Almanac 2012: Adult cardiac surgery: The national society journals present selected research that has driven recent advances in clinical cardiology | Revista Portuguesa de Cardiologia (English edition)

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(B): cardiac CT (MPR), 12 mm thickness, in the same view." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Faustino, Nuno Ferreira, Nuno Bettencourt, Mónica Carvalho, Daniel Leite, Vasco Gama" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Ana" "apellidos" => "Faustino" ] 1 => array:2 [ "nombre" => "Nuno" "apellidos" => "Ferreira" ] 2 => array:2 [ "nombre" => "Nuno" "apellidos" => "Bettencourt" ] 3 => array:2 [ "nombre" => "Mónica" "apellidos" => "Carvalho" ] 4 => array:2 [ "nombre" => "Daniel" "apellidos" => "Leite" ] 5 => array:2 [ "nombre" => "Vasco" "apellidos" => "Gama" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S0870255112003046" "doi" => "10.1016/j.repc.2012.07.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255112003046?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913000287?idApp=UINPBA00004E" "url" => "/21742049/0000003200000002/v1_201305171228/S2174204913000287/v1_201305171228/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "Editors’ network" "titulo" => "Almanac 2012: Adult cardiac surgery: The national society journals present selected research that has driven recent advances in clinical cardiology" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "173" "paginaFinal" => "180" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Ben Bridgewater" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Ben" "apellidos" => "Bridgewater" "email" => array:1 [ 0 => "ben.bridgewater@uhsm.nhs.uk" ] ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Department of Cardiothoracic Surgery, Wythenshave Hospital, Manchester, UK" ] ] ] ] "textoCompleto" => "IntroductionCardiac surgery remains an important treatment option for many patients with coronary artery disease, valvular heart disease and heart failure. Coronary artery remains the commonest operation undertaken in most centres, but its proportion is decreasing in the UK.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> More patients are undergoing mitral and aortic valve procedures, both by conventional and novel approaches including smaller incisions for conventional surgery and insertion of new prostheses using catheter-based devices. This article will summarise publications from recent years that are having an impact on the practice of cardiac surgery.Coronary artery surgeryThere are marked changes in patients coming to coronary artery surgery over time that have been shown clearly from the analyses of large series from the USA and UK. A report from the Society for Thoracic Surgeons (STS) database has described the increasing risk proﬁle of patients coming to surgery with fewer smokers, more patients with diabetes and more use of the left internal mammary artery (LIMA) as a bypass conduit. Overall, there has been a signiﬁcant decline in postoperative mortality and morbidity.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Similar trends have been reported in the UK from the national adult cardiac surgery database, where there has been a greater than 50% reduction in risk adjusted mortality since 2000, again with increasing risk proﬁles, and more use of the internal mammary artery.<a class="elsevierStyleCrossRefs" href="#bib0005">1,3</a> However, despite some evidence for their efﬁcacy, off-pump surgery and multiple arterial grafts have not become widespread (see below).<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Coronary artery surgery or PCI for anginaThe major contemporary randomised clinical trial to inform decision making in patients with multi-vessel coronary artery disease is the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial. The study randomised 1800 patients with previously treated three vessel or left main coronary artery disease or both in 85 sites in 17 countries across Europe and the USA. The 1-year results were published in 2009, showing that the percutaneous coronary intervention (PCI) group had higher rates of the combined end point of major adverse cardiac or cerebrovascular events and failed to achieve the predeﬁned end point of non-inferiority.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> This difference was driven by a high rate of repeat revascularisation in the PCI group (13.5% PCI, 5.9% coronary artery bypass grafting (CABG)). The 1-year rates of death or myocardial infarction (MI) were not different between the groups. These differences persist over longer follow-up with 3-year MACCE rates (death stroke, MI or repeat revascularisation) being higher in the PCI group (28%) than the CABG group (20%), again driven mainly by repeat revascularisation, but there was no difference in the primary safety end point or the incidence of stroke. On subgroup analysis, there was no difference in major adverse events in the patients with left main stem (LMS) stenosis, but outcomes were worse following PCI in the three vessel subgroup.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> Analysis of outcomes based on procedural risk from the syntax score has shown at 4 years that the curves are diverging overall, but with no difference in the low risk patients (<a href="http://%20www.syntaxscore.com/">http://www.syntaxscore.com</a>).In line with the data from SYNTAX, a large registry-based study from the USA linked the ACCF National Cardiovascular registry and the STS adult cardiac surgery database to the Medicare and Medicaid registries and used propensity scoring to match patients who were 65 years or older undergoing PCI and CABG. Four years after intervention there was a mortality advantage in the CABG group, which persisted in the important subgroups.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>While the late outcomes of most higher risk patients with multi-vessel coronary artery disease seem to be better with CABG, in both randomised and registry-based studies, the outcome following intervention for LMS stenosis is not so clear cut, certainly during early follow-up. In a meta-analysis of patients with unprotected LMS stenosis analysing 2905 patients from eight clinical studies, there was no signiﬁcant difference between the two groups with respect to mortality or a composite end point of death, MI or stroke at 1 year.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> Another meta-analysis of 3773 patients looking out to 3 years gave similar ﬁndings.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> Analysis of the left main subgroup of the SYNTAX study also showed no difference up to 3 years.<a class="elsevierStyleCrossRefs" href="#bib0025">5,9</a> More recently, the Premier of Randomised Comparison of Bypass Surgery Versus Angioplasty using Sirolimus-Eluting Stent in Patients with Coronary Artery Disease trial has reported results of 300 patients in each arm to 2 years, and showed PCI to be non-inferior, but the authors accept that the non-inferiority margin was wide, leaving open the need for further studies.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> Similar ﬁndings have also been detected in a smaller study.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> To understand better the safety and efﬁcacy of the place of PCI for LMS stenosis, the Evaluation of Xience Prime versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularisation trial is ongoing in patients with LMS disease and syntax scores of ≤32.<a class="elsevierStyleCrossRefs" href="#bib0060">12,13</a>ESC/EACTS revascularisation guidelinesThe European Society for Cardiology and European Association of Cardiothoracic Surgery published guidelines for revascularisation in 2010 that were developed by a balanced writing team of interventional cardiologists, non-interventional cardiologists and surgeons. The guidelines recommend decision making through an appropriately conﬁgured ‘heart team’ and suggest that surgery is the better option for revascularisation for the majority of anatomical forms of coronary artery disease.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> Data published since the guidelines were released, including later analyses of the SYNTAX trial, have further reinforced the evidence on which the guidelines were based. Potential implications of these recommendations have been reported,<a class="elsevierStyleCrossRefs" href="#bib0075">15,16</a> but detailed analyses of any changes in practice are not yet available.Is off pump coronary artery surgery safe?Controversy remains surrounding the relative beneﬁts of undertaking coronary artery surgery with or without the cardiopulmonary bypass machine.<a class="elsevierStyleCrossRefs" href="#bib0085">17,18</a> In the UK, around 20% of cases are undertaken off pump but there are conﬂicting data about safety and longer-term outcomes.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Concern was raised from the ROOBY trial in which 2203 patients undergoing CABG were randomised to surgery on or off pump. There was no signiﬁcant difference in 30-day mortality, but there were a higher proportion of patients receiving fewer grafts than planned in the off-pump group. Of concern, there was a signiﬁcantly worse 1-year composite end point of death, repeat revascularisation or non-fatal MI and poorer graft patency in the off-pump group.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> Critics of the study have commented that the trial enrolled low risk, male patients who would be the least likely to beneﬁt from avoiding cardiopulmonary bypass, the surgeons were inexperienced and there was a high (12%) rate of intraoperative conversion to bypass surgery.