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John Dunning

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I am a cardiothoracic surgeon who has worked in the area of heart and lung failure for the last 30 years. I am currently the Director of Heart and Lung Transplantation, and Mechanical Circulatory Support at Harefield Hospital, UK.

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Gilbert Shardey

Oswaldo Valencia

King's College London

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Papers by John Dunning

Effect of surgical training on outcome and hospital costs in coronary surgery

Heart, 2001

Background-There is a perceived conflict between the need for service provision and surgical trai... more Background-There is a perceived conflict between the need for service provision and surgical training within the National Health Service (NHS). Trainee surgeons tend to be slower (thereby reducing theatre throughput), and may have more complications (increasing hospital stay and costs). Objective-To quantify the eVect of training on outcome and costs. Design-Data on 2740 consecutive isolated coronary artery bypass (CABG) operations were analysed retrospectively. Redo and emergency procedures were excluded. The seniority of the operating surgeon was related to operating times, risk stratified outcome, and overall hospital costs. Setting-Regional cardiothoracic surgery unit. Main outcome measures-Postoperative mortality; hospital costs. Results-Consultants, senior trainees, intermediate trainees, and junior trainees performed 1524, 759, 434, and 23 procedures, respectively. Trainees at the three diVerent levels were directly supervised by a consultant in 55%, 95%, and 100% of cases. The unadjusted mortalities were 3.2%, 2.0%, 2.3%, and 4.3%, respectively (NS). There were no significant diVerences between the groups with respect to time in the intensive care unit and length of hospital stay. The mean cost per patient was £6619, £6572, £6494, and £6404 (NS). Conclusions-Trainees performed 44.4% of all CABG operations. There was no detrimental eVect on patient outcome, length of hospital stay, or overall hospital costs. There need be little conflict between service and training needs, even in hospitals with extensive training programmes.

Aspergillus endocarditis of the mitral valve in a lung-transplant patient

Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital, 2007

A 57-year-old man underwent bilateral lung transplantation at our hospital. On histopathology, as... more A 57-year-old man underwent bilateral lung transplantation at our hospital. On histopathology, aspergillomas were identified in the upper lobes of the explanted lungs. After being treated and discharged from the hospital, he returned 4 months later with ischemic chest pain, which was due to a myocardial infarction complicated by cardiogenic shock. He also had a large vegetation on the anterior mitral leaflet. Herein, we describe the patient's symptoms, complications, treatment, and recovery. To the best of our knowledge, ours is only the 2nd report of a patient who developed Aspergillus endocarditis after lung transplantation and the 1st such patient to have undergone successful mitral valve replacement.

Cardiopulmonary exercise testing suggests a beneficial response to pulmonary endarterectomy in a patient with chronic thromboembolic obstruction and normal preoperative pulmonary hemodynamics

Pulmonary circulation, 2014

Pulmonary endarterectomy offers a symptomatic and survival benefit in patients with chronic throm... more Pulmonary endarterectomy offers a symptomatic and survival benefit in patients with chronic thromboembolic pulmonary hypertension through sustained improvement in right ventricular function. However, its role in patients with symptom limitation, chronic thrombotic obstruction, and a normal pulmonary hemodynamic profile is less clear. Cardiopulmonary exercise testing (CPET) stresses the cardiopulmonary system and has a characteristic response in pulmonary hypertension. CPET may therefore reveal abnormalities in patients with chronic thrombotic obstruction where hemodynamic investigations conducted at rest are reassuring. Using incremental CPET, we demonstrated improvements in right ventricular performance and ventilatory efficiency following pulmonary endarterecomy in a patient with preoperative exercise limitation and normal pulmonary hemodynamics. Careful evaluation of exercise responses may extend the potential benefit offered by pulmonary endarterectomy in patients with chronic t...

Medium Term Longitudinal Follow Up of All Patients Referred to a Transcatheter Aortic Valve Multi-Disciplinary Team

Journal of the American College of Cardiology, 2010

Background: Transcatheter Aortic Valve Implantation (TAVI) has revolutionized the treatment of ao... more Background: Transcatheter Aortic Valve Implantation (TAVI) has revolutionized the treatment of aortic valve stenosis of high surgical risk. Research has focussed on those undergoing TAVI. We have comprehensively studied all TAVI candidates, their pathway and the decision process. Methods: All patients (n = 109) referred to the Papworth multidisciplinary team (MDT) for a TAVI were prospectively enrolled. Baseline demographics and outcomes were recorded. Results: Patients (n=26) awaiting treatment / final MDT decision were excluded. 17 patients were treated by TAVI (7 transfemoral, 10 transapical), 27 by conventional surgical AVR (csAVR), 9 with balloon valvuloplasty (BAV) and 30 medically. There were no differences in baseline characteristics (but for an excess of prior CABG in the TAVI group vs. csAVR (13/17 vs. 3/27; p <0.001)) nor in logistic EuroSCORE (ES):

Are non–brain stem-dead cardiac donors acceptable donors?

