Surgery (Austin & Northern Health) - Research Publications
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ItemModern Cardiac Surgical Outcomes in Nonagenarians: A Multicentre Retrospective Observational Study.(Frontiers Media SA, 2022)BACKGROUND: There have been multiple recent advancements in the selection, optimisation and management of patients undergoing cardiac surgery. However, there is limited data regarding the outcomes in nonagenarians, despite this cohort being increasingly referred for these interventions. The objective of this study was to describe the patient characteristics, management and outcomes of a cohort of nonagenarians undergoing cardiac surgery receiving contemporary peri-operative care. METHODS: After receiving ethics approval, we conducted a retrospective observational study of nonagenarians who had undergone cardiac surgery requiring a classic median sternotomy. All operative indications were included. We excluded patients who underwent transcatheter aortic valve implantation (TAVI), and surgery on the thoracic aorta via an endovascular approach (TEVAR). Patients undergoing TEVAR often have the procedure done under sedation and regional blocks with local anesthetic solution. There is no open incision and these patients do not require cardiopulmonary bypass. We also excluded patients undergoing minimally invasive mitral valve surgery via a videoscope assisted approach. These patients do not have a median sternotomy, have the procedure done via erector spinae block, and often are extubated on table. Data were collected from four hospitals in Victoria, Australia, over an 8-year period (January 2012-December 2019). The primary objective was to assess 6-month mortality in nonagenarian patients undergoing cardiac surgery and to provide a detailed overview of postoperative complications. We hypothesized that cardiac surgery in nonagenarian patients would be associated with a 6-month postoperative mortality <10%. As a secondary outcome, we hypothesized that significant postoperative complications (i.e., Clavien Dindo Grade IIIb or greater) would occur in > 30% of patients. RESULTS: A total of 12,358 adult cardiac surgery patients underwent surgery during the study period, of whom 18 nonagenarians (0.15%) fulfilled inclusion criteria. The median (IQR) [min-max] age was 91.0 years (90.0:91.8) [90-94] and the median body mass index was 25.0 (kg/m2) (22.3:27.0). Comorbidities, polypharmacy, and frailty were common. The median predicted mortality as per EuroSCORE-II was 6.1% (4.1:14.5). There were no cases of intra-operative, in-hospital, or 6-month mortality. One (5.6%) patient experienced two Grade IIIa complications. Three (16.7%) patients experienced Grade IIIb complications. Three (16.7%) patients had an unplanned hospital readmission within 30 days of discharge. The median value for postoperative length of stay was 11.6 days (9.8:17.6). One patient was discharged home and all others were discharged to an inpatient rehabilitation facility. CONCLUSION: In this selected, contemporary cohort of nonagenarian patients undergoing cardiac surgery, postoperative 6-month mortality was zero. These findings support carefully selected nonagenarian patients being offered cardiac surgery (Trials Registry: https://www.anzctr.org.au/ACTRN12622000058774.aspx).
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ItemPaving the way for E-vita open NEO hybrid prosthesis implantation for complex aortic arch disease in Asia-Pacific(WILEY, 2021-10)We report first in man implantations of the newly designed Evita-open-NEO hybrid prosthesis for complex aortic arch disease from three different countries in Asia-Pacific including instructions on how to proceed with perioperative coagulation management.
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ItemFast-track recovery program after cardiac surgery in a teaching hospital: a quality improvement initiative(SPRINGERNATURE, 2021-05-22)OBJECTIVE: Fast-track cardiac anesthesia (FTCA) is a technique that may improve patient access to surgery and maximize workforce utilization. However, feasibility and factors impacting FTCA implementation remain poorly explored both locally and internationally. We describe the specific intraoperative and postoperative protocols for our FTCA program, assess protocol compliance and identify reasons for FTCA failure. RESULTS: We tested the program in 16 patients undergoing elective cardiac surgery requiring cardiopulmonary bypass. There was 100% compliance with the FTCA protocols. Four (25%) patients successfully completed the FTCA protocol (extubated < 4 h postoperatively and discharged from the intensive care unit on the same operative day).
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ItemTechnique and rationale for branch-first total aortic arch repair(ELSEVIER, 2020-12)OBJECTIVE: Our objective was to describe the technique and rationale for branch-first total aortic arch repair. METHODS: Branch-first total aortic arch repair involves serial clamping, reconstruction, and reperfusion of each of the arch branches using a specially designed trifurcation graft with a side port. During this sequence, perfusion to the heart and distal organs are preserved and continuous antegrade cerebral perfusion is permitted via the trifurcation graft. The diseased aorta is excised and replaced with a Dacron graft (W.L. Gore and Associates, Newark, Del) with a perfusion side port. The trifurcation graft is anastomosed to the new proximal ascending aorta. RESULTS: The branch-first technique permits total aortic arch repair without global cerebral circulatory arrest and excessive hypothermia. It shortens distal organ and cardiac ischemic time, and reduces the opportunity for air and particulate embolization during aortic repair. CONCLUSIONS: Branch-first total aortic arch repair allows continuous antegrade cerebral perfusion and shortens distal organ and cardiac ischemic time, with unobstructed access to the full extent of the diseased aortic arch.
