Gianni Angelini

• MD, MCh, FRCS, FECTS, F Med Sci
• Professor at University of Bristol

Aim: Reconstructive surgery is a life-saving treatment for individuals with advanced thoracic aortic aneurysms (TAAs) at risk of rupture. No effective pharmacological treatments are available to halt aortic dilatation before it reaches this critical point. Unravelling the cellular and molecular pathways involved in TAA formation and expansion is fu...

Purpose The Outcome Monitoring After Cardiac Surgery (OMACS) cohort study was set-up with the aim of establishing a rich source of biological samples and health status data from patients who undergo cardiac surgery. The objectives were to use these data to inform the design of new clinical studies and to provide samples and data to answer research...

Coronary artery aneurysms are a relatively uncommon finding during coronary angiography and can present certain challenges in terms of treatment options. This may be due to unclear underlying mechanisms and varying presentations, as well as a lack of large-scale outcome data. In this case report we present the successful use of percutaneous coronar...

Pulmonary Embolism (PE) is a serious medical condition with high short and long term morbidity and mortality, which requires immediate diagnosis and treatment. Catheter-directed therapies should be considered more often when treating intermediate and high-risk patients as they provide faster and more effective results for reperfusion and positive c...

Background Cardiac surgery with cardiopulmonary bypass (CPB) triggers pulmonary injury. In this trial we assessed the feasibility, safety, and efficacy of low frequency ventilation (LFV) during CPB in patients undergoing valvular surgery. Methods and Results Patients with severe mitral or aortic valve disease were randomized to either LFV or usual...

Background/Objectives: Grafting of LIMA to LAD has long been considered the gold-standard conduit choice for patients undergoing CABG. Despite this, the LSV remains the most used conduit by volume and some patients may not receive even a single arterial conduit. However, the outcomes in this group are not frequently explored. This study, therefore,...

OBJECTIVES To describe evolving demographic trends and early outcomes in patients undergoing triple-valve surgery in the UK between 2000 and 2019. METHODS We planned a retrospective analysis of national registry data including patients undergoing triple-valve surgery for all aetiologies of disease. We excluded patients in a critical preoperative s...

Objectives Early meta-analyses comparing minimally invasive mitral valve surgery (MIMVS) with conventional sternotomy (CS) have determined the safety of MIMVS. We performed this review and meta-analysis based on studies from 2014 onwards to examine the differences in outcomes between MIMVS and CS. Specifically, some outcomes of interest included re...

Coronary artery disease (CAD) is a major health issue. This study focused on pericardial macrophages and small extracellular vesicles (sEVs) in CAD. The macrophages in CAD patients showed reduced expression of protective markers and unchanged levels of proinflammatory receptors. Similar changes were observed in buffy-coat–derived macrophages when s...

The transition from the second to the third millennium happened to be a turning point in the history of myocardial revascularization on a beating heart, which moved from technical development to critical evaluation. This article describes how the initial acceptance and spread of off-pump coronary artery bypass grafting (OPCABG) was followed by the...

Objective. The learning curve of coronary artery bypass grafting with multiple arterial grafting and without the use of cardiopulmonary bypass (off-pump) is perceived as an advanced subspeciality associated with increased surgical risk. We compared the trends and early clinical outcomes between trainees and consultants as the first operator in the...

Background The Society of Thoracic Surgeons and European System for Cardiac Operative Risk Evaluation (EuroSCORE) II risk scores are the most commonly used risk prediction models for in-hospital mortality after adult cardiac surgery. However, they are prone to miscalibration over time and poor generalization across data sets; thus, their use remain...

Introduction The trial hypothesized that minimally invasive extra-corporeal circulation (MiECC) reduces the risk of serious adverse events (SAEs) after cardiac surgery operations requiring extra-corporeal circulation without circulatory arrest. Methods This is a multicentre, international randomized controlled trial across fourteen cardiac surgery...

Background: Ischemic heart disease (IHD) is characterized by insufficient myocardial blood flow and aggravated by diabetes. IHD is often treated by coronary revascularization. Complementary therapies that increase the microvascular flow by promoting endothelial homeostasis and repair are still lacking and require the identification of new therapeut...

