London, United Kingdom
London, United Kingdom

Time filter

Source Type

Skouras C.,Royal Infirmary | Jarral O.,The London Chest Hospital | Deshpande R.,North Manchester General Hospital | Zografos G.,National and Kapodistrian University of Athens | And 2 more authors.
International Journal of Surgery | Year: 2012

A best evidence topic was written according to a structured protocol. The question addressed was whether early laparoscopic cholecystectomy (ELC) in patients presenting with a short history of acute cholecystitis provides better post-operative outcomes than a delayed laparoscopic cholecystectomy (DLC). A total of 92 papers were found using the reported searches of which 10 represented the best evidence; 3 meta-analyses, 4 randomized control trials, 1 prospective controlled study and 2 retrospective cohort studies were included. The authors, date, journal, study type, population, main outcome measures and results were tabulated.No significant difference in complication or conversion rates were shown between the ELC and the DLC group, in the meta-analyses of Gurusamy et al, Lau et al and Siddiqui et al. The ELC group had a decreased hospital stay whereas the DLC group presented a considerable risk for subsequent emergency surgery during the interval period, with a high rate of conversion to open cholecystectomy. All three meta-analyses were based on the randomized control trials of Lo et al, Lai et al, Kolla et al and Johansson et al; the results of each study are summarized.We conclude that there is strong evidence that early laparoscopic cholecystectomy for acute cholecystitis offers an advantage in the length of hospital stay without increasing the morbidity or mortality. The operating time in ELC can be longer, however the incidence of serious complications (i.e. common bile duct injury), is comparable to the DLC group. Larger randomized studies are required before solid conclusions are reached. © 2012 Surgical Associates Ltd.


McCormack A.C.,The London Chest Hospital | Jarral O.A.,The London Chest Hospital | Shipolini A.R.,The London Chest Hospital | McCormack D.J.,The London Chest Hospital
Interactive Cardiovascular and Thoracic Surgery | Year: 2011

A best evidence topic was written according to a structured protocol. The question addressed was, in what proportion of patients is the nerve of Kuntz identifiable? A total of 55 papers were found using the reported search, of which six represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. The nerve of Kuntz was originally described in 1927 as being a connection from the second intercostal nerve to the first thoracic ventral ramus. Controversy exists as to whether it is present universally and thus whether it should be identified during thoracoscopic sympathectomy. The six studies highlighted involved dissection of the upper thoracic sympathetic chain of adult cadavers with descriptions of the anatomical variations. A study by Cho et al. [Cho HM, Lee DY, Sung SW. Anatomical variations of rami communicants in the upper thoracic sympathetic trunk. Eur J Cardiothorac Surg 2005;27:320-324] suggested that anatomical variation was more common at T2 compared to T3 and T4, of which 60% corresponded to the original description of the nerve of Kuntz. A similar prevalence was found by Marhold and colleagues [Marhold F, Izay B, Zacherl J, Tschabitscher M, Neumayer C. Thoracoscopic and anatomic landmarks of Kuntz's nerve: implications for sympathetic surgery. Ann Thorac Surg 2008;86:1653-1658], who also suggested that open dissection led to significantly easier identification of this anatomy than thoracoscopy. The same authors frequently found that the nerve of Kuntz was associated with a superior intercostal vein located parallel to it, meaning that these subpleural veins may act as an anatomical landmark. In four of the papers where cadavers where dissected bilaterally, variations in the anatomy of the sympathetic chain were not always symmetrical. We conclude that most patients will have some form of variation in the anatomy of their T2 ganglion, which often corresponds to the original description of the nerve of Kuntz. The appreciation of this variation may be more difficult during thoracoscopy as compared to open anatomic dissection. © 2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.


