Tertiary Cardiothoracic Centre Research Articles

Long-term quality improvement in radiology specialty training at a tertiary cardiothoracic centre

ObjectivesThis quality improvement project (QIP) aimed to foster radiology training at a regional tertiary cardiothoracic centre that had very low trainee satisfaction rankings. MethodsTo study the problem and intervene timely, multiple methods were applied, including a local feedback survey, placement reorganisation, consultant encouragement to train as accredited supervisors, followed by departmental education portal creation and start of externally funded Visiting Fellowships and salaried Clinical Fellowships. The regional rating was monitored. The local feedback survey was distributed and analysed using descriptive statistics. Alongside the QIP, service expansion occurred. ResultsThe site regionally ranked 9/19 in 2 years. Local survey responses (53) showed continuous improvement; cardiothoracic subspecialty interest (+39%) and audit/academic involvement (+36%) increased. Multiple Fellowships were completed; internationally reputable placements were agreed upon. Most consultants trained as supervisors. Per increased demand, compulsory deanery posts were changed to motivation-based, and an additional salaried position was offered. Five fellows stayed in the region as subspecialist consultants. Unexpected challenges included space and workstation loss with service expansion, lack of regional surveys since 2019, and the global pandemic. Regardless, the results were positive with subspecialty interest and projected reputational effect increase. Local long-term survey provided sustainable data in detecting improvement areas. ConclusionsGiven the national radiologist shortage, this quality improvement project shows a possible positive impact of similar interventions, including workforce retention/recruitment and thus improving patient care. Advances in knowledgeContinuous feedback and quality improvement maintenance are valuable to enhance training quality locally and beyond.

Subclinical venous thromboembolism after pulmonary resection for lung cancer: an observational study

BackgroundSubclinical venous thromboembolism is a hidden pathology which may present with catastrophic consequences if not diagnosed at an early stage. This study was undertaken to estimate the occurrence and associated risk factors of subclinical deep vein thrombosis after lung resection for lung cancer patients. A prospective observational cohort study was performed in a tertiary cardiothoracic surgery center. One hundred fifty patients who underwent different types of lung resection for lung cancer were enrolled. Caprini’s risk score was assessed in all patients. All patients received prophylactic stockings and anticoagulants. On the 5th postoperative day, a duplex venous ultrasound of bilateral lower limbs was performed on every asymptomatic patient.ResultsOut of 150 patients enrolled in the study, 147 patients completed the study. Four patients (2.72%) developed subclinical deep vein thrombosis. The patients were divided into 2 groups: group 1 (n = 143) post-lung resection and no DVT and group 2 (n = 4) with post-lung resection subclinical DVT. No patient developed postoperative clinical DVT. The incidence was found to be highest in the group of individuals who had a longer stay in the ICU (odds ratio 37.9) (p = 0.04). Among the various pathologies, the incidence was higher in patients who received preoperative chemotherapy (odds ratio 21.9) (p = 0.001). One patient in the subclinical DVT group (25%) died, while no mortality was observed in the no DVT group.ConclusionsThe incidence of subclinical deep vein thrombosis is low in the postoperative period among patients undergoing lung resection for lung cancer if appropriate prophylactic measures are applied. However, patients receiving preoperative chemotherapy and those with longer periods of immobilization are at a higher risk of developing postoperative DVT despite anticoagulant prophylaxis. Due to the sample size and design limitations, the mentioned risk factors could be associated with DVT not a cause of DVT. It might be justified to screen these high-risk groups to detect subclinical DVT to allow for post-discharge prophylaxis.

Comparative Analysis of Logistic Regression, Gradient Boosted Trees, SVM, and Random Forest Algorithms for Prediction of Acute Kidney Injury Requiring Dialysis After Cardiac Surgery.