Background The COVID-19 pandemic necessitated major re-allocation of health care services. Our aim was to assess the impact on pediatric procedures for congenital heart disease during different periods of the COVID-19 pandemic compared to the pre-pandemic period to inform appropriate responses to future major disruptions of health services. Methods...

Objectives To characterise the variation in access to and outcomes of cardiac surgery for people in England. Methods We included people >18 years of age with a hospital admission for ischaemic heart disease (IHD) and heart valve disease (HVD) between 2010 and 2019. Within these populations, we identified patients who had coronary artery bypass graf...

Introduction Cardiac surgery with cardiopulmonary bypass and cardioplegic arrest is known to be responsible for ischaemia and reperfusion organ injury. In a previous study, ProMPT, in patients undergoing coronary artery bypass or aortic valve surgery we demonstrated improved cardiac protection when supplementing the cardioplegia solution with propo...

Introduction Large language models (LLM), such as Chat Generative Pre-trained Transformer (ChatGPT) and Bard utilise deep learning algorithms that have been trained on a massive data set of text and code to generate human-like responses. Several studies have demonstrated satisfactory performance on postgraduate examinations, including the United S...

Background Data on the postoperative outcomes for patients with infective endocarditis complicated by an aortic root abscess is sparse due to the condition’s low incidence and high mortality rates. This systematic review and meta-analysis aims to evaluate existing data on the impact of aortic root abscesses on the postoperative outcomes and to info...

Background The ProMPT-2 trial (Propofol for Myocardial Protection Trial #2) aims to compare the safety and efficacy of low- and high-dose propofol supplementation of the cardioplegia solution during adult cardiac surgery versus sham supplementation. This update presents the statistical analysis plan, detailing how the trial data will be analysed an...

Introduction On-pump coronary artery bypass (ONCABG) grafting in patients with a pre-existing poor renal reserve is known to carry significant morbidity and mortality. There is limited controversial evidence on the benefit of off-pump coronary artery bypass (OPCABG) grafting in these high-risk groups of patients. We compared early clinical outcomes...

Brain injury is still a serious complication after cardiac surgery. Gaseous microemboli (GME) are known to contribute to both short and longer-term brain injury after cardiac surgery. Hypobaric and novel dual-chamber oxygenators use the physical behaviors and properties of gases to reduce GME. The aim of this review was to present the basic physics...

OBJECTIVES This nationwide retrospective cohort study assessed the impact of the explanted valve type on reoperative outcomes in aortic valve surgery within the UK (UK) over a 23-year period. METHODS Data were sourced from the National Institute for Cardiovascular Outcomes Research (NICOR) database. All patients undergoing first-time isolated reop...

Cerebrovascular accident is the most ominous complication observed after cardiac surgery, carrying an increased risk of morbidity and mortality. Analysis of the problem shows its multidimensional nature. In this study, we aimed to identify major determinants among classic variables, either demographic, clinical or type of surgical procedure, based...

Background Surgical pulmonary embolectomy is rarely used for the treatment of massive acute pulmonary embolism. The aim of this study was to assess the incidence and outcomes of this operation by undertaking a retrospective analysis of a large national registry in the UK. Methods All acute pulmonary embolectomies performed between 1996 and 2018 we...

Background Redo sternotomy aortic root surgery is technically demanding, and the evidence on outcomes is mostly from retrospective, small sample, single-centre studies. We report the trend, early clinical results and outcome predictors of redo aortic root replacement over 20 years in the United Kingdom. Methods We retrospectively analysed collecte...

Background: Osteopontin has been implicated in vascular calcification formation and vein graft intimal hyperplasia, and its expression can be triggered by pro-inflammatory activation of cells. The role of osteopontin and the temporal formation of microcalcification in vein grafts is poorly understood with a lack of understanding of the interaction...

Background: Although electronic health records (EHR) provide useful insights into disease patterns and patient treatment optimisation, their reliance on unstructured data presents a difficulty. Echocardiography reports, which provide extensive pathology information for cardiovascular patients, are particularly challenging to extract and analyse, be...

Background Transcatheter aortic valve replacement (TAVR) determines the creation of outer area between the cage and the aortic wall named the ‘anatomic sinus’ (Figure 1 A-B). This newly formed space of the sinuses of Valsalva (SOV) might disrupt the physiological currents of Valsalva and contribute to the formation of subclinical leaflets thrombosi...