Sepehripour A.H.,Wythenshawe Hospital | Jarral O.A.,The London Chest Hospital | Shipolini A.R.,The London Chest Hospital | McCormack D.J.,The London Chest Hospital
Interactive Cardiovascular and Thoracic Surgery | Year: 2011

A best evidence topic was written according to a structured protocol. The question addressed was whether harvesting the saphenous vein (SV) as a conduit for coronary artery bypass grafting (CABG) using a no-touch technique would result in better patency rates. This technique involves the harvest of the SV with a pedicle of peri-vascular tissue left intact and the avoidance of distension of the vein prior to anastomosis. A total of 405 papers were found using the reported searches of which eight represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. The studies found analysed the ultrastructural and mechanical properties of the endothelium and vessel walls of the two harvesting techniques; the protein and enzymatic expression and activity observed; the early atherosclerotic changes detected; and the overall patency of the grafts during short-and long-term angiographical follow-up. Three small prospectively randomised studies compared the patency of grafts harvested using the two techniques and found significant improvements in graft patency using the no-touch harvesting technique in comparison to both the conventional technique and more importantly comparable to the left internal thoracic artery (LITA) patency. The most favourable difference was that of graft patency after 8.5 years of follow-up [90% vs. 76% (P=0.01), LITA patency 90%], and incidence of graft stenosis [11% vs. 25% (P=0.006)]. These findings were supported by the demonstrated improvements in the cellular integrity of the vessels and the reduction in the mechanisms leading to graft failure seen in the no-touch harvested SV grafts. These morphological and cellular analyses were carried by five small comparative studies, demonstrating improved endothelial integrity and reduced injury, decelerated atherosclerotic processes, intact adventitial collagen layers, increase in the total area of vasa vasorum, elevated endothelial nitric oxide synthase expression and activity, and increased peri-vascular leptin levels and activity. We conclude that there are clear enhancements in vessel wall properties at a cellular level and angiographical evidence of superior graft patency when the no-touch SV harvesting technique is employed. © 2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.


Lo T.T.H.,The London Chest Hospital | Jarral O.A.,The London Chest Hospital | Shipolini A.R.,The London Chest Hospital | McCormack D.J.,The London Chest Hospital
Interactive Cardiovascular and Thoracic Surgery | Year: 2011

A best evidence topic was written according to a structured protocol. The question addressed was whether incidentally found patent foramen ovale (PFO) during isolated coronary surgery should be closed. A total of 573 papers were found using the reported searches of which six represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. There is currently no evidence to suggest that incidental PFO in patients undergoing cardiac surgery is linked with increased morbidity, mortality or decreased long-term survival. The most significant study identified examined the outcomes of 2277 patients with incidentally found PFO during cardiac surgery of whom 639 underwent closure. After propensity matched analysis, the authors found closure was associated with a significantly higher risk of postoperative stroke with no advantage in terms of long-term survival. A recent survey of 438 cardiac surgeons from the USA showed no consensus on decision-making behind closure, but that factors taken in to account include PFO size, right atrial pressure and a history of paradoxical embolism. This is not surprising given that morphological research has confirmed that larger PFO size is indeed associated with cryptogenic stroke. © 2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.


Attaran S.,The London Chest Hospital | Somov P.,The London Chest Hospital | Awad W.I.,The London Chest Hospital
European Journal of Cardio-thoracic Surgery | Year: 2010

Background: Both cancer patients and patients undergoing surgery are thought to be at an increased risk of thrombo-embolic events. Consequently, low-molecular-weight heparin (LMWH) is administered to all such patients perioperatively. There is a lack of consensus in guidelines regarding the timing of administration and the dosage of thromboprophylactic agents. Studies have shown that thrombo-elastography (TEG) is a useful test in assessing global haemostatic function, and has been validated in monitoring the dosage of LMWH. In this study, we assess the coagulation status of patients undergoing thoracic surgery with TEG, and the effectiveness of administered LMWH for thromboprophylaxis. Methods: Thirty patients with primary lung cancer (LC) and 30 with benign lung disease (BL) were studied prospectively. Patients were randomised to receive subcutaneous LMWH 40 mg once or twice per day perioperatively. Their coagulation status was monitored with TEG preoperatively and postoperatively for 3 consecutive days. Results: Preoperative TEG parameters (k time, alpha angle and maximum amplitude (MA)) were within the normal range in both the LC and BL groups. Preoperative r time was prolonged in both the groups, but with no significant difference between the two groups (p > 0.05). Postoperatively, r time was prolonged in some patients receiving LMWH twice daily, suggesting a possible adequate thromboprophylaxis in these patients only. Conclusion: This study demonstrates that the majority of patients with LC are not hypercoagulable. We also showed that LMWH once or twice a day might not provide sufficient thromboprophylaxis. We advocate screening for patients demonstrating hypercoagulable states and ensuring adequate thromboprophylaxis in this group of patients with careful monitoring. © 2009 European Association for Cardio-Thoracic Surgery.


