) most commonly for ischaemic cardiomyopathy 8/16 (50%). 10/16 (62.5%) were non-elective. Pre-transplantation MCS was required in 10/16 (62.5%). Of the 6 patients that had no preoperative support one patient (16.7%) needed central ECMO & IABP for PGD. Donors were male 12/16 (75%) with median age of 34 (17.5). Duration on Organ Care System (OCS) was 272 min (65). The Functional Warm Ischaemic Time (FWIT) defined as either (time of ischaemia from systolic blood pressure (SBP) < 50 mmHg until cold cardioplegia (FWITCP) or FWITOP (SBP < 50 mmHg until organ reperfusion on OCS)) was 18 min (1) and 30 min (4) respectively. There was one mortality in this cohort, 1/16 (6.25%).
Conclusion: DCD heart transplantation provides equivalent post-transplant survival compared with both UK DBD and DCD heart transplantation results. Furthermore, since its introduction DCD has increased activity by 25% with a low incidence of PGD and low reliance on post-transplant MCS support.

A324 Should atrial myxoma size be the main determining factor in timing of surgery
Sylvia Yew1, Amy Tang1, Osama Rashwan2, Khalid Mujahid2, Stewart Craig2, David Varghese2
1University of Glasgow, Glasgow, United Kingdom. 2GJNH, Glasgow, United Kingdom
Correspondence: Sylvia Yew
Journal of Cardiothoracic Surgery 2024, 19(2):A324
Background: Atrial myxomas (AM) are benign cardiac tumours that can cause serious complications. The optimal timing of surgery for AM is unclear. The purpose of this study was to examine if the size of the AM measured by 2-dimensional echocardiography (2-DES) was related to the presence or absence of symptoms.
Methods: Retrospective review of all patients operated on for isolated left AM between 2010 and 2022 in our unit. Out of 76 patients, 46 had an echocardiographic report and form the basis for this study. Data was analysed using Unistat. Results are expressed as median (inter-quartile range) and n (%).
Results: The patients were aged 64 (15), predominantly female 35 (76%) and logistic Euroscore of 4.1 (4.3). Surgery was stratified as elective 13 (28.3%) vs non-elective 33 (71.7%). The 2-DES of the AM was 5.8 (4.8) cm2 elective and 12.0 (14.4) cm2 non-elective group, p = 0.02. Twenty eight (61%) were symptomatic, elective 6 (46%) vs non-elective 22 (66.7%), p = 0.99. Time from referral to surgery was elective 83 (97) vs non-elective 8 (19) days, p = 0.0009. Operative mortality was 0. Survival after surgery was 6.5 (5) years. 34 (74%) are still alive at close follow up. There was 1 (2%) recurrence. Logistic regression showed no correlation between tumour size and symptomatic status, p = 0.28.
Conclusion: Our findings suggest that 2-DES did not predict symptoms, and that surgery should be performed promptly after diagnosis of AM, irrespective of the tumour size, to prevent the potential complications of AM.
A325 Is virtual reality mindfulness effective in improving peri-operative wellbeing and pain in patients admitted for elective thoracic surgery?—A feasibility study
Natawadee Chantima1, Jade Taylor2, Huzaifa Ahmad1, Sridhar Rathinam1
1Glenfield Hospital, Leicester, United Kingdom. 2University of Leicester Medical School, Leicester, United Kingdom
Correspondence: Natawadee Chantima
Journal of Cardiothoracic Surgery 2024, 19(2):A325
Objectives: Procedure-induced anxiety and stress negatively affect patient recovery and worsen perception of pain, which may lead to increased opioid use and extended hospital stays.
Mindfulness based interventions have been promoted to benefit physical and psychological wellbeing. This study investigates the effectiveness of virtual reality (VR) mindfulness on improving anxiety and wellbeing in patients undergoing elective thoracic surgery with the aim of improving pain and enhancing recovery.
Methods: Patients scheduled for elective thoracic surgery (benign and malignant) were recruited to undergo one immersive seven-minute mindfulness session using the Rescape VR Headset. Wellbeing, stress, anxiety, and pain levels were assessed using pre- and post-experience questionnaires. Physiological observations were recorded before and after each session.
Results: We recruited 15 thoracic surgery patients (7 pre-operative and 8 post-operative). A significant 80% of patients felt the session was enjoyable and reported increased relaxation. 73% of patients felt less stressed and 67% felt noticeable calmness after the experience.
Three out of eight post-operative patients (37.5%) with pre-existing pain had reported relief, suggesting a differentiated response in pain management. No significant physiological changes post-experience were observed.
Conclusions: VR-facilitated mindfulness sessions were associated with positive psychological outcomes and stress reduction by most participants. This is a potentially promising adjunct as a non-pharmacological intervention to enhance peri-operative thoracic surgery experience and patient recovery.
This pilot study’s findings advocate for further research into VR mindfulness efficacy on postoperative pain and patients’ recovery, possibly by regular, multi-session VR mindfulness exercises throughout the duration of hospitalisation.
A326 The heart’s blueprint: precision planning with 3D models in congenital cardiac surgery and interventional cardiology
Mislav Planinc, Lisa Ferrie, Vitor Ramos, Carin Van Doorn, Imre Kassai, Orsolya Friedrich, Ahmed Sallam, Kennedy Osemobor, Preeti Kathel, Giuseppe Pelella
Leeds Teaching Hospital NHS Trust, Leeds, United Kingdom
Correspondence: Mislav Planinc
Journal of Cardiothoracic Surgery 2024, 19(2):A326
Objectives: Review of 3D pre-procedural planning to introduce novel techniques and minimize procedure related failure.
Methods: We conducted a retrospective analysis of our unit’s 3D planning service. DICOM data were obtained from CT or MRI scans. The 3D models were generated with imaging segmentation and used to virtually test the feasibility of the proposed intervention.
Results: Between November 2022 and November 2023, twenty-two patients had models created. Median age was 31 years [2 to 40 years]. Eight (34.7%) were children. Twelve adult patients with PAPVD were assessed for transcatheter SVC stenting with sinus venous ASD closure. After virtual intervention 6 (50%) were deemed suitable candidates for the catheter intervention. In one (16.6%) patient who underwent prior stenting, the model was used to plan successful re-stenting for residual leak. Six (50%) were felt high risk of pulmonary vein obstruction. All but one [with high comorbidities] were referred for surgery and one (16.6%) patient successfully underwent surgery. Two adult patients with scimitar syndrome were evaluated for the Lugones procedure. Four children were assessed for biventricular repair. Two models were created to display images in the operating theatre and facilitate MAPCA`s unifocalization. One patient awaiting Fontan completion, with IVC on the left of the spine, had a 3D model for virtual placement of the intra/extra cardiac conduit. One patient had a successful Glenn procedure.