This study aimed to identify the best-performing algorithm for predicting Acute Kidney Injury (AKI) necessitating dialysis following cardiac surgery. The dataset encompassed patient data from a tertiary cardiothoracic center in Malaysia between 2011 and 2015, sourced from electronic health records. Extensive preprocessing and feature selection ensured data quality and relevance. Four machine learning algorithms were applied: Logistic Regression, Gradient Boosted Trees, Support Vector Machine, and Random Forest. The dataset was split into training and validation sets and the hyperparameters were tuned. Accuracy, Area Under the ROC Curve (AUC), precision, F-measure, sensitivity, and specificity were some of the evaluation criteria. Ethical guidelines for data use and patient privacy were rigorously followed throughout the study. With the highest accuracy (88.66%), AUC (94.61%), and sensitivity (91.30%), Gradient Boosted Trees emerged as the top performance. Random Forest displayed strong AUC (94.78%) and accuracy (87.39%). In contrast, the Support Vector Machine showed higher sensitivity (98.57%) with lower specificity (59.55%), but lower accuracy (79.02%) and precision (70.81%). Sensitivity (87.70%) and specificity (87.05%) were maintained in balance via Logistic Regression. These findings imply that Gradient Boosted Trees and Random Forest might be an effective method for identifying patients who would develop AKI following heart surgery. However specific goals, sensitivity/specificity trade-offs, and consideration of the practical ramifications should all be considered when choosing an algorithm.

Determinants of trans-prosthetic gradients after isolated surgical aortic valve replacement and effect on survival

Abstract Background Surgical aortic valve replacement (sAVR) remains the primary therapeutic approach for severe symptomatic aortic stenosis. Patient-prosthetic mismatch (PPM) occurs when the implanted valve is too small for the patient and is characterized by a small orifice area and elevated trans-valvular pressure gradient identified on post-operative transthoracic echocardiography (TTE). PPM is thought to be associated with adverse clinical outcomes, especially when severe, however data is conflicting. Purpose We sought to determine the impact of patient- and prosthesis-related parameters on post-operative trans-valvular pressure gradient, as a surrogate of PPM, and identify its influence on survival in a large single centre study. Methods This was a retrospective study of patients who underwent isolated sAVR between June 2003 and February 2017 at our tertiary cardiothoracic centre. Patients were excluded if their clinical and surgical records were incomplete, they hadn’t attended post-operative follow up or they had undergone valve replacement with anything other than a conventional stented tissue or mechanical prosthesis. All patients underwent postoperative follow up at eight weeks, six months and annually thereafter in keeping with local guidelines. TTE was performed between six and 12 months after surgery. Peak trans-valvular gradient was calculated using the continuity equation based upon continuous wave doppler assessment through the aortic valve. The highest value obtained from multiple views was recorded. Independent predictors of post-operative gradient were determined using a cox-proportional hazards model. Survival analysis was evaluated by Kaplein-Meier curves and log-rank test. Results One thousand seven hundred and ninety patients underwent isolated SAVR during the study period, of which 604 patients satisfied the inclusion and exclusion criteria. Mean age was 69.5 (±11.4) years and 346 (59%) were male. Mean peak pressure gradient was 29.96 (±12.4) mmHg. Independent predictors of increased post-operative gradients were: smaller valve size, postoperative diuretic use, age, gender and operating surgeon (p<0.001) (Table 1). Seventy-two patients (12%) died during follow-up. Mean survival was 12.1 years. After adjusting for confounders, post-operative pressure gradient was identified as a significant predictor of mortality (HR 1.02, p=0.001), alongside age (HR 1.06, p=0.001) and diabetes mellitus (HR 2.18, p=0.007) (Figure 1). Conclusion In a large cohort of patients undergoing sAVR at a single centre in the UK, valve size was the biggest determinant of postoperative pressure gradient alongside sex, diabetes, diuretic use and operating surgeon. Postoperative pressure gradient was a significant predictor of all-cause mortality. Accordingly, implanting the largest possible valve size should be considered the single most effective way of reducing the post-operative gradient and long-term mortality in patients undergoing sAVR.Table 1:Multivariate linear regressionFigure 1:K-M curve

Ultrasound-Enhancing Agent Safely Enhances Left Ventricular Visualization by Transthoracic Echocardiography in Patients on ECMO Support