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> Furthermore, endoscopic vein harvesting was associated with worse outcomes at 1 year in the study (see further below).<a class="elsevierStyleCrossRef" href="#bib0105">21</a> In addition, Moller et al have reported randomised trial data on 341 high risk (EuroSCORE >5) patients with three vessel disease undergoing surgery on or off pump in the Best Bypass Surgery trial. There was no signiﬁcant difference in primary outcome of adverse cardiac and cerebrovascular events during a median follow-up of 3.7 years, although all cause mortality was higher in the off-pump group.<a class="elsevierStyleCrossRef" href="#bib0110">22</a>More reassuring data have recently been published from the MASS 3 trial with 5-year follow-up from a single centre with no difference in a composite end point of death, MI or further revascularisation between the groups and from the CORONARY study, which randomised 4752 patients to on or off pump and showed no signiﬁcant difference in 30-day mortality or the incidence of MI, stroke and renal failure.<a class="elsevierStyleCrossRefs" href="#bib0115">23,24</a> Later outcomes data from this study are awaited with interest.There has also been a meta-analysis of 35 propensity score studies on 123 137 patients undergoing on or off pump surgery. This suggested that off-pump surgery was superior for short-term mortality and other outcomes.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> In a single centre study of 14 766 patients reported by Puskas et al there was no difference in operative mortality in the lowest risk quartile but increasing beneﬁt for higher risk patients, which supports the argument used by critics of the ﬁndings of the ROOBY study.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> Similar ﬁndings have been reported on 349 survivors of two randomised studies comparing on and of pump surgery in which 199 patients had graft patency assessed, and in 299 patients health-related quality of life, with no difference seen between the groups at 6–8 years.<a class="elsevierStyleCrossRef" href="#bib0135">27</a>While the beneﬁts or otherwise of off-pump surgery are not yet clearly deﬁned, there remains interest in optimising outcomes from on-pump surgery by reﬁning bypass techniques. For example, a recent trial has drawn attention to how the brain might be protected by using a minimal extracorporeal circulation.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> In this randomised comparison of minimal versus conventional extracorporeal circulation, the minimal circuit was associated with improved cerebral perfusion during cardiopulmonary bypass and improved neurocognitive performance on direct testing at discharge, with evidence of sustained effects at 3 and 14 months. The data suggest that some of the advantages proposed by off-pump enthusiasts, particularly cerebral protection, might be achieved by modifying on-pump strategies.Is endoscopic vein harvesting safe?In line with other moves towards less invasive surgery, there has been a signiﬁcant move towards harvesting the long saphenous vein through minimally invasive, including endoscopic, approaches but there remains some concern over safety. As described previously, a subgroup analysis of the ROOBY trial suggested that endoscopic vein harvesting was associated with worse outcomes.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> A secondary analysis of patients from the PREVENT IV trial at 3 years of follow-up also showed worse outcomes for patients undergoing endoscopic harvesting, but this ﬁnding has not been conﬁrmed in other observational studies.<a class="elsevierStyleCrossRefs" href="#bib0145">29–31</a>Should bilateral internal mammary artery grafts be used for coronary artery surgery?It is generally accepted that using the LIMA graft to the left anterior descending coronary artery is associated with better inhospital mortality, long-term survival and freedom from angina, and a number of observers suggest that if one mammary is good, two would be better. Despite this, <10% of coronary artery operations in the UK receive both internal mammary arteries.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> To address this, the ART trial is a large randomised study, which has now reported 1-year data on 1554 patients receiving a single LIMA graft and 1548 receiving bilateral mammary arteries (BIMA). It has been powered to look at survival at 10 years. The 1-year data show no mortality difference between the groups but there was a three times increase in the rate of sternal wound reconstruction in the BIMA group.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> In view of our understanding of the timing of vein graft failure it would have been surprising to see any beneﬁt from BIMA grafting at this stage. Further supportive evidence for the beneﬁcial effect of BIMA has been shown from a single centre propensity matched study of 928 BIMA versus 928 LIMA and saphenous vein grafts reporting to 17 years with a survival beneﬁt of 10% at 10 years and 18% at 15 years.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> There has been great interest in the use of the radial artery as a conduit for coronary artery bypass surgery, with enthusiasts recommending its use, either alongside both internal mammary arteries for a total arterial grafting approach or in addition to a single mammary artery, to improve long-term outcomes. However, a randomised study of 733 patients comparing radial artery grafts to saphenous veins has recently shown similar graft patency at 1 year (both 89%).<a class="elsevierStyleCrossRef" href="#bib0170">34</a> Of concern, the radial artery was associated with a higher incidence of vasospasm in this study and the saphenous vein had better outcomes in diabetic patients. Further concern has been raised from a study using CT scanning to assess graft patency.<a class="elsevierStyleCrossRef" href="#bib0175">35</a> However, there remain a numbers of reports claiming good late patency rates.<a class="elsevierStyleCrossRefs" href="#bib0180">36–38</a>Most of the studies looking at comparative outcomes of different surgical strategies have relied on late outcomes, with mortality being most important, and these data are obviously difﬁcult to collect and they only provide useful information many years ‘after the event’. To help provide useful and more timely differential data, some workers have been looking at techniques to assess preoperative risk other than clinical outcomes such as per-operative injury to the left ventricular myocardium. This is hard to quantify and was the subject of a recent study from Oxford in which 40 patients underwent cardiac MR before and after CABG with serial assessment of troponin I (TnI).<a class="elsevierStyleCrossRef" href="#bib0195">39</a> TnI correlated closely with the mass of new cardiac MR necrosis (r<0.83, p<0.001), with sensitivity and speciﬁcity values of 75% and 87%, making it a robust means of diagnosing this type of MI.Alongside analyses of ways to optimise operative surgical strategy, there is also an increasing focus on non-mortality postoperative outcomes and pathways. For example, a study published in this journal has examine the implications of postoperative anaemia in a retrospective analysis of 2553 CABG patients included in the IMAGINE trial.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> They showed that postoperative anaemia sustained for >50 days is associated with an increased incidence of cardiovascular events during the ﬁrst 3 months. The researchers also found that ACE inhibition slowed recovery from postoperative anaemia and increased the incidence of cardiovascular events after CABG, although the mechanism and therapeutic implication of this observation is not clear. It is also become increasingly accepted that formal cardiac rehabilitation is beneﬁcial to enhance recovery after CABG surgery, with an emphasis being placed on exercise programmes. While the best means of delivering these programmes is unclear, a Canadian study favoured a home-based strategy based on a 6-year follow-up of patients randomised to hospital versus telephone-monitored home-based exercise training.<a class="elsevierStyleCrossRef" href="#bib0205">41</a>Coronary artery surgery for heart failure?The STICH trial has showed that there is no difference in survival between patients with heart failure and poor left ventricular function, randomised to either medical therapy or medical therapy plus CABG. In a subset of this study in which myocardial viability was assessed, the presence of viable myocardium was associated with better survival overall, but this was not signiﬁcant after adjusting for other baseline variables.<a class="elsevierStyleCrossRefs" href="#bib0210">42,43</a> Taken at face value these are profound ﬁndings for the practice of coronary artery surgery and are at odds with many physicians and surgeons preconceptions, but some observers have questioned whether the ﬁndings of the trial are valid because of difﬁculties in trial recruitment leading to changes in trial design after instigation alongside a crossover rate of 17% to CABG, therefore underestimating the beneﬁts of surgery and suggesting that CABG should still be considered if CAD is severe and viable myocardium is seen.<a class="elsevierStyleCrossRef" href="#bib0220">44</a> For example, a recent propensity matched study of CABG versus medical therapy in these patients (designed to mimic the STICH trial inclusion) showed a clear survival advantage of CABG at 10 years.