Conclusions: 3D segmentation is an additional tool to plan a customized cardiac procedure. It enables novel and complex cardiac repairs and with virtual intervention prevents procedure-related failure.
A327 Authorship diversity and representation in high-impact evidence synthesis in cardiovascular surgery
Shreyas Bellur1,2, Vivek Bhat2, Ahmad Ozair3,1, Siddharth Pahwa4
1Miami Cancer Institute, Miami, USA. 2St. John's Medical College, Bengaluru, USA. 3Johns Hopkins University, Baltimore, USA. 4University of Louisville, Louisville, USA
Correspondence: Shreyas Bellur
Journal of Cardiothoracic Surgery 2024, 19(2):A327
Objective: To determine global representation and gender diversity in the authorship of high-impact evidence synthesis- Cochrane systematic reviews related to cardiovascular surgery.
Methods: We searched Cochrane Library, a global representative of high-impact evidence synthesis, on 1st July 2023 using the filter: topic “Heart and Circulation.” We included all cardiovascular surgery reviews and excluded those concerning cardiology, internal medicine and hematology. We extracted author details, dividing their national affiliation based on World Bank 2023 classification into low- and lower-middle-income countries (LMICs) and non-LMICs. We employed manual web searches to ascertain gender, capturing at least one webpage demonstrating their gender or pronouns and recording them using historical gender conventions. Authors whose gender could not be ascertained were excluded from the gender-based analysis. All data were cross-verified by a second author for accuracy.
Results: From 833 eligible records, we included 202 cardiovascular surgery surgery with 879 authors. Authors from LMICs represented only 1.02% (n = 9/879) of total authors. The top five most represented countries were the United Kingdom (38.45%; n = 338/879), Brazil (8.65%; n = 76/879), Netherlands (5.35%; n = 47/879), Canada (4.89%; n = 43/879) and Germany (4.44%; n = 39/879). The gender ascertainment rate was 87.59% (n = 770/879). Women comprised 37.01% (n = 285/770) of all co-authors, 48.35% (n = 88/182) of first authors, and 39.34% (n = 72/183) of corresponding authors.
Conclusion: LMICs are poorly represented in authorship of the highest levels of evidence in cardiovascular surgery. While representation of coauthors and corresponding authors remains skewed towards males, women were better represented as first authors. Multipronged efforts toward equitable representation in cardiac surgery are warranted.

A328 An evidence-based approach to targeted respiratory prehabilitation addressing frailty, deprivation, and malnutrition to reduce Postoperative Pulmonary Complications (PPC)
Michaela Richards, Tracy Jones, Elizabeth Ford, Sammy Bradley, Mark Bennett
Swansea Bay UHB—Morriston hospital, Swansea, United Kingdom
Correspondence: Michaela Richards
Journal of Cardiothoracic Surgery 2024, 19(2):A328
This retrospective data analysis aims to develop a Quality Improvement (QI) project targeting the reduction of the incidences of Postoperative Pulmonary Complications (PPC) and identifying a specific population for intervention.
Over a two-year period, PPC affected 29% of cases. Frailty was significantly associated with a PPC (p < 0.01), manifesting in 40% of frail patients. Frailty carries the same risk of PPC as being malnourished, both of which double the risk of being a current smoker.
PPC increases days requiring level 2/3 respiratory support by 3 days and decreases the number of days at home in the first 30 days (DAH30) by 7 days. The cost of level 2/3 respiratory support is around £1700 per day, while ward care costs £500 per day. Consequently, a PPC incurred expenses of approximately £8600 per patient, making targeted intervention crucial.
The potential benefits of inspiratory muscle training (IMT) suggest a possible reduction in length of stay (LOS) of 1 day when applied to all patients. There is a lack of data for high-risk groups, such as frail, malnourished, and current smokers.
The cost of IMT intervention is £60 per patient. This investment addresses the training of staff and the immediate needs of patients. It contributes to the long-term improvement of healthcare practices and patient outcomes in the context of respiratory prehabilitation programmes.
In conclusion, our study presents a robust, patient-centred, evidence-based and financially viable approach to a quality improvement plan to introduce IMT training and address the high rate of PPC after cardiac surgery.
A330 The importance of the LIMA in CABG for early and long-term outcomes in the over 75s
Ettorino Di Tommaso1, Lauren Dixon1, Marco Gemelli1,2, Roberto Natali1, Vito Domenico Bruno3, Raimondo Ascione4
1Bristol Heart Institute, Bristol, United Kingdom. 2University of Padova, Padova, Italy. 3I.R.C.C.S. Ospedale Galeazzi—Sant'Ambrogio, Milan, Italy. 4University of Bristol, Bristol, United Kingdom
Correspondence: Ettorino Di Tommaso
Journal of Cardiothoracic Surgery 2024, 19(2):A330
Objectives: This study aimed to determine the importance of the Left Internal Mammary Artery (LIMA) for CABG in patients over 75 years.
Methods: All consecutive patients, aged 75 and above, undergoing elective/urgent isolated CABG from January 2001 to December 2021 were included. We compared demographic and outcome data using Wilcoxon rank sum; Pearson’s Chi-squared and Fisher’s exact test. Mortality and survival data between the patients who received a LIMA graft or a Saphenous Vein Graft (SVG) to the Left Anterior Descending artery (LAD). Groups were compared using multivariable logistic regression, Cox Proportional-Hazards and Kaplan–Meier models.
Results: 3,240 patients were included—2,741 LIMA and 499 SVG grafts. The median follow-up was 6.8 years (IQR 3.4–10.3). The LIMA to LAD graft was protective against both 30-day mortality (OR 0.62, CI 0.38, 0.98, p = 0.048) and long-term mortality (OR 0.75, CI 0.59, 0.95, p = 0.02) on multivariable logistic regression analysis. On univariable Cox proportional hazard modelling, the LIMA graft was important for survival (HR 0.77, CI 0.68, 0.87, p < 0.001); this protective benefit remained after adjusting for differences in baseline characteristics (adjusted HR 0.87, CI 0.76–0.98, p = 0.02). On Kaplan–Meier survival analysis over 10 years, there was a significant difference in survival, favouring those patients who received a LIMA graft (p < 0.001).