Background: Ischemic heart disease (IHD), which is characterized by reduced myocardial blood flow, is aggravated by diabetes mellitus (DM). Non-coding RNAs, including microRNAs (miRs) and circular RNAs (circRNAs), regulate gene expression and impact angiogenesis. Canonically, miRs bind to the 3’UTR region of their target messenger RNAs (mRNA) to me...

Background: The human pericardial fluid (PF) contains heart-derived small extracellular vesicles (sEVs) able to induce vascular responses via microRNA (miR) transfer. People with diabetes (DM) are particularly at risk of severe ischemic heart disease (IHD) and might require personalized therapeutic treatment. Hypothesis: The PF-sEVs molecular profi...

Background The ProMPT-2 trial (Propofol for Myocardial Protection Trial #2) aims to compare the safety and efficacy of low and high dose propofol supplementation of the cardioplegia solution during adult cardiac surgery versus sham supplementation. This update presents the statistical analysis plan, detailing how the trial data will be analysed and...

Objectives: To determine whether sex-based differences exist following surgery for degenerative mitral valve disease. Methods: Using a national database, we analysed data on mitral valve surgery for degenerative disease (n = 22,658) between January 2000 and March 2019 in the UK. We split the cohort into men (n = 14,681) and women (n = 7977) and com...

The landmark 2016 Minimal Invasive Extracorporeal Technologies International Society (MiECTiS) position paper promoted the creation of a common language between cardiac surgeons, anesthesiologists and perfusionists which led to the development of a stable framework that paved the way for the advancement of minimal invasive perfusion and related tec...

Background: Although electronic health records (EHR) provide useful insights into disease patterns and patient treatment optimisation, their reliance on unstructured data presents a difficulty. Because of their narrative structure, echocardiography reports, which provide extensive pathology information for cardiovascular patients, are particularly...

Introduction Congenital heart disease (CHD) represents the most common birth defect, affecting from 0.4% to 1.2% of children born in developed countries. The survival of these patients has increased significantly, but CHD remains one of the major causes of neonatal and childhood death. The aetiology of CHD is complex, with some evidence of both gen...

Subclinical leaflets valve thrombosis (SLT) is a recently identified phenomenon with multidetector computer tomography after tissue aortic valve replacement. Whether SLT is more frequent after transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) is currently not known. Thus, the aim of this pairwise meta-analysi...

Objectives: The popularity of off pump coronary artery bypass grafting varies across the world, ranging from 20% in Europe and USA to 56% in Asia. We present the trend and early clinical outcomes in off pump in the United Kingdom. Method: All patients who underwent elective or urgent isolated CABG from 1996 to 2019 were extracted from the Nation...

Objective The introduction of new clinical risk scores (e.g. European System for Cardiac Operative Risk Evaluation (EuroSCORE) II) superseding original scores (e.g. EuroSCORE I) with different variable sets typically result in disparate datasets due to high levels of missingness for new score variables prior to time of adoption. Little is known abo...

Objective: To model the referral, diagnostic and treatment pathway for cardiovascular disease (CVD) in the English National Health Service (NHS) to provide commissioners and managers with a methodology to optimise patient flow and reduce waiting lists. Study design: A systems dynamics approach modelling the CVD healthcare system in England. The...

Objectives: Concomitant revascularization of coronary artery disease at the same time as treatment for aortic valvopathy favourably impacts survival. However, combined surgery maybe associated with increased adverse outcomes compared to aortic valve replacement or coronary artery bypass grafting in isolation. Methods: We retrospectively analyzed...

Coronary artery bypass grafting remains the treatment of choice for a large cohort of patients with significant coronary disease. Despite the increased use of arterial grafts, the long saphenous vein remains the most commonly used conduit. Long-term graft patency continues to be the Achilles heel of saphenous vein grafts. This is due to the develop...

BACKGROUND There is an ongoing debate over whether a procedural specific (e.g. Society of Thoracic Surgeons (STS)) or universal model (e.g. EuroSCORE II (ES II)) should be used for patient selection in cardiac surgery. Recently, we showed that ES II suffers from severe performance drift across several important metrics and that ML approaches such a...

