Durability Of Repair Research Articles

Ischaemic Mitral Incompetence: Optimising Outcomes From Repair and Replacement

Retention of the posterior leaflet is usual at the time of mitral valve replacement but durable repair, where possible, offers better outcomes. The anterior mitral leaflet (AML) is the most important contributor to left ventricular (LV) function through the valvular ventricular interaction but is usually resected to prevent mechanical valve leaflet entrapment or outflow tract obstruction with a bioprosthesis.

Mid-term Outcomes of Open Thoracoabdominal Aortic Aneurysm Repair Following Thoracic Endovascular Aortic Repair

The aim of this study was to evaluate the safety and durability of open repair in patients with thoracoabdominal aortic aneurysm (TAAA) after thoracic endovascular aortic repair (TEVAR). Data were analyzed for 65 patients (20 men; 30.8%) undergoing open TAAA repair (TAAAR) at a median of 2.6 years after TEVAR. Outcomes were compared between patients with and without Marfan syndrome (MFS) (n = 39; 60%). Mean age at TAAAR was 41 ± 11 years. Before TAAAR, 27 patients (41.5%) underwent re-TEVAR. Type I endoleak was seen in 21 patients (32.3%), type II endoleak in 4 (6.2%), patent false lumen in 38 (58.5%), aortic rupture in 10 (15.4%), and graft infection in 2 (3.1%). TAAAs were Crawford extent I in 10 (15.4%), II in 23 (35.4%), III in 23 (35.4%), and IV in 9 (13.8%). Maximal TAA size was 72 ± 22 mm (Table). Emergent TAAAR was done in 11 (16.9%). Femoro-femoral bypass was used in 36 (55.4%) and circulatory arrest in 23 (35.4%). Endograft was explanted in 33 (50.8%). Stroke, paraplegia, and acute kidney injury occurred in five (7.7%), seven (10.8%), and seven (10.8%) patients, respectively. Operative mortality was 16.9% (11/65), due to stroke (n = 5), respiratory failure (n = 2), bowel necrosis (n = 1), low cardiac output (n = 1), and coagulopathy (n = 2). Endograft extraction was predictive of operative death (odds ratio, 5.63; 95% confidence interval, 1.11-28.52; P = .037). Clinical and computed tomography follow-up was complete in 100% (54/54) at a mean of 3.1 ± 1.4 years. Branch vessel events occurred in 11 patients at a median of 10 months (range, 0.4-18.3), including intercostal atrial (IA) dilation in six, IA stenosis in three, and iliac stenosis in one, exclusively seen in MFS (32.4% [11/34] vs 0; P = .004). Aortic graft infection occurred in two patients at 0.4 and 3.7 years, respectively; one died and one survived after medical therapy. Ascending aortic + total arch repair was done for retrograde type A dissection in two patients at 2.5 and 1.3 years, respectively. Late death occurred in four patients at 1.9 ± 1.7 years from aortotracheal fistula in two, and sepsis and stroke in one each. At 5 years, survival and freedom from reoperation were 73.6% and 95.7%, respectively, which did not differ significantly between MFS and non-MFS patients (P = .084 and P = .465, respectively). In this series of thoracoabdominal aortic aneurysm after TEVAR, open repair was safe and achieved favorable early and midterm outcomes. Endograft extraction predicted early mortality risk. Although not at increased risk of mortality and late