The authors investigated if the use of ultrasound-enhancing agents (UEA) can safely improve left ventricular (LV) image quality by transthoracic echocardiography (TTE) in patients on extracorporeal membrane oxygenation (ECMO). This study was performed in a tertiary cardiothoracic and ECMO center in London, United Kingdom. The authors included 18 prospectively identified consecutive patients requiring TEE supported on peripherally implanted ECMO. TTE was performed before and after the UEA administration. The authors assessed the LV image quality using the biplane (apical-4-chamber and apical-2-chamber views) endocardial border definition index (1=good, 2=suboptimal, 3=poor, and 4=unavailable), as well as the feasibility of LV ejection fraction (LVEF) measurement. The authors also gathered sequential clinical information for the next 24 hours. The patients' median age was 47 years (35, 65), and 5 (28%) were women. The biplane endocardial border definition index improved from the suboptimal to the good range (2.167 [1.812, 3.042] v 1.500 [1.417, 1.792], p=0.0004) after the use of UEA. The feasibility of LVEF tripled from 25% (n=5) to 83% (n=15) (p=0.0008) with UEA use. The UEA did not set off the bubble alarm and did not impact clinical or ECMO parameters. The use of UEA significantly improved the quality of LV biplane images by transthoracic echocardiography, transforming them from suboptimal to good in patients supported with peripherally implanted ECMO. UEA use tripled the feasibility of measuring LVEF by TTE without affecting clinical and ECMO parameters.

1136 Modified Nuss Bar Procedure for Pectus Excavatum – Our Experience in Patients Aged 20 and Over

Abstract Background Pectus excavatum (PE) is a common congenital anterior chest wall deformity characterized by a sunken appearance. The incidence rate is approximately 0.1% with a male to female ratio of 4:1. It is associated with connective tissue disorders, neuromuscular diseases, and linked with some genetic conditions. In 1987, the Nuss procedure was invented by Dr Nuss and his colleagues as a minimally invasive procedure to correct PE. This is a two-staged procedure and involved lesser hospital stays, smaller incisions, and early mobilisation. Applying this procedure to video-assisted thoracoscopic surgery (VATS), we present our experience on insertion as well as removal of the Nuss bar in patients aged 20 and over with PE. Method This is a single centre, retrospective study carried out in a tertiary cardiothoracic centre. A total of 104 patients, aged 20-57 years, who underwent Nuss bar insertions and removals between 2016 and 2021 (5 years) were included in our study. All the procedures were performed by a single consultant cardiothoracic surgeon using biotech stainless steel bars. Results A total of 24 bar insertions, 79 bar removals and 1 bar revision were performed between 2016-2021. The data included 95 male and 9 female patients. The average hospital stay was 2.5 days. Postoperative complications for the procedure included pleural effusions (3%), pericardial effusion (0.9%), post-operative bleeding requiring re-operation (0.9%), bar dislodgement (0.9%) and wound infection (4%). Conclusions We can conclude that VATS-Nuss procedure is a safe procedure for adult patients resulting in shorter hospital stays and reduced post-operative complications.

COVID-19 Associated Pulmonary Aspergillosis in Patients on Extracorporeal Membrane Oxygenation Treatment-A Retrospective Study.

The incidence and outcome of pulmonary aspergillosis in coronavirus disease (COVID-19) patients on extracorporeal membrane oxygenation (ECMO) are unknown and have not been fully addressed. We investigated the incidence, risk factors and outcome of pulmonary aspergillosis in COVID-19 ECMO patients. In addition, the diagnostic utility of bronchoalveolar lavage fluid and CT scans in this setting were assessed. We conducted a retrospective study on incidence and outcome of pulmonary aspergillosis in COVID-19 ECMO patients by reviewing clinical, radiological, and mycological evidence. These patients were admitted to a tertiary cardiothoracic centre during the early COVID-19 surge between March 2020 and January 2021. Results and measurements: The study included 88 predominantly male COVID-19 ECMO patients with a median age and a BMI of 48 years and 32 kg/m2, respectively. Pulmonary aspergillosis incidence was 10% and was associated with very high mortality. Patients with an Aspergillus infection were almost eight times more likely to die compared with those without infection in multivariate analysis (OR 7.81, 95% CI: 1.20-50.68). BALF GM correlated well with culture results, with a Kappa value of 0.8 (95% CI: 0.6, 1.0). However, serum galactomannan (GM) and serum (1-3)-β-D-glucan (BDG) lacked sensitivity. Thoracic computed tomography (CT) diagnostic utility was also inconclusive, showing nonspecific ground glass opacities in almost all patients. In COVID-19 ECMO patients, pulmonary aspergillosis incidence was 10% and associated with very high mortality. Our results support the role of BALF in the diagnosis of pulmonary aspergillosis in COVID-19 ECMO patients. However, the diagnostic utility of BDG, serum GM, and CT scans is unclear.