Objectives There is an ongoing debate over whether a procedural specific (e.g. Society of Thoracic Surgeons (STS)) or universal model (e.g. EuroSCORE II (ES II)) should be used for patient selection in cardiac surgery. Recently, we showed that ES II suffers from severe performance drift across several important metrics and that ML approaches such a...

Objectives: To assess the effectiveness of injectable tissue pulmonary valve compared with standard pulmonary valve in patients requiring pulmonary valve replacement surgery. Design: A multicentre, single-blind, parallel two-group randomised controlled trial. Participants were blind to their allocation. Follow-up continued for 6 months. Randomis...

Introduction: Postoperative Atrial Fibrillation (POAF) is a common complication of cardiac surgery, associated with increased mortality, stroke risk, cardiac failure and prolonged hospital stay. Our study aimed to assess the patterns of release of systemic cytokines in patients with and without POAF. Methods: A post-hoc analysis of the Remote Isch...

Objectives Using a large national database, we sought to describe outcome-trends in mitral valve surgery between 2000-2019. Methods The study cohort was split into mitral valve repair or replacement, including all patients regardless of concomitant procedures. Patients were grouped by four-year admission periods into groups (A to E). The primary o...

Introduction Brain injury is common following open heart valve surgery. Carbon dioxide insufflation (CDI) has been proposed to reduce the incidence of brain injury by reducing the number of air microemboli entering the bloodstream in surgery. The CO2 Study will evaluate the efficacy and safety of CDI in patients undergoing planned left-sided open h...

Objectives To perform a systematic comparison of in-hospital mortality risk prediction post-cardiac surgery, between the predominant scoring system-European System for Cardiac Operative Risk Evaluation(EuroSCOREII), logistic regression(LR) retrained on the same variables and alternative machine learning techniques(ML)-random forest(RF), neural netw...

Introduction Minimally invasive cardiac surgery has been evolving, with the intention of reducing surgical trauma, improve cosmesis and patient satisfaction. Single dose, crystalloid cardioplegia such as Del Nido cardioplegia and Custoidol solution have been increasingly used to reduce the interruption from repeating cardioplegia dosing to minimise...

Objectives: Intermittent cold blood cardioplegia is commonly used in children whereas intermittent warm blood cardioplegia is widely used in adults. We aimed to compare clinical and biochemical outcomes with these two methods. Methods: A single centre, randomized controlled trial was conducted to compare the effectiveness of warm (≥34°C) versus...

BACKGROUND Mortality after reoperative aortic valve surgery continues to decline but remains high compared to primary isolated replacement. We sought to examine temporal trends, morbidity, and mortality in patients undergoing isolated first-time reoperative aortic valve surgery. METHODS The study included all patients undergoing reoperative aortic...

Objectives The Society of Thoracic Surgeons (STS), and EuroSCORE II (ES II) risk scores, are the most commonly used risk prediction models for adult cardiac surgery post-operative in-hospital mortality. However, they are prone to miscalibration over time, and poor generalisation across datasets and their use remain controversial. It has been sugges...

Background: Post-infarct ventricular septal defect (PIVSD) is a serious complication of myocardial infarction. We evaluated 3D-printing models in PIVSD clinical assessment and the feasibility of statistical shape modeling for morphological analysis of the defects. Methods: Models (n = 15) reconstructed from computed tomography data were evaluate...

Objective Surgical aortic valve replacement (SAVR) is traditionally the gold-standard treatment in patients with aortic valve disease. The advancement of transcatheter aortic valve replacement (TAVR) provides an alternative treatment to patients with high surgical risks and those who had previous cardiac surgery. We aim to evaluate the trend, early...

Introduction More than 30 000 cardiac surgery procedures are performed in the UK each year, however, postoperative complications and long-term failure of interventions are common, leading to repeated surgeries. This represents a significant burden on the patient and health service. Routinely, patients are discharged to their general practitioner 6...

Background The effect of metabolic syndrome (MetS), defined as insulin resistance along with two or more of: obesity, atherogenic dyslipidaemia and elevated blood pressure, on postoperative complications after isolated heart valve intervention remains controversial. We hypothesized that MetS may negatively influence the postoperative course in thes...

Background Deep hypothermic circulatory arrest (DHCA) at ≤20°C for aortic arch surgery has been widely used for decades, with or without cerebral perfusion (CP), antegrade (antegrade cerebral perfusion [ACP]), or retrograde. In recent years nadir temperature progressively increased to 26°C–28°C (moderately hypothermic circulatory arrest [MHCA]), ad...

