Royal Brompton and Harefield Hospital

Harefield, United Kingdom

Royal Brompton and Harefield Hospital

Harefield, United Kingdom
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Gardiner H.M.,Imperial College London | Gardiner H.M.,Royal Brompton and Harefield Hospital | Gardiner H.M.,University of Houston | Kovacevic A.,Royal Brompton and Harefield Hospital | And 10 more authors.
Heart | Year: 2014

Objective Determine maternity hospital and lesionspecific prenatal detection rates of major congenital heart disease (mCHD) for hospitals referring prenatally and postnatally to one Congenital Cardiac Centre, and assess interhospital relative performance (relative risk, RR). Methods We manually linked maternity data (3 hospitals prospectively and another 16 retrospectively) with admissions, fetal diagnostic and surgical cardiac data from one Congenital Cardiac Centre. This Centre submits verified information to National Institute for Cardiovascular Outcomes Research (NICOR-Congenital), which publishes aggregate antenatal diagnosis data from infant surgical procedures. We included 120 198 unselected women screened prospectively over 11 years in 3 maternity hospitals (A, B, C). Hospital A: colocated with fetal medicine, proactive superintendent, on-site training, case-review and audit, hospital B: on-site training, proactive superintendent, monthly telemedicine clinics, and hospital C: sonographers supported by local obstetrician. We then studied 321 infants undergoing surgery for complete transposition (transposition of the great arteries (TGA), n=157) and isolated aortic coarctation (CoA, n=164) screened in hospitals A, B, C prospectively, and 16 hospitals retrospectively. Results 385 mCHD recorded prospectively from 120 198 (3.2/1000) screened women in 3 hospitals. Interhospital relative performance (RR) in Hospital A:1.68 (1.4 to 2.0), B:0.70 (0.54 to 0.91), C:0.65 (0.5 to 0.8). Standardised prenatal detection rates (funnel plots) demonstrating inter-hospital variation across 19 hospitals for TGA (37%, 0.00 to 0.81) and CoA (34%, 0.00 to 1.06). Conclusions Manually linking data sources produced hospital-specific and lesion-specific prenatal mCHD detection rates. More granular, rather than aggregate, data provides meaningful feedback to improve screening performance. Automatic maternal and infant record linkage on a national scale, requires verified, prospective maternity audit and integration of health information systems.

Ludman P.F.,Queen Elizabeth Hospital | Moat N.,Royal Brompton and Harefield Hospital | De Belder M.A.,James Cook University | Blackman D.J.,Leeds Teaching Hospitals | And 14 more authors.
Circulation | Year: 2015

Background - We assessed trends in the performance of transcatheter aortic valve implantation in the United Kingdom from the first case in 2007 to the end of 2012. We analyzed changes in case mix, complications, outcomes to 6 years, and predictors of mortality. Methods and Results - Annual cohorts were examined. Mortality outcomes were analyzed in the 92% of patients from England and Wales for whom independent mortality tracking was available. A total of 3980 transcatheter aortic valve implantation procedures were performed. In successive years, there was an increase in frequency of impaired left ventricular function, but there was no change in Logistic EuroSCORE. Overall 30-day mortality was 6.3%; it was highest in the first cohort (2007-2008), after which there were no further significant changes. One-year survival was 81.7%, falling to 37.3% at 6 years. Discharge by day 5 rose from 16.7% in 2007 and 2008 to 28% in 2012. The only multivariate preprocedural predictor of 30-day mortality was Logistic EuroSCORE ≥40. During long-term follow-up, multivariate predictors of mortality were preprocedural atrial fibrillation, chronic obstructive pulmonary disease, creatinine >200 μmol/L, diabetes mellitus, and coronary artery disease. The strongest independent procedural predictor of long-term mortality was periprocedural stroke (hazard ratio=3.00; P<0.0001). Nonfemoral access and postprocedural aortic regurgitation were also significant predictors of adverse outcome. Conclusions - We analyzed transcatheter aortic valve implantation in an entire country, with follow-up over 6 years. Although clinical profiles of enrolled patients remained unchanged, longer-term outcomes improved, and patients were discharged earlier. Periprocedural stroke, nonfemoral access, and postprocedural aortic regurgitation are predictors of adverse outcome, along with intrinsic patient risk factors. © 2015 American Heart Association, Inc.

