No abstract

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.

Background Early studies conclude patients with Covid-19 have a high risk of death, but no studies specifically explore cardiac surgery outcome. We investigate UK cardiac surgery outcomes during the early phase of the Covid-19 pandemic. Methods This retrospective observational study included all adult patients undergoing cardiac surgery between 1st March and 30th April 2020 in nine UK centres. Data was obtained and linked locally from the National Institute for Cardiovascular Outcomes Research Adult Cardiac Surgery database, the Intensive Care National Audit and Research Centre database and local electronic systems. The anonymised datasets were analysed by the lead centre. Statistical analysis included descriptive statistics, propensity score matching (PSM), conditional logistic regression and hierarchical quantile regression. Results Of 755 included individuals, 53 (7.0%) had Covid-19. Comparing those with and without Covid-19, those with Covid-19 had increased mortality (24.5% v 3.5%, p < 0.0001) and longer post-operative stay (11 days v 6 days, p = 0.001), both of which remained significant after PSM. Patients with a pre-operative Covid-19 diagnosis recovered in a similar way to non-Covid-19 patients. However, those with a post-operative Covid-19 diagnosis remained in hospital for an additional 5 days (12 days v 7 days, p = 0.024) and had a considerably higher mortality rate compared to those with a pre-operative diagnosis (37.1% v 0.0%, p = 0.005). Conclusions To mitigate against the risks of Covid-19, particularly the post-operative burden, robust and effective pre-surgery diagnosis protocols alongside effective strategies to maintain a Covid-19 free environment are needed. Dedicated cardiac surgery hubs could be valuable in achieving safe and continual delivery of cardiac surgery.

The aim of this study is to evaluate the efficacy of bilateral thoracoscopic sympathectomy in alleviating symptoms and improving quality of life in patients with hyperhidrosis or facial blushing and to investigate the occurrence, severity and possible underlying factors to compensatory sweating after surgery. One hundred and sixty-three patients in a single institution underwent bilateral thoracoscopic sympathectomy with a mean follow-up period of 51 (5-140) months. Indications were for palmar hyperhidrosis (41%), axillary hyperhidrosis (17%), combined palmar and axillary hyperhidrosis (27%) and facial blushing+/-facial hyperhidrosis (15%). Success rates were palmar 98.5%, axillary 96.4%, palmar and axillary 97.7% and facial blushing+/-facial hyperhidrosis 84%. Compensatory sweating occurred in 77% of patients and its severity was related to the severity of the primary complaint. Recurrence rates were palmar 4.6%, axillary 7.4%, palmar and axillary 9.3% and facial blushing+/-facial hyperhidrosis 4.7% at a mean of 22 (3-72) months. An improvement in quality of life was seen in 85% and a diminution of quality of life was noted in 5% due to compensatory sweating. This large mature series demonstrates that bilateral thoracoscopic division of the sympathetic chain as opposed to resection can be performed effectively in patients with success rates higher than 90% and low recurrence rates.

To support the global restart of elective surgery, data from an international prospective cohort study of 8492 patients (69 countries) was analysed using artificial intelligence (machine learning techniques) to develop a predictive score for mortality in surgical patients with SARS-CoV-2. We found that patient rather than operation factors were the best predictors and used these to create the COVIDsurg Mortality Score (https://covidsurgrisk.app). Our data demonstrates that it is safe to restart a wide range of surgical services for selected patients.