Anterosuperior Research Articles

Morphologic Characteristics and Relating Factors to the Need of Technical Modification in Transcatheter Closure of Large Atrial Septal Defect (≥5 mm)

Background and ObjectivesThe rigid coupling between the delivery wire and the right atrial disk has been occasionally encountered during transcatheter closure of atrial septal defect (ASD). Therefore the device frequently makes a perpendicular angle, and the leading edge of left atrial disk slips through the defect and prolapses into right atrium (RA) before it is properly placed in the septum. The purpose of this study is to investigate relating factors to the need of technical modification in transcatheter closure of large ASD and to evaluate relevant morphologic characteristics of atrial septal rim in this situation.Subjects and MethodsFrom July, 2003 to May, 2007, 312 patients underwent transcatheter occlusion of ASD with Amplatzer Septal Occluder® (ASO, AGA medical corporation, Golden Valley, MN, USA) at Yonsei Cardiovascular Center and among them 109 patients had large ASD (≥25 mm) and these patients were enrolled in our study. Patients were divided into two groups according to the deploying methods of the device (Group I: standard method, Group II: modified methods). Assessments of the defects and its surrounding rims were made by echocardiography.ResultsThere were no differences between 2 groups in age, body weight and height except for balloon-stretched diameter (stop-flow technique) and device size. Group II patients with modified methods showed larger balloon-stretched diameter and device size than group I patients with standard method. The mean length of anterosuperior (AS) rim in group II was significantly shorter than group I (p<0.05). As the size of the device used in procedure increased, there was a trend towards increase in the need of modified methods.ConclusionThis study shows that AS rim deficiency and the size of ASD may be the relating factors to the need of technical modification in transcatheter closure of ASD. Therefore, when the initial try with standard method is not successful in large ASD with deficient AS rim, we suggest that changing strategy of implantation may save time and efforts and possibly reduce the risk of complications associated with prolonged procedure.

Approach for Systematic Resection of the Liver Anterosuperior Area: Exposing Glissonean Pedicles by Prior Dissection of the Major Hepatic Fissure

F r c t s a l i p M ost hepatocellular carcinomas (HCC) invade the portal ein and form intrahepatic metastases at an early stage. So atients with HCC require a systematic resection (SR) of he area containing the tumor. The most important step n the SR is to ligate the Glissonean pedicles (GPs) of this rea precisely before dissection of parenchyma of the liver. ecause of moderate to severe cirrhosis, the liver function f HCC patients is often not sufficient to allow them to ndergo lobectomy or segmentectomy. For such patients, R of a smaller area is chosen to achieve a curative resection hile maintaining adequate remnant liver function. mong them, the anterosuperior (AS) area is located in the enter of the liver and the GPs in this area are not visible rom the liver’s surface or hilum, so some kind of procedure s necessary to ligate GPs of this area precisely before disection of parenchyma of the liver. We present a safe ethod for SR of the AS area, based on earlier dissection of he major hepatic fissure (MHF) and exposing GPs of this rea.

Absent posteroinferior and anterosuperior atrial septal defect rims: factors affecting nonsurgical closure of large secundum defects using the amplatzer occluder

Using transesophageal echocardiography, we sought to determine the anatomic characteristics of the secundum atrial septal defects (ASDs) that extend into the inferior sinus venosus and have no posteroinferior (PI) rim, to determine the factors related to potential closure with an Amplatzer occluder. We also sought to understand why large secundum ASDs with a PI but without an anterosuperior (AS) rim may require special techniques to reorient the left atrial disk before deployment of the waist and right atrial disk. We measured the lengths of 5 separate rims of the circumferences of 76 secundum ASDs, including anteroinferior, AS, superior, posterosuperior, and PI rims. We also measured anteroposterior and superoinferior defect diameters, total septal lengths, and the ratios of defect diameter to total septal length. The atrial depth was measured at the axial angle of the delivery sheath in 5 defects with no AS rim for which special techniques were required to achieve successful closure. Of 76 secundum ASDs, 13 (17%) had no PI rim. Each defect extended from the fossa ovalis into the inferior sinus venosus. Compared with defects with a PI rim, the factors related to potential closure included 100% larger defect diameters, shorter posterosuperior rim lengths, larger defect to total septal length ratios, and completely flat posterior atrial walls. When the AS rim was absent the factors related to the need for special techniques included diameters ≥ 22 mm, atrial depth < the calculated Amplatzer occluder left atrial disk diameter, rigid wire/disk interface, and obligatory left atrial disk orientation more or less perpendicular to the atrial septal plane.