Herbst S.,Imperial College London | Shah A.,Imperial College London | Mazon Moya M.,Imperial College London | Marzola V.,Imperial College London | And 7 more authors.
EMBO Molecular Medicine | Year: 2015

Transplant recipients on calcineurin inhibitors are at high risk of invasive fungal infection. Understanding how calcineurin inhibitors impair fungal immunity is a key priority for defining risk of infection. Here, we show that the calcineurin inhibitor tacrolimus impairs clearance of the major mould pathogen Aspergillus fumigatus from the airway, by inhibiting macrophage inflammatory responses. This leads to defective early neutrophil recruitment and fungal clearance. We confirm these findings in zebrafish, showing an evolutionarily conserved role for calcineurin signalling in neutrophil recruitment during inflammation. We find that calcineurin-NFAT activation is phagocytosis dependent and collaborates with NF-κB for TNF-α production. For yeast zymosan particles, activation of macrophage calcineurin-NFAT occurs via the phagocytic Dectin-1-spleen tyrosine kinase pathway, but for A. fumigatus, activation occurs via a phagosomal TLR9-dependent and Bruton's tyrosine kinase-dependent signalling pathway that is independent of MyD88. We confirm the collaboration between NFAT and NF-κB for TNF-α production in primary alveolar macrophages. These observations identify inhibition of a newly discovered macrophage TLR9-BTK-calcineurin-NFAT signalling pathway as a key immune defect that leads to organ transplant-related invasive aspergillosis. © 2015 The Authors. Published under the terms of the CC BY 4.0 license.

Bergmann I.,University of Gottingen | Gohner A.,University of Gottingen | Crozier T.A.,University of Gottingen | Hesjedal B.,University of Gottingen | And 4 more authors.
British Journal of Anaesthesia | Year: 2013

BackgroundThe surgical pleth index (SPI) is an index based on changes in plethysmographic characteristics that correlate with the balance between the sympathetic and parasympathetic nervous system. It has been proposed as a measure of the balance between nociception and anti-nociception. The goal of this study was to test whether it could be used to titrate remifentanil in day-case anaesthesia.MethodsA total of 170 outpatients were given total i.v. anaesthesia with propofol and remifentanil. The patients were randomized to have the remifentanil dose either adjusted according to the SPI (SPI group) or to clinical parameters (control group). The propofol dose was adjusted according to entropy in both groups. The consumption of anaesthetic drugs, recovery times, and complications were compared.ResultsThe mean [standard deviation (sd)] remifentanil and propofol infusion rates in the SPI and control groups were 0.06 (0.04) vs 0.08 (0.05) μg kg-1 min-1 and 6.0 (2.1) vs 7.5 (2.2) mg kg-1 h-1, respectively (both P<0.05). The mean (sd) times to eye opening were -0.08 (4.4) and 3.5 (4.3) min and to extubation were 1.2 (4.4) and 4.4 (4.5) min in the SPI and control groups, respectively (both P<0.05). There was no difference between the groups with regard to satisfaction with the anaesthetic or intensity of postoperative pain. No patient reported intraoperative awareness.ConclusionsAdjusting the remifentanil dosage according to the SPI in outpatient anaesthesia reduced the consumption of both remifentanil and propofol and resulted in faster recovery. © 2012 © The Author [2012]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email:

Mohsen T.A.,Cairo University | Zeid A.A.A.,Cairo University | Meshref M.,Cairo University | Tawfeek N.,Cairo University | And 4 more authors.
European Journal of Cardio-thoracic Surgery | Year: 2011