<a class="elsevierStyleCrossRef" href="#bib0225">45</a>Aortic valve surgeryThe practice of aortic valve surgery is changing. In the USA, an analysis of 108 687 isolated aortic valve replacement (AVR) patients from 1997 to 2006 was reported in 2009.<a class="elsevierStyleCrossRef" href="#bib0230">46</a> Morbidity and mortality have fallen despite gradual increases in patient age and overall risk proﬁle, alongside an increase in biological valve use. Similar trends have been seen in the UK with a report of 41 227 patients between 2004 and 2009 with an overall inhospital mortality of 4.1%. The annual number increased by 20%, with signiﬁcant increases in the mean age of patients with aortic stenosis, octogenarians, the proportion of high-risk patients and again those receiving biological valves (which is almost certainly inﬂuenced by surgeons’ views of better longevity of modern biological valves and the promise of a transcatheter valve solution for subsequent valve failure).<a class="elsevierStyleCrossRef" href="#bib0235">47</a> Over this time, inhospital mortality decreased from 4.4% to 3.7%.<a class="elsevierStyleCrossRef" href="#bib0240">48</a> While transcatheter valve insertion (TAVI) (see below) is having an impact on valve surgery, in contract to just eroding the numbers of conventional valve operations, it has been reported that starting a TAVI service may increase overall aortic valve interventions, including those for conventional surgery.<a class="elsevierStyleCrossRef" href="#bib0245">49</a> There remains some controversy about the timing of surgery in asymptomatic aortic stenosis (see parallels with mitral valve repair below). Some work is being produced suggesting beneﬁts from earlier intervention but other observers have published data suggesting beneﬁts and safety of the watchful waiting approach.<a class="elsevierStyleCrossRefs" href="#bib0250">50–53</a>Transcatheter valve insertionThe major change in the treatment of patients with aortic stenosis in recent years has been the advent of TAVI, which has now been shown to be a good option for the treatment of some patients with aortic stenosis. The Partner study Cohort A trial of 358 patients who were not considered suitable for conventional AVR showed that TAVI decreased the rate of mortality at 1 year (from 51% to 31%) and reduced cardiac symptoms compared with conventional treatment.<a class="elsevierStyleCrossRef" href="#bib0270">54</a> The 2-year results have also been reported showing persistent survival advantage, but a high rate of stroke in the TAVI group, due to more ischaemic strokes in the ﬁrst 30 days after the procedure and more haemorrhagic events thereafter. The rate of rehospitalisation was 35% in the TAVI group and 72% in the conventional group. Quality of life studies on these patients using the Kansas City Cardiomyopathy Questionnaire and the SF-12 showed signiﬁcant beneﬁts in the TAVI group going out to 1 year.<a class="elsevierStyleCrossRef" href="#bib0275">55</a> An economic analysis of these data demonstrated an incremental cost per life-year gained that was well within the acceptable range.<a class="elsevierStyleCrossRef" href="#bib0280">56</a>TAVI has also been shown to be comparable with conventional aortic valve surgery. In the Partner study Cohort B, 699 patients with severe aortic stenosis who were deemed to be high risk were randomised to TAVI or conventional surgery.<a class="elsevierStyleCrossRef" href="#bib0285">57</a> There was no signiﬁcant difference in mortality rates at 30 days (3.4% TAVI and 6.5% conventional surgery) or 1 year (24.2% TAVI, 26.8% conventional surgery). Two-year data have also been reported, again showing no difference in mortality rates.<a class="elsevierStyleCrossRef" href="#bib0290">58</a> Procedural complication rates were different between the groups, with major vascular complications being more common in the TAVI patients and bleeding and new onset atrial ﬁbrillation (AF) more common in conventional surgery. A number of large registry studies have also conﬁrmed acceptable procedural and longer-term outcomes.<a class="elsevierStyleCrossRefs" href="#bib0295">59–63</a>Transcatheter aortic valves are now being inserted in increasing numbers through the femoral artery, trans-apically directly via the left ventricle and through the aortic approach.<a class="elsevierStyleCrossRefs" href="#bib0320">64–66</a> In response to potential beneﬁts from less invasive approaches, there has also been increasing interest in conducting ‘conventional’ surgery through a variety of smaller incisions including mini-sternotomy, para-sternotomy, transverse sternotomy and right anterior thoracotomy. Various studies including single centre experiences and meta-analyses have shown that it can be applied safely in expert centres.<a class="elsevierStyleCrossRefs" href="#bib0335">67,68</a> Alongside less invasive approaches, to minimise insertion times and allow easier valve implantation through small incisions, various novel aortic valves are being developed and tested which have ‘sutureless’ implantation techniques.<a class="elsevierStyleCrossRefs" href="#bib0345">69,70</a>A ﬁnal word on aortic valve surgery and TAVI is that there are now consensus statements produced about the practice of TAVI and to understand better how to achieve optimal outcomes from conventional AVR, health service research studies have shown that outcomes of surgery are better for higher risk patients under high volume surgeons, which lays down a challenge for conﬁguration of surgical services for these patients.<a class="elsevierStyleCrossRefs" href="#bib0355">71,72</a>Mitral valve surgeryThe major advances in understanding of mitral valve surgery in recent years are related to mitral valve repair. It is now well accepted that repair is a better option than replacement for most patients with degenerative mitral valve disease, and that inhospital and later mortality outcomes are dependent on the degree of symptoms and left ventricular dysfunction at the time of surgery. Evidence from the UK suggests that many patients are still being referred late in the disease process with 47% of patients having NYHA class 3 or 4 symptoms and 31% of people displaying left ventricular (LV) ejection fractions of <50% at the time of surgery.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Surgical treatment for mitral valve disease is changing over time, and a report on 58 370 patients with isolated mitral regurgitation from the STS database in the 8 years to December 2007 showed progressive adoption of mitral repair rather than replacement from 51% to 69%. There was also a decrease in the use of mechanical rather than biological valves over that time from 68% to 37% (and there are similar data from the UK).<a class="elsevierStyleCrossRefs" href="#bib0005">1,73</a> This, of course, indicates that one in three patients with severe MR undergo a valve replacement, and this remains a concern from the perspective of health service delivery.<a class="elsevierStyleCrossRef" href="#bib0370">74</a>The major controversy around patients with severe MR is around the timing of surgery. There are no randomised trial data to support early surgery or ‘watchful waiting’ and so the evidence is derived from observation studies. In 2005, Enriquez-Sarano and colleagues from the Mayo Clinic reported an observational study on 456 patients with symptomatic organic mitral regurgitation, showing that patients with an effective regurgitant oriﬁce area of >40mm2 had a survival at 5 years that was lower than expected.<a class="elsevierStyleCrossRef" href="#bib0375">75</a> On this basis, they recommended mitral valve repair for patients with genuinely severe mitral regurgitation, purely on the basis of symptoms, irrespective of left ventricular size or function. Similar ﬁndings have been reported from Korea on 447 consecutive asymptomatic patients undergoing early surgery or conventional treatment strategy with early surgery associated with improved long-term event rates by decreasing cardiac mortality and congestive heart failure hospitalisation.<a class="elsevierStyleCrossRef" href="#bib0380">76</a> A further observational study of 192 patients followed up for 8.5 years, divided into an early surgery and a conservative group, also showed better outcomes in the conservative group.<a class="elsevierStyleCrossRef" href="#bib0385">77</a>Conversely, Rosenhek et al have reported outcomes on 132 patients and only intervened at the time of onset of symptoms, left ventricular impairment or signiﬁcant LV dilatation according to the accepted guidelines of the time of onset of symptoms, left ventricular impairment or signiﬁcant LV dilatation.<a class="elsevierStyleCrossRefs" href="#bib0390">78,79</a> Overall, late outcomes were excellent, and only a third of patients required surgery during the follow-up period of 5 years, but it is obviously important that if this strategy is followed, follow-up must be robust and comprehensive.Guidance from the American College of Cardiology/American Heart Association from 2006 suggests that early surgery should be considered for asymptomatic patients at low procedural risk in ‘experienced centres’ as long as the likelihood of successful repair is >90%.<a class="elsevierStyleCrossRef" href="#bib0400">80</a> An attempt has been made from a UK consensus study to describe the criteria associated with an experienced centre.<a class="elsevierStyleCrossRef" href="#bib0405">81</a> However, if one comes from an surgical epidemiology approach there must be some concern about an overall early surgery strategy for these patients.<a class="elsevierStyleCrossRef" href="#bib0370">74</a> In a report of 13 614 patients with mitral regurgitation undergoing surgery from the STS database there was marked variation in overall volumes per year, and higher volume centres showed higher rates of valve repair and lower risk adjusted mortality.