The Journal of Heart and Lung Transplantation, 2004

Background: The deleterious effects of brainstem death (BSD) on donor cardiac function and endoth... more Background: The deleterious effects of brainstem death (BSD) on donor cardiac function and endothelial integrity have been documented previously. Domino cardiac donation (heart of a heart-lung recipient transplanted into another recipient) is a way to avoid the effects of brainstem death and may confer both short-and long-term benefits to allograft recipients. Methods: This study evaluates short-and long-term outcome in heart recipients of BSD donors (cadaveric) as compared with domino hearts explanted from patients who underwent heart-lung transplantation. Results: Patients having undergone cardiac transplantation between April 1989 and August 2001 at Papworth Hospital were included (n ϭ 571). Domino donor hearts were used in 81 (14%) of these cases. The pre-operative transpulmonary gradient was not significantly different between the two groups (p ϭ 0.7). There was no significant difference in 30-day mortality (4.9% for domino vs 8.6% for BSD, p ϭ 0.38) or in actuarial survival (p ϭ 0.72). Ischemic time was significantly longer in the BSD group (p Ͻ 0.001). Acute rejection and infection episodes were not significantly different (p ϭ 0.24 vs: 0.08). Relative to the BSD group, the risk (95% confidence interval) of acute rejection in the domino group was 0.89 (0.73 to 1.08). Similarly, the relative risk of infection was 0.78 (0.59 to 1.03). The 5-year actuarial survival rates (95% confidence interval) were 78% (69% to 87%) and 69% (65% to 73%) in the domino and BSD groups respectively. Angiography data at 2 years were available in 50 (62%) and 254 (52%) patients in the domino and BSD groups, respectively. The rates for 2-year freedom from cardiac allograft vasculopathy (CAV) were 96% (91% to 100%) and 93% (90% to 96%), respectively. Conclusion: Despite the lack of endothelial cell activation after brainste, death and a shorter ischemic time, the performance of domino donor hearts was similar to that of BSD donor hearts. This may indicate a similar pathology (i.e., endothelial cell activation) in the domino donors.

Apparent obstruction of the superior vena cava and a continuous murmur: signs of a fistula between a vein graft aneurysm and the right atrium

Heart, 1992

A previously undescribed complication of a saphenous vein aortocoronary bypass graft, namely form... more A previously undescribed complication of a saphenous vein aortocoronary bypass graft, namely formation of a fistula between a vein graft aneurysm and the right atrium is reported. A patient presented with a continuous murmur and a combination of signs suggesting superior vena cava obstruction. This pathology was shown by both echocardiography and angiography. Surgical treatment was attempted.

Safety and Efficacy of Aprotinin and Tranexamic Acid in Pulmonary Endarterectomy Surgery With Hypothermia: Review of 200 Patients

The Annals of Thoracic Surgery, 2010

Background. The effectiveness and safety of aprotinin in cardiac surgery has been questioned. The... more Background. The effectiveness and safety of aprotinin in cardiac surgery has been questioned. The study aim was to compare both the blood-sparing effect and side effects of aprotinin and tranexamic acid in patients undergoing pulmonary endarterectomy. Methods. Data were analyzed retrospectively for 200 consecutive patients who underwent pulmonary endarterectomy between October 2006 and September 2009. Pulmonary endarterectomy was performed with deep hypothermia (20°C) in all patients. Antifibrinolytic therapy changed from aprotinin to tranexamic acid in June 2008 after the withdrawal of aprotinin in the United Kingdom. Results. Mean age was 55.9 years, and 58% of subjects were male. One hundred patients were studied in each group. Postoperatively, a higher incidence of seizures in the first 48 hours was seen with tranexamic acid compared with aprotinin (11% versus 4%, p ‫؍‬ 0.06). This difference became statistically significant when excluding patients with structural brain lesions from both groups (7 versus 0, p ‫؍‬ 0.02). Tranexamic acid patients had significantly higher median blood loss (700 mL versus 525 mL, p ‫؍‬ 0.01). There was no significant difference between the groups in reexploration for bleeding, renal failure requiring hemofiltration, intensive care unit stay, median total stay in hospital, or in-hospital mortality. Conclusions. In our experience of patients undergoing pulmonary endarterectomy, the tranexamic acid group had a higher median blood loss and more seizures. The trend to increased seizure frequency in the tranexamic acid group may be a direct consequence of this treatment, consistent with other recently published reports.

Surgical Management of Extensive Pulmonary Artery Sarcoma

The Annals of Thoracic Surgery, 2009

tumors are most often spherical or ovoid, firm or rubbery. Our patient presented with dyspnea cau... more tumors are most often spherical or ovoid, firm or rubbery. Our patient presented with dyspnea caused by the compression of the lung with mediastinal shifting. Like our patient, most tumors are well circumscribed or encapsulated, and an associated nerve has been identified for 17% to 43% of the cases [3, 4]. Microscopically, cellular schwannomas differ from the classic schwannoma by virtue of a cellular Antoni A component and absence of Verocay bodies [2, 3]. Some amounts of Antoni B may also be present, usually not exceeding 10% of the lesion, but this was not seen in our patient. Some nuclear palisading may be present, and necrosis is generally absent. Mitotic activity may be observed but is usually low, up to 4 of 10 high-power fields. Support of a microscopic diagnosis of cellular schwannoma can be obtained by immunostains. Like classic schwannomas, cellular schwannomas are usually diffusely and strongly reactive to S-100 protein. Cellular schwannoma must be distinguished mainly from well-differentiated malignant peripheral nerve sheath tumor, leiomyosarcoma, fibrosarcoma, melanotic schwannoma, and solitary fibrous tumor. Errors in diagnosis are reported in 21% to 28% of patients [3-5]. Local recurrences have been reported, but no metastasis or tumor-related deaths [3, 4]. So, it is important to recognized cellular schwannoma as a benign tumor to avoid overtreatment. Cellular schwannomas commonly have hemorrhage but seldom display cystic degeneration [2]. Partly cystic change has been grossly evident in 3 (5%) patients reported by White and colleagues [3] and in 4 patients (6%) of Casadei and colleagues [4]. To the best of our knowledge, only one cystic pelvic cellular schwannoma has been reported, measuring 15.5 cm at its greatest dimension [3]. As with our patient, much tan-brown fluid and muddy content drained from the cystic interior on sectioning. No relationship between larger tumors and cyst formation has been noted in the literature. Nevertheless, the 2 cystic tumors were large and occupied cavities such as the pelvis and thorax. In summary, the patient reported here had a rare, huge, cystic, thin-wall cellular schwannoma occupying the thoracic cavity that underwent successful surgical treatment.

