Latest articles

Heart disease remains a major cause of death and disability in Scotland, accounting for around 10,000 deaths each year.¹ Ischaemic heart disease is still Scotland’s single biggest killer, responsible for 11.3% of all deaths in 2018, and accounts for 25,000 hospital admissions each year. While it is true that there have been improvements in survival from heart attacks and other acute events in Scotland over the last half century, it is also the case that significant challenges remain.

The reduction in deaths from heart attacks means that more people are living with heart disease as a long-term condition. On top of this, the population is getting older,² and increasingly people are living with associated comorbidities, many requiring long-term support. The number of people living with cardiovascular risk factors in Scotland continues to increase, health inequalities persist and in some cases, have worsened.³

Beyond ischaemic heart disease, the incidence of conditions like heart failure,⁴ heart valve disease,⁵ and atrial fibrillation are increasing. There is also a need to consider the impact of less common, but no less important conditions, such as congenital heart disease and inherited heart conditions. Around 28,000 people in Scotland have an inherited heart condition, the most common of which is hypertrophic cardiomyopathy. Congenital heart disease is one of the most common birth defects in Scotland, affecting around one in every 150 births. Improved survival rates mean that a growing number of people are living into adulthood with congenital heart disease.

This review focuses on the role of CytoSorb® (CytoSorbents Corporation, Monmouth Junction, New Jersey, USA), a technology for purifying extracorporeal blood. The technology is designed for several indications to prevent bleeding complications during on-pump cardiac surgery, including removal of the antiplatelet agent, ticagrelor, and the oral anticoagulant, rivaroxaban, from the blood. Recent clinical studies are briefly reviewed.

Cardiac implantable electronic device (CIED)-related complications and infections typically lead to prolonged hospital stays and, very occasionally, death. A new CIED insertion protocol was implemented in a district general hospital. The primary objective of this study was to determine whether a significant reduction in complication and infection rates occurred after implementation of the new protocol. Medical records were reviewed for patients who had a CIED inserted in the two years pre- and post-protocol implementation, and any complications were identified in a one-year follow-up period.

An increase in the complexity of the devices implanted after introduction of the protocol was observed. The number of complications was significantly reduced from 6.86% to 3.95% (p<0.0001). In the two years prior to protocol implementation, 14 of 871 (1.6%) patients suffered a CIED-related infection. In contrast, four of 683 (0.44%) patients suffered a CIED-related infection in the two years post-implementation. This was not statistically significant (p=0.093).

In conclusion, implementing a standardised protocol for CIED insertion significantly reduced the rate of complications, and also reduced the rate of infection, but this was not statistically significant.

“I will not lose; either I win or I learn” – Marian Ionescu, circa 1971

The pericardial heart valve concept is the remarkable legacy of a man and his genius. His single most defining contribution has changed the course of cardiac surgery over the last half a century and benefitted millions of patients worldwide. Since the initial design by Hufnagel of the ball-cage valve implanted in the descending thoracic aorta (1953) to correct a regurgitant aortic valve, nearly 150 valves have been designed and tested. None has stood the test of time as well as the pericardial valve (figure 1). Since the first successful human implant of the pericardial valve in the mitral position in 1971, 10 million of these have been implanted worldwide. Pericardial valves now constitute 80% of all implanted valves. The invention has driven a multi-billion dollar industry that today forms the backbone of the healthcare technology sector.

The Fontan procedure provides a palliative surgical repair for complex congenital heart disease, but it is associated with many long-term problems, including liver cirrhosis, and hepatocellular carcinoma. The current suggestion from international guidance is that end-organ surveillance should be carried out, with a particular focus on regular blood tests and imaging for liver function.

In this study, retrospective analysis was performed on adult patients who had previously had a Fontan operation performed to determine the regularity of end-organ surveillance in regards to their liver function covering the three calendar years from 2016 to 2018, and the first six months of 2019.

Eighty-six patients were identified in South Wales monitored by the adult congenital heart disease unit. We found that the number of investigations performed in the first six months of 2019 was comparable to other calendar years in their entirety. Liver function tests had been performed in 57% of patients throughout 2018, with only 8% having had an alpha-fetoprotein taken, and only 9% having had imaging of the liver performed. Over the course of their lifetime, 97% of patients had had a liver function blood test performed at some point, with 17% having had an alpha-fetoprotein taken, and 49% having their liver imaged.

In conclusion, end-organ surveillance is an important follow-up for patients with a Fontan circulation, with guidelines proposing yearly blood test and imaging investigations. This study shows the opportunities to improve surveillance in this group of patients to highlight the development of liver cirrhosis, and/or hepatocellular carcinoma.