A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether there was a difference in postoperative outcomes [namely permanent pacemaker (PPM) insertion, rhythm disturbance, reoperation for bleeding, hospital stay and in-hospital mortality] between trans-septal or superior (extended) trans-septal (STS) approaches in comparison with the conventional left atriotomy (LA) used in mitral valve surgery. Using the reported search strategy, 353 papers were found of which 11 represented the best evidence to answer the clinical question. The authors, journal, year and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Two papers compared all 3 atrial incisions with neither showing a difference in PPM implantation rate, whereas 2 papers compared just the trans-septal with the LA approach, again both finding no significant difference in PPM implantation. Seven studies compared the STS approach with the LA approach with regard to PPM implantation; 1 study showed that the STS approach was an independent risk factor for PPM implantation, PPM insertion was not necessary in 2 studies and there was no difference in PPM insertion in 4 studies. Postoperative junctional rhythm was studied in 5 papers that compared the STS approach with the LA approach; junctional rhythm was more prevalent in the STS approach in 2 studies, albeit transient, whereas 3 papers did not show a significant difference. Mortality, hospital stay and re-exploration for bleeding did not differ among the 3 groups.
Background and aim of the study
To determine whether the type of atrial access to the mitral valve (left atriotomy, superior trans‐septal, or limited trans‐septal) influenced postoperative permanent pacemaker implantation and to investigate the effect of the sinoatrial (SA) node artery origin (right coronary or circumflex arteries) on the rate of pacemaker insertion.
Methods
We retrospectively reviewed consecutive cases of patients who had mitral valve surgery at the Trent Cardiac Centre (2008‐2016). The primary outcome was the incidence of permanent pacemaker insertion. The data were analyzed using univariate then binary multivariate regression analysis.
Result
Four hundred sixty nine patients had mitral valve surgery. The mean age was 66.5 ± 12.3 years and 47.5% were female. One hundred fifty patients (32%) had mitral valve surgery via the standard left atriotomy approach, while 226 (48.2%) and 93 (19.8%) cases were performed using the limited trans‐septal and superior trans‐septal approaches, respectively. Concomitant tricuspid valve surgery was carried out in 33 cases (7%). The overall rate of pacemaker implantation was 5.3%. On univariate analysis, only age (≥70 years old) and concomitant tricuspid valve surgery were significant predictors of postoperative pacemaker insertion, while on multivariate analysis only age (≥70 years old) remained as a predictor. The type of atrial incision and the origin of the SA node artery did not affect the rate of pacemaker implantation.
Conclusion
The type of atrial approach to the mitral valve and the origin of the SA node artery did not influence the incidence of postoperative permanent pacemaker insertion.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which originated in China, is the cause of the global pandemic Coronavirus Disease 19 (Covid-19). To date, there is no widely available vaccine or treatment, hence containment strategies are currently centred around measures ameliorating human transmission via social distancing and quarantine. Due to the magnitude of the pandemic, elective operative work had ceased within cardiac surgery at our institution and strategies adapted
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which originated in China, is the cause of the global pandemic Coronavirus Disease 19 . To date, there is no widely available vaccine or treatment, hence containment strategies are currently centred around measures ameliorating human transmission via social distancing and quarantine. Due to the magnitude of the pandemic, elective operative work had been halted within cardiac surgery at our institution and protocols adapted to facilitate safe operating and discharge of surgical patients. With rapidly emerging data on the characteristics of SARS-CoV-2, we present 2 in-patient cases at our institution with prolonged viral shedding detected on real-time polymerase chain reaction (RT-PCR) oropharyngeal swabs; one asymptomatic, and another pauci-symptomatic. These cases highlight the need for further research into the duration of viral shedding and the viability of SARS-CoV-2, especially with respect to viral transmission, over a drawn-out period.
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