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ItemPermanent pacing and conduction recovery in patients undergoing cardiac surgery for active infective endocarditis in an Australian Tertiary Center(WILEY, 2019-08)BACKGROUND: Postoperative heart block is common among patients undergoing surgery for infective endocarditis (IE). Limited data exists allowing cardiologists to predict who will require permanent pacemaker (PPM) implantation postoperatively. We aimed to determine the rate of postoperative PPM insertion, predictors for postoperative PPM, and describe PPM utilization and rates of device-related infection during follow-up. MATERIALS AND METHODS: A retrospective analysis was performed of 191 consecutive patients from a single institution who underwent cardiac surgery for IE between 2001 and 2017. Preoperative and operative predictors for postoperative PPM were evaluated using univariate and multivariate logistic regression. RESULTS: The rate of postoperative PPM implantation was 11% (17/154). The PPM group had more preoperative prolonged PR interval alone (33% vs 12%; P = .03), coexistent prolonged PR and QRS durations (13% vs 2%; P = .01), infection beyond the valve leaflets (82% vs 41%; P = .001), aortic root debridement (65% vs 23%; P = <.001), patch repair (47% vs 20%; P = .01), postoperative prolonged PR interval (50% vs 24%; P = .01), and prolonged QRS duration (47% vs 15%; P = .001). On multivariate analysis, infection beyond the valve leaflets emerged as an independent predictor for postoperative PPM (odds ratio, 1.94, 95% confidence interval, 1.14-3.28; P = .014). A reduction in PPM utilization was observed in five patients while eight patients continued to show significant ventricular pacing with no underlying rhythm at 12 months. There were no device-related infections. CONCLUSION: Postoperative PPM was required in 11% of patients undergoing surgery for IE over a 16-year period. Infection beyond the valve leaflet was an independent predictor for postoperative PPM insertion.
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ItemCOVID-19: An Australian center's perspective(WILEY, 2021-05)SARS CoV-2 (COVID 19) is having a deep and lasting impact around the world. We review the effect it has had on our cardiothoracic surgery practice in Australia and give insights into our contingency planning, restructuring, practice changes, and the effect on our patients in this evolving pandemic.
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ItemTrends and controversies in type A aortic surgery in the 21st century: Branch first aortic arch replacement(WILEY, 2021-05)BACKGROUND: Acute type A dissection (ATAAD) remains a morbid condition with reported surgical mortality as high as 26%. AIMS: We describe our surgical approach to ATAAD using a "branch first" total arch replacement technique which avoids a traditional approach of ascending aorta and "hemi-arch" replacement utilising deep hypothermic circulatory arrest (DHCA) and an open distal anastomosis. We also discuss the indications for adjunct techniques such as the frozen elephant trunk or complete aortic repair with endovascular methods. MATERIALS & METHODS: Thirty-nine patients underwent a "branch first" total aortic arch replacement for ATAAD. RESULTS: We had an overall 5(12.8%) hospital mortalities and 2 (5.1%) strokes. There were no deaths or strokes in patients without pre-operative organ malperfusion or shock. DISCUSSION: Arch replacement using the "branch-first technique" allows for complete proximal aortic replacement and sets up for straightforward future distal aortic intervention. CONCLUSION: The use of a branch first aortic arch replacement technique in ATAAD results in improved outcomes and is an approach applicable to all cardiac surgeons not only the aortic sub specialist.
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ItemAortic arch replacement using the branch-first and frozen elephant trunk techniques(AME PUBLISHING COMPANY, 2020-05)
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ItemPlatypnea-orthodeoxia associated with a fenestrated atrial septal aneurysm: case report.(Springer Science and Business Media LLC, 2005-09-13)BACKGROUND: Platypnea-orthodeoxia describes the condition of combined dyspnea and hypoxia respectively, whilst in the upright position, which improves in the recumbent position. CASE REPORT: We present a case of platypnea-orthodeoxia due to a fenestrated atrial septal defect associated with an atrial septal aneurysm. Due to the fenestrated nature of the atrial septal defect, surgical rather than percutaneous correction was performed. CONCLUSION: A high index of suspicion is required to diagnose the syndrome of platypnea-orthodeoxia. Careful echocardiographic evaluation is required to identify the syndrome, and to determine suitability for percutaneous repair.