Anatomic and radiographic analysis of arthroscopic tack placement into the superior glenoid

Purpose: To anatomically and radiographically describe tack location within the anterosuperior (AS) and posterosuperior (PS) aspects of the glenoid when performing simulated repairs of type II SLAP lesions. Type of Study: Cadaveric anatomic and radiographic analysis. Methods: Arthroscopy was performed on 7 fresh-frozen cadaveric shoulders and bioabsorbable tacks were placed in the AS and PS aspects of the glenoid to simulate repair of a type II SLAP lesion. The PS tack was placed through an accessory portal 1 cm lateral and 1 cm anterior to the posterolateral corner of the acromion. Dissection was then performed, and the incision made in the rotator cuff when creating the posterolateral accessory portal (PLAP) was identified and measured. Tack location within the glenoid was visually studied after removal of all soft tissues and recorded as being either completely within bone or partially within bone. The tacks were recannulated with guide pins and 3 radiographs were then taken of each specimen (true anteroposterior, axillary, and en face glenoid views) and angles of entry determined. In addition, the angle of deviation from the orthogonal at the point of entry of each tack was measured on the en face glenoid view. Results: The average incision made in the rotator cuff for creation of the PLAP measured 10.3 mm in maximum diameter. In 6 of 7 specimens, this incision was made through muscle and not tendon. Seven of 7 AS tacks were completely within bone, and only 5 of 7 PS tacks remained completely within bone. On the true anteroposterior view, the average angle of entry from the vertical for the AS tack was 64°. For the PS tack, this angle measured 86°. On the axillary view, the angle of placement from the coronal averaged 22° for the AS tack and 42° for the PS tack. For the en face glenoid view, the angle of entry from the vertical was 34° for the AS tack and 93° for the PS tack. Lastly, the angle of deviation from the orthogonal on the en face glenoid view was 12° and 35° for the AS and PS tacks, respectively. This difference was statistically significant at P <.001. Conclusions: This study provides quantitative data on the angle of placement and location of tacks within the superior glenoid when performing repairs of type II SLAP lesions. It also shows the PLAP to be a safe portal for the placement of devices into the posterosuperior aspect of the glenoid. Furthermore, the data show the AS tack to be more reliably placed than the PS tack.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 4 (April), 2002: pp 366–371

Glenoid labrum tears related to the long head of the biceps

Tears of the glenoid labrum were observed in 73 baseball pitchers and other throwing athletes who underwent arthroscopic examination of the dominant shoulder. Most of the tears were located over the anterosuperior portion of the glenoid labrum near the origin of the tendon of the long head of the biceps muscle into the glenoid. At arthroscopy, the tendon of the long head of the biceps appeared to originate through and be continuous with the superior portion of the glenoid labrum. In many cases it appeared to have pulled the anterosuperior portion of the labrum off the glenoid. This observation was verified at arthroscopy by viewing the origin of the biceps tendon into the glenoid labrum as the muscle was electrically stimulated. With stimulation of the muscle, the tendinous portion became quite taut, particularly near its attachment to the glenoid labrum, and actually lifted the labrum off the glenoid. Three-dimensional high-speed cinematography with computer analysis revealed that the moment acting about the elbow joint to extend the joint through an arc of about 50 degrees was in excess of 600 inch-pounds. The extremely high velocity of elbow extension which is generated must be decelerated through the final 30 degrees of elbow extension. Of the muscles of the arm that provide the large deceleration forces in the follow-through phase of throwing, only the biceps brachii traverses both the elbow joint and the shoulder joint. Additional forces are generated in the biceps tendon in its function as a "shunt" muscle to stabilize the glenohumeral joint during the throwing act.(ABSTRACT TRUNCATED AT 250 WORDS)