Background The use of the Frozen Elephant Trunk (FET) device to manage complex surgical pathologies of the aorta (such as acute type A aortic dissection) has gained popularity since its introduction in the early 2000s. Though the distal anastomosis was traditionally performed at aortic Zone 3 (Z‐3‐FET), preference gradually shifted towards Zone 2 (Z‐2‐FET) in favor of improved surgical access and clinical outcomes. This review seeks to elucidate whether proximalization of arch repair to Zone 0 (Z‐0‐FET) would further improve postoperative outcomes. Methods We performed a review of available literature to evaluate the comparative efficacies of Z‐2‐FET versus Z‐0‐FET, in terms of surgical technique, clinical outcomes, and incidence of adverse events. Results Z‐0‐FET seems to be associated with a more accessible surgical approach, and shorter cardiopulmonary bypass, antegrade cerebral perfusion, and cardioplegia durations than Z‐2‐FET. Further, Z‐0‐FET is could potentially be associated with a lower incidence of neurological, renal, and recurrent laryngeal nerve injury, as well as mortality and reintervention rates than Z‐2‐FET. This said, Z‐0‐FET is itself associated with significant challenges, and efficacy in terms of postoperative true lumen integrity and false lumen thrombosis is mixed. Conclusion Current literature seems to suggest that Z‐0‐FET procedures are more straightforward and associated with lower rates of certain adverse events, however, the majority of data reviewed is retrospective. This review, therefore, recommends prospective research into the comparative strengths and limitations of Z‐0‐FET and Z‐2‐FET to better substantiate whether proximalization of arch repair represents a concept, or a true challenge to advance surgical intervention for arch pathologies.

Background Use of the Frozen Elephant Trunk (FET) device to manage complex surgical pathologies of the aorta (e.g. acute Type A aortic dissection) has gained popularity since its introduction in the early 2000s. Though the distal anastomosis was traditionally performed at Zone 3 (Z-3-FET), preference gradually shifted towards Zone 2 (Z-2-FET) in favour of improved surgical access and outcomes. This review seeks to elucidate whether proximalisation of arch repair to Zone 0 (Z-0-FET) would further improve postoperative outcomes. Methods We performed a review of available literature to evaluate the comparative efficacies of Z-2-FET versus Z-0-FET, in terms of surgical technique, clinical outcomes, and incidence of adverse events. Results Z-0-FET seems to be associated with a more accessible surgical approach, and shorter cardiopulmonary bypass, antegrade cerebral perfusion, and cardioplegia durations than Z-2-FET. Further, Z-0-FET is could potentially be associated with a lower incidence of neurological, renal, and recurrent laryngeal nerve injury, as well as mortality and reintervention rates than Z-2-FET. This said, Z-0-FET is itself associated with significant challenges, and efficacy in terms of postoperative true lumen integrity and false lumen thrombosis is mixed. Conclusion Current literature seems to suggest that Z-0-FET procedures are more straightforward and associated with lower rates of certain adverse events, however, the majority of data reviewed is retrospective. This review therefore recommends prospective research into the comparative strengths and limitations of Z-0-FET and Z-2-FET to better substantiate whether proximalisation of arch repair represents a concept, or a true challenge to advance surgical intervention for arch pathologies.

Introduction: Primary cardiac sarcomas (PCSs) are an extremely rare and aggressive type of malignancies that have been described only by a limited number of observational studies. This study aimed to evaluate the currently existing evidence comparing surgical to multimodality treatment of PCS.Methods: We systematically reviewed Embase, MEDLINE, Cochrane Database, and Google Scholar, from inception to December 2020, for original articles about surgical and multimodality treatment of PCS. The outcomes included were mortality at various time points, resection margin status, and mean estimated survival. The pooled treatment effects were calculated using a random-effects model.Results: Ten studies including a total of 1570 patients met our inclusion criteria. Surgery was associated with significantly lower mortality when compared to conservative treatment at 1, 2, and 3 years, whereas no significant difference was found at 5 years. Furthermore, multimodality treatment showed significantly lower mortality at 1 year when compared to surgery alone, but not at 2 and 5 years. We found no difference in mortality between angiosarcomas and other PCS subtypes. Conclusion:Overall, surgery was found to provide a significant mortality advantage to PCS patients up to 3 years following treatment. Multimodality treatment might be of additional benefit, although only within the first year. Prospective randomized studies are needed to further explore these differences in the treatment of PCS.