Conclusions: Over our 20 year experience, the LIMA graft during CABG is protective against short and long-term mortality in patients over the age of 75. There is a clear benefit to survival before and after adjustments for differences in patient risk profiles.

454
A331 Surgical management for acute type A aortic dissection: impact of aortic-specialist on-call rota on outcomes and complexity of repair
Robert Pruna-Guillen, Ana Lopez-Marco, Benjamin Adams, Aung Oo
Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom
Correspondence: Robert Pruna-Guillen
Journal of Cardiothoracic Surgery 2024, 19(2):A331
Acute type A aortic dissection (ATAD) repair is a complex and high-risk procedure, often associated with a significant in-hospital mortality rate. We evaluated the impact of introducing an aortic-specialist-On-call Rota on the outcomes of ATAD repair within our deparment. Between January 2015 and October 2023, a total of 406 ATAD surgical repairs were performed. In September 2020, we introduced an aortic-specialist-On-call Rota, which required surgeons to have a minimum of 10-major-aortic-cases/year and 4-ATAD-repair-cases/year. Outcomes between two groups were compared: the pre-specialist Rota group (Group A) and the post-specialist Rota group(Group B).
There were no significant differences in preoperative patient characteristics between the two groups. The mean age 59 years (50–72), 68%male. The overall in-hospital mortality rate was 21.6% (88/406 patients). Notably, a significant decrease in mortality in group B 16.4% (28/170) compared to 25.4% (60/236) in group A (p-value = 0.03) was observed.
While there were no significant differences in operative techniques, a trend toward more complex repairs in Group B was noted: Aortic root replacement (44%vs33%) and total arch replacement/FET (20%vs14%). Inversely, interposition graft alone (38%vs45%) higher in group A.
Postoperative complications showed no significant differences, but Group B had lower rates of permanent stroke, tracheostomy, and temporary dialysis (11%, 14%,and 25%, respectively) compared to Group A (15%, 20%, and 31%).
The implementation of an aortic-specialist On-call Rota for the surgical treatment of ATAD has a positive impact on in-hospital mortality and morbidity outcomes. Additionally, there is a discernible trend toward more complex repairs following the introduction of a specialist aortic Rota.
A333 Step down to step up: ward recovery after pneumonectomy
Ross Hoffman, Michael Shackcloth, Neeraj Mediratta, Julius Asante-Siaw, Susannah Love, Steven Woolley, Amy Hill, Richard Page
Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
Correspondence: Ross Hoffman
Journal of Cardiothoracic Surgery 2024, 19(2):A333
Introduction: Admitting post-pneumonectomy patients to a critical care area (CCA) is routine despite limited analysis of its effects on outcomes and resources. This audit evaluates such admissions for optimising care and resource allocation.
Aims: This retrospective audit aims to analyse post-pneumonectomy patient outcomes in a CCA, including stay duration, time to discharge, morbidity, mortality, mechanical ventilation use, and hemodynamic support needs. It also seeks to identify predictors for planned CCA admission and reviews existing literature.
Methods: A retrospective review of 40 cases from January 19, 2021, to December 14, 2022, involving 40 patients (23 males, 17 females, mean age 66) overseen by 6 consultants, was conducted.
Results: Morbidity occurred in 14 out of 38 patients, with 2 in-hospital deaths. The most common complications were pneumonia (4), atrial fibrillation (4), and stroke (2). CCA length of stay varied from one to nine nights, with most staying one night and three needing readmission. Preoperative risk prediction using Thoracoscore had a mean of 4.73%, which did not correlate significantly with CCA stay length.
Discussion: Findings suggest that, while the patient group is high-risk, a portion could be managed in wards postoperatively. Complications typically occurred after the first day, indicating a potential for stable patients to bypass a CCA, especially if surgeries are scheduled early to allow extended recovery time. The challenge remains in predicting which patients may deteriorate, emphasizing the need for cautious selection for ward-based recovery.
A334 Chronic pulmonary aspergillosis after surgical treatment for non-small cell lung cancer: an analysis of risk factors and clinical outcomes
George Whittaker1, Marcus Taylor1,2, Mathilde Chamula3, Felice Granato1, Haval Balata1,2, Chris Kosmidis4,3
1Wythenshawe Hospital, Manchester, United Kingdom. 2University of Manchester, Manchester, United Kingdom. 3National Aspergillosis Centre, Manchester, United Kingdom. 4Manchester Academic Health Science Centre, Manchester, United Kingdom
Correspondence: George Whittaker
Journal of Cardiothoracic Surgery 2024, 19(2):A334
Objectives: To describe the outcomes of patients who developed chronic pulmonary aspergillosis (CPA) following surgery for non-small cell lung cancer (NSCLC) and identify risk factors associated with its development following lung resection.
Methods: All consecutive patients who underwent lung resection for primary NSCLC at Manchester University NHS Foundation Trust between January 2012 and December 2019 were identified in the Northwest Clinical Outcomes Research Registry database. Patients who subsequently developed CPA following lung resection were cross-referenced with the National Aspergillosis Centre database. A comparative analysis was performed between CPA and non-CPA groups. Outcomes included 90-day, 1-year, and overall survival, post-operative length of stay, and post-operative complications.
Results: Eleven (0.2%) patients with a subsequent diagnosis of CPA were identified from a cohort of 4,425 patients who underwent surgery for NSCLC. A diagnosis of post-operative CPA was associated with a significantly lower survival rate (p = 0.020). Between CPA and non-CPA groups there was no significant difference in 90-day survival (100% vs 97.2%, p = 0.674), 1-year survival (100% vs 91.7%, p = 0.319), median length of stay (5 days vs 5 days, 0.595%), or complication rates (27.3% vs 16.6%, p = 0.341). On univariate analysis, a lower mean percentage predicted FEV1 (p = 0.010), ischaemic heart disease (p = 0.033), and COPD (p = 0.015) increased the risk of developing CPA.
Conclusions: CPA is a rare complication following lung cancer surgery which has a significant negative impact on long-term survival. Several cardiorespiratory diseases were associated with increased risk of developing CPA post-operatively. Further research should be conducted with a larger cohort.

A335 The impact and benefits of a dedicated thoracic physiotherapist and a ward based gym
Ashleigh Leggett
Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
Correspondence: Ashleigh Leggett
Journal of Cardiothoracic Surgery 2024, 19(2):A335
The role of physiotherapy in thoracic surgery services is pivotal for postoperative care, enhancing patient recovery, and reducing complications. This abstract emphasises the impact of physiotherapy and the utilisation of an on-site gym within a thoracic surgery ward. Incorporating a physiotherapist on the thoracic surgical team, patients receive tailored respiratory management, facilitating improved pulmonary function and expedited sputum clearance.
