Over the last 4 months, the novel coronavirus, SARS‐CoV‐2, has caused a significant economic, political, and public health impact on a global scale. The natural history of the disease and surge in the need for invasive ventilation has required the provision of intensive care beds in London to be reallocated. NHS England have proposed the formation of a Pan‐London Emergency Cardiac surgery (PLECS) service to provide urgent and emergency cardiac surgery for the whole of London. In this initial report, we outline our experience of setting up and delivering a pan‐regional service for the delivery of urgent and emergency cardiac surgery with a focus on maintaining a COVID‐free in‐hospital environment. In doing so, we hope that other regions can use this as a starting point in developing their own region‐specific pathways if the spread of coronavirus necessitates similar measures be put in place across the United Kingdom.
Atrial fibrillation is a significant worldwide contributor to cardiovascular morbidity and mortality. Few studies have investigated the differences in gene expression between the left and right atrial appendages, leaving their characterization largely unexplored. In this study, differential gene expression was investigated in atrial fibrillation and sinus rhythm using left and right atrial appendages from the same patients. RNA sequencing was performed on the left and right atrial appendages from five sinus rhythm (SR) control patients and five permanent AF case patients. Differential gene expression in both the left and right atrial appendages was analyzed using the Bioconductor package edgeR. A selection of differentially expressed genes, with relevance to atrial fibrillation, were further validated using quantitative RT-PCR. The distribution of the samples assessed through principal component analysis showed distinct grouping between left and right atrial appendages and between SR controls and AF cases. Overall 157 differentially expressed genes were identified to be downregulated and 90 genes upregulated in AF. Pathway enrichment analysis indicated a greater involvement of left atrial genes in the Wnt signaling pathway whereas right atrial genes were involved in clathrin-coated vesicle and collagen formation. The differing expression of genes in both left and right atrial appendages indicate that there are different mechanisms for development, support and remodeling of AF within the left and right atria.
Background: Epicardial adipose tissue (EAT) directly overlies the myocardium with changes in its morphology and volume associated with myriad cardiovascular and metabolic diseases. However, EAT's immune structure and cellular characterization remain incompletely described. This study aimed to define the immune phenotype of EAT in humans, and compare such profiles across lean, obese and diabetic patients. Methods: A total of 152 adult patients undergoing open chest coronary artery bypass grafting (CABG), valve repair/replacement (VR) surgery or combined CABG/valve surgery were recruited to the study. Patients' clinical and biochemical data alongside epicardial adipose tissue (EAT), subcutaneous adipose tissue (SAT) and pre-operative 3 blood samples were collected. Immune cell profiling was evaluated by flow cytometry and complemented by gene expression studies of immune mediators. Bulk RNA-seq was performed in EAT across different metabolic profiles to assess whole transcriptome changes observed in these groups.Results: Flow cytometry analysis demonstrated that EAT is highly enriched in adaptive immune (T and B) cells. Whilst overweight/obese and diabetic patients had similar EAT cellular profiles to lean control patients, the EAT exhibited significantly (P≤.01) raised expression of immune mediators including: interleukin1 (IL1), IL6, tumour necrosis factorα (TNFα) and interferonγ (IFNγ). These changes were not observed in either SAT or blood. Neither underlying coronary artery disease nor the presence of hypertension significantly altered the immune profiles observed. Bulk RNA-seq demonstrated significant alterations in metabolic and inflammatory pathways in the EAT of overweight/obese patients compared with lean controls.Conclusions: Adaptive immune cells are the predominant immune cell constituent in human EAT and SAT. The presence of underlying cardiometabolic conditions, specifically obesity and diabetes, rather than cardiac disease phenotype appears to alter the inflammatory profile of EAT. Obese states markedly alter EAT metabolic and inflammatory signalling genes, underlining the impact of obesity on the EAT transcriptome profile.
Introduction: Cor-Knot automated fastener has been used as an adjunct in heart valve surgery to eliminate the need for manual tying during valve implantation. Although reduced operative time and facilitation for minimally invasive surgery are clear benefits, whether their use translates to improved patient outcome remains debatable. This study aims to review the safety and efficacy of automated fasteners in heart valve surgeries. Method: Specific searches were conducted via online medical databases (Pubmed, Embase, Ovid) between 1950 and June 2019. Longitudinal studies were included that provided operative parameters. Results: The initial literature search identified 3773 articles, but only eight met the inclusion criteria and were used for analysis: four studies related to aortic valve replacement (AVR), four related to mitral valve (MV) intervention (total n = 810). The meta-analysis revealed the significantly shorter aortic cross-clamp time in the Cor-knot group compared to manual tying, both in AVR and MV surgeries (P < .05). Cardiopulmonary bypass time was significantly shorter in the Cor-knot group when analyzing studies in MV surgery (weighted mean difference [WMD]: 110.0; 95% confidence interval: 12.3-207.7; P = .027) The use of Cor-Knot did not increase the risk of permanent pacemaker implantation, paravalvular leak, and 30-day mortality. The majority of studies reported no change in the length of intensive unit care and total hospital stay. Conclusion:We confirmed that the majority of existing literatures indicated the safety and intraoperative efficacy with automated fastener application. Nevertheless, there is currently no evidence to support automated fastened sutures can translate its intraoperative advantages to improved patient outcome. K E Y W O R D S aortic, automated fastener, clinical review, cor-knot, heart valves, mitral 1 | BACKGROUND Surgery for valvular heart disease is well-established and remains a superior treatment option for many valvular pathologies in many patient groups. Both replacement (with prosthetic valves) and repair Abbreviations: AS, aortic stenosis; AVR, aortic valve replacement; AXT, aortic cross-clamp time; CPB, cardiopulmonary bypass time; ICU, intensive care unit; LV, left ventricular; Mini-AVR, minimally invasive aortic valve replacement; Mini-MV repair, minimally invasive mitral valve repair; MR, mitral regurgitation; MV, mitral valve; PPI, permanent pacemaker implantation; PVL, paravalvular leak; TAVR, transcatheter aortic valve replacement. Lueh Chien and M. Yousuf Salmasi are Joint first authors.
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