Factors associated with long-term outcomes in adult congenital heart disease patients with infective endocarditis: a 16-year tertiary single-centre experience.

Studies concerning factors associated with long-term outcomes in adult congenital heart disease (ACHD) patients after infective endocarditis (IE) are scarce, while IE-related mortality in these patients remains a burden. We evaluated the factors associated with long-term survival in ACHD patients admitted for IE. We performed a retrospective single-centre study of all ACHD patients admitted for IE to a tertiary cardiothoracic centre between 1999 and 2015. Underlying ACHD, detailed echocardiographic and clinical data, surgical treatment and long-term follow-up were analysed. We identified 151 ACHD patients admitted due to 176 episodes IE with 30-day, 6-month and 1-, 5- and 10-year survival of 95.4%, 92.7%, 92.7%, 84.7% and 75.6%, respectively. In a multivariable analysis, adjusted estimated probability of death was consistently higher after an IE episode among patients with complex as compared to simple/moderate ACHD: 10.6% vs 2.4% at 30 days, 15.0% vs 3.4% at 6 months and 1 year, 30.4% vs 7.8% at 5 years and 44.9% vs 13.1% at 10 years. Risk of death was higher among patients with prosthetic valve in comparison with those without (risk ratios 1.73-1.92). Surgical treatment was required in 76 (43.2%) episodes with 30-day mortality of 3.9%. Risk of death appeared to be lower than in the conservatively treated subgroup (risk ratios 0.71-0.78). We demonstrated satisfactory long-term survival in ACHD patients who were treated for IE in a tertiary cardiothoracic centre. Early mortality tended to be lower in the surgically treated subgroup. Factors negatively associated with long-term survival were complex ACHD and presence of prosthetic valve.

The Effects of the COVID-19 Pandemic on Cardiac Surgery Volumes and Outcomes in New Zealand.

New Zealand adopted an "elimination strategy" in response to the 2020 COVID pandemic with strict early border controls and early national lockdowns. The international experience of cardiac surgery provision during the COVID pandemic was of reduced case numbers, difficulties with the provision of elective surgery and in some cases increased morbidity associated with waiting for surgery and from developemnt of the infection in post operative patients. We aim to review the effects the COVID-19 pandemic has had on adult cardiac surgery volumes and outcomes in the Wellington region. Utilising local data submitted to the New Zealand National cardiac surgical database, we analysed all cardiac operations completed at a tertiary cardiothoracic centre between January 1st 2019 till December 31st 2020. The COVID-19 lockdown period (March-April 2020) was compared with its' 2019 counterpart as well as the sequential months to analyse for any 'rebound' effect. Number of surgeries, proportion of elective cases, and surgery type were assessed. The lockdown period of March-April/2020 showed a higher number of cardiac surgery cases per month compared to a the same period in 2019 (48.5 vs 39.0 cases/month, P=0.74). A surge in acute cases was noted in September-December 2020 with 57 acute operations completed, compared to 23 for the corresponding time period in 2019. The New Zealand response to the COVID pandemic resulted in low relative rates of community transmission and only a small number of patients admitted to hospital. We did not see a reduction in routine cardiac operations or changes in clincial outcome over this period. Despite the lockdown period, due to low numbers of community and COVID cases in our ICU and hospital we were able to maintain a full operating capacity throughout. We did observe an increase in acute cases following the lockdown likely due to the reduced access to routine cardiology clinics and deferrable diagnostic services.