reoperation, patients with MFS are prone to developing branch vessel dilation/stenosis early after open TAAAR.TablePatient profile, operative data, and late outcomes of thoracoabdominal aortic aneurysm repair (TAAAR) after thoracic endovascular aneurysm repair (TEVAR)VariableWhole series (n = 65)MFSP valueYes (n = 39)No (n = 26)Baseline characteristics Age, years41 ± 1134 ± 752 ± 8<.001 Male gender20 (30.8)18 (46.2)2 (7.7).001 Body mass index >25 kg/m221 (32.3)8 (20.5)13 (50).017 Hypertension34 (52.3)11 (28.2)23 (88.5).000 Smoking23 (35.4)8 (20.5)15 (57.7).003 Indications for prior TEVAR.001Type B aortic dissection43 (66.2)23 (59)20 (76.9)Type A aortic dissection18 (27.7)16 (41)2 (7.7)Penetrating aortic ulcer3 (4.6)0 (0)3 (11.5)Aortic rupture1 (1.5)0 (0)1 (3.8) Maximal proximal aortic size, mm30 ± 529 ± 431 ± 5.110 Maximal distal aortic size, mm72 ± 2266 ± 1580 ± 27.014Operative data Emergency repair11 (16.9)2 (5.1)9 (34.6).005 Distal perfusion strategy.019Simple aortic clamping9 (13.8)4 (10.3)5 (19.2).465Aorto-iliac bypass20 (30.8)17 (43.6)3 (11.5).007Femoro-femoral bypass36 (55.4)18 (46.2)18 (69.2).080Deep hypothermic circulatory arrest23 (35.4)9 (23.1)14 (53.8).017 Part or complete graft extraction33 (50.8)15 (38.5)18 (69.2).023 Clamp and ischemic times, minutesProximal aortic clamp time16 (0-21)17 (12-26)0 (0-17.5).026Intercostal artery38 (23-59)38 (21-57)39 (27-69).558Superior mesenteric artery33 (24-43)36 (24-45)28 (24-36).098Celiac artery, unprotected40 (30-57)45 (35-59)31 (25-39).006Maximal renal artery44 (35-52)45 (40-55)37.5 (28-46).008 Intercostal/lumbar artery reattachment52 (80)34 (87.2)18 (69.2).114 Reconstruction of subclavian artery15 (23.1)9 (23.1)6 (23.1)1.000 Reconstruction of right iliac artery37 (57.8)24 (61.5)13 (52).604 Cerebrospinal fluid drainage45 (69.2)31 (79.5)14 (53.8).053Early outcomes Operative mortality11 (16.9)5 (12.8)6 (23.1).325 Stroke5 (7.7)2 (5.1)3 (11.5).382 Paraplegia7 (10.8)2 (5.1)5 (19.2).106 Reoperation for bleeding8 (10.8)5 (11.6)3 (9.7)1.000 Acute kidney injury requiring dialysis7 (10.8)3 (7.7)4 (15.4).424 Pulmonary complications19 (29.2)7 (17.9)12 (46.2).025 Gastrointestinal dysfunction4 (6.2)2 (5.1)2 (7.7)1.000 Length of intensive care unit stay, days3.7 (1.7-5.6)3.5 (1.6-5.3)4.3 (2.4-7.1).090Late outcomes(n = 54, %)(n = 34, %)(n = 20, %) Follow-up duration, years3.1 ± 1.43.3 ± 1.32.7 ± 1.5.275 Late death4 (7.4)1 (2.9)3 (15).138 Late reoperation2 (3.7)2 (5.9)0 (0).525 Branch vessel dilation or stenosisa11 (20.4)11 (32.4)0 (0).004 5-year Kaplan-Meier survival, %73.6 (58.9-83.8)81.0 (59.7-91.7)61.5 (37.2-78.8).084 5-year freedom from reoperation, %95.7 (72.9-99.4)93.3 (61.3-99.0)100 (100).465MFS, Marfan syndrome; TAAAR, thoracoabdominal aortic aneurysm repair; TEVAR, thoracic endovascular aortic repair.Data are presented as mean ± standard deviation, median (interquartile range), number (%), or % (95% confidence interval).aRefers to aneurysmal dilation or stenosis (or occlusion) in abdominal aortic branches and the iliac arteries. 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Feasibility of structural retrofit concrete pipelines using limestone calcined clay cement Engineered Cementitious Composites (LC3 ECC)