<a class="elsevierStyleCrossRef" href="#bib0410">82</a> Again from the STS database in an analysis of 28 507 patients undergoing isolated mitral valve surgery with or without tricuspid valve or concomitant AF surgery under 1088 surgeons, the mean rate of repair by surgeon was only 41%. The median annual number of operation was 5 (1-166) and increasing surgeon volume was independently associated with increased probability of repair.<a class="elsevierStyleCrossRef" href="#bib0415">83</a> The consensus-based opinion study from the UK has suggested that hospitals should be undertaking more than 50 mitral repair operations each year to get optimal outcomes, and individual surgeons should be doing more than 25. It seems that many hospitals and surgeons fall short of this. Offering an early surgical strategy in the absence of assurance about high repair rates and excellent durability of repair procedures may not be in the patients’ best interests.There have been some developments in the techniques of mitral valve repair with a move towards more use of artiﬁcial chordae tendinae and preservation of leaﬂet tissue rather than resection and increasing use of less invasive techniques.<a class="elsevierStyleCrossRefs" href="#bib0420">84–89</a> While there are a growing number of reports suggesting the safety of minimally invasive approaches, there is signiﬁcant anecdotal reporting of the concern about these techniques and their safety.There are also developments in catheter-based treatments of mitral regurgitation, and the Endovascular valve edge to edge repair (EVEREST 2) trial has reported the outcomes of 78 patients at high risk from conventional surgery having an ‘edge to edge’ treatment with the ‘MitralClip’ showing a procedural mortality of 7.7% with a reduction in MR in most patients with an improvement in clinical symptoms in three-fourths of the patients.<a class="elsevierStyleCrossRef" href="#bib0450">90</a>Risk modellingThe assessment of operative risk in cardiac surgery is important to guide decision making (eg, conventional surgery or TAVI for patients with aortic stenosis), support informed consent and for governance and public reporting of hospital and surgeon mortality rates. The STS scores were published in 2009 after analysing data from the STS database, with models published for coronary artery surgery, valve surgery and combined coronary and valve surgery. These model a standard set of outcomes for all procedures including mortality, stroke, reoperation, renal failure, deep sternal wound infection, prolonged ventilation, composite major morbidity, prolonged length of stay and short length of stay.<a class="elsevierStyleCrossRefs" href="#bib0455">91–94</a>More recently, it has been accepted that the EuroSCORE is no longer suitable for contemporary practice and the EuroSCORE 2 has been published.<a class="elsevierStyleCrossRefs" href="#bib0475">95,96</a> Unlike the STS models, which are procedure speciﬁc, the EuroSCORE 2 is a generic model covering all cardiac surgery, which has some potential strengths and weaknesses. It was derived from a patient population of 22 381 consecutive patients undergoing major cardiac surgery in 154 hospitals in 43 countries over a 12-week period (May 2010 to July 2010). The ﬁelds required to derive the score have been updated from the previous model and include creatinine clearance, modiﬁcations to the categorisation of LV ejection fraction and introduction of a limited mobility ﬁeld.<a class="elsevierStyleCrossRefs" href="#bib0480">96,97</a> The ‘weight of intervention’ is also dealt with differently from the original EuroSCORE model. The developers report good discrimination and calibration and it is likely this model will be widely adopted, but it will require robust external validation. There remains debate about the derivation and use of this type of model.<a class="elsevierStyleCrossRef" href="#bib0490">98</a>ContributorsBB wrote the manuscript.Competing interestsNone.Provenance and peer reviewCommissioned; internally peer reviewed." "textoCompletoSecciones" => array:1 [ "secciones" => array:17 [ 0 => array:2 [ "identificador" => "xres177672" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 2 => array:2 [ "identificador" => "sec0010" "titulo" => "Coronary artery surgery" ] 3 => array:2 [ "identificador" => "sec0015" "titulo" => "Coronary artery surgery or PCI for angina" ] 4 => array:2 [ "identificador" => "sec0020" "titulo" => "ESC/EACTS revascularisation guidelines" ] 5 => array:2 [ "identificador" => "sec0025" "titulo" => "Is off pump coronary artery surgery safe?" ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Is endoscopic vein harvesting safe?" ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Should bilateral internal mammary artery grafts be used for coronary artery surgery?" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Coronary artery surgery for heart failure?" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Aortic valve surgery" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Transcatheter valve insertion" ] 11 => array:2 [ "identificador" => "sec0055" "titulo" => "Mitral valve surgery" ] 12 => array:2 [ "identificador" => "sec0060" "titulo" => "Risk modelling" ] 13 => array:2 [ "identificador" => "sec0065" "titulo" => "Contributors" ] 14 => array:2 [ "identificador" => "sec0070" "titulo" => "Competing interests" ] 15 => array:2 [ "identificador" => "sec0075" "titulo" => "Provenance and peer review" ] 16 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-11-15" "fechaAceptado" => "2012-11-15" "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "This review covers the important publications in adult cardiac surgery in the last few years, including the current evidence base for surgical revascularisation and the use of off-pump surgery, bilateral internal mammary arteries and endoscopic vein harvesting. The changes in conventional aortic valve surgery are described alongside the outcomes of clinical trials and registries for transcatheter aortic valve implantation, and the introduction of less invasive and novel approaches of conventional aortic valve replacement surgery. Surgery for mitral valve disease is also considered, with particular reference to surgery for asymptomatic degenerative mitral regurgitation." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Secondary publication. This article was published in its entirety, with the consent of the authors and editors, in Heart 2012;98:1412–7 doi:10.1136/heartjnl-2011-301539." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:98 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Demonstrating Quality; The Sixth National Annual Cardiac Database Report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "B. Bridgewater" 1 => "R. Kinsman" 2 => "P. 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Almanac 2012: Adult cardiac surgery: The national society journals present selected research that has driven recent advances in clinical cardiology

Ben Bridgewater

Department of Cardiothoracic Surgery, Wythenshave Hospital, Manchester, UK

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiac surgery remains an important treatment option for many patients with coronary artery disease&#44; valvular heart disease and heart failure&#46; Coronary artery remains the commonest operation undertaken in most centres&#44; but its proportion is decreasing in the UK&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> More patients are undergoing mitral and aortic valve procedures&#44; both by conventional and novel approaches including smaller incisions for conventional surgery and insertion of new prostheses using catheter-based devices&#46; This article will summarise publications from recent years that are having an impact on the practice of cardiac surgery&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Coronary artery surgery</span><p id="par0010" class="elsevierStylePara elsevierViewall">There are marked changes in patients coming to coronary artery surgery over time that have been shown clearly from the analyses of large series from the USA and UK&#46; A report from the Society for Thoracic Surgeons &#40;STS&#41; database has described the increasing risk pro&#64257;le of patients coming to surgery with fewer smokers&#44; more patients with diabetes and more use of the left internal mammary artery &#40;LIMA&#41; as a bypass conduit&#46; Overall&#44; there has been a signi&#64257;cant decline in postoperative mortality and morbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Similar trends have been reported in the UK from the national adult cardiac surgery database&#44; where there has been a greater than 50&#37; reduction in risk adjusted mortality since 2000&#44; again with increasing risk pro&#64257;les&#44; and more use of the internal mammary artery&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> However&#44; despite some evidence for their ef&#64257;cacy&#44; off-pump surgery and multiple arterial grafts have not become widespread &#40;see below&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Coronary artery surgery or PCI for angina</span><p id="par0015" class="elsevierStylePara elsevierViewall">The major contemporary randomised clinical trial to inform decision making in patients with multi-vessel coronary artery disease is the Synergy between PCI with Taxus and Cardiac Surgery &#40;SYNTAX&#41; trial&#46; The study randomised 1800 patients with previously treated three vessel or left main coronary artery disease or both in 85 sites in 17 countries across Europe and the USA&#46; The 1-year results were published in 2009&#44; showing