The presence of an in-ward gym equipped for rehabilitation allows for immediate and frequent intervention, significantly influencing patient recovery trajectories. Qualitative assessments indicate that dedicated physiotherapy regimens contribute to avoiding invasive procedures such as bronchoscopy by managing retained secretions through non-invasive techniques. Case discussions reveal that regular, structured gym sessions under physiotherapist guidance can reduce atelectasis as evident in follow-up X-rays, further advocating for their routine inclusion in postoperative care protocols.
This integrated approach, emphasising physiotherapeutic expertise and resources like an in-ward gym, underscores an evolving standard of care in thoracic surgery that maximises patient recovery and optimizes resource utilisation within the healthcare system.
A336 Rib fractures: to fix or not? A single, major trauma centre’s experience
Chiemezie Okorocha1,2, Oluwanifemi Akintoye3, Moustafa Ahmed2, Veena Surendrakumar2, Luis Hernandez2, Antonio Martin-Ucar2, Styliani Maria Kolokotroni2
1Queen Elizabeth Hospital, Birmingham, United Kingdom. 2University Hospital Coventry and Warwickshire, Coventry, United Kingdom. 3Royal Papworth Hospital, Cambridge, United Kingdom
Correspondence: Chiemezie Okorocha
Journal of Cardiothoracic Surgery 2024, 19(2):A336
Objectives: Rib fractures are a common feature of blunt chest trauma. This retrospective study assessed rib fixation vs. conservative management of thoracic trauma patients presenting to University Hospital Coventry and Warwickshire (UHCW).
Methods: A retrospective cohort study of all trauma patients presenting to UHCW over a 7-year period (2016–2022) was conducted, and filtered for cardiothoracic surgery (CTS) admission. In-hospital survival (IHS) and length of stay (LOS) in patients who had no surgery, ORIF or other operations (thoracic and non-thoracic procedures) were compared.
Results: 3,386 trauma patients presented to UHCW over the 7-year period. Of 1,147 patients with rib fractures admitted to CTS, 167 (14.6%) had ORIF ribs. There was a threefold increase in IHS (p = 0.005) in the ORIF group compared to those conservatively managed (Fig. 1). However, there was no statistically significant difference in LOS (p = 0.212).
A statistically significant difference was observed in survival outcomes between ORIF patients and those who had other operations. ORIF patients had a threefold increase in IHS (Table 1). Again, there's no significant difference in LOS (p = 0.212).
Discussion: Rib fixation is indicated for 3 or more consecutive rib fractures, displaced ribs, flail segments, and severe chest wall deformity. The absolute indications for ORIF are still being debated, but there is evidence that there is a reduction in inpatient LOS and better long-term recovery in patients with ORIF, as seen in our study.
In conclusion, this study has shown that in blunt chest trauma, ORIF is beneficial in increasing in-hospital survival.

A337 Key predictors of prolonged length of stay in a thoracic surgery ERAS programme
Douglas Miller1, Eveline Internullo1, Rakesh Krishnadas1, Christopher Sadler1, Matt Molyneux1, Lesley Wood1, Neil Rasburn1, Tim Batchelor2, Natasha Joshi1, Lauren Dixon1
1Bristol Royal Infirmary, Bristol, United Kingdom. 2Barts Health NHS Trust, Bristol, United Kingdom
Correspondence: Douglas Miller
Journal of Cardiothoracic Surgery 2024, 19(2):A337
Background: Enhanced Recovery After Surgery (ERAS) protocols in Thoracic Surgery are designed to improve post-operative recovery including reducing length of hospital stay (LOS). The aim of this study is to investigate predictors of length of stay in a Thoracic Surgery ERAS programme.
Methods: Prospectively collected data of all consecutive patients undergoing primary lung cancer resection and following the 15 point ERAS programme in our centre, from August 2013-July 2023, were included. Our primary outcome was length of hospital stay (LOS) and prolonged LOS was defined as 5 days or more. Retrospective univariable and multivariable logistic regression analyses were performed to identify key predictors of prolonged LOS.
Results: Overall 2,192 patients underwent primary lung cancer resection and followed an ERAS programme during the 10 year period. The cases were 64% lobectomy, 33% sub-lobar resection and 4% pneumonectomy. Surgeries were performed VATS in 80% of cases. The median length of stay was 4 days.
On multi-variable regression analysis, key predictors of LOS are: age (OR 1.02, CI 1.01–1.03, p < 0.001), VATS approach (OR 0.38, CI 0.24 -0.59, p < 0.001), pre-operative carbohydrate drink (OR 0.84, CI 0.71, 1.01, p = 0.05), early mobilisation (OR 0.78, CI 0.60–0.92, p = 0.04) and ITU/HDU admission (OR 3.72, CI 2.91, 4.76, p < 0.001).
Conclusions: The most important factors identified in reducing LOS following primary lung cancer resection are VATS approach, pre-operative carbohydrate drinks and early mobilisation. The patient at most risk of a prolonged LOS and our older patient and those admitted to ITU/HDU post-operatively.
A338 Stroke following cardiac surgery: an analysis of a large UK tertiary centre
Ujjawal Kumar, Ismail Vokshi, Narain Moorjani
Royal Papworth Hospital, Cambridge, United Kingdom
Correspondence: Ujjawal Kumar
Journal of Cardiothoracic Surgery 2024, 19(2):A338
Objectives: Postoperative strokes are a serious complication of cardiac surgery, occurring in up to 10% of cases. No national cardiac surgical guidelines for stroke mitigation exist, with rates varying significantly between units. We investigated institutional postoperative strokes, evaluated patient risk factors, and assessed mitigation strategies utilised.
Methods: A retrospective analysis of prospectively collected data was conducted for all patients undergoing cardiac surgery within the most recent NACSA reporting period (April 2019–March 2022). Pre-operative, intra-operative and post-operative parameters were compared, and mitigation strategy use was examined.
Results: 4533 patients underwent cardiac surgery with 36 experiencing a radiologically confirmed stroke in the first 30 days post-operatively. Significant differences were seen between the groups (Table), notably EuroSCORE II (11.89 vs 4.201), CPB (190.3 vs 117 min) and XCT (102.0 vs 77.5 min), indicating higher operative complexity and risk of the stroke group. Risk factors for CVA were more prevalent in this group, e.g., LV dysfunction, smoking history and prior CVA. Despite routine use of cerebral perfusion during procedures involving hypothermic circulatory arrest, stroke rates were significantly higher in these patients (2.79% vs 0.53%).