Surgical treatment of pulmonary artery sarcoma

The Journal of Thoracic and Cardiovascular Surgery, 2001

Pulmonary artery sarcomas are rare and usually fatal tumors. The diagnosis is difficult and delay... more Pulmonary artery sarcomas are rare and usually fatal tumors. The diagnosis is difficult and delayed in most cases. Newer imaging techniques could allow early diagnosis in patients with symptoms of pulmonary vascular obstruction. Surgical resection improves clinical symptoms and offers the only chance of cure. We report the case histories of 7 patients with primary pulmonary artery sarcomas treated by surgical resection with or without adjuvant therapy. Methods: Seven patients (3 women and 4 men; mean age, 52.3 years; preoperative New York Heart Association functional class III/IV, n = 5/2) underwent operations. Malignancy was preoperatively suspected in 5 patients, and 2 patients had a presumptive diagnosis of chronic pulmonary embolism. Tumor resection with partial or total prosthetic replacement (n = 2), reconstruction (n = 5), or both, of central parts of the pulmonary arteries was performed in 6 patients. Thromboendarterectomy was necessary in 4 patients, and pneumonectomy was necessary in 2 patients. Six patients received adjuvant therapy. Results: There was no perioperative mortality. All patients had a substantial improvement in exercise tolerance and hemodynamics 3 months after their operations. Four patients died 7, 9, 18, and 19 months after their operations because of recurrent tumor or pulmonary metastases. Two patients are alive 21 and 35 months after primary surgical repair, with pulmonary metastases detected by computed tomographic scans. One patient is alive 62 months after resection without clinical or radiologic signs of tumor recurrence or metastasis. Conclusions: Early diagnosis of primary pulmonary artery sarcomas can be improved by computed tomography and magnetic resonance scanning. Radical surgical resection probably presents the only chance for cure. The role of neoadjuvant or adjuvant treatment modalities has to be defined. Pulmonary artery sarcoma need not necessarily be a fatal diagnosis.

Characterization of cell proliferation in idiopathic pulmonary fibrosis

Journal of Allergy and Clinical Immunology, 2019

RATIONALE: Dysregulated cell proliferation in the lung is one of the key hallmarks in idiopathic ... more RATIONALE: Dysregulated cell proliferation in the lung is one of the key hallmarks in idiopathic pulmonary fibrosis (IPF). Proliferation of type II alveolar epithelial cells (AECs) and fibroblasts is a particularly important event in IPF development. However, it is not understood how such proliferation leads to an advanced stage of fibrosis. Therefore, it is very important to characterize the proliferation of type II AECs in IPF lungs with different histological appearances. METHODS: Lung samples were removed from the whole lung explants of patients with IPF and patients with pulmonary arterial hypertension (PAH, control subjects) undergoing lung transplantation at Tampa General Hospital (IRB protocol Pro00032158). Paraffin-embedded lung sections were immunohistochemically labeled for Ki67 (proliferation marker) and pro-SPC (a lineage marker for type II AEC). RESULTS: In normal looking alveoli of PAH and IPF lungs, Ki67 signals were sparsely colocalized with pro-SPC. In mildly affected alveoli with thickened interstitium in IPF lungs, Ki67 signals are noted with higher density than normal alveoli of PAH and IPF. Intriguingly, most of them are either weakly positive or negative for pro-SPC. In severely fibrotic regions in IPF lungs, most of the Ki67 positive cells are negative for pro-SPC. CONCLUSIONS: The results indicate that type II AEC proliferation is a key event in IPF. The results also suggest that type II AEC proliferation gradually shifts to proliferation of different cell types as the lung becomes more fibrotic. These cells are presumably dedifferentiated type II AECs that have lost pro-SPC expression or other progenitor cell types.

Improvement in the pulmonary circulation following pulmonary thromboendarterectomy

Heart, 2001

Reverse saphenous interposition vein graft repair of a giant atherosclerotic aneurysm of the left anterior descending coronary artery

The Journal of Thoracic and Cardiovascular Surgery, 2002

T he incidence of coronary artery aneurysm is reported to be around 5%. 1 The involvement of the ... more T he incidence of coronary artery aneurysm is reported to be around 5%. 1 The involvement of the left anterior descending coronary artery (LAD) varies from 32% 2 to 52%. 3 Several repair techniques have been described and include proximal or distal ligation of the aneurysm, 4 aneurysmal thrombectomy, 5 aneurysmorrhectomy, 6 aneurysmal resection with direct end-to-end anastomosis, 7 intraluminal stenting, 8 coil embolization, 9 and reverse saphenous interposition grafting. 10 We describe our experience in dealing with a giant (Ͼ5 cm in diameter) atherosclerotic coronary aneurysm of the LAD using the latter technique.

Extrusion of TeflonS aortic pledgets from a sternal wound six years after cardiac surgery

European Journal of Cardio-Thoracic Surgery, 1997

We present a case of a cardiac surgery patient with a persistent low-grade discharge from his ste... more We present a case of a cardiac surgery patient with a persistent low-grade discharge from his sternal wound for over six years. It finally healed when some suture material and Teflon@ felt pledgets were extruded. These had been used intraoperatively to close the aortic cannulation site. The extrusion of prosthetic material from this site after this length of time has never been described.

Pulmonary Thromboendarterectomy for Chronic Thromboembolic Pulmonary Hypertension

Anesthesiology, 2014

Pulmonary thromboendarterectomy is the most effective therapy for chronic thromboembolic pulmonar... more Pulmonary thromboendarterectomy is the most effective therapy for chronic thromboembolic pulmonary hypertension. The pathophysiology, anesthetic management, and perioperative outcomes of patients with chronic thromboembolic pulmonary hypertension undergoing pulmonary thromboendarterectomy are reviewed.