Kung V.W.S.,The London Chest Hospital | Jarral O.A.,The London Chest Hospital | Shipolini A.R.,The London Chest Hospital | McCormack D.J.,The London Chest Hospital
Interactive Cardiovascular and Thoracic Surgery | Year: 2011

A best evidence topic was written according to a structured protocol. The question addressed was 'Is it safe to perform coronary angiography (CA) in acute endocarditis?' Three hundred and ninety-seven papers were found using the reported search, of which six represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, key results and limitations of these papers are tabulated. One of the papers is a case report, which reported a fatal vegetation embolism from an infected aortic valve into the left main coronary artery 14 h after angiography. The remaining five papers are cohort studies. Four of these studies were performed between 1970 and 1980 before the era of echocardiography and were aimed at quantifying the severity of valvular regurgitation. No embolic complications or dislodgement of vegetations occurred in any of the five studies (186 patients). Guidelines published by the European Society of Cardiology (ESC) in 2009 recommended CA in the context of infective endocarditis (IE) for men > 40 years old, postmenopausal women, and patients with at least one cardiovascular risk factor or a history of coronary artery disease. Exceptions include patients with large aortic vegetations which may be dislodged during catheterisation, and when emergency surgery is necessary - 1) native aortic or mitral IE with severe acute regurgitation or valve obstruction, or prosthetic valve IE with severe prosthetic dysfunction (dehiscence or obstruction) causing refractory pulmonary oedema or cardiogenic shock; 2) native aortic, mitral, or prosthetic valve IE with fistula into a cardiac chamber or pericardium causing refractory pulmonary oedema or shock. This is reiterated by the guidelines on the management of valvular heart disease published by the ESC in 2007. From the findings of the six papers, it can be concluded that coronary angiography can be performed safely in IE and should be performed if deemed necessary, unless the patients are haemodynamically unstable requiring emergency surgery, or have large vegetations of the aortic valve. This is consistent with the ESC guidelines. © 2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.


Deseive S.,Ludwig Maximilians University of Munich | Pugliese F.,The London Chest Hospital | Meave A.,National Autonomous University of Mexico | Alexanderson E.,National Autonomous University of Mexico | And 4 more authors.
Journal of Cardiovascular Computed Tomography | Year: 2015

Background: Concerns have been raised about radiation dose of coronary CT angiography. Although high-pitch acquisition technique yields high potential for radiation dose savings, it is more vulnerable to artifacts, which impair diagnostic image quality. Objective: The purpose of this study was to compare 2 scan strategies for coronary CT angiography: a high-pitch helical scan first or a conventional scan first strategy. Methods: In this prospective, multicenter trial, we randomized 303 consecutive patients with a low and stable heart rate to either of the aforementioned mentioned strategies. Intravenous β-blockers were administered to achieve target heart rates. All scans were performed on a second-generation dual-source CT scanner. In case of nondiagnostic image quality, coronary CT angiography was allowed to be repeated. The primary end point was to demonstrate noninferior image quality in the high-pitch group. Image quality was assessed on a 4-point scale (1: nondiagnostic, 4: excellent). Secondary end point was total radiation dose. Results: In the high-pitch helical first group, repeat scanning was necessary in 21 patients compared with 14 patients in the conventional first scan group (. P = .25). Image quality in the high-pitch group was noninferior compared to the conventional scan group (3.81 ± 0.35 vs 3.83 ± 0.37; P for noninferiority <.0001). The total effective radiation dose estimate was 58% lower in the high-pitch group (2.0 ± 2.4 vs 4.7 ± 4.8 mSv; P < .0001). Conclusions: In patients with a low and stable heart rate diagnostic image quality can be maintained with a high-pitch helical scan first strategy while 58% of radiation dose can be saved. © 2015 Society of Cardiovascular Computed Tomography.