Objective: To compare the efficacy, safety, and outcome of thoracoscopic talc poudrage (TTP) versus povidone-iodine pleurodesis (PIP) through a thoracostomy tube as a palliative treatment of pleural effusion due to metastatic breast carcinoma (MBC). Methods: A total of 42 MBC patients were prospectively enrolled in a randomized controlled trial. Twenty-two patients received TTP (group A), whereas 20 patients (group B) underwent pleurodesis by instilling povidone-iodine through a thoracostomy tube, as a bedside procedure. Results: The mean age was 48.2 ± 9.9 (range: 29-64) years and 50.2 ± 7 (range: 32-62) years for groups A and B, respectively (p= ns). At presentation, all patients had moderate to severe dyspnea, New York Heart Association (NYHA) > II and Medical Research Council (MRC) dyspnea scale 3-5. Morbidity in both groups was low. Post-procedure analgesic requirements due to severe pleuritic chest pain were higher in group A (18% vs 0%, p= 0.2). Four patients in group A (18%) and one in group B (5%) were febrile (>38 °C) within 48. h of the procedure. Both groups achieved good symptom control, with improvement in MRC dyspnea scale (1-3). There were no in-hospital deaths. Post-procedure hospital stay was lower in group B (p= 0.009). The mean progression-free interval was 6.6 (range 3-15) months. At follow-up (mean: 22.6 (range: 8-48) months), recurrence of significant pleural effusion requiring intervention was noted in two and three patients in group A and group B, respectively (p= ns). Conclusion: Povidone-iodine can be considered as a good alternative to TTP to ensure effective pleurodesis for patients with malignant pleural effusion due to MBC. The drug is available, cost effective and safe, can be given through a thoracostomy tube and can be repeated if necessary. © 2010 European Association for Cardio-Thoracic Surgery.

Foin N.,Imperial College London | Di Mario C.,Biomedical Research Unit | Di Mario C.,Royal Brompton and Harefield Hospital | Francis D.P.,Imperial College London | Davies J.E.,Imperial College London
International Journal of Cardiology | Year: 2013

The "concertina effect", longitudinal deformation of the proximal segments of a deployed stent when force is applied from a guide catheter or other equipment, is a recently recognised problem which seems to particularly affect more recent stent designs. Until now, flexibility and deliverability have been paramount aims in stent design. Developments have focussed on optimising these features which are commonly evaluated by clinicians and demanded by regulatory bodies. Contemporary stent designs now provide high flexibility by reducing the number of connecting links between stent segments and by allowing the connecting links to easily change their length. These design evolutions may, however, simultaneously reduce longitudinal strength and have the unintended effect of inducing some risk of longitudinal compression of the stent (the "concertina effect") during difficult clinical cases. Progress in stent design and elimination of restenosis by drug coating has improved PCI outcome and enabled new applications. Here we discuss design trade-offs that shaped evolution and improvement in stent design, from early bare metal designs to the latest generation of drug eluting stent (DES) platforms. Longitudinal strength was not recognised as a critical parameter by clinicians or regulators until recently. Measurements, only now becoming publically available, seem to confirm vulnerability of some modern designs to longitudinal deformation. Clinicians could be more guarded in their assumption that changes in technology are beneficial in all clinical situations. Sometimes a silent trade-off may have taken place, adopting choices that are favourable for the vast majority of patients but exposing a few patients to unintended hazard. © 2011 Elsevier Ireland Ltd. All rights reserved.

Mansur A.,University Hospital Freiburg | Klee Y.,University Hospital Freiburg | Popov A.F.,Royal Brompton and Harefield Hospital | Erlenwein J.,University Hospital Freiburg | And 4 more authors.
BMJ Open | Year: 2015