Diagnostic performance of echocardiography to predict cardiac tamponade after cardiac surgery.

OBJECTIVESCardiac tamponade is a life-threatening complication after cardiac surgery. Echocardiography, both transthoracic (TTE) and transesophageal (TEE), may help to identify cardiac tamponade after surgery, but its diagnostic value remains unverified after cardiac surgery.METHODSThis retrospective single-centre cohort study used the electronic medical record and echocardiography database of the Catharina Hospital Eindhoven, a tertiary referral cardiothoracic centre, to identify patients who received echocardiography because they were clinically suspected of having cardiac tamponade within the 4 weeks after cardiac surgery. Overall diagnostic accuracy of both TTE and TEE was calculated (sensitivity, specificity, positive predictive value, negative predictive value, and receiver operation characteristics curves). Subgroup analyses were performed based on the timing of the echocardiography after primary surgery (<24, 24–72, >72 h).RESULTSThe query identified 427 echocardiographs, 373 TTEs and 54 TEEs, being performed in 414 patients (65% males, mean age 67 years). Of them, 116 patients underwent surgical re-exploration in which a cardiac tamponade was determined in 105 patients with a 30-day mortality of 8.6%. The area under the receiver operation characteristics curve for echocardiography in the 4 weeks after cardiac surgery was 0.78 [95% confidence interval (CI): 0.72–0.84, P < 0.001]. In the first 24 h after surgery was the positive predictive value of echocardiography 58.3% (95% CI: 28.6–83.5) with an area under the curve of 0.64 (95% CI: 0.49–0.80, P = 0.06). The diagnostic accuracy improved over time for both TTE and TEE.CONCLUSIONSDiagnostic accuracy of echocardiography in the 4 weeks after cardiac surgery for cardiac tamponade is acceptable and improves over time. However, in the early postoperative phase (<24 h), the diagnostic accuracy of echocardiography is poor.

1313 Unusual Supraannular Aortic Root Intimal Tear in a Patient with Severe Aortic Regurgitation

Abstract We present an extremely rare case of occult supraannular aortic root intimal tear in a patient presenting with acute severe aortic regurgitation (AR) and a previously undiagnosed bicuspid aortic valve. A 41-year-old Africo-Carribean female presented to the emergency department with acute pulmonary oedema and increasing dyspnea on exertion. She had been treated empirically with antibiotics for a chest infection. Initial concerns were either aortic dissection or infective endocarditis. Transthoracic echocardiography (TTE) demonstrated a normal size left ventricle with hyperdynamic systolic function and severe AR. The patient was transferred to a tertiary cardiothoracic surgical centre for urgent surgical treatment in view of haemodynamic instability and acute AR. A gated computed tomography aortogram identified pulmonary oedema with an asymmetrically dilated aortic root (maximal diameter 45 mm). Despite advanced multimodality preoperative imaging, diagnosis was made intraoperatively and prompted Bentall procedure with mechanical aortic valve. After median sternotomy and initiation of cardiopulmonary bypass, a supraannular aortic intimal tear starting from the right coronary cusp/noncoronary cusp commissure was found with no extension into the aorta. The aortic valve was bicuspid and severe AR not amenable to repair was found. Bentall procedure was performed using the 23/26mm Carbomedics Carbo Seal Valsalva composite graft (Sulzer Carbomedics Inc, Austin, TX, USA). The patient was discharged on the 7th postoperative day in sinus rhythm. At 30-day clinical follow-up she was symptom free with a satisfactory TTE.

An audit of ventilation and perfusion SPECT reporting for the diagnosis of pulmonary embolism in a tertiary cardiothoracic centre.

The aim of the study was to identify reporting patterns of ventilation and perfusion single-photon emission computed tomography (V/Q SPECT) scans done in our department over 3 months in 2016. Factors impacting on reporting and patient groups that would most benefit from the addition of low-dose computed tomography (CT) to V/Q SPECT were analysed. Among 178 patients, 173 (97.2%) had a definitive (positive/negative) report and 2.8% had an equivocal report. As the majority of the equivocal reports were seen in patients aged ≥70 years, we believe that addition of low-dose CT with V/Q SPECT to this patient group will reduce the non-diagnostic rate.