Right Ventricular Reverse Remodeling after Pulmonary Endarterectomy: Magnetic Resonance Imaging and Clinical and Right Heart Catheterization Assessment

Pulmonary Circulation, 2014

The objective of this study was to assess the effect of pulmonary endarterectomy (PEA) on right v... more The objective of this study was to assess the effect of pulmonary endarterectomy (PEA) on right ventricular (RV) reverse remodeling using magnetic resonance imaging (MRI) and to correlate MRI findings with clinical and hemodynamic outcomes postsurgery. We performed a retrospective analysis in 72 patients undergoing PEA surgery in whom MRI and right heart catheterization (RHC) were performed preoperation and 3 months postoperation. RV volumes and mass were assessed by MRI. Continuous variables were expressed as means, changes were compared with a paired t test, and associations between the variables were explored using Pearson correlation coefficients. The mean age was 57 years, and 51% were male. Both RV end-diastolic volume (EDV; 176-117 mL; P < 0.001) and RV end-systolic volume (ESV; 129-64 mL; P < 0.001) reduced significantly following PEA. Preoperative pulmonary artery pressure (PAP) correlated moderately with ESV (r ¼ 0.46, P < 0.001). Postoperatively, PAP correlated with EDV (r ¼ 0.45, P < 0.001) and ESV (r ¼ 0.44, P < 0.001). Moderate correlation was present between hemodynamic parameters: PAP, pulmonary vascular resistance, and right atrial pressure with pre-and postoperation endsystolic and end-diastolic RV mass (P < 0.001). RHC and MRI measurements of cardiac output and RV volumes were significantly different (P < 0.001). In conclusion, RV reverse remodeling, as measured by improvement in RV volumes and mass by MRI, was observed for 3 months in patients who underwent PEA surgery. This is the largest series of patients with pre-and post-PEA MRI assessment so far reported. MRI detects changes in parameters reflecting cardiac remodeling and pulmonary clearance, but measurements are significantly different from those of RHC.

The Use of Biophysical Flow Models in the Surgical Management of Patients Affected by Chronic Thromboembolic Pulmonary Hypertension

Frontiers in Physiology, 2018

Conclusion: This study provides a proof of concept that patient-specific computational modeling c... more Conclusion: This study provides a proof of concept that patient-specific computational modeling can be used as a noninvasive tool for assisting surgical decisions in CTEPH based on hemodynamics metrics. Our technique enables determination of the proximal relative pressure, which could subsequently be compared to the total pressure drop to determine the degree of distal and proximal vascular resistance. In the longer term this approach has the potential to form the basis for a more quantitative classification system of CTEPH types.

Mini-Stern Trial: A randomized trial comparing mini-sternotomy to full median sternotomy for aortic valve replacement

The Journal of thoracic and cardiovascular surgery, Jan 4, 2018

Aortic valve replacement (AVR) can be performed either through full median sternotomy (FS) or upp... more Aortic valve replacement (AVR) can be performed either through full median sternotomy (FS) or upper mini-sternotomy (MS). The Mini-Stern trial aimed to establish whether MS leads to quicker postoperative recovery and shorter hospital stay after first-time isolated AVR. This pragmatic, open-label, parallel randomized controlled trial (RCT) compared MS with FS for first-time isolated AVR in 2 United Kingdom National Health Service hospitals. Primary endpoints were duration of postoperative hospital stay and the time to fitness for discharge from hospital after AVR, analyzed in the intent-to-treat population. In this RCT, 222 patients were recruited and randomized (n = 118 in the MS group; n = 104 in the FS group). Compared with the FS group, the MS group had a longer hospital length of stay (mean, 9.5 days vs 8.6 days) and took longer to achieve fitness for discharge home (mean, 8.5 days vs 7.5 days). Adjusting for valve type, sex, and surgeon, hazard ratios (HRs) from Cox models did ...

The outcome of reoperative pulmonary endarterectomy surgery

Interactive cardiovascular and thoracic surgery, Jan 23, 2018

Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboemboli... more Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (PH). Despite excellent outcomes following PEA, a small proportion of patients have residual proximal disease or present with recurrent chronic thromboembolic PH and may benefit from further surgery. The aim of this study was to analyse outcomes following reoperative PEA at a high-volume national tertiary referral centre for the management of chronic thromboembolic PH. This retrospective analysis was performed using our prospectively maintained PH database to identify all patients who underwent reoperative PEA surgery between the commencement of the programme in 1997 and January 2017, and the patients' data were collected for analysis. Twelve patients underwent reoperative PEA during the period of study. The mean interval between primary procedure and reoperative procedure was 6.3 years. Significant improvements were observed in pulmonary haemodynamics follow...

Age should not be a barrier for pulmonary endarterectomy in carefully selected patients

The European respiratory journal, Dec 1, 2017

CTEPH patients over 80 years old undergoing pulmonary endarterectomy have similar outcomes to tho... more

Dynamic Risk Stratification of Patient Long-Term Outcome After Pulmonary Endarterectomy: Results From the UK National Cohort

Circulation, Jan 6, 2016

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) results from incomplete resolut... more Background: Chronic thromboembolic pulmonary hypertension (CTEPH) results from incomplete resolution of pulmonary emboli. Pulmonary endarterectomy (PEA) is potentially curative, but residual PH following surgery is common and its impact on long-term outcome is poorly understood. We wanted to identify factors correlated with poor long-term outcome after surgery and specifically define clinically relevant residual PH post-PEA. Methods and Results: 880 consecutive patients (mean age 57 years) underwent PEA for CTEPH. Patients routinely underwent detailed reassessment with right heart catheterisation and non-invasive testing at 3-6 months and annually thereafter with discharge if clinically stable at 3-5 years and not requiring pulmonary vasodilator therapy. Cox regressions were used for survival (time-to-event) analyses. Overall survival was 86%, 84%, 79% and 72% at 1, 3, 5 and 10 years for the whole cohort and 91% and 90% at 1 and 3 years for the recent half of the cohort. The majority of patient deaths after the peri-operative period were not due to right ventricular failure (CTEPH). At reassessment a mean pulmonary artery pressure (mPAP)  30 mmHg correlated with pulmonary vasodilator therapy initiation post-PEA. An mPAP  38 mmHg and pulmonary vascular resistance  425 dyne/sec/cm-5 at reassessment correlated with worse long-term survival. Conclusions: Our data confirm excellent long-term survival and maintenance of good functional status post-PEA. Haemodynamic assessment 3-6 and/or 12 months post-PEA allows stratification of patients at higher risk of dying 4 from CTEPH and identifies a level of residual pulmonary hypertension which may guide the long-term management of patients post-surgery.