that the percutaneous coronary intervention &#40;PCI&#41; group had higher rates of the combined end point of major adverse cardiac or cerebrovascular events and failed to achieve the prede&#64257;ned end point of non-inferiority&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> This difference was driven by a high rate of repeat revascularisation in the PCI group &#40;13&#46;5&#37; PCI&#44; 5&#46;9&#37; coronary artery bypass grafting &#40;CABG&#41;&#41;&#46; The 1-year rates of death or myocardial infarction &#40;MI&#41; were not different between the groups&#46; These differences persist over longer follow-up with 3-year MACCE rates &#40;death stroke&#44; MI or repeat revascularisation&#41; being higher in the PCI group &#40;28&#37;&#41; than the CABG group &#40;20&#37;&#41;&#44; again driven mainly by repeat revascularisation&#44; but there was no difference in the primary safety end point or the incidence of stroke&#46; On subgroup analysis&#44; there was no difference in major adverse events in the patients with left main stem &#40;LMS&#41; stenosis&#44; but outcomes were worse following PCI in the three vessel subgroup&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Analysis of outcomes based on procedural risk from the syntax score has shown at 4 years that the curves are diverging overall&#44; but with no difference in the low risk patients &#40;<a href="http://%20www.syntaxscore.com/">http&#58;&#47;&#47;www&#46;syntaxscore&#46;com</a>&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In line with the data from SYNTAX&#44; a large registry-based study from the USA linked the ACCF National Cardiovascular registry and the STS adult cardiac surgery database to the Medicare and Medicaid registries and used propensity scoring to match patients who were 65 years or older undergoing PCI and CABG&#46; Four years after intervention there was a mortality advantage in the CABG group&#44; which persisted in the important subgroups&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">While the late outcomes of most higher risk patients with multi-vessel coronary artery disease seem to be better with CABG&#44; in both randomised and registry-based studies&#44; the outcome following intervention for LMS stenosis is not so clear cut&#44; certainly during early follow-up&#46; In a meta-analysis of patients with unprotected LMS stenosis analysing 2905 patients from eight clinical studies&#44; there was no signi&#64257;cant difference between the two groups with respect to mortality or a composite end point of death&#44; MI or stroke at 1 year&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Another meta-analysis of 3773 patients looking out to 3 years gave similar &#64257;ndings&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Analysis of the left main subgroup of the SYNTAX study also showed no difference up to 3 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;9</span></a> More recently&#44; the Premier of Randomised Comparison of Bypass Surgery Versus Angioplasty using Sirolimus-Eluting Stent in Patients with Coronary Artery Disease trial has reported results of 300 patients in each arm to 2 years&#44; and showed PCI to be non-inferior&#44; but the authors accept that the non-inferiority margin was wide&#44; leaving open the need for further studies&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Similar &#64257;ndings have also been detected in a smaller study&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> To understand better the safety and ef&#64257;cacy of the place of PCI for LMS stenosis&#44; the Evaluation of Xience Prime versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularisation trial is ongoing in patients with LMS disease and syntax scores of &#8804;32&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">ESC&#47;EACTS revascularisation guidelines</span><p id="par0030" class="elsevierStylePara elsevierViewall">The European Society for Cardiology and European Association of Cardiothoracic Surgery published guidelines for revascularisation in 2010 that were developed by a balanced writing team of interventional cardiologists&#44; non-interventional cardiologists and surgeons&#46; The guidelines recommend decision making through an appropriately con&#64257;gured &#8216;heart team&#8217; and suggest that surgery is the better option for revascularisation for the majority of anatomical forms of coronary artery disease&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Data published since the guidelines were released&#44; including later analyses of the SYNTAX trial&#44; have further reinforced the evidence on which the guidelines were based&#46; Potential implications of these recommendations have been reported&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a> but detailed analyses of any changes in practice are not yet available&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Is off pump coronary artery surgery safe&#63;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Controversy remains surrounding the relative bene&#64257;ts of undertaking coronary artery surgery with or without the cardiopulmonary bypass machine&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> In the UK&#44; around 20&#37; of cases are undertaken off pump but there are con&#64258;icting data about safety and longer-term outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Concern was raised from the ROOBY trial in which 2203 patients undergoing CABG were randomised to surgery on or off pump&#46; There was no signi&#64257;cant difference in 30-day mortality&#44; but there were a higher proportion of patients receiving fewer grafts than planned in the off-pump group&#46; Of concern&#44; there was a signi&#64257;cantly worse 1-year composite end point of death&#44; repeat revascularisation or non-fatal MI and poorer graft patency in the off-pump group&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Critics of the study have commented that the trial enrolled low risk&#44; male patients who would be the least likely to bene&#64257;t from avoiding cardiopulmonary bypass&#44; the surgeons were inexperienced and there was a high &#40;12&#37;&#41; rate of intraoperative conversion to bypass surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Furthermore&#44; endoscopic vein harvesting was associated with worse outcomes at 1 year in the study &#40;see further below&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> In addition&#44; Moller <span class="elsevierStyleItalic">et al</span> have reported randomised trial data on 341 high risk &#40;EuroSCORE &#62;5&#41; patients with three vessel disease undergoing surgery on or off pump in the Best Bypass Surgery trial&#46; There was no signi&#64257;cant difference in primary outcome of adverse cardiac and cerebrovascular events during a median follow-up of 3&#46;7 years&#44; although all cause mortality was higher in the off-pump group&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">More reassuring data have recently been published from the MASS 3 trial with 5-year follow-up from a single centre with no difference in a composite end point of death&#44; MI or further revascularisation between the groups and from the CORONARY study&#44; which randomised 4752 patients to on or off pump and showed no signi&#64257;cant difference in 30-day mortality or the incidence of MI&#44; stroke and renal failure&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> Later outcomes data from this study are awaited with interest&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">There has also been a meta-analysis of 35 propensity score studies on 123 137 patients undergoing on or off pump surgery&#46; This suggested that off-pump surgery was superior for short-term mortality and other outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> In a single centre study of 14 766 patients reported by Puskas <span class="elsevierStyleItalic">et al</span> there was no difference in operative mortality in the lowest risk quartile but increasing bene&#64257;t for higher risk patients&#44; which supports the argument used by critics of the &#64257;ndings of the ROOBY study&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Similar &#64257;ndings have been reported on 349 survivors of two randomised studies comparing on and of pump surgery in which 199 patients had graft patency assessed&#44; and in 299 patients health-related quality of life&#44; with no difference seen between the groups at 6&#8211;8 years&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">While the bene&#64257;ts or otherwise of off-pump surgery are not yet clearly de&#64257;ned&#44; there remains interest in optimising outcomes from on-pump surgery by re&#64257;ning bypass techniques&#46; For example&#44; a recent trial has drawn attention to how the brain might be protected by using a minimal extracorporeal circulation&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> In this randomised comparison of minimal versus conventional extracorporeal circulation&#44; the minimal circuit was associated with improved cerebral perfusion during cardiopulmonary bypass and improved neurocognitive performance on direct testing at discharge&#44; with evidence of sustained effects at 3 and 14 months&#46; The data suggest that some of the advantages proposed by off-pump enthusiasts&#44; particularly cerebral protection&#44; might be achieved by modifying on-pump strategies&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Is endoscopic vein harvesting safe&#63;</span><p id="par0060" class="elsevierStylePara elsevierViewall">In line with other moves towards less invasive surgery&#44; there has been a signi&#64257;cant