Essex Cardiothoracic Centre

Background and Objectives: Minimally invasive surgery (MIS) has become a cornerstone approach in cardiac surgery. A debate persists regarding the optimal aortic clamp occlusion strategy, with limited comparative data. The two principal strategies, which are transthoracic cross-clamping (TTCC) and endo-aortic balloon occlusion (EABO), offer distinct advantages, but comparative clinical data remain limited. This study compares the two techniques in terms of procedural safety and early outcome. Materials and Methods: This single-center retrospective study included consecutive adult patients undergoing elective MIS via video-assisted right mini-thoracotomy between 2012 and 2018 for mitral valve surgery. Tricuspid repair, atrial fibrillation and redo surgery were included in the final cohort. Aortic occlusion was performed with transthoracic cross-clamping (TTCC) or endo-aortic balloon occlusion (EABO). Primary endpoints were intra-operative complications and the rate of conversion to full sternotomy; secondary outcomes were overall mortality and Society of Thoracic Surgeons (STS)-defined comorbidities. Results: A total of 163 patients were analyzed (TTCC: n = 99, 60%; EABO: n = 64, 40%). While both techniques demonstrated equivalent safety profiles (overall mortality: 0%), EABO was associated with higher conversion to full sternotomy [(n = 7, 10.9%) vs. TTCC (n = 1, 1.3%), p = 0.016]. In a generalized estimation equations (GEE) model, no patient-level covariate predicted conversion, suggesting technical or procedural factors as the primary contributors. In addition, EABO was associated with longer cross-clamp time [median: 87 min (IQR: 73, 100) vs. TTCC median: 77 min (IQR: 65.5, 87.5), p = 0.03]. Stroke, acute kidney injury, respiratory failure, reoperation and wound infection did not differ significantly; also, hospital stay was similar between groups. Conclusions: In this single-center series, EABO showed longer operative times and a higher conversion rate to sternotomy, but without excess mortality or major complications. This may be correlated with the initial learning phase and redo cases; further comparison is needed to assess the benefits of EABO.

IntroductionInherited cardiac conditions, including dilated cardiomyopathy (DCM) and hypertrophic cardiomyopathy (HCM), may have a monogenic cause identified through genetic testing (GT). Confirmation of pathogenic gene variants can have important implications for the patient and their relatives. The UK National Genomic Test Directory (NGTD) provides strict criteria on the indications for GT; however, the European Society of Cardiology (ESC) recommends wider GT. We reviewed the prevalence of pathogenic genotypes in patients undergoing GT who did not meet the NGTD criteria.MethodsWe conducted a retrospective analysis of patients who underwent GT with a confirmed diagnosis of HCM or DCM attending the Essex Inherited Cardiac Conditions Clinic between January 2023 and January 2025.Results257 patients were included in the analysis, with 136 patients with DCM (52.9%) and 121 patients with HCM (47.1%). The diagnostic yield of GT was 19.9% in DCM and 17.4% in HCM.14.8% of gene-positive patients with DCM and 14.3% of gene-positive patients with HCM did not meet current UK testing criteria, predominantly due to age of onset. All gene-positive patients in the DCM subgroup not meeting current NGTD criteria for testing had evidence of myocardial fibrosis.ConclusionA significant minority of patients (1 in 7) with cardiomyopathy and a pathogenic genotype did not meet current UK testing criteria; each patient has an average of 4 first-degree relatives at risk who will benefit from predictive GT. We propose the adoption of the wider ESC guidance, removing the strict age-related cut-offs and being guided more by the severity of the phenotype, particularly involving myocardial scarring.

Intracoronary (IC) imaging-guided percutaneous coronary intervention (PCI) improves clinical outcomes in patients with high clinical and anatomical risk when compared to interventions guided by angiography alone. Recent Class I recommendations for the use of IC imaging guidance when performing PCI in left main stem or complex lesions may result in a significant uptake as the technology is embraced as standard of care. Routine application of IC imaging will provide interventional cardiologists with a wealth of high-fidelity intracoronary data on plaque composition and distribution. When paired with emerging data regarding the importance of plaque anatomical characteristics, developments in artificial intelligence and computational fluid dynamics, lesion stratification with IC imaging may herald the next paradigm shift in this field. In this review, we will explore this important emerging application of IC imaging to inform morphology-guided PCI, identify high-risk lesions for targeted therapies, and consider the prospects of harnessing automated image interpretation with artificial intelligence technologies to achieve an integrated physiological and morphological assessment. Lesion stratification with IC imaging has the potential to shape the future of interventional cardiology practice to guide therapies within and beyond the confines of the cardiac catheterisation laboratory.