Cerebral protective measures such as cerebral oximetry, restrictive transfusion threshold, and appropriate postoperative antidysrhythmic treatment were used. Preoperative imaging like CT and carotid duplex were inconsistently used for assessing stroke risk.
Conclusions: Postoperative stroke is uncommon, despite our complex patient population. However, by pinpointing risk factors and assessing institutional use of mitigation strategies, we aim to enhance informed consent and establish a national protocol for stroke mitigation in cardiac surgery.
A341 The evolution of surgical management of costal margin rupture associated with intercostal hernia
Pradeep Wijereathne, Jagan Rao, Sara Tenconi, Ashok Kar, John Edwards
Northern General Hospital, Sheffield, United Kingdom
Correspondence: Pradeep Wijereathne
Journal of Cardiothoracic Surgery 2024, 19(2):A341
Introduction: Costal margin rupture (CMR) with intercostal herniation (IH) present is rare, symptomatic and provides a significant management challenge. Surgical failure rates up to 60% are reported and optimal surgical techniques are unclear. We have characterised these injuries and describe the evolution of surgical management.
Methods: Patients were identified prospectively in a regional thoracic surgery centre, covering a 1.9 million population. Injury characteristics, patient management and follow-up were recorded. Results were analysed according to the Sheffield classification, with specific focus on the management of IH present injury types (CMR + IH, Trans-Diaphragmatic IH).
Results: Of 62 patients with CMR, 22 had CMR + IH and 10 TDIH. IH was associated with chronic presentation, expulsive aetiology, higher BMI, absence of other costal cartilage fractures, presence of other rib fractures and lower level of CMR (all p < 0.05). 19 of the 32 patients underwent surgery, with 7 requiring reoperation. Surgical techniques evolved according to patient outcomes. There were 8 suture repairs (SR), 3 extrathoracic mesh repairs, with 2 reoperations. The Double Layer Mesh Repair (DLMR) was introduced (4 Mk 1, 5 Mk 2 and 3 Mk 3) with 2,1 and 0 reoperations respectively. The Mk 3 operation involves DLMR sandwiching titanium rib buttress plates, incorporating surgical stabilisation of rib fractures (SSRF) when required. Re-operation for the failed Mk 2 repair required the placement of titanium buttress plates, SSRF and intercostal wiring.
Conclusions: Robust repair of CMR + IH/TDIH is challenging, but experienced based evolution of techniques has led to a durable Mk 3 repair.

A342 Changing trends in access for mediastinal surgery using uni-portal sub-xiphoid 3D VATS approach
Ahmed Hamada1,3, Namariq Abbaker1, Jayanta Nandi1,2
1Hammersmith Hospital, London, Imperial College Healthcare NHS Trust, United Kingdom. 2Senior Lecturer NHLI, Imperial College London; 3Lecturer, Faculty of Medicine, Cairo University
Correspondence: Ahmed Hamada
Journal of Cardiothoracic Surgery 2024, 19(2):A342
Background: Mediastinal surgery has traditionally been performed through an open approach. Recently, with the increase in adoption of minimally invasive approaches, there has been use of multi-portal VATS with associated risks of intercostal neuralgia and post-thoracotomy pain. We have increasingly adopted 3D-sub-xiphoid uni-portal VATS approach (3D-SxUVATS) which allows access to the anterior mediastinum, better visualisation of the phrenic nerves and access to both sides of the thorax. We present our trends in subxiphoid approach for a single surgeon at our institution.
Method: We analysed our prospectively collected database to identify patients undergoing mediastinal procedures along with the type of access from 2017–2023. We compared patients undergoing 3D-SxUVATS with other incisions used for mediastinal surgery and collected perioperative and outcomes data.
Results: 64 patients underwent mediastinal surgery with 40.6% having surgery using the 3D-SxUVATS approach. There were no mortalities in either group. Median age was comparable 57 years (IQR:39–63) for the 3D-SxVATS Group versus 53 years (IQR: 39–61) (p = 0.61) for the non-subxiphoid group. Post operative median length of stay was 3 days (IQR: 3–5) for the 3D-SxVATS group versus 4 days (IQR: 3–4) for the non-subxiphoid group (p = 0.15). There was a trend towards higher percentage of cases being performed using the Subxiphoid approach over the years:
Conclusion: We have increasingly adopted the 3D-SxUVATS approach for anterior mediastinal and bilateral thoracic cavity access and have found it to be a safe and feasible approach with some trend towards reduction in length of post operative stay although this failed to approach statistical significance.
A343 The prognostic value of proliferation index in pulmonary carcinoid tumours
Amber Ahmed-Issap, Alina Budacan, Rana Mehdi, Kajan Mahendran, Lakshmi Srinivasan, Shilajit Ghosh, Udo Abah
University Hospital of North Midlands, Stoke-on-Trent, United Kingdom
Correspondence: Alina Budacan
Journal of Cardiothoracic Surgery 2024, 19(2):A343
Background: Carcinoid tumours represent approximately 2% of all lung tumours. In pulmonary surgical oncology prognosis is typically discussed in terms of typical versus atypical. Little importance is placed on proliferative index, which is commonly used to predict prognosis in other primary carcinoid sites. We reviewed of our institutional data to exam the relationship of proliferative index and recurrence following resection of pulmonary carcinoid tumours.
Methods: Data was extracted from a prospectively filled surgical database to identify all patients who underwent resection for pulmonary carcinoids between 2012 and 2021. Patient’s demographics, perioperative data and histological data were examined.
Results: 116 patients were identified, 69% of patients were female and the average age was 65.6 years. 106 patients had proliferative index reported on; of these 16 patients had atypical carcinoid and 90 typical carcinoid tumours resected. Recurrence rates stratified by histological diagnosis were 44% in the atypical group and 6% in the typical group (P < 0.05). Recurrence rates stratified by proliferation index ranges 0–2%, > 2%-10%, and > 10% were 6.3%, 8.3%, and 71.4%, respectively (P < 0.05). Within the atypical group 75% of patients had a proliferation index of > 10% and in the typical cohort all patients bar one had a proliferation index < 5%. The average proliferation index in the atypical carcinoid group was 12.7% and 2.39% in typical carcinoid group.
Conclusion: The use of proliferative index adds additional prognostic information to the histological classification of carcinoid tumours. A proliferation rate > 10% has a significant risk of recurrence warranting an increased frequency of postoperative surveillance.