PubMed | Glaxosmithkline, Queen Mary, University of London and The London Chest Hospital
Type: Clinical Trial, Phase III | Journal: American journal of respiratory and critical care medicine | Year: 2016

Patients with chronic obstructive pulmonary disease develop increased cardiovascular morbidity with structural alterations.To investigate through a double-blind, placebo-controlled, crossover study the effect of lung deflation on cardiovascular structure and function using cardiac magnetic resonance.Forty-five hyperinflated patients with chronic obstructive pulmonary disease were randomized (1:1) to 7 (maximum 14) days inhaled corticosteroid/long-acting 2-agonist fluticasone furoate/vilanterol 100/25 g or placebo (7-day minimum washout). Primary outcome was change from baseline in right ventricular end-diastolic volume index versus placebo.There was a 5.8 ml/m(2) (95% confidence interval, 2.74-8.91; P<0.001) increase in change from baseline right ventricular end-diastolic volume index and a 429 ml (P<0.001) reduction in residual volume with fluticasone furoate/vilanterol versus placebo. Left ventricular end-diastolic and left atrial end-systolic volumes increased by 3.63 ml/m(2) (P=0.002) and 2.33 ml/m(2) (P=0.002). In post hoc analysis, right ventricular stroke volume increased by 4.87 ml/m(2) (P=0.003); right ventricular ejection fraction was unchanged. Left ventricular adaptation was similar; left atrial ejection fraction improved by +3.17% (P<0.001). Intrinsic myocardial function was unchanged. Pulmonary artery pulsatility increased in two of three locations (main +2.9%, P=0.001; left +2.67%, P=0.030). Fluticasone furoate/vilanterol safety profile was similar to placebo.Pharmacologic treatment of chronic obstructive pulmonary disease has consistent beneficial and plausible effects on cardiac function and pulmonary vasculature that may contribute to favorable effects of inhaled therapies. Future studies should investigate the effect of prolonged lung deflation on intrinsic myocardial function. Clinical trial registered with www.clinicaltrials.gov (NCT 01691885).


PubMed | The London Chest Hospital and University College London
Type: Journal Article | Journal: Turk Kardiyoloji Dernegi arsivi : Turk Kardiyoloji Derneginin yayin organidir | Year: 2015

Cardiomyopathies are myocardial disorders that are not explained by abnormal loading conditions and coronary artery disease. They are classified into a number of morphological and functional phenotypes that can be caused by genetic and non-genetic mechanisms. The dominant themes in papers published in 2012-2013 are similar to those reported in Almanac 2011, namely, the use (and interpretation) of genetic testing, development and application of novel non-invasive imaging techniques and use of serum biomarkers for diagnosis and prognosis. An important innovation since the last Almanac is the development of more sophisticated models for predicting adverse clinical events.


PubMed | Ludwig Maximilians University of Munich, TU Munich, National Autonomous University of Mexico and The London Chest Hospital
Type: Journal Article | Journal: Journal of cardiovascular computed tomography | Year: 2015

Concerns have been raised about radiation dose of coronary CT angiography. Although high-pitch acquisition technique yields high potential for radiation dose savings, it is more vulnerable to artifacts, which impair diagnostic image quality.The purpose of this study was to compare 2 scan strategies for coronary CT angiography: a high-pitch helical scan first or a conventional scan first strategy.In this prospective, multicenter trial, we randomized 303 consecutive patients with a low and stable heart rate to either of the aforementioned mentioned strategies. Intravenous -blockers were administered to achieve target heart rates. All scans were performed on a second-generation dual-source CT scanner. In case of nondiagnostic image quality, coronary CT angiography was allowed to be repeated. The primary end point was to demonstrate noninferior image quality in the high-pitch group. Image quality was assessed on a 4-point scale (1: nondiagnostic, 4: excellent). Secondary end point was total radiation dose.In the high-pitch helical first group, repeat scanning was necessary in 21 patients compared with 14 patients in the conventional first scan group (P = .25). Image quality in the high-pitch group was noninferior compared to the conventional scan group (3.81 0.35 vs. 3.83 0.37; P for noninferiority <.0001). The total effective radiation dose estimate was 58% lower in the high-pitch group (2.0 2.4 vs. 4.7 4.8 mSv; P < .0001).In patients with a low and stable heart rate diagnostic image quality can be maintained with a high-pitch helical scan first strategy while 58% of radiation dose can be saved.

Loading The London Chest Hospital collaborators
Loading The London Chest Hospital collaborators