Whilst aortic stenosis remains the most prevalent valvular abnormality, the management of asymptomatic severe aortic stenosis remains a clinical challenge. Recently, two randomised-controlled trials (RCTs) - EVOLVED (Early Intervention in Patients With Asymptomatic Severe Aortic Stenosis and Myocardial Fibrosis) and Early TAVR (Transcatheter Aortic-Valve Replacement for Asymptomatic Severe Aortic Stenosis) - have been published, alongside an extended follow-up from the AVATAR (Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis) study. In response, we conducted a systematic review of PubMed, Ovid, and Cochrane databases, identifying RCTs up to October 29, 2024, that compared early intervention with conventional management. Four studies met the inclusion criteria, with a combined total of 1427 patients across the trials. Meta-analysis of the primary endpoints across these studies demonstrated a benefit with early intervention (HR=0.50, 95% CI: 0.35-0.73). However, we did not find mortality and cardiac mortality to show significant reductions (HR=0.68, 95% CI: 0.40-1.18 and HR=0.66, 95% CI: 0.33-1.29, respectively). Crucially, stroke outcomes were improved with early intervention (HR=0.60, 95% CI: 0.38-0.95), as were unplanned hospitalizations (HR=0.40, 95% CI: 0.30-0.53). These findings confirm the safety of early intervention and suggest a reduction in stroke incidence, although no significant benefits were observed in overall or cardiac mortality; results which can help to guide shared decision-making with patients and prevent adverse health outcomes.

To explore modifications of the 2021 European Resuscitation Council/European Society of Intensive Care Medicine (ERC/ESICM) guideline algorithm for neuroprognostication after cardiac arrest to improve its prognostic accuracy. Post-hoc analysis of four prospective multicentre studies (TTM, TTM2, KORHN and ProNeCA). We raised the Glasgow Coma Scale motor (GCS-M) inclusion threshold at 72h after cardiac arrest from the current GCS-M<4 to GCS-M<6 (all unconscious patients). Secondly, we included good outcome predictors (GCS-M 4-5, neuron-specific enolase<17µg/L, benign electroencephalography patterns≤72h post-arrest and normal magnetic resonance imaging at 72-168h post-arrest) in the algorithm. Functional outcome was assessed dichotomously at six months, including modified Rankin Scale 0-3, Cerebral Performance Category 1-2 or Glasgow Outcome Scale 4-5 (no symptoms to moderate disability) as good outcome. We analysed 3,388 patients, of whom 2,079 had GCS-M<4 at≥72h. Of the 874 patients identified by the 2021 ERC/ESICM poor outcome criteria, 870 had poor functional outcome (specificity: 99.6% [95%CI 99.0-99.9]). Using the GCS-M<6 threshold, 366 more patients entered the algorithm (N=2,445). Seven more patients with poor outcomes were identified, with close to identical specificity. Good outcome predictors thereafter identified 673 patients with potential recovery, of whom 411 (61%) had a good functional outcome at six months. With the updated algorithm, the number of prognosticated patients with an indeterminate prognosis decreased from 1,205/2,079 (58%) to 891/2,445 (36%). Raising the GCS-M inclusion threshold and adding favourable predictors to the 2021 ERC/ESICM prognostication algorithm reduced prognostic uncertainty without increasing falsely pessimistic predictions.

BackgroundThe routine use of sedation and analgesia during post-cardiac arrest care and its association with clinical outcomes remain unclear. This study aimed to describe the use of sedatives and analgesics in post-cardiac arrest care, and evaluate associations with good functional outcome, survival, clinical seizures, and late awakening.MethodsThis was a post hoc analysis of the TTM2-trial, which randomized 1900 out-of-hospital cardiac arrest patients to either normothermia or hypothermia. In both groups, deep sedation (Richmond Agitation and Sedation Scale ≤ -4) was mandatory during the 40-h intervention. Cumulative doses of sedatives and analgesic drugs were recorded within the first 72 h from randomization. Outcomes were functional outcome (modified Rankin Scale) and survival status at 6 months, occurrence of clinical seizures during the intensive care stay, and late awakening (Full outline of unresponsiveness motor score of four 96 h after randomization). Cumulative propofol doses were divided into quartiles (Q1-Q4). Logistic regression models were used to assess associations between sedative doses and functional outcome and survival, clinical seizures, and late awakening, adjusting for the severity of illness and other clinical factors influencing sedation.ResultsA total of 1861 patients were analyzed. In a multivariable logistic regression model, higher propofol doses (Q3, 100.7–153.6 mg/kg) were associated with good functional outcome (OR 1.62, 95%CI 1.12—2.34) and (Q2 and Q3, 43.9–153.6 mg/kg) with survival (OR 1.49, 95%CI 1.05—2.12 and OR 1.84, 95%CI 1.27—2.65, respectively). Receiving fentanyl and remifentanil were associated with good functional outcome (OR 1.69, 95%CI 1.27—2.26 and OR 1.50, 95%CI 1.11—2.02) and survival (OR 1.80, 95%CI 1.35—2.40 and OR 1.56, 95%CI 1.16—2.10). Receiving fentanyl (OR 0.64, 95%CI 0.48—0.86) and higher propofol doses (Q2-4 (43.9–669.4 mg/kg) were associated with the occurrence of clinical seizures. The highest quartile of propofol dose (153.7–669.4 mg/kg, OR 3.19, 95%CI 1.91—5.42) was associated with late awakening.ConclusionsIn this study, higher doses of propofol and the use of remifentanil and fentanyl were associated with good functional outcome and survival, occurrence of clinical seizures, and late awakening.