A344 Thoracic Endovascular Aortic Repair (TEVAR) for chronic type B aortic dissection. A systematic review of contemporary outcomes
Katie O'Sullivan, Jonathan Strickland, Gemma McKevitt, Stephen Badger, Anton Collins, Reuben Jeganathan, Alsir Ahmed
Royal Victoria Hospital, Belfast, United Kingdom
Correspondence: Jonathan Strickland
Journal of Cardiothoracic Surgery 2024, 19(2):A344
Objective: Thoracic endovascular aortic repair (TEVAR) is a rapidly expanding field and has been transformational in the management of a range of aortic pathologies in recent years. TEVAR is now considered a standard of care for complicated acute type B aortic dissection however, the management of chronic type B dissection is a more complex issue. While traditionally these patients were managed with best medical therapy the use of TEVAR is growing. In view of this evolving and important application of TEVAR, the purpose of this systematic review is to provide a contemporary update of the procedural outcomes.
Methods: A systematic review of the current literature to identify outcomes of TEVAR for chronic type B aortic dissection was undertaken. To ensure a review of contemporary practice, studies published 2016 -2021 were included.
Results: A total of 1,248 patients were identified from 17 studies. Indications for TEVAR varied but typically encompassed aneurysmal expansion > 55 mm, rapid expansion, malperfusion, pain, rupture, or refractory hypertension. Overall rate of left subclavian artery (LSA) coverage was 31.6%, access complications 3.3%, acute kidney injury 3.1%, malperfusion 2.7%. Incidence of stroke was 1.2% and paraplegia 1.8%. The overall 30-day mortality rate was 3%. Overall rates of reintervention and retrograde dissection were 10.9 and 2% respectively. Overall rate of endoleak was 10.9%.
Conclusions: Contemporary outcomes of TEVAR for chronic type B dissection in studies examined to date are acceptable. Ongoing examination of this subgroup of patients is required with focus on categories of chronicity.
A345 Virtual online consultations: should we still be assessing new thoracic surgical patients via video consultation?
Charlotte Hope, Sofina Begum
Royal Brompton Hospital, London, United Kingdom
Correspondence: Charlotte Hope
Journal of Cardiothoracic Surgery 2024, 19(2):A345
Introduction: Video consultations have become routine since the COVID-19 pandemic. New patient consultations are of high value to the surgical team, as they allow a full history and physical assessment, which is of high importance during the preoperative assessment of the patients. Video consultation can be advantageous for both patients and healthcare providers. However, it can also be seen as clinically risky and less acceptable to patients. Literature on video consultations remains limited, therefore in a post-pandemic era should we continue to see new patients by video consultation?
Aims: To evaluate clinicians' and new patients' experience of initial consultation via video compared to in-person.
Method: Surveys were developed and piloted for clinicians and new patients. All new patients in the thoracic surgery outpatient clinic who are scheduled for video consultation between October 30th 2023 and December 11th 2023 will be invited to complete a patient satisfaction questionnaire at the end of their consultation.
Results: We hypothesise patients who are technically capable and with significant travel distance will prefer video consultations. We anticipate overall patient choice will be a favourable outcome of the survey. Results are due end of December 2023.
Discussion: Since the COVID-19 pandemic, video consultation has provided a valuable consultation modality for patients and healthcare professionals. However, there are also clinical limitations. Therefore, we review whether we should continue to see new patients via video consultation. We anticipate the overall outcome will favour patient choice in their assessment modality.
A345 Surgical explantation of transcatheter aortic valves: a single-centre experience and systematic review of the literature
Riccardo Giuseppe Abbasciano1, Panagiotis Theodoropoulos1, Carla Lucarelli2, Thanos Athanasiou1, Alessandro Viviano1
1Imperial College Healthcare NHS Trust, London, United Kingdom. 2HCA Healthcare, London, United Kingdom
Correspondence: Carla Lucarelli
Journal of Cardiothoracic Surgery 2024, 19(2):A345
Background: Indication to surgical explantation of TAVR is becoming increasingly more frequent, due to the higher number of procedures performed in patients with longer life expectancy. We performed a systematic review and meta-analysis with meta-regression to identify factors that can determine an increase in the high mortality and morbidity that characterize these surgical procedures. We reviewed the outcomes from our experience to compare them with those published in literature.
Methods: MEDLINE and Embase were searched for relevant studies. Twelve studies were eligible according to our inclusion criteria. Standard Cochrane methods were adopted.
We reviewed the outcomes from our series of patients operated in the period between 2022 and 2023.
Results: TAVR explantation was confirmed as a procedure with high mortality 30-days (0.17; 95% CI, 0.14–0.21) and morbidity (stroke incidence 5%; 95% CI, 0.04–0.07; kidney injury incidence 16%; 95% CI, 0.11–0.24). The type of transcatheter valve implanted during the index procedure, the requirement for aortic reconstruction and the indication for the operation did not influence the outcomes after surgical explantation in the metaregression analysis performed.
Four patients were operated in our centre in the period analysed. We did not record in-hospital mortality or major adverse cardiovascular events. One patient required a pacemaker implantation.
Conclusions: The need for these high-risk operations is growing and it will likely expand in the next years. Specific tools for risk stratification are required. Our internal series showed good short term outcomes, possibly as a result of an effective collaboration with the cardiology service in selecting the patients.
A346 The effect of peri-operative carotid artery intervention on in-hospital and 30-day outcomes when performed at the time of coronary artery bypass grafting: a systematic review and meta-analysis
John David Kehoe1,2, Tara Ni Dhonnchu1
1Cork University Hospital, Cork, Ireland. 2University College Cork, Cork, Ireland
Correspondence: John David Kehoe
Journal of Cardiothoracic Surgery 2024, 19(2):A346
Introduction: Cerebrovascular accidents (CVA) remain a devastating complication following coronary artery bypass grafting (CABG). Carotid artery stenosis is a recognised risk factor and may be managed peri-operatively with carotid endarterectomy or stenting. However, previous reviewers have reserved full endorsement of carotid intervention (CI) given the lack of parallel data comparing combined CABG-CI to isolated CABG.
Objectives: The aim of this systematic review and meta-analysis is to evaluate the current literature comparing outcomes of CI to non-interventional controls in those undergoing CABG with severe carotid stenosis.
Methods: A search of two electronic databases (PubMed and EMBASE) was performed in April 2023 for relevant papers published following the year 2000, yielding 1553 potentially relevant studies. All titles were reviewed and eligibility criteria were applied to selected article abstracts, followed by full texts.