Introduction: Ischemic heart disease (IHD) is characterized by reduced blood supply to the myocardium and is aggravated by Type 2 Diabetes Mellitus (T2DM). Most of the RNA produced by the human genome is “non-coding” in potential and involved in regulatory processes. These include circular RNAs (circRNAs) and microRNAs (miRNAs). miRNAs bind to the...

Objectives Valve repair is the gold standard for treatment of degenerative mitral valve disease. As the population ages, patients undergoing valve degeneration and therefore considered for mitral valve surgery will naturally be getting older. We sought to evaluate whether mitral repair retained a survival advantage over replacement in patients ≥80...

Introduction Coronary artery bypass grafting (CABG) remains a good revascularization strategy in octogenarians with excellent clinical outcomes and quality of life postoperatively. However, the benefits of off‐pump over on‐pump CABG in the elderly population are still controversial. We investigated this issue in the UK National Audit database. Met...

Aims Standardized data definitions are necessary for the quantification of quality of care and patient outcomes in observational studies and randomised controlled trials (RCTs). The European Unified Registries for Heart Care Evaluation and Randomised Trials (EuroHeart) project of the European Society of Cardiology (ESC) aims to create pan-European...

Background. Deep hypothermic circulatory arrest (DHCA) at ≤20°C for aortic arch surgery has been widely used for decades, with or without cerebral perfusion (CP), antegrade (ACP) or retrograde. In recent years nadir temperature progressively increased to 26-28 °C (moderately hypothermic circulatory arrest, MHCA), adding ACP. Aim of this multicentri...

Objectives Female sex is considered a risk factor for mortality and morbidity following cardiac surgery. This study is the first to review the UK adult cardiac surgery national database to compare outcomes following surgical coronary revascularisation and valvular procedures between females and males. Methods Using data from National Adult Cardiac...

Background. The effect of metabolic syndrome (MetS), defined as insulin resistance along with two or more of: obesity, atherogenic dyslipidaemia and elevated blood pressure, on post-operative complications after isolated heart valve intervention remains controversial. We hypothesized that MetS may negatively influence the post-operative course in t...

Being able to perform surgery first‐hand represents the backbone of every training program and the key to successful development of the new generation of skilful surgeons. In this issue of the Journal, Comanici et al. presented a thorough systematic summary of the current evidence on the outcomes of cardiothoracic operations performed by trainees....

Introduction: The second best conduit for coronary artery bypass grafting is uncertain. The objective of this study is to determine the second best conduit according to graft patency results from randomized controlled trials using a network meta-analysis. Methods: A systematic literature search was conducted for randomized controlled trials comp...

Introduction: Coronary artery bypass grafting remains one of the best therapies for advanced coronary artery disease. The most used conduit remains the great saphenous vein, which is susceptible to short-term and long-term failure, the result of acute thrombosis, intimal hyperplasia, and late superimposed atheroma. In this review, we present the c...

Being able to perform surgery first-hand represents the backbone of every training program and the key to successful development of the new generation of skilful surgeons. In this issue of the Journal, Comanici et al. presented a thorough systematic summary of the current evidence on the outcomes of cardiothoracic operations performed by trainees.1...

Aim To evaluate the impact of aortic root abscess (ARA) on the postoperative outcomes of surgically managed infective endocarditis (IE) and to inform optimal surgical approach. Method Between 2009 and 2020, 143 consecutive patients who underwent surgical management for aortic-valve IE were included in a retrospective cohort study. Multivariate and...

Risk stratification plays a major role in the clinical decision-making process, patient consent and clinical governance analysis. However, the calibration of current risk scores (e.g., European System for Cardiac Operative Risk Evaluation (EuroSCORE), The Society of Thoracic Surgeons (STS) risk score) has been shown to deteriorate over time – a pro...

Introduction Changes in cardiac metabolites in adult patients undergoing open-heart surgery using ischemic cardioplegic arrest have largely been reported for non-ventricular tissue or diseased left ventricular tissue, with few studies attempting to assess such changes in both ventricular chambers. It is also unknown whether such changes are altered...