Effect of surgical training on outcome and hospital costs in coronary surgery

Heart, 2001

Background-There is a perceived conflict between the need for service provision and surgical trai... more Background-There is a perceived conflict between the need for service provision and surgical training within the National Health Service (NHS). Trainee surgeons tend to be slower (thereby reducing theatre throughput), and may have more complications (increasing hospital stay and costs). Objective-To quantify the eVect of training on outcome and costs. Design-Data on 2740 consecutive isolated coronary artery bypass (CABG) operations were analysed retrospectively. Redo and emergency procedures were excluded. The seniority of the operating surgeon was related to operating times, risk stratified outcome, and overall hospital costs. Setting-Regional cardiothoracic surgery unit. Main outcome measures-Postoperative mortality; hospital costs. Results-Consultants, senior trainees, intermediate trainees, and junior trainees performed 1524, 759, 434, and 23 procedures, respectively. Trainees at the three diVerent levels were directly supervised by a consultant in 55%, 95%, and 100% of cases. The unadjusted mortalities were 3.2%, 2.0%, 2.3%, and 4.3%, respectively (NS). There were no significant diVerences between the groups with respect to time in the intensive care unit and length of hospital stay. The mean cost per patient was £6619, £6572, £6494, and £6404 (NS). Conclusions-Trainees performed 44.4% of all CABG operations. There was no detrimental eVect on patient outcome, length of hospital stay, or overall hospital costs. There need be little conflict between service and training needs, even in hospitals with extensive training programmes.

Aspergillus endocarditis of the mitral valve in a lung-transplant patient

Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital, 2007

A 57-year-old man underwent bilateral lung transplantation at our hospital. On histopathology, as... more A 57-year-old man underwent bilateral lung transplantation at our hospital. On histopathology, aspergillomas were identified in the upper lobes of the explanted lungs. After being treated and discharged from the hospital, he returned 4 months later with ischemic chest pain, which was due to a myocardial infarction complicated by cardiogenic shock. He also had a large vegetation on the anterior mitral leaflet. Herein, we describe the patient's symptoms, complications, treatment, and recovery. To the best of our knowledge, ours is only the 2nd report of a patient who developed Aspergillus endocarditis after lung transplantation and the 1st such patient to have undergone successful mitral valve replacement.

Cardiopulmonary exercise testing suggests a beneficial response to pulmonary endarterectomy in a patient with chronic thromboembolic obstruction and normal preoperative pulmonary hemodynamics

Pulmonary circulation, 2014

Pulmonary endarterectomy offers a symptomatic and survival benefit in patients with chronic throm... more Pulmonary endarterectomy offers a symptomatic and survival benefit in patients with chronic thromboembolic pulmonary hypertension through sustained improvement in right ventricular function. However, its role in patients with symptom limitation, chronic thrombotic obstruction, and a normal pulmonary hemodynamic profile is less clear. Cardiopulmonary exercise testing (CPET) stresses the cardiopulmonary system and has a characteristic response in pulmonary hypertension. CPET may therefore reveal abnormalities in patients with chronic thrombotic obstruction where hemodynamic investigations conducted at rest are reassuring. Using incremental CPET, we demonstrated improvements in right ventricular performance and ventilatory efficiency following pulmonary endarterecomy in a patient with preoperative exercise limitation and normal pulmonary hemodynamics. Careful evaluation of exercise responses may extend the potential benefit offered by pulmonary endarterectomy in patients with chronic t...

Medium Term Longitudinal Follow Up of All Patients Referred to a Transcatheter Aortic Valve Multi-Disciplinary Team

Journal of the American College of Cardiology, 2010

Background: Transcatheter Aortic Valve Implantation (TAVI) has revolutionized the treatment of ao... more Background: Transcatheter Aortic Valve Implantation (TAVI) has revolutionized the treatment of aortic valve stenosis of high surgical risk. Research has focussed on those undergoing TAVI. We have comprehensively studied all TAVI candidates, their pathway and the decision process. Methods: All patients (n = 109) referred to the Papworth multidisciplinary team (MDT) for a TAVI were prospectively enrolled. Baseline demographics and outcomes were recorded. Results: Patients (n=26) awaiting treatment / final MDT decision were excluded. 17 patients were treated by TAVI (7 transfemoral, 10 transapical), 27 by conventional surgical AVR (csAVR), 9 with balloon valvuloplasty (BAV) and 30 medically. There were no differences in baseline characteristics (but for an excess of prior CABG in the TAVI group vs. csAVR (13/17 vs. 3/27; p <0.001)) nor in logistic EuroSCORE (ES):

Are non–brain stem-dead cardiac donors acceptable donors?

The Journal of Heart and Lung Transplantation, 2004

Background: The deleterious effects of brainstem death (BSD) on donor cardiac function and endoth... more Background: The deleterious effects of brainstem death (BSD) on donor cardiac function and endothelial integrity have been documented previously. Domino cardiac donation (heart of a heart-lung recipient transplanted into another recipient) is a way to avoid the effects of brainstem death and may confer both short-and long-term benefits to allograft recipients. Methods: This study evaluates short-and long-term outcome in heart recipients of BSD donors (cadaveric) as compared with domino hearts explanted from patients who underwent heart-lung transplantation. Results: Patients having undergone cardiac transplantation between April 1989 and August 2001 at Papworth Hospital were included (n ϭ 571). Domino donor hearts were used in 81 (14%) of these cases. The pre-operative transpulmonary gradient was not significantly different between the two groups (p ϭ 0.7). There was no significant difference in 30-day mortality (4.9% for domino vs 8.6% for BSD, p ϭ 0.38) or in actuarial survival (p ϭ 0.72). Ischemic time was significantly longer in the BSD group (p Ͻ 0.001). Acute rejection and infection episodes were not significantly different (p ϭ 0.24 vs: 0.08). Relative to the BSD group, the risk (95% confidence interval) of acute rejection in the domino group was 0.89 (0.73 to 1.08). Similarly, the relative risk of infection was 0.78 (0.59 to 1.03). The 5-year actuarial survival rates (95% confidence interval) were 78% (69% to 87%) and 69% (65% to 73%) in the domino and BSD groups respectively. Angiography data at 2 years were available in 50 (62%) and 254 (52%) patients in the domino and BSD groups, respectively. The rates for 2-year freedom from cardiac allograft vasculopathy (CAV) were 96% (91% to 100%) and 93% (90% to 96%), respectively. Conclusion: Despite the lack of endothelial cell activation after brainste, death and a shorter ischemic time, the performance of domino donor hearts was similar to that of BSD donor hearts. This may indicate a similar pathology (i.e., endothelial cell activation) in the domino donors.