Results: Eight studies were eligible for analysis including one randomised clinical trial and seven observational studies, yielding 9,596 patients that underwent combined CABG-CI and 31,989 that underwent CABG alone. CI was found to significantly increase the risk of 30-day CVA (OR 2.5 [1.07,5.85], p = 0.03), in-hospital mortality (OR 1.23 [1.04,1.45], p = 0.01) and 30-day mortality (OR 1.15 [1.02,1.3], p = 0.02), whilst having no effect on the risk of in-hospital CVA (OR 1.2 [0.73,1.95], p = 0.47) or in-hospital TIA (OR 0.92 [0.52,1.62], p = 0.77).
Conclusion: We provide the first review examining the effectiveness of CI compared to non-interventional controls in CABG patients with severe carotid stenosis. Our findings suggest that CI may increase the risk of 30-day adverse outcomes, challenging the validity of this therapeutic approach.
A347 Outcomes following Post Cardiotomy Veno-Arterial Extra-Corporeal Membrane Oxygenation (PC VA-ECMO) following adult cardiac surgery: a 15-year single-centre experience
Ahmed Mohamed Abdel Shafi, Jason Ali, Narain Moorjani, David Jenkins, Alain Vuylsteke, Marius Berman, Hassiba Smail
Royal Papworth Hospital, Cambridge, United Kingdom
Correspondence: Ahmed Mohamed Abdel Shafi
Journal of Cardiothoracic Surgery 2024, 19(2):A347
Objectives: Cardiac surgery has seen a shift in the patient population with increasing disease severity. Some patients are unable to wean from cardiopulmonary bypass safely following surgery. The increased availability & reliability of ECMO has allowed mechanical circulatory support (MCS) to become a viable option for selected patients in this situation. Our objectives were to assess the outcomes of PC VA-ECMO at our institution.
Methods: This was a retrospective study of all patients that underwent cardiac surgery from January 2008 until July 2023 at our institution from prospectively collected databases. Patients initiated on ECMO prior to surgery, placed on VV-ECMO or VAD were excluded. Patients initiated onto VA-ECMO post cardiotomy were identified and their records analysed.
Results: 28,310 general adult cardiac operations were performed, of which 172 (0.61%) patients fulfilled inclusion criteria with a median age of 66.5 years. Pre-operatively, 59/172 (34.3%) patients had a LVEF < 30%, 42/172 (24.4%) were in cardiogenic shock & 36/172 (20.9%) were on inotropes.
The urgency of the index procedure was elective in 29.1% (50/172), urgent in 29.1% (50/1972) & emergency/salvage in 41.8% (72/172), with 28/172 (16.3%) undergoing a redo-sternotomy. VA-ECMO was instituted at the index operation in 107/172 (62.2%), with the median number of days on ECMO 4.17 days. 9/172 (5.2%) patients went onto further MCS (1-LVAD, 2-BiVAD & 6-RVAD), Table 1 shows complications, mortality & survival outcomes.
Conclusion: Post cardiotomy ECMO is utilised in a small percentage of patients. Although associated with a high mortality & complication rate, its use confers a survival benefit in carefully selected patients to avoid futility.
A348 Validation of the STUMBL score for isolated chest trauma at a Major Trauma Centre
Amber Ahmed-Issap, Daniel Magee, Isabel Soans, Callum Chaney, Nicholas Wong, Kajan Mahendran, Shilajit Ghosh, Lakshmi Srinivasan, Udo Abah
Royal Stoke Hospital, Stoke-on-Trent, United Kingdom
Correspondence: Amber Ahmed-Issap
Journal of Cardiothoracic Surgery 2024, 19(2):A348
Objectives: The STUMBL score is a prognostic tool that has been devised for Emergency Medicine (EM) clinicians to predict complications following blunt chest trauma and determine hospital admission. Scores are assigned to five variables: age, number of fractured ribs, chronic lung disease, anticoagulation and oxygen saturation. This study was designed to test the effectiveness of the scoring tool.
Methods: Patients between 01/06/2021 and 12/09/2023 who attended the Emergency Department (ED) of our tertiary hospital were examined. Exclusion criteria included under age 18, ‘old fractures’, patients with missing STUMBL variables, and polytrauma. Patients were divided into three cohorts depending on the STUMBL score: ‘Discharge’ (0–11), ‘Admission’ (12–26) and ‘ICU input’ (≥ 27). Outcomes measured include: infection, haemothorax, pleural effusion, intensive care admission, re-admission and 90-day mortality.
Results: 1867 patients were examined in the ED with blunt chest trauma. 438 patients met the inclusion criteria. Decision to admit by the EM clinician had a sensitivity of 69.9% and specificity of 66.8% in predicting complications. A score of ≥ 12 had a sensitivity of 84.2%, specificity of 31.2% and positive predictive value of 37.7%. The STUMBL score was statistically significantly different in patients who developed complications compared to those without complications (20.5 [14,26] vs 15 [10,20], p < 0.000001), but would not be clinically relevant for admission decision. 146 patients in total developed complications (Table 1).
Conclusion: The STUMBL score of ≥ 12 to determine admission in preparation for expected complications is higher in sensitivity but much lower in specificity when compared to the ED clinician’s judgement.
Study of the Management of Blunt chest wall trauma (STUMBL) score has been developed to predict complications after rib fractures. It has been advised that patients with a STUMBL score of 0–11 should be discharged, 12-26 should be admitted for monitoring and ≥ 27 should have Intensive Care Unit (ICU) input.
A349 Is thoracic surgery safe during pregnancy? A single-centre retrospective review of surgical and anaesthetic considerations
Denis Ajdarpasic, Karishma Chandarana, Mohammad Hawari
Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
Correspondence: Denis Ajdarpasic
Journal of Cardiothoracic Surgery 2024, 19(2):A349
Background: Around 1% of pregnant women undergo non-obstetric surgery in the UK and USA, with the majority of thoracic surgery in a non-elective setting. Maternal outcomes are comparable with non-pregnant patients undergoing similar abdominal and pelvic procedures; however, the literature is limited in addressing outcomes and recommendations are non-specific for pregnant patients undergoing thoracic surgery.
Objectives: We shall discuss surgical and anaesthetic considerations when performing thoracic surgery in pregnant females, focusing on the pre, intra- and postoperative period, and provide recommendations for the thoracic multidisciplinary team in these unfamiliar circumstances.