move towards harvesting the long saphenous vein through minimally invasive&#44; including endoscopic&#44; approaches but there remains some concern over safety&#46; As described previously&#44; a subgroup analysis of the ROOBY trial suggested that endoscopic vein harvesting was associated with worse outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> A secondary analysis of patients from the PREVENT IV trial at 3 years of follow-up also showed worse outcomes for patients undergoing endoscopic harvesting&#44; but this &#64257;nding has not been con&#64257;rmed in other observational studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#8211;31</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Should bilateral internal mammary artery grafts be used for coronary artery surgery&#63;</span><p id="par0065" class="elsevierStylePara elsevierViewall">It is generally accepted that using the LIMA graft to the left anterior descending coronary artery is associated with better inhospital mortality&#44; long-term survival and freedom from angina&#44; and a number of observers suggest that if one mammary is good&#44; two would be better&#46; Despite this&#44; &#60;10&#37; of coronary artery operations in the UK receive both internal mammary arteries&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> To address this&#44; the ART trial is a large randomised study&#44; which has now reported 1-year data on 1554 patients receiving a single LIMA graft and 1548 receiving bilateral mammary arteries &#40;BIMA&#41;&#46; It has been powered to look at survival at 10 years&#46; The 1-year data show no mortality difference between the groups but there was a three times increase in the rate of sternal wound reconstruction in the BIMA group&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> In view of our understanding of the timing of vein graft failure it would have been surprising to see any bene&#64257;t from BIMA grafting at this stage&#46; Further supportive evidence for the bene&#64257;cial effect of BIMA has been shown from a single centre propensity matched study of 928 BIMA versus 928 LIMA and saphenous vein grafts reporting to 17 years with a survival bene&#64257;t of 10&#37; at 10 years and 18&#37; at 15 years&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> There has been great interest in the use of the radial artery as a conduit for coronary artery bypass surgery&#44; with enthusiasts recommending its use&#44; either alongside both internal mammary arteries for a total arterial grafting approach or in addition to a single mammary artery&#44; to improve long-term outcomes&#46; However&#44; a randomised study of 733 patients comparing radial artery grafts to saphenous veins has recently shown similar graft patency at 1 year &#40;both 89&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Of concern&#44; the radial artery was associated with a higher incidence of vasospasm in this study and the saphenous vein had better outcomes in diabetic patients&#46; Further concern has been raised from a study using CT scanning to assess graft patency&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> However&#44; there remain a numbers of reports claiming good late patency rates&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#8211;38</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Most of the studies looking at comparative outcomes of different surgical strategies have relied on late outcomes&#44; with mortality being most important&#44; and these data are obviously dif&#64257;cult to collect and they only provide useful information many years &#8216;after the event&#8217;&#46; To help provide useful and more timely differential data&#44; some workers have been looking at techniques to assess preoperative risk other than clinical outcomes such as per-operative injury to the left ventricular myocardium&#46; This is hard to quantify and was the subject of a recent study from Oxford in which 40 patients underwent cardiac MR before and after CABG with serial assessment of troponin I &#40;TnI&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> TnI correlated closely with the mass of new cardiac MR necrosis &#40;r&#60;0&#46;83&#44; p&#60;0&#46;001&#41;&#44; with sensitivity and speci&#64257;city values of 75&#37; and 87&#37;&#44; making it a robust means of diagnosing this type of MI&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Alongside analyses of ways to optimise operative surgical strategy&#44; there is also an increasing focus on non-mortality postoperative outcomes and pathways&#46; For example&#44; a study published in this journal has examine the implications of postoperative anaemia in a retrospective analysis of 2553 CABG patients included in the IMAGINE trial&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> They showed that postoperative anaemia sustained for &#62;50 days is associated with an increased incidence of cardiovascular events during the &#64257;rst 3 months&#46; The researchers also found that ACE inhibition slowed recovery from postoperative anaemia and increased the incidence of cardiovascular events after CABG&#44; although the mechanism and therapeutic implication of this observation is not clear&#46; It is also become increasingly accepted that formal cardiac rehabilitation is bene&#64257;cial to enhance recovery after CABG surgery&#44; with an emphasis being placed on exercise programmes&#46; While the best means of delivering these programmes is unclear&#44; a Canadian study favoured a home-based strategy based on a 6-year follow-up of patients randomised to hospital versus telephone-monitored home-based exercise training&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Coronary artery surgery for heart failure&#63;</span><p id="par0080" class="elsevierStylePara elsevierViewall">The STICH trial has showed that there is no difference in survival between patients with heart failure and poor left ventricular function&#44; randomised to either medical therapy or medical therapy plus CABG&#46; In a subset of this study in which myocardial viability was assessed&#44; the presence of viable myocardium was associated with better survival overall&#44; but this was not signi&#64257;cant after adjusting for other baseline variables&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a> Taken at face value these are profound &#64257;ndings for the practice of coronary artery surgery and are at odds with many physicians and surgeons preconceptions&#44; but some observers have questioned whether the &#64257;ndings of the trial are valid because of dif&#64257;culties in trial recruitment leading to changes in trial design after instigation alongside a crossover rate of 17&#37; to CABG&#44; therefore underestimating the bene&#64257;ts of surgery and suggesting that CABG should still be considered if CAD is severe and viable myocardium is seen&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> For example&#44; a recent propensity matched study of CABG versus medical therapy in these patients &#40;designed to mimic the STICH trial inclusion&#41; showed a clear survival advantage of CABG at 10 years&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Aortic valve surgery</span><p id="par0085" class="elsevierStylePara elsevierViewall">The practice of aortic valve surgery is changing&#46; In the USA&#44; an analysis of 108 687 isolated aortic valve replacement &#40;AVR&#41; patients from 1997 to 2006 was reported in 2009&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> Morbidity and mortality have fallen despite gradual increases in patient age and overall risk pro&#64257;le&#44; alongside an increase in biological valve use&#46; Similar trends have been seen in the UK with a report of 41 227 patients between 2004 and 2009 with an overall inhospital mortality of 4&#46;1&#37;&#46; The annual number increased by 20&#37;&#44; with signi&#64257;cant increases in the mean age of patients with aortic stenosis&#44; octogenarians&#44; the proportion of high-risk patients and again those receiving biological valves &#40;which is almost certainly in&#64258;uenced by surgeons&#8217; views of better longevity of modern biological valves and the promise of a transcatheter valve solution for subsequent valve failure&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> Over this time&#44; inhospital mortality decreased from 4&#46;4&#37; to 3&#46;7&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> While transcatheter valve insertion &#40;TAVI&#41; &#40;see below&#41; is having an impact on valve surgery&#44; in contract to just eroding the numbers of conventional valve operations&#44; it has been reported that starting a TAVI service may increase overall aortic valve interventions&#44; including those for conventional surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> There remains some controversy about the timing of surgery in asymptomatic aortic stenosis &#40;see parallels with mitral valve repair below&#41;&#46; Some work is being produced suggesting bene&#64257;ts from earlier intervention but other observers have published data suggesting bene&#64257;ts and safety of the watchful waiting approach&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50&#8211;53</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Transcatheter valve insertion</span><p id="par0090" class="elsevierStylePara elsevierViewall">The major change in the treatment of patients with aortic stenosis in recent years has been the advent of TAVI&#44; which has now been shown to be a good option for the treatment of some patients with aortic stenosis&#46; The Partner study Cohort A trial of 358 patients who were not considered suitable for