Impact of the perioperative inotropic support in grown-up congenital heart patients undergoing cardiac surgery: a propensity score adjusted analysis

BackgroundGrown-up congenital heart (GUCH) patients represent a growing population with a high morbidity risk when undergoing reparative surgery. A main preoperative feature is right ventricular failure, which represents a risk factor for postoperative low cardiac output syndrome. Levosimendan has a potentially beneficial effect. This retrospective study included consecutive GUCH patients with surgeries in a tertiary cardiothoracic centre between 01-01-2013 and 01-10-2017, to test the hypothesis that the postoperative use of levosimendan might be associated with shorter time of mechanical ventilation, when compared with the use of milrinone. To adjust for bias related to the probability of treatment assignment, it uses the inverse propensity score weighting methodology.ResultsOverall 363 patients had GUCH surgeries during the study period, their mean age was 31.39 ± 15.31 years, 87 patients were eligible for analysis in the Levosimendan group and 117 in the Milrinone group. The propensity score used pre- and intraoperative variables and resulted in a good balance between covariates. The Levosimendan group included patients with higher preoperative risk scores, a higher prevalence of left and right ventricular failure, who required more often the addition of epinephrine, renal replacement therapy, prolonged mechanical ventilation and intensive care stay. However, after propensity score weighting, patients in the Levosimendan group had shorter durations of mechanical ventilation (average treatment effect − 37.59 h IQR [− 138.85 to − 19.13], p = 0.01) and intensive care stay (average treatment effect − 3.11 days IQR [− 10.03 to − 1.48], p = 0.009). The number of days of additional epinephrine support was shorter and the vasoactive inotropic scores lower.ConclusionWe report a beneficial effect in terms of duration of mechanical ventilation and intensive care stay, and on inotropic requirements of the use of levosimendan following GUCH surgeries. The use of levosimendan in this setting requires validation at a larger scale.

Successful COVID-19 rescue therapy by extra-corporeal membrane oxygenation (ECMO) for respiratory failure: a case report

BackgroundThe value of extracorporeal membrane oxygenation (ECMO) for patients suffering from novel coronavirus disease 2019 (COVID-19) as a rescue therapy for respiratory failure remains controversial and associated with high mortality rates of 50 to 82% in early reports from Wuhan, China. We hypothesized that patient outcomes would be improved at our tertiary cardiothoracic surgery referral center with a protocolized team-approach for ECMO treatment of patients with severe COVID-19 disease.Case presentationA 51-year-old healthy female developed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) bilateral pneumonia while vacationing in Colorado with her family. She was transferred to our facility for a higher level of care. Her respiratory status continued to deteriorate despite maximized critical care, including prone positioning ventilation and nitric oxide inhalation therapy. Veno-venous ECMO was initiated on hospital day 7 in conjunction with a 10-day course of compassionate use antiviral treatment with remdesivir. The patient’s condition improved significantly and she was decannulated from ECMO on hospital day 17 (ECMO day 11). She was successfully extubated and eventually discharged to rehabilitation on hospital day 28.ConclusionThis case report demonstrates a positive outcome in a young patient with COVID-19 treated by the judicious application of ECMO in conjunction with compassionate use antiviral treatment (remdesivir). Future prospective multi-center studies are needed to validate these findings in a larger cohort of patients.

Venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock-A six-year service evaluation.