Methods: A departmental database was used to identify pregnant females who underwent thoracic surgery at our unit over a 25-year period. Data was collected from electronic hospital records and physical notes, identifying measures taken to minimise risk to mother and baby.
Results: Six patients were included in our study with a median age of 35; five patients (83%) were in their third trimester when undergoing thoracic surgery. All patients had surgery in a non-elective setting. All patients received general anaesthesia. Obstetricians were informed in all cases, and physically present during two thoracic procedures (33%).
Special considerations included patient positioning, analgesia, CTG monitoring, administration of steroids and VTE prophylaxis. No maternal or foetal mortality occurred during the inpatient stay.
Conclusions: Thoracic surgery is safe in pregnancy, where multidisciplinary consensus recommends surgical intervention. Individualised management plans with early anaesthetist and obstetrician involvement help to optimise maternal physiology and manage foetal risks; whilst tackling logistical issues such as timing, location and surgical approach.

A350 Transforming thoracic trauma care: the impact of a new Major Trauma Centre
Stamatina Koskolou, Jennifer Williams, Vasileios Valtzoglou, Ainis Pirtnieks, Malgorzata Kornaszewska, Tom Combellack
University Hospital of Wales, Cardiff, United Kingdom
Correspondence: Stamatina Koskolou
Journal of Cardiothoracic Surgery 2024, 19(2):A350
Background: Cardiff’s Major Trauma Centre (MTC) started operating in September 2020. This led to improved infrastructure and resources to treat trauma patients, including a specialised multi-disciplinary trauma team and dedicated MTC operating theatres.
Objective: To explore MTC’s impact on thoracic surgery trauma cases.
Methods: We analyzed pain team data from 2016 to 2022 and identified thoracic trauma patients through electronic databases (Theatreman, PATS, WCP) from 2017 to October 2023.
Results: Over the two-year period preceding the MTC launch, pain team referrals for blunt chest trauma increased by 25%, while, over the two-year period following the launch, referrals surged by 127%. Simultaneously, an increase in referrals for thoracic surgical review was noted, with approximately 10% leading to surgery.
Pre-MTC, an annual average of eleven thoracic trauma operations occurred, with surgical stabilisation of rib fractures (SSRFs) constituting 47%. Post-MTC, the annual total number of operations significantly increased by an average of 33 cases (294%) [p = 0.004], and SSRFs by 30 cases (556%) [p = 0.003] and comprised 78% of total operations.
Other thoracic trauma procedures also increased, sometimes performed concomitant with SSRF, including eight debridements/evacuations of haemothorax, six diaphragm repairs, two lung repairs, and one bronchoscopy yearly. Around five cases per year required concurrent procedures by other specialties. All procedures were performed in the MTC operating theatre, without impacting the elective thoracic surgery workstream.
Conclusion: The MTC had a significant impact on thoracic trauma patient management, increasing surgical interventions but without affecting elective workload. Improved collaboration with other trauma specialties was an additional key development.

A351 Joint clinical oncology and thoracic surgery lung cancer clinics reduce waiting times to start treatment
Jonathan Strickland1, Jonathan McAleese2, Rory Beattie1, Ralitsa Baranowski1, Gerard Hanna2, Donovan Campbell3
1Royal Victoria Hospital, Belfast, United Kingdom. 2Belfast City Hospital, Belfast, United Kingdom. 3Queen's University, Belfast, United Kingdom
Correspondence: Jonathan Strickland
Journal of Cardiothoracic Surgery 2024, 19(2):A351
Background: For complex cases of non-small cell lung cancer, guidelines recommend assessment by both a clinical oncologist (CO) and thoracic surgeon (TS) to assess whether radical surgery or radiotherapy would be more appropriate. We piloted a joint clinic attended by both TS and CO to undertake such assessments simultaneously and aimed to assess the impact on treatment time-lines.
Methods: All patients treated with RR or RS in 2019 were assessed for evidence of referral to both TS and CO. The time from MDM referral to assessment and first oncological treatment (TTT) was determined.
Results: 15% of those undergoing RS or RR were referred to both TS and CO. 35% of these referrals were to TS first with subsequent referral to CO (sequential pathway). 65% had a simultaneous referral, 87% of these were to the joint clinic. There was a time delay between TS and CO assessments in sequential referrals; median 26 days. 41% of these cases had evidence of progression (worsening cancer or performance status), compared to 0% in the joint clinic. The TTT for those treated with RR in the joint clinic was median 47 days, and was median 64 days in the sequential group (p value 0.03). The TTT, for those treated with RS, in the joint clinic pathway was median 96 days, and in the surgery only pathway was 58 days.
Conclusions: A joint clinic demonstrates a reduction in timelines to radiotherapy treatment compared to sequential referral patterns. This reduces risk of disease progression while awaiting treatment.
A352 The role of surgical intervention in thoracic endometriosis: a single-centre experience
Laurence Orchard, Akshay Patel, Kumar Kunde, Janice Rymer, Shaheen Kazali, Denis Tsepov, Andrea Bille
Guys Hospital, London, United Kingdom
Correspondence: Laurence Orchard
Journal of Cardiothoracic Surgery 2024, 19(2):A352
Background: The thoracic cavity represents the most frequent site of extragenital endometriosis, depending on the exact site and volume of the deposits it can manifest in a wide range of presenting symptoms, such as pneumothorax, haemothorax, haemoptysis and pulmonary nodules. These are defined clinically as thoracic endometriosis syndrome (TES). TES can present in isolation, however the majority of patients presenting with TES with have concomitant pelvic disease. Despite the morbidity associated with the disease the exact mechanism behind the cause remains poorly understood. By studying the presentation, treatment, and outcomes of a case series we aim to gain further understanding into the disease process and clinical presentation.
Methods: We conducted a single-centre retrospective case-series analysis over a 24-month period. We collected all demographic, histopathological and outcome data in the short-term period.
Results: We have operated on 31 patients with TES. Presenting complaints ranged from chest pain (n = 28), catamenial pneumothorax (n = 1), haemoptysis (n = 1) and endometriotic pain (n = 1). All patients underwent diagnostic thoracic exploration via robotic (n = 29) or VATS (n = 2) approach. Twenty-five patients underwent diaphragmatic resection of deposits and reconstruction, 3 underwent additional lung resection for endometriotic deposits and 3 underwent parietal pleurectomy. Median length of hospital stay was 2 days (2–5). Long-term follow-up is being conducted to determine recurrence.
Conclusions: This represents a complex group of patients with a heterogeneous disease process and presentation. Management requires a multi-disciplinary approach in order t