Apparent obstruction of the superior vena cava and a continuous murmur: signs of a fistula between a vein graft aneurysm and the right atrium

Heart, 1992

A previously undescribed complication of a saphenous vein aortocoronary bypass graft, namely form... more A previously undescribed complication of a saphenous vein aortocoronary bypass graft, namely formation of a fistula between a vein graft aneurysm and the right atrium is reported. A patient presented with a continuous murmur and a combination of signs suggesting superior vena cava obstruction. This pathology was shown by both echocardiography and angiography. Surgical treatment was attempted.

Safety and Efficacy of Aprotinin and Tranexamic Acid in Pulmonary Endarterectomy Surgery With Hypothermia: Review of 200 Patients

The Annals of Thoracic Surgery, 2010

Background. The effectiveness and safety of aprotinin in cardiac surgery has been questioned. The... more Background. The effectiveness and safety of aprotinin in cardiac surgery has been questioned. The study aim was to compare both the blood-sparing effect and side effects of aprotinin and tranexamic acid in patients undergoing pulmonary endarterectomy. Methods. Data were analyzed retrospectively for 200 consecutive patients who underwent pulmonary endarterectomy between October 2006 and September 2009. Pulmonary endarterectomy was performed with deep hypothermia (20°C) in all patients. Antifibrinolytic therapy changed from aprotinin to tranexamic acid in June 2008 after the withdrawal of aprotinin in the United Kingdom. Results. Mean age was 55.9 years, and 58% of subjects were male. One hundred patients were studied in each group. Postoperatively, a higher incidence of seizures in the first 48 hours was seen with tranexamic acid compared with aprotinin (11% versus 4%, p ‫؍‬ 0.06). This difference became statistically significant when excluding patients with structural brain lesions from both groups (7 versus 0, p ‫؍‬ 0.02). Tranexamic acid patients had significantly higher median blood loss (700 mL versus 525 mL, p ‫؍‬ 0.01). There was no significant difference between the groups in reexploration for bleeding, renal failure requiring hemofiltration, intensive care unit stay, median total stay in hospital, or in-hospital mortality. Conclusions. In our experience of patients undergoing pulmonary endarterectomy, the tranexamic acid group had a higher median blood loss and more seizures. The trend to increased seizure frequency in the tranexamic acid group may be a direct consequence of this treatment, consistent with other recently published reports.

Surgical Management of Extensive Pulmonary Artery Sarcoma

The Annals of Thoracic Surgery, 2009

tumors are most often spherical or ovoid, firm or rubbery. Our patient presented with dyspnea cau... more tumors are most often spherical or ovoid, firm or rubbery. Our patient presented with dyspnea caused by the compression of the lung with mediastinal shifting. Like our patient, most tumors are well circumscribed or encapsulated, and an associated nerve has been identified for 17% to 43% of the cases [3, 4]. Microscopically, cellular schwannomas differ from the classic schwannoma by virtue of a cellular Antoni A component and absence of Verocay bodies [2, 3]. Some amounts of Antoni B may also be present, usually not exceeding 10% of the lesion, but this was not seen in our patient. Some nuclear palisading may be present, and necrosis is generally absent. Mitotic activity may be observed but is usually low, up to 4 of 10 high-power fields. Support of a microscopic diagnosis of cellular schwannoma can be obtained by immunostains. Like classic schwannomas, cellular schwannomas are usually diffusely and strongly reactive to S-100 protein. Cellular schwannoma must be distinguished mainly from well-differentiated malignant peripheral nerve sheath tumor, leiomyosarcoma, fibrosarcoma, melanotic schwannoma, and solitary fibrous tumor. Errors in diagnosis are reported in 21% to 28% of patients [3-5]. Local recurrences have been reported, but no metastasis or tumor-related deaths [3, 4]. So, it is important to recognized cellular schwannoma as a benign tumor to avoid overtreatment. Cellular schwannomas commonly have hemorrhage but seldom display cystic degeneration [2]. Partly cystic change has been grossly evident in 3 (5%) patients reported by White and colleagues [3] and in 4 patients (6%) of Casadei and colleagues [4]. To the best of our knowledge, only one cystic pelvic cellular schwannoma has been reported, measuring 15.5 cm at its greatest dimension [3]. As with our patient, much tan-brown fluid and muddy content drained from the cystic interior on sectioning. No relationship between larger tumors and cyst formation has been noted in the literature. Nevertheless, the 2 cystic tumors were large and occupied cavities such as the pelvis and thorax. In summary, the patient reported here had a rare, huge, cystic, thin-wall cellular schwannoma occupying the thoracic cavity that underwent successful surgical treatment.