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Background Lifestyle modifications are cornerstone of hypertension prevention and treatment. We aimed to systematically review hypertension guidelines on their recommendations on non-pharmacological factors including lifestyle interventions, to highlight strength of evidence, similarities, and differences. Methods The systematic review was registered with the international Prospective Register of Systematic Reviews (CRD42021288815). Publications in MEDLINE and EMBASE over 10 years since January 2010 to June 2020 were identified. We also included the search from websites of organizations responsible for guidelines development. Study Selection Two reviewers screened the titles and abstracts to identify relevant guidelines. Data Extraction Two reviewers independently assessed rigor of guideline development using the AGREEII instrument, and one reviewer extracted recommendations. Results Of the identified guidelines, 10 showed good rigor of development (AGREE Score ≥ 60%) and were included in the systematic review. The guidelines were consistent in most recommendations (reduced salt intake, weight, dietary patterns, increased physical activity and smoking cessation, and limiting alcohol intake). Some areas of disagreement were identified, regarding recommendations on novel psychological and environmental factors such as stress or air pollution, alcohol intake thresholds, meat, coffee and tea consumption and refined sugars. Conclusions Current guidelines agree on the importance of lifestyle in the treatment and prevention of hypertension. Consensus on smoking cessation, limited salt intake, increased physical activity support their integration in management of hypertensive patients and in public health measurements in general population as preventative measurements. Further research into the role of environmental and psychological factors may help clarify future recommendations.

Background: Aortic aneurysm (AA) is a common atherosclerotic condition, accounting for nearly 6000 deaths in England and up to 175,000 deaths globally each year. The pathological outward bulging of the aorta typically results from atherosclerosis or hereditary connective tissue disorders. AAs are usually asymptomatic until spontaneous rupture or detected on incidental screening. Eight in 10 patients do not survive the rupture and die either before reaching hospital or from complications following surgery. Similar to other cardiovascular pathologies, AA is thought to be subject to chronobiological patterns of varying incidence.Methods: We performed a literature review of the current literature to evaluate the association between circadian rhythms, seasonal variations, and genetic factors and the pathogenesis of AA, reviewing the impact of chronobiology.Results: The incidence of AA is found to peak in the early morning (6-11 a.m.) and colder months, and conversely troughs towards the evening and warmer months, exhibiting a similar pattern of chronobiological rhythm as other cerebrovascular pathologies, such as myocardial infarcts, or cerebrovascular strokes. Conclusion:Literature suggests there exists a clear relationship between chronobiology and the incidence and pathogenesis of ruptured AA; incidence increases in the morning (6-11 a.m.), and during colder months (December-January). This is more pronounced in patients with Marfan syndrome, or vitamin D deficiency. The underlying pathophysiology and implications this has for chronotherapeutics, are also discussed.Our review shows a clear need for further research into the chronotherapeutic approach to preventing ruptured AA in the journey towards precision medicine.

Background Aortic Aneurysm (AA) is a common atherosclerotic condition, accounting for nearly 6,000 deaths in England and up to 175,000 deaths globally each year. The pathological outward bulging of the aorta typically results from atherosclerosis or hereditary connective tissue disorders. AAs are usually asymptomatic until spontaneous rupture or detected on incidental screening. 8 in 10 patients do not survive the rupture and die either before reaching hospital or from complications following surgery. Similar to other cardiovascular pathologies (CVPs), AA is thought to be subject to chronobiological patterns of varying incidence. Methods We performed a literature review of the current literature to evaluate the association between circadian rhythms, seasonal variations, and genetic factors and the pathogenesis of AA, reviewing the impact of chronobiology. Results The incidence of AA is found to peak in the early morning (6 AM – 11 AM) and colder months, and conversely troughs towards the evening and warmer months, exhibiting a similar pattern of chronobiological rhythm as other CVPs such as myocardial infarcts, or cerebrovascular strokes. Conclusion Literature suggests there exists a clear relationship between chronobiology and the incidence and pathogenesis of ruptured AA; incidence increases in the morning (6am - 11am), and during colder months (December – January). This is more pronounced in patients with Marfan Syndrome, or vitamin D deficiency. The underlying pathophysiology and implications this has for chronotherapeutics, are also discussed. Our review shows a clear need for further research into the chronotherapeutic approach to preventing ruptured AA in the journey towards precision medicine.

Introduction External Ventricular Drainage (EVD) is a neurosurgical technique used to lower the intercranial pressure while cerebrospinal fluid (CSF) flow is obstructed. The infection rate associated with the EVD insertion in the UK is 9.3%, with ventriculitis being the most common one. The aim of the audit was to compare our outcomes and infection rates and national standards and to implement an EVD Management protocol to improve patient outcome. Methods The data was collected from 43 patients, 98% of whom were emergency admitted cases. For all EVD procedures, silver coated catheters were used. The surgical factors such as the surgical team performance and the average operative time (1h 11min) were accounted for in the audit. The most common reason for EVD insertion was subarachnoid haemorrhage. Prophylactic antibiotics were administered in all cases before the surgery. 12% of the EVDs were used for Intercranial Pressure Monitoring. Results 12% patients’ samples had catheter associated infections. The average EVD insertion period was 18 days. Leaks occurred in 11 cases (26%). 3 of them subsequently developed ventriculitis. White cell count result was over 10,000 cells per mm3 in 40% of patients. Conclusions Twice longer sampling time then the national average (8 days) increased the number of ITU transfers. The cause would be the use of out-of-date EVD type. However, the silver impregnated lines versus non-impregnated have a lower cerebrospinal fluid infection rate, the bolt connected EVDs would be more precise and decrease the rate of resuturing and hence decrease a chance of CSF infection.