conventional AVR showed that TAVI decreased the rate of mortality at 1 year &#40;from 51&#37; to 31&#37;&#41; and reduced cardiac symptoms compared with conventional treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> The 2-year results have also been reported showing persistent survival advantage&#44; but a high rate of stroke in the TAVI group&#44; due to more ischaemic strokes in the &#64257;rst 30 days after the procedure and more haemorrhagic events thereafter&#46; The rate of rehospitalisation was 35&#37; in the TAVI group and 72&#37; in the conventional group&#46; Quality of life studies on these patients using the Kansas City Cardiomyopathy Questionnaire and the SF-12 showed signi&#64257;cant bene&#64257;ts in the TAVI group going out to 1 year&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> An economic analysis of these data demonstrated an incremental cost per life-year gained that was well within the acceptable range&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">TAVI has also been shown to be comparable with conventional aortic valve surgery&#46; In the Partner study Cohort B&#44; 699 patients with severe aortic stenosis who were deemed to be high risk were randomised to TAVI or conventional surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> There was no signi&#64257;cant difference in mortality rates at 30 days &#40;3&#46;4&#37; TAVI and 6&#46;5&#37; conventional surgery&#41; or 1 year &#40;24&#46;2&#37; TAVI&#44; 26&#46;8&#37; conventional surgery&#41;&#46; Two-year data have also been reported&#44; again showing no difference in mortality rates&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> Procedural complication rates were different between the groups&#44; with major vascular complications being more common in the TAVI patients and bleeding and new onset atrial &#64257;brillation &#40;AF&#41; more common in conventional surgery&#46; A number of large registry studies have also con&#64257;rmed acceptable procedural and longer-term outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">59&#8211;63</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Transcatheter aortic valves are now being inserted in increasing numbers through the femoral artery&#44; trans-apically directly via the left ventricle and through the aortic approach&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">64&#8211;66</span></a> In response to potential bene&#64257;ts from less invasive approaches&#44; there has also been increasing interest in conducting &#8216;conventional&#8217; surgery through a variety of smaller incisions including mini-sternotomy&#44; para-sternotomy&#44; transverse sternotomy and right anterior thoracotomy&#46; Various studies including single centre experiences and meta-analyses have shown that it can be applied safely in expert centres&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">67&#44;68</span></a> Alongside less invasive approaches&#44; to minimise insertion times and allow easier valve implantation through small incisions&#44; various novel aortic valves are being developed and tested which have &#8216;sutureless&#8217; implantation techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">69&#44;70</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">A &#64257;nal word on aortic valve surgery and TAVI is that there are now consensus statements produced about the practice of TAVI and to understand better how to achieve optimal outcomes from conventional AVR&#44; health service research studies have shown that outcomes of surgery are better for higher risk patients under high volume surgeons&#44; which lays down a challenge for con&#64257;guration of surgical services for these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">71&#44;72</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Mitral valve surgery</span><p id="par0105" class="elsevierStylePara elsevierViewall">The major advances in understanding of mitral valve surgery in recent years are related to mitral valve repair&#46; It is now well accepted that repair is a better option than replacement for most patients with degenerative mitral valve disease&#44; and that inhospital and later mortality outcomes are dependent on the degree of symptoms and left ventricular dysfunction at the time of surgery&#46; Evidence from the UK suggests that many patients are still being referred late in the disease process with 47&#37; of patients having NYHA class 3 or 4 symptoms and 31&#37; of people displaying left ventricular &#40;LV&#41; ejection fractions of &#60;50&#37; at the time of surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Surgical treatment for mitral valve disease is changing over time&#44; and a report on 58 370 patients with isolated mitral regurgitation from the STS database in the 8 years to December 2007 showed progressive adoption of mitral repair rather than replacement from 51&#37; to 69&#37;&#46; There was also a decrease in the use of mechanical rather than biological valves over that time from 68&#37; to 37&#37; &#40;and there are similar data from the UK&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;73</span></a> This&#44; of course&#44; indicates that one in three patients with severe MR undergo a valve replacement&#44; and this remains a concern from the perspective of health service delivery&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The major controversy around patients with severe MR is around the timing of surgery&#46; There are no randomised trial data to support early surgery or &#8216;watchful waiting&#8217; and so the evidence is derived from observation studies&#46; In 2005&#44; Enriquez-Sarano and colleagues from the Mayo Clinic reported an observational study on 456 patients with symptomatic organic mitral regurgitation&#44; showing that patients with an effective regurgitant ori&#64257;ce area of &#62;40<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span> had a survival at 5 years that was lower than expected&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a> On this basis&#44; they recommended mitral valve repair for patients with genuinely severe mitral regurgitation&#44; purely on the basis of symptoms&#44; irrespective of left ventricular size or function&#46; Similar &#64257;ndings have been reported from Korea on 447 consecutive asymptomatic patients undergoing early surgery or conventional treatment strategy with early surgery associated with improved long-term event rates by decreasing cardiac mortality and congestive heart failure hospitalisation&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">76</span></a> A further observational study of 192 patients followed up for 8&#46;5 years&#44; divided into an early surgery and a conservative group&#44; also showed better outcomes in the conservative group&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Conversely&#44; Rosenhek <span class="elsevierStyleItalic">et al</span> have reported outcomes on 132 patients and only intervened at the time of onset of symptoms&#44; left ventricular impairment or signi&#64257;cant LV dilatation according to the accepted guidelines of the time of onset of symptoms&#44; left ventricular impairment or signi&#64257;cant LV dilatation&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">78&#44;79</span></a> Overall&#44; late outcomes were excellent&#44; and only a third of patients required surgery during the follow-up period of 5 years&#44; but it is obviously important that if this strategy is followed&#44; follow-up must be robust and comprehensive&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Guidance from the American College of Cardiology&#47;American Heart Association from 2006 suggests that early surgery should be considered for asymptomatic patients at low procedural risk in &#8216;experienced centres&#8217; as long as the likelihood of successful repair is &#62;90&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">80</span></a> An attempt has been made from a UK consensus study to describe the criteria associated with an experienced centre&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">81</span></a> However&#44; if one comes from an surgical epidemiology approach there must be some concern about an overall early surgery strategy for these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a> In a report of 13 614 patients with mitral regurgitation undergoing surgery from the STS database there was marked variation in overall volumes per year&#44; and higher volume centres showed higher rates of valve repair and lower risk adjusted mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">82</span></a> Again from the STS database in an analysis of 28 507 patients undergoing isolated mitral valve surgery with or without tricuspid valve or concomitant AF surgery under 1088 surgeons&#44; the mean rate of repair by surgeon was only 41&#37;&#46; The median annual number of operation was 5 &#40;1-166&#41; and increasing surgeon volume was independently associated with increased probability of repair&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">83</span></a> The consensus-based opinion study from the UK has suggested that hospitals should be undertaking more than 50 mitral repair operations each year to get optimal outcomes&#44; and individual surgeons should be doing more than 25&#46; It seems that many hospitals and surgeons fall short of this&#46; Offering an early surgical strategy in the absence of assurance about high repair rates and excellent durability of repair procedures may not be in the patients&#8217; best interests&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">There have been some developments in the techniques of mitral