Objectives Perioperative atrial fibrillation (AF) is associated with increased mortality, morbidity and excess healthcare costs. The objective of our study was to assess if preoperative AF in patients undergoing coronary artery bypass grafting is a predictor of operative mortality, postoperative stroke and need for postoperative dialysis by interro...

Background Data on the postoperative outcomes for patients with infective endocarditis complicated by an aortic root abscess is sparse due to the condition’s low incidence and high mortality rates. This systematic review and meta-analysis aims to evaluate existing data on the impact of aortic root abscesses (ARA) on the postoperative outcomes of su...

Significant dilemma exists regarding the management of the aortic root pathology in acute aortic dissections. Several strategies for both repair and replacement exist and there is a lack of clarity on the superiority of one over the other. Important factors that influence management strategies include involvement of the sinuses, the competence of t...

Significant dilemma exists regarding management of the aortic root pathology in acute aortic dissections. Several strategies for both repair and replacement exist and there is a lack of clarity on the superiority of one over the other. Important factors that influence management strategies include involvement of the sinuses, competence of the aorti...

Objective: To narratively describe the challenges and solutions required in delivering a non-commercial study of children undergoing cardiac surgery using a novel subcutaneous hormone collection device. Results: The challenges faced by the research team are divided into those of conducting healthcare research in children and those specific to th...

Objectives Benefits of using multiple arterial grafting, over single arterial grafting in major adverse cardiac event rates and the need for repeat revascularisation, have been widely reported. Several guidelines have recommended the use of multiple arterial grafting in selected patients. We report the trend of multiple arterial grafting in patient...

Objectives To establish the impact of the COVID-19 pandemic on adult cardiac surgery by reviewing current data and use this to establish methods for safely continuing to carry out surgery. Methods Conduction of a literature search via PubMed using the search terms: ‘(adult cardiac OR cardiothoracic OR surgery OR minimally invasive OR sternotomy OR...

Major surgery and critical illness produce a potentially life-threatening systemic inflammatory response. The hypothalamic–pituitary–adrenal (HPA) axis is one of the key physiological systems that counterbalances this systemic inflammation through changes in adrenocorticotrophic hormone (ACTH) and cortisol. These hormones normally exhibit highly co...

Our earlier work has shown inter‑disease and intra‑disease differences in the cardiac proteome between right (RV) and left (LV) ventricles of patients with aortic valve stenosis (AVS) or coronary artery disease (CAD). Whether disease remodeling also affects acute changes occuring in the proteome during surgical intervention is unknown. This study i...

Objectives To evaluate the impact of aortic root abscess (ARA) on the postoperative outcomes of surgically managed infective endocarditis (IE) and to inform optimal surgical approach. Methods Between 2009 and 2020, 143 consecutive patients who underwent surgical management for aortic‐valve IE were included in a retrospective cohort study. Multivar...

Implications of elevated troponin on time-to-surgery in non-ST elevation myocardial infarction(NIHR Health Informatics Collaborative:TROP-CABG study). Benedetto et al. Background The optimal timing of coronary artery bypass grafting (CABG) in patients with non-ST elevation myocardial infarction (NSTEMI) and the utility of pre-operative troponin le...

Objectives: Female sex is considered a risk factor for mortality and morbidity following cardiac surgery. This study is the first to review the UK adult cardiac surgery national database to compare outcomes following surgical coronary revascularisation and valvular procedures between females and males. Methods: Using data from National Adult Cardia...

Background and Aims: Atherosclerosis is a chronic inflammatory disease that remains the leading cause of morbidity and mortality worldwide. Despite decades of research into the development and progression of this disease, current management and treatment approaches remain unsatisfactory and further studies are required to understand the exact patho...

Acute type A aortic dissection is a life‐threatening event that requires prompt management, a complex interaction among the timing of aortic surgical repair, presence or absence of organ malperfusion, and surgical outcomes exists. Whether resection of intimal entry tear should be deferred after reversal of malperfusion and end‐organ ischemia is a m...

We have read the article by Sandner et al. with great interest. The authors have undertaken a post hoc analysis of the VEST III Trial to examine the impact of open versus endoscopic harvesting techniques on saphenous vein graft patency and degree of intimal hyperplasia. As already acknowledged by the authors, these results should be viewed as hypot...