Background. Prothrombin complex concentrate (PCC) has recently emerged as effective alternative to fresh frozen plasma (FFP) in treating excessive perioperative bleeding. We performed a systematic review and meta-analysis to evaluate the safety and efficacy of PCC administration as first-line treatment for coagulopathy following adult cardiac surgery. Methods. We searched PubMed/MEDLINE, EMBASE, and the Cochrane Library from inception to the end of March 2018 to identify eligible articles. Adult patients undergoing cardiac surgery and receiving perioperative PCC were compared to those receiving FFP. Results. A total of 861 adult patients from 4 studies were retrieved. No randomized studies were identified. Pooled odds ratio (OR) showed that PCC cohort was associated with a significant reduction in the risk of RBC transfusion (OR: 2.22; 95% confidence interval [CI] 1.45-3.40) and units of RBC received (OR: 1.34; 95%CI: 0.78-1.90). No differences were observed between the groups for re

BackgroundThoracic aortic disease has a high mortality. We sought to establish the contribution of unwarranted variation in care to regional differences in outcomes observed in patients with thoracic aortic disease in England.Methods and ResultsData from the Hospital Episode Statistics (HES) and the National Adult Cardiac Surgery Audit (NACSA) were extracted. A parallel systematic review/meta‐analysis through December 2015, and structure and process questionnaire of English cardiac surgery units were also accomplished. Treatment and mortality rates were investigated. A total of 24 548 adult patients in the HES study, 8058 in the NACSA study, and 103 543 from a total of 33 studies in the systematic review were obtained. Treatment rates for thoracic aortic disease within 6 months of index admission ranged from 7.6% to 31.5% between English counties. Risk‐adjusted 6‐month mortality in untreated patients ranged from 19.4% to 36.3%. Regional variation persisted after adjustment for disease or patient factors. Regional cardiac units with higher case volumes treated more‐complex patients and had significantly lower risk‐adjusted mortality relative to low‐volume units. The results of the systematic review indicated that the delivery of care by multidisciplinary teams in high‐volume units resulted in better outcomes. The observational analyses and the online survey indicated that this is not how services are configured in most units in England.ConclusionsChanges in the organization of services that address unwarranted variation in the provision of care for patients with thoracic aortic disease in England may result in more‐equitable access to treatment and improved outcomes.

Key PointsQuestionIs transcatheter aortic valve implantation (TAVI) noninferior to surgical aortic valve replacement (surgery) in patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk?FindingsIn this randomized clinical trial that included 913 patients at moderately increased operative risk due to age or comorbidity, all-cause mortality at 1 year was 4.6% with TAVI vs 6.6% with surgery, a difference that met the prespecified noninferiority margin of 5%.MeaningAmong patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk, treatment with TAVI was noninferior to surgery with respect to all-cause mortality at 1 year.

AVR can be undertaken with excellent results in octogenarians and the current risk is significantly lower than what is predicted with conventional risk-scoring systems. Patients with advanced age should not necessarily be excluded from being candidates for AVR.

Floating thrombi in the aorta are a rare finding in the absence of any coagulation abnormality. They often represent a surgical emergency. Our case refers to a 45-year-old woman who presented with acute ischemia of the upper extremity. This was a result of peripheral embolism originating in a floating thrombus in the ascending aorta. A free-floating lesion held by a pedicle from the lateral ascending aortic wall was demonstrated using computed tomography and magnetic resonance scans. There was no pre-existing clotting abnormality. Conservative treatment with oral anticoagulation was not successful in removing the lesion. Therefore, a surgical approach was selected through a median sternotomy and cardiopulmonary bypass. Under temporary hypothermic circulatory arrest, the ascending aorta was opened. The lesion was removed along with a rim of aortic wall, circulation was re-established and the aorta was reconnected with use of a synthetic interposition graft. Postoperative course was uneventful. The patient was discharged on oral anticoagulation. Histopathology confirmed the lesion as thrombus. Only a few cases of intra-aortic thrombus without any coagulation abnormality basis are described in literature. Occasionally, they present as distal embolism. Treatment should be surgical excision on cardiopulmonary bypass, a procedure performed safely with excellent outcome.