valve repair with a move towards more use of arti&#64257;cial chordae tendinae and preservation of lea&#64258;et tissue rather than resection and increasing use of less invasive techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">84&#8211;89</span></a> While there are a growing number of reports suggesting the safety of minimally invasive approaches&#44; there is signi&#64257;cant anecdotal reporting of the concern about these techniques and their safety&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">There are also developments in catheter-based treatments of mitral regurgitation&#44; and the Endovascular valve edge to edge repair &#40;EVEREST 2&#41; trial has reported the outcomes of 78 patients at high risk from conventional surgery having an &#8216;edge to edge&#8217; treatment with the &#8216;MitralClip&#8217; showing a procedural mortality of 7&#46;7&#37; with a reduction in MR in most patients with an improvement in clinical symptoms in three-fourths of the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">90</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Risk modelling</span><p id="par0140" class="elsevierStylePara elsevierViewall">The assessment of operative risk in cardiac surgery is important to guide decision making &#40;eg&#44; conventional surgery or TAVI for patients with aortic stenosis&#41;&#44; support informed consent and for governance and public reporting of hospital and surgeon mortality rates&#46; The STS scores were published in 2009 after analysing data from the STS database&#44; with models published for coronary artery surgery&#44; valve surgery and combined coronary and valve surgery&#46; These model a standard set of outcomes for all procedures including mortality&#44; stroke&#44; reoperation&#44; renal failure&#44; deep sternal wound infection&#44; prolonged ventilation&#44; composite major morbidity&#44; prolonged length of stay and short length of stay&#46;<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">91&#8211;94</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">More recently&#44; it has been accepted that the EuroSCORE is no longer suitable for contemporary practice and the EuroSCORE 2 has been published&#46;<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">95&#44;96</span></a> Unlike the STS models&#44; which are procedure speci&#64257;c&#44; the EuroSCORE 2 is a generic model covering all cardiac surgery&#44; which has some potential strengths and weaknesses&#46; It was derived from a patient population of 22 381 consecutive patients undergoing major cardiac surgery in 154 hospitals in 43 countries over a 12-week period &#40;May 2010 to July 2010&#41;&#46; The &#64257;elds required to derive the score have been updated from the previous model and include creatinine clearance&#44; modi&#64257;cations to the categorisation of LV ejection fraction and introduction of a limited mobility &#64257;eld&#46;<a class="elsevierStyleCrossRefs" href="#bib0480"><span class="elsevierStyleSup">96&#44;97</span></a> The &#8216;weight of intervention&#8217; is also dealt with differently from the original EuroSCORE model&#46; The developers report good discrimination and calibration and it is likely this model will be widely adopted&#44; but it will require robust external validation&#46; There remains debate about the derivation and use of this type of model&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">98</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Contributors</span><p id="par0150" class="elsevierStylePara elsevierViewall">BB wrote the manuscript&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Competing interests</span><p id="par0155" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Provenance and peer review</span><p id="par0160" class="elsevierStylePara elsevierViewall">Commissioned&#59; internally peer reviewed&#46;</p></span></span>"
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          "titulo" => "Coronary artery surgery or PCI for angina"
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          "titulo" => "ESC&#47;EACTS revascularisation guidelines"
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          "titulo" => "Is off pump coronary artery surgery safe&#63;"
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          "titulo" => "Is endoscopic vein harvesting safe&#63;"
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          "titulo" => "Should bilateral internal mammary artery grafts be used for coronary artery surgery&#63;"
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          "titulo" => "Coronary artery surgery for heart failure&#63;"
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          "titulo" => "Aortic valve surgery"
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          "titulo" => "Transcatheter valve insertion"
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          "titulo" => "Mitral valve surgery"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">This review covers the important publications in adult cardiac surgery in the last few years&#44; including the current evidence base for surgical revascularisation and the use of off-pump surgery&#44; bilateral internal mammary arteries and endoscopic vein harvesting&#46; The changes in conventional aortic valve surgery are described alongside the outcomes of clinical trials and registries for transcatheter aortic valve implantation&#44; and the introduction of less invasive and novel approaches of conventional aortic valve replacement surgery&#46; Surgery for mitral valve disease is also considered&#44; with particular reference to surgery for asymptomatic degenerative mitral regurgitation&#46;</p>"
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                      "titulo" => "Comparison of coronary bypass surgery with drug-eluting stenting for the treatment of left main and&#47;or three-vessel disease&#58; 3-year follow-up of the SYNTAX trial"
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                      "titulo" => "Unraveling the EXCEL&#58; promises and challenges of the next trial of left main percutaneous coronary intervention"
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                        Validating the EXCEL hypothesis&#58; a propensity score matched 3-year comparison of percutaneous coronary intervention versus coronary artery bypass graft in left main patients with SYNTAX score \n
                        &lt;!--&lt;32--&gt;
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                          "autores" => array:3 [ …3]
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Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2013.02.010

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2024 November	5	4	9
2024 October	23	31	54
2024 September	32	24	56
2024 August	28	30	58
2024 July	34	24	58
2024 June	22	29	51
2024 May	25	20	45
2024 April	25	24	49
2024 March	22	13	35
2024 February	27	27	54
2024 January	18	20	38
2023 December	10	26	36
2023 November	23	21	44
2023 October	13	17	30
2023 September	17	16	33
2023 August	12	17	29
2023 July	20	10	30
2023 June	18	9	27
2023 May	40	20	60
2023 April	16	2	18
2023 March	37	19	56
2023 February	28	17	45
2023 January	16	6	22
2022 December	27	19	46
2022 November	35	21	56
2022 October	21	20	41
2022 September	15	17	32
2022 August	18	27	45
2022 July	11	18	29
2022 June	13	13	26
2022 May	12	23	35
2022 April	14	27	41
2022 March	12	18	30
2022 February	15	16	31
2022 January	15	12	27
2021 December	13	22	35
2021 November	15	34	49
2021 October	23	35	58
2021 September	12	28	40
2021 August	17	21	38
2021 July	15	21	36
2021 June	20	20	40
2021 May	20	37	57
2021 April	15	36	51
2021 March	18	12	30
2021 February	26	9	35
2021 January	24	11	35
2020 December	11	4	15
2020 November	19	7	26
2020 October	4	4	8
2020 September	14	6	20
2020 August	12	4	16
2020 July	29	6	35
2020 June	7	1	8
2020 May	15	8	23
2020 April	10	5	15
2020 March	9	6	15
2020 February	23	31	54
2020 January	10	5	15
2019 December	12	2	14
2019 November	7	4	11
2019 October	10	4	14
2019 September	12	7	19
2019 August	10	2	12
2019 July	15	9	24
2019 June	7	4	11
2019 May	14	10	24
2019 April	16	14	30
2019 March	7	7	14
2019 February	19	6	25
2019 January	6	5	11
2018 December	12	7	19
2018 November	83	7	90
2018 October	344	27	371
2018 September	98	10	108
2018 August	160	15	175
2018 July	32	3	35
2018 June	46	9	55
2018 May	104	10	114
2018 April	29	4	33
2018 March	220	8	228
2018 February	21	2	23
2018 January	12	8	20
2017 December	34	12	46
2017 November	19	15	34
2017 October	29	13	42
2017 September	18	7	25
2017 August	30	9	39
2017 July	11	9	20
2017 June	33	4	37
2017 May	24	8	32
2017 April	19	3	22
2017 March	19	32	51
2017 February	27	5	32
2017 January	15	7	22
2016 December	29	8	37
2016 November	23	4	27
2016 October	28	1	29
2016 September	26	5	31
2016 August	11	3	14
2016 July	10	3	13
2016 June	15	2	17
2016 May	12	4	16
2016 April	11	17	28
2016 March	17	12	29
2016 February	40	13	53
2016 January	30	9	39
2015 December	17	5	22
2015 November	27	9	36
2015 October	35	9	44
2015 September	25	9	34
2015 August	27	7	34
2015 July	18	5	23
2015 June	11	0	11
2015 May	48	12	60
2015 April	22	10	32
2015 March	15	5	20
2015 February	21	3	24
2015 January	27	2	29
2014 December	28	6	34
2014 November	21	5	26
2014 October	30	3	33
2014 September	25	5	30
2014 August	15	8	23
2014 July	41	7	48
2014 June	37	6	43
2014 May	27	5	32
2014 April	11	4	15
2014 March	41	10	51
2014 February	37	9	46
2014 January	40	10	50
2013 December	35	5	40
2013 November	36	14	50
2013 October	43	13	56
2013 September	51	10	61
2013 August	64	13	77
2013 July	36	11	47
2013 June	32	4	36
2013 May	38	8	46
2013 April	51	16	67
2013 March	49	11	60

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