Only a small number of English hospitals provide postcardiotomy venoarterial extracorporeal membrane oxygenation (VA-ECMO) and there are doubts about its efficacy and safety. The aim of this service evaluation was to determine local survival rates and report on patient demographics. This was a retrospective service evaluation of prospectively recorded routine clinical datafrom a tertiary cardiothoracic center in the United Kingdom offering services including cardiac and thoracic surgery, heart and lung transplantation, venovenous extracorporeal membrane oxygenation (VV-ECMO) for respiratory failure, and all types of mechanical circulatory support. In six years, 39 patients were supported with VA-ECMO for refractory postcardiotomy cardiogenic shock (PCCS). We analyzed survival data and looked for associations between survival rates and patient characteristics. The intervention wasvenoarterial-ECMO in patients with PCCS either following weaning from cardiopulmonary bypass or following a trial of inotropes and intra-aortic balloon counterpulsation on the intensive care unit. 30-day, hospital discharge, 1-year and 2-year survivals were 51.3%, 41%, 37.5%, and 38.5%, respectively. The median(IQR [range]) duration of support was 6 (4-9 [1-35]) days. Nonsurvival was associated with advanced age, shorter intensive care length of stay, and the requirement for postoperative hemofiltration. Reasonable survival rates can be achieved in selected patients who may have been expected to have a worse mortality without VA-ECMO. We suggest postoperative VA-ECMO should be available to all patients undergoing cardiac surgery be it in their own center or through an established pathway to a specialist center.

2405When do cardiac rhythm management device complications occur?

Abstract Background The rate of implantation of cardiac rhythm management devices continues to increase but it is difficult to compare the complication rates of routine cardiac implantable electronic device procedures as the follow-up durations published in literature vary widely (peri-procedure to 3 years). Purpose We demonstrate the appropriate follow-up duration for a complication to be attributed to an index procedure, by analysing the complications within the first year of routine cardiac implantable electronic device procedures (primary implant, generator replacement, lead revision only, generator and lead revision, system upgrade and reburial) and the timing of complication interventions. Methods A retrospective database was constructed of all de novo CIED operations performed at a tertiary cardio-thoracic centre between April 2008 – March 2016. Procedures were identified from theatre logbooks, with demographic and procedural data extracted from contemporaneously maintained health records (paper and electronic). Objective complications were defined as follows; 1. Any pneumothorax identified on chest x-ray, 2. Any pericardial effusion identified on transthoracic echocardiogram performed post procedure due to intra-operative clinical concern, 3. Haematoma requiring surgical evacuation, 4. Device pocket revision or system reburial, 5. Lead intervention requiring repositioning or placement of a new lead and 6. System explant/ extraction due to any indication. Post-operative complications were identified through theatre log books and cross-referenced with 3 contemporaneously maintained records (clinical health records, TOMCAT electronic database, audit department archive). All data collection was performed by a single investigator, independent of the procedures performed and operating physicians. Results 10,125 procedures were reviewed; 6,583 primary implant procedures, 2,170 generator replacements, 382 lead revisions, 253 generator and lead interventions, 575 system upgrades and 162 reburial procedures. The procedures involved 3,403 female patients and 6,722 male, with a median age 73 years (±13.7). 2,303 procedures were acute and 7,822 elective. The complication rates were; 4.3% primary implant, 4.0% generator replacements, 12.6% lead revisions, 13.0% generator and lead interventions, 6.9% system upgrades and 22.8% reburial procedures. The timing of complication intervention varied significantly (Figure 1). Timing of Complication Intervention Conclusion Complications within the first year of any cardiac implantable electronic device intervention is common, particularly system reburials, lead revisions and generator and lead procedures. 10% of complications after generator replacement, system upgrades or reburial procedures occurred at between 36–52 weeks. For lead and combined generator and lead procedures this figure rose to approximately 15%.

Differential Risk of ST-Segment Elevation Myocardial Infarction in Male and Female Smokers

BackgroundSmoking is a well-documented risk for acute ST-segment elevation myocardial infarction (STEMI). The differential effect between sexes has yet to be quantified. ObjectivesThe purpose of this study was to differentiate the effect of smoking on increased risk of STEMI between sexes. MethodsFor this retrospective ecological cohort study, all patients at a U.K. tertiary cardiothoracic center who presented between 2009 and 2014 with acute STEMI were combined with population data to generate incidence rates of STEMI. Age-standardized incidence rate ratios (IRRs) using the Poisson distribution were calculated comparing STEMI rates between smokers and nonsmokers stratified by sex and 3 age groups (18 to 49, 50 to 64, and >65 years). ResultsA total of 3,343 patients presented over 5,639,328 person-years. Peak STEMI rate for current smokers was in the 70 to 79 years age range for women (235 per 100,000 patient-years) and 50 to 59 years (425 per 100,000 patient-years) in men. Smoking was associated with a significantly greater increase in STEMI rate for women than men (IRR: 6.62; 95% confidence interval [CI]: 5.98 to 7.31, vs. 4.40; 95% CI: 4.15 to 4.67). The greatest increased risk was in women age 18 to 49 (IRR: 13.22; 95% CI: 10.33 to 16.66, vs. 8.60; 95% CI: 7.70 to 9.59 in men). The greatest risk difference was in the age 50 to 64 years group, with IRR of 9.66 (95% CI: 8.30 to 11.18) in women and 4.47 (95% CI: 4.10 to 4.86) in men. ConclusionsThis study quantifies the differential effect of smoking between sexes, with women having a significantly increased risk of STEMI than men. This information encourages continued efforts to prevent smoking uptake and promote cessation.