Surgical treatment of pulmonary artery sarcoma

The Journal of Thoracic and Cardiovascular Surgery, 2001

Pulmonary artery sarcomas are rare and usually fatal tumors. The diagnosis is difficult and delay... more Pulmonary artery sarcomas are rare and usually fatal tumors. The diagnosis is difficult and delayed in most cases. Newer imaging techniques could allow early diagnosis in patients with symptoms of pulmonary vascular obstruction. Surgical resection improves clinical symptoms and offers the only chance of cure. We report the case histories of 7 patients with primary pulmonary artery sarcomas treated by surgical resection with or without adjuvant therapy. Methods: Seven patients (3 women and 4 men; mean age, 52.3 years; preoperative New York Heart Association functional class III/IV, n = 5/2) underwent operations. Malignancy was preoperatively suspected in 5 patients, and 2 patients had a presumptive diagnosis of chronic pulmonary embolism. Tumor resection with partial or total prosthetic replacement (n = 2), reconstruction (n = 5), or both, of central parts of the pulmonary arteries was performed in 6 patients. Thromboendarterectomy was necessary in 4 patients, and pneumonectomy was necessary in 2 patients. Six patients received adjuvant therapy. Results: There was no perioperative mortality. All patients had a substantial improvement in exercise tolerance and hemodynamics 3 months after their operations. Four patients died 7, 9, 18, and 19 months after their operations because of recurrent tumor or pulmonary metastases. Two patients are alive 21 and 35 months after primary surgical repair, with pulmonary metastases detected by computed tomographic scans. One patient is alive 62 months after resection without clinical or radiologic signs of tumor recurrence or metastasis. Conclusions: Early diagnosis of primary pulmonary artery sarcomas can be improved by computed tomography and magnetic resonance scanning. Radical surgical resection probably presents the only chance for cure. The role of neoadjuvant or adjuvant treatment modalities has to be defined. Pulmonary artery sarcoma need not necessarily be a fatal diagnosis.

Characterization of cell proliferation in idiopathic pulmonary fibrosis

Journal of Allergy and Clinical Immunology, 2019

RATIONALE: Dysregulated cell proliferation in the lung is one of the key hallmarks in idiopathic ... more RATIONALE: Dysregulated cell proliferation in the lung is one of the key hallmarks in idiopathic pulmonary fibrosis (IPF). Proliferation of type II alveolar epithelial cells (AECs) and fibroblasts is a particularly important event in IPF development. However, it is not understood how such proliferation leads to an advanced stage of fibrosis. Therefore, it is very important to characterize the proliferation of type II AECs in IPF lungs with different histological appearances. METHODS: Lung samples were removed from the whole lung explants of patients with IPF and patients with pulmonary arterial hypertension (PAH, control subjects) undergoing lung transplantation at Tampa General Hospital (IRB protocol Pro00032158). Paraffin-embedded lung sections were immunohistochemically labeled for Ki67 (proliferation marker) and pro-SPC (a lineage marker for type II AEC). RESULTS: In normal looking alveoli of PAH and IPF lungs, Ki67 signals were sparsely colocalized with pro-SPC. In mildly affected alveoli with thickened interstitium in IPF lungs, Ki67 signals are noted with higher density than normal alveoli of PAH and IPF. Intriguingly, most of them are either weakly positive or negative for pro-SPC. In severely fibrotic regions in IPF lungs, most of the Ki67 positive cells are negative for pro-SPC. CONCLUSIONS: The results indicate that type II AEC proliferation is a key event in IPF. The results also suggest that type II AEC proliferation gradually shifts to proliferation of different cell types as the lung becomes more fibrotic. These cells are presumably dedifferentiated type II AECs that have lost pro-SPC expression or other progenitor cell types.

Improvement in the pulmonary circulation following pulmonary thromboendarterectomy

Heart, 2001

Reverse saphenous interposition vein graft repair of a giant atherosclerotic aneurysm of the left anterior descending coronary artery

The Journal of Thoracic and Cardiovascular Surgery, 2002

T he incidence of coronary artery aneurysm is reported to be around 5%. 1 The involvement of the ... more T he incidence of coronary artery aneurysm is reported to be around 5%. 1 The involvement of the left anterior descending coronary artery (LAD) varies from 32% 2 to 52%. 3 Several repair techniques have been described and include proximal or distal ligation of the aneurysm, 4 aneurysmal thrombectomy, 5 aneurysmorrhectomy, 6 aneurysmal resection with direct end-to-end anastomosis, 7 intraluminal stenting, 8 coil embolization, 9 and reverse saphenous interposition grafting. 10 We describe our experience in dealing with a giant (Ͼ5 cm in diameter) atherosclerotic coronary aneurysm of the LAD using the latter technique.

Extrusion of TeflonS aortic pledgets from a sternal wound six years after cardiac surgery

European Journal of Cardio-Thoracic Surgery, 1997

We present a case of a cardiac surgery patient with a persistent low-grade discharge from his ste... more We present a case of a cardiac surgery patient with a persistent low-grade discharge from his sternal wound for over six years. It finally healed when some suture material and Teflon@ felt pledgets were extruded. These had been used intraoperatively to close the aortic cannulation site. The extrusion of prosthetic material from this site after this length of time has never been described.

Pulmonary Thromboendarterectomy for Chronic Thromboembolic Pulmonary Hypertension

Anesthesiology, 2014

Pulmonary thromboendarterectomy is the most effective therapy for chronic thromboembolic pulmonar... more Pulmonary thromboendarterectomy is the most effective therapy for chronic thromboembolic pulmonary hypertension. The pathophysiology, anesthetic management, and perioperative outcomes of patients with chronic thromboembolic pulmonary hypertension undergoing pulmonary thromboendarterectomy are reviewed.