Objective: To investigate whether common infection foci (pulmonary, intra-abdominal and primary bacteraemia) are associated with variations in mortality risk in patients with sepsis. Design: Prospective, observational cohort study. Setting: Three surgical intensive care units (ICUs) at a university medical centre. Participants: A total of 327 adult Caucasian patients with sepsis originating from pulmonary, intra-abdominal and primary bacteraemia participated in this study. Primary and secondary outcome measures: The patients were followed for 90 days and mortality risk was recorded as the primary outcome variable. To monitor organ failure, sepsis-related organ failure assessment (Sequential Organ Failure Assessment, SOFA) scores were evaluated at the onset of sepsis and throughout the observational period as secondary outcome variables. Results: A total of 327 critically ill patients with sepsis were enrolled in this study. Kaplan-Meier survival analysis showed that the 90-day mortality risk was significantly higher among patients with primary bacteraemia than among those with pulmonary and intra-abdominal foci (58%, 35% and 32%, respectively; p=0.0208). To exclude the effects of several baseline variables, we performed multivariate Cox regression analysis. Primary bacteraemia remained a significant covariate for mortality in the multivariate analysis (HR 2.10; 95% CI 1.14 to 3.86; p=0.0166). During their stay in the ICU, the patients with primary bacteraemia presented significantly higher SOFA scores than those of the patients with pulmonary and intra-abdominal infection foci (8.5±4.7, 7.3±3.4 and 5.8±3.5, respectively). Patients with primary bacteraemia presented higher SOFA-renal score compared with the patients with other infection foci (1.6±1.4, 0.8±1.1 and 0.7±1.0, respectively); the patients with primary bacteraemia required significantly more renal replacement therapy than the patients in the other groups (29%, 11% and 12%, respectively). Conclusions: These results indicate that patients with sepsis with primary bacteraemia present a higher mortality risk compared with patients with sepsis of pulmonary or intra-abdominal origins. These results should be assessed in patients with sepsis in larger, independent cohorts.

Suman-Horduna I.,Royal Brompton and Harefield Hospital | Ernst S.,Royal Brompton and Harefield Hospital
Progress in Pediatric Cardiology | Year: 2012

Radiofrequency ablation of cardiac arrhythmias in patients with congenital heart disease has emerged as a superior alternative treatment to antiarrhythmic medication. However, more accurate pre- and peri-operative definition of the anatomical details through advanced three-dimensional imaging techniques, as well as use of remotely steered catheters to reach inaccessible areas is necessary in most cases to improve the ablation outcome. The remote controlled techniques, the various procedural approaches and the clinical outcome published to date are discussed herein separately for different underlying anatomical substrates. © 2012 Elsevier Ireland Ltd.

Popov A.F.,Royal Brompton and Harefield Hospital | Hosseini M.T.,Royal Brompton and Harefield Hospital | Zych B.,Royal Brompton and Harefield Hospital | Simon A.R.,Royal Brompton and Harefield Hospital | Bahrami T.,Royal Brompton and Harefield Hospital
Annals of Thoracic Surgery | Year: 2012

The HeartWare left ventricular assist device (LVAD) is a new addition to the family of second-generation continuous-flow LVADs. The miniaturized dimensions of the HeartWare LVAD provide the opportunity for its safe implantation through nonsternotomy incisions. We present our technique for HeartWare LVAD implantation through bilateral anterior thoracotomy incisions. This technique has proved to be safe and reproducible, with good clinical outcome. © 2012 The Society of Thoracic Surgeons.

Furck A.K.,Children Hospital Bult | Furck A.K.,Royal Brompton and Harefield Hospital | Richter J.W.,Children Hospital Bult | Kattner E.,Children Hospital Bult
Journal of Perinatology | Year: 2010

Introduction: Premature infants should be vaccinated at the appropriate vaccinating age, without correcting for their gestational week and regardless of their weight. Uncertainty with regard to possible severe adverse events exists among physicians. Methods: In all, 473 patients with a birth weight under 1500 g were included in a prospective observational study for adverse events that included cardiorespiratory events, local reactions and fever. Three vaccination combinations were used at different time periods. Results: The median birth weight was 910 (375 to 1495) g. Gestational week at birth was 27.6 (22.6 to 34.3). At the time of vaccination, the gestational week was 37.4 (31.5 to 48.3). The frequency of adverse events for local reactions/fever was 2.8% and for apnea/bradycardia it was 10.8%. Apnea appeared significantly more often in children who were younger at the time of immunization. This is in concordance with the fact that they were also younger at birth. If apnea appeared, the chance of the development of bradycardia had an odds ratio of 6.4 (3.2:13.0). Children with higher-grade hemorrhages and/or with periventricular leukomalacia did not experience more adverse events, except fever. Conclusion: Timely vaccination of premature infants with a birth weight under 1500 g is safe, but the occurrence of cardiorespiratory events is related to earlier gestational week. © 2010 Nature Publishing Group All rights reserved.

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