P115Changing clinical practice of downstream investigations following CTCA; Impact of CTFFR in a large tertiary cardiothoracic centre.

P115Changing clinical practice of downstream investigations following CTCA; Impact of CTFFR in a large tertiary cardiothoracic centre.

Early transthoracic echocardiography has useful prognostic value in left-sided native valve endocarditis despite limited diagnostic performance.

To investigate the prognostic implications of findings on early transthoracic echocardiography (TTE) in patients with definite left-sided native valveinfective endocarditis (LNVIE). We reviewed a 10-year retrospective cohort of consecutive patients with definite LNVIE treated at a tertiary cardiothoracic centre. TTEstudies performed within the first sevendays of the index blood culture (for culture-positive cases) or hospital admission (for culture-negative cases) were reviewed for the presence of valvular vegetations, perivalvular abscesses, aortic or mitral regurgitation of moderate or greater severity or a bicuspid aortic valve. Six-week outcomes included all-cause mortality, cardiac surgery for endocarditis or new embolic cerebral infarction. Early TTE was performed in 118 of 151 episodes of definite LNVIE at a median of twodays after the index blood culture or hospital admission. Findings on these studies included valvular vegetations or abscesses in 74 patients, moderate or severe aortic or mitral regurgitation in 67 patients and a bicuspid aortic valve in 19 patients. The presence of any of these findings conferred a relative risk of any adverse six-week outcome of 4.80 (95% confidence interval 1.6-17, p = 0.001). The presence of a bicuspid aortic valve appeared particularly predictive of the need for cardiac surgery, including for clinically occult paravalvular abscesses. Early TTE can be used to stratify patients with LNVIE by the risk of major endocarditis-related adverse outcomes occurring within the first sixweeks of treatment.

Transfer of Patients With Cardiogenic Shock Using Veno-Arterial Extracorporeal Membrane Oxygenation

The authors describe the experience of patient transfer on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) used as a salvage therapy for refractory cardiogenic shock, examining feasibility and long-term outcomes. A retrospective case series. A tertiary referral cardiothoracic transplantation center. Since 2012, the authors' multidisciplinary team has traveled to the referring center of 15 patients referred with refractory cardiogenic shock. Of these, 13 were instituted on VA ECMO support (8 peripheral and 5 central) and subsequently transferred to the authors' center. A further 11 patients were transferred to the authors' institution by the referring team, already having been placed on VA-ECMO (8 peripheral and 3 central). All patients were safely transferred. The distance travelled ranged from 16 to 341 miles. The median duration of support on VA-ECMO was 4 days, ranging from 1 to 24 days. The VA-ECMO support was weaned, or the patient underwent a definitive surgical management (including 4 undergoing cardiac transplantation and 3 pulmonary endarterectomy) in 15 (62.5%) patients. The median intensive care unit stay was 15 days (range 1-109). Overall 30-day survival for this patient cohort was 69.6% with 1-year survival of 59.8%. For patients who were weaned from VA-ECMO, the 30-day survival was 100% and 1-year survival 92.9%. The authors' experience demonstrates the feasibility and survival benefit of a salvage VA-ECMO retrieval service for carefully selected patients with refractory cardiogenic shock. The authors suggest that a system based on the model of nationally commissioned severe respiratory failure services could be organized to support the transfer of these patients.