Right Ventricular Reverse Remodeling after Pulmonary Endarterectomy: Magnetic Resonance Imaging and Clinical and Right Heart Catheterization Assessment

Pulmonary Circulation, 2014

The objective of this study was to assess the effect of pulmonary endarterectomy (PEA) on right v... more The objective of this study was to assess the effect of pulmonary endarterectomy (PEA) on right ventricular (RV) reverse remodeling using magnetic resonance imaging (MRI) and to correlate MRI findings with clinical and hemodynamic outcomes postsurgery. We performed a retrospective analysis in 72 patients undergoing PEA surgery in whom MRI and right heart catheterization (RHC) were performed preoperation and 3 months postoperation. RV volumes and mass were assessed by MRI. Continuous variables were expressed as means, changes were compared with a paired t test, and associations between the variables were explored using Pearson correlation coefficients. The mean age was 57 years, and 51% were male. Both RV end-diastolic volume (EDV; 176-117 mL; P < 0.001) and RV end-systolic volume (ESV; 129-64 mL; P < 0.001) reduced significantly following PEA. Preoperative pulmonary artery pressure (PAP) correlated moderately with ESV (r ¼ 0.46, P < 0.001). Postoperatively, PAP correlated with EDV (r ¼ 0.45, P < 0.001) and ESV (r ¼ 0.44, P < 0.001). Moderate correlation was present between hemodynamic parameters: PAP, pulmonary vascular resistance, and right atrial pressure with pre-and postoperation endsystolic and end-diastolic RV mass (P < 0.001). RHC and MRI measurements of cardiac output and RV volumes were significantly different (P < 0.001). In conclusion, RV reverse remodeling, as measured by improvement in RV volumes and mass by MRI, was observed for 3 months in patients who underwent PEA surgery. This is the largest series of patients with pre-and post-PEA MRI assessment so far reported. MRI detects changes in parameters reflecting cardiac remodeling and pulmonary clearance, but measurements are significantly different from those of RHC.

The Use of Biophysical Flow Models in the Surgical Management of Patients Affected by Chronic Thromboembolic Pulmonary Hypertension

Frontiers in Physiology, 2018

Conclusion: This study provides a proof of concept that patient-specific computational modeling c... more Conclusion: This study provides a proof of concept that patient-specific computational modeling can be used as a noninvasive tool for assisting surgical decisions in CTEPH based on hemodynamics metrics. Our technique enables determination of the proximal relative pressure, which could subsequently be compared to the total pressure drop to determine the degree of distal and proximal vascular resistance. In the longer term this approach has the potential to form the basis for a more quantitative classification system of CTEPH types.

Mini-Stern Trial: A randomized trial comparing mini-sternotomy to full median sternotomy for aortic valve replacement

The Journal of thoracic and cardiovascular surgery, Jan 4, 2018

Aortic valve replacement (AVR) can be performed either through full median sternotomy (FS) or upp... more Aortic valve replacement (AVR) can be performed either through full median sternotomy (FS) or upper mini-sternotomy (MS). The Mini-Stern trial aimed to establish whether MS leads to quicker postoperative recovery and shorter hospital stay after first-time isolated AVR. This pragmatic, open-label, parallel randomized controlled trial (RCT) compared MS with FS for first-time isolated AVR in 2 United Kingdom National Health Service hospitals. Primary endpoints were duration of postoperative hospital stay and the time to fitness for discharge from hospital after AVR, analyzed in the intent-to-treat population. In this RCT, 222 patients were recruited and randomized (n = 118 in the MS group; n = 104 in the FS group). Compared with the FS group, the MS group had a longer hospital length of stay (mean, 9.5 days vs 8.6 days) and took longer to achieve fitness for discharge home (mean, 8.5 days vs 7.5 days). Adjusting for valve type, sex, and surgeon, hazard ratios (HRs) from Cox models did ...

The outcome of reoperative pulmonary endarterectomy surgery

Interactive cardiovascular and thoracic surgery, Jan 23, 2018

Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboemboli... more Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (PH). Despite excellent outcomes following PEA, a small proportion of patients have residual proximal disease or present with recurrent chronic thromboembolic PH and may benefit from further surgery. The aim of this study was to analyse outcomes following reoperative PEA at a high-volume national tertiary referral centre for the management of chronic thromboembolic PH. This retrospective analysis was performed using our prospectively maintained PH database to identify all patients who underwent reoperative PEA surgery between the commencement of the programme in 1997 and January 2017, and the patients' data were collected for analysis. Twelve patients underwent reoperative PEA during the period of study. The mean interval between primary procedure and reoperative procedure was 6.3 years. Significant improvements were observed in pulmonary haemodynamics follow...

Age should not be a barrier for pulmonary endarterectomy in carefully selected patients

The European respiratory journal, Dec 1, 2017

CTEPH patients over 80 years old undergoing pulmonary endarterectomy have similar outcomes to tho... more

Dynamic Risk Stratification of Patient Long-Term Outcome After Pulmonary Endarterectomy: Results From the UK National Cohort

Circulation, Jan 6, 2016

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) results from incomplete resolut... more Background: Chronic thromboembolic pulmonary hypertension (CTEPH) results from incomplete resolution of pulmonary emboli. Pulmonary endarterectomy (PEA) is potentially curative, but residual PH following surgery is common and its impact on long-term outcome is poorly understood. We wanted to identify factors correlated with poor long-term outcome after surgery and specifically define clinically relevant residual PH post-PEA. Methods and Results: 880 consecutive patients (mean age 57 years) underwent PEA for CTEPH. Patients routinely underwent detailed reassessment with right heart catheterisation and non-invasive testing at 3-6 months and annually thereafter with discharge if clinically stable at 3-5 years and not requiring pulmonary vasodilator therapy. Cox regressions were used for survival (time-to-event) analyses. Overall survival was 86%, 84%, 79% and 72% at 1, 3, 5 and 10 years for the whole cohort and 91% and 90% at 1 and 3 years for the recent half of the cohort. The majority of patient deaths after the peri-operative period were not due to right ventricular failure (CTEPH). At reassessment a mean pulmonary artery pressure (mPAP)  30 mmHg correlated with pulmonary vasodilator therapy initiation post-PEA. An mPAP  38 mmHg and pulmonary vascular resistance  425 dyne/sec/cm-5 at reassessment correlated with worse long-term survival. Conclusions: Our data confirm excellent long-term survival and maintenance of good functional status post-PEA. Haemodynamic assessment 3-6 and/or 12 months post-PEA allows stratification of patients at higher risk of dying 4 from CTEPH and identifies a level of residual pulmonary hypertension which may guide the long-term management of patients post-surgery.