Advances in pipeline rehabilitation technology are urgently needed to address aging concrete pipelines operating in aggressive conditions. Current repair methods have limitations on enhancing pipe structurally. In this research, ductile ECC was employed as a durable retrofitting material for concrete pipe. Firstly, two strength grades of ECC were developed. Tensile strain capacity ranging from 5.4 to 9.3 % was obtained. Owing to the tailored crack width (average 61.6 μm at 8% strain) and self-healing capacity, the 2% pre-tensioned ECC retained 10-10 m/s of the coefficient of permeability after 14 d of testing. The cracked concrete pipe was repaired by ECC/mortar, then examined by three-edge loading and flexural tests. Although ECC had lower strength than the referenced mortar, ECC-repaired pipe attained higher load and deformation capacity than the mortar-repaired pipe. ECC distributed the macro crack into multiple tiny cracks, leading to the pipe being an oval shape with residual load capacity after crushing, compared to the brittle failure of the mortar-repaired pipe. The cracked ECC pipe retained its structural integrity and enabled the intrinsic leak-proof function of the cracked ECC pipe. Finally, ECC demonstrated the ability to structurally and functionally (leak-proof) retrofit the concrete pipe, suggesting a durable promising repair material for concrete pipe.

P-080 THE GRIP CONCEPT CONSIDERS BIOMECHANICAL PRINCIPLES FOR A DURABLE REPAIR OF INCISIONAL HERNIA – 3 YEAR FOLLOW UP

Abstract Aim Durable hernia repair is based on specific biomechanical principles. How are the results after three years in primary and recurrent hernias? Material and methods The biomechanical principles were analyzed ex vivo with cyclic loading using a self-built bench test. The minimal requirements for a biomechanically durable repair were defined. The resulting GRIP concept was clinically applied. Results A total of 233 patients (123 males and 110 females) were treated for incisional hernia. Primary hernia was repaired in 170, recurrence in 63 patients with an average of 1.3 risk factors with most patients grouped as ASA III (n= 120). Emergency repairs were necessary in 11 patients. Hernia orifices were mostly median (N= 209) and lateral (89 patients, 59 combined). Hernia sizes were on average 9 + 6 cm wide and 13 ± 8 cm long. The mesh-defect area ratio was 7.8. Fixation was necessary (median of 60 fixation points). Recurrences required more effort for a durable repair (Primary OR duration: 165 ± 75 min; recurrence: 233 ± 89 min). A total of 138 patients were followed for three years so far. Four patients died during follow-up (Follow-up rate 100%). A second hernia in the un-repaired abdominal wall occurred three times (gunshot wound, appendectomy, cholecystectomy). Pain levels were low (median NAS = 0 at rest and under load). One recurrence was detected 8 months after primary repair in a liver transplant recipient reconstructed with a sandwich. Conclusion Primary and recurrent incisional hernia can be repaired durably based on biomechanical principles.

OC-120 ROBOTIC TRANSABDOMINAL RETROMUSCULAR RECTUS DIASTASIS (R-TARRD) REPAIR - A NEW APPROACH

Abstract Aim To present our innovative robotic approach for the treatment of rectus diastasis with concurrent primary or incisional ventral hernias. Material &amp; Methods We performed 45 r-TARRD repairs for symptomatic rectus diastasis with concomitant associated ventral/incisional umbilical and/or epigastric hernias. Data on patient demographics, type of hernia, operative time, complications, recurrence rate and hospital stay were retrospectively analyzed. Follow-up was scheduled at 1 month, 6 months and 1 year after surgery. Results 45 patients (13 M, 32 F) underwent r-TARRD repair. Mean age was 54,8 years (range 31–68) and mean BMI was 26,74 Kg/m2 (range 21,1–31). Mean ASA was 2,2 (range 1–3). In all patients we used a polypropylene mesh 25×15 cm, properly shaped. Mean operative time was 192 min (range115–260). Mean hospital stay 4,2 days (range 2–7). No conversion to laparoscopy or open surgery and no major complications occurred. At 1 month follow up one mesh infection (2,22%) was observed and it was treated conservatively. Four recurrences (8,88%) were reported at 1 year follow up. Conclusions Robot-assisted TARRD repair is conceived as a novel alternative minimally invasive procedure for RD with concurrent midline defects ensuring a primary fascial defect closure and mesh implantation in a sublay position with a wide overlap. It is important to better evaluate the suture that should be used to perform the repair and multicenter studies with standardization of patient's demographics, RD characteristics and long-term follow-up outcomes are mandatory to assess the effectiveness and durability of r-TARDD repair.

Chordal force profile after neochordal repair of anterior mitral valve prolapse: An ex vivo study

ObjectiveThis study aimed to biomechanically evaluate the force profiles on the anterior primary and secondary chordae after neochord repair for anterior valve prolapse with varied degrees of residual mitral regurgitation using an ex vivo heart simulator. MethodsThe experiment used 8 healthy porcine mitral valves. Chordal forces were measured using fiber Bragg grating sensors on primary and secondary chordae from A2 segments. The anterior valve prolapse model was generated by excising 2 primary chordae at the A2 segment. Neochord repair was performed with 2 pairs of neochords. Varying neochord lengths simulated postrepair residual mitral regurgitation with regurgitant fraction at >30% (moderate), 10% to 30% (mild), and <10% (perfect repair). ResultsRegurgitant fractions of baseline, moderate, mild, and perfect repair were 4.7% ± 0.8%, 35.8% ± 2.1%, 19.8% ± 2.0%, and 6.0% ± 0.7%, respectively (P < .001). Moderate had a greater peak force of the anterior primary chordae (0.43 ± 0.06 N) than those of baseline (0.19 ± 0.04 N; P = .011), mild (0.23 ± 0.05 N; P = .041), and perfect repair (0.21 ± 0.03 N; P = .006). In addition, moderate had a greater peak force of the anterior secondary chordae (1.67 ± 0.17 N) than those of baseline (0.64 ± 0.13 N; P = .003), mild (0.84 ± 0.24 N; P = .019), and perfect repair (0.68 ± 0.14 N; P = .001). No significant differences in peak and average forces on both primary and secondary anterior chordae were observed between the baseline and perfect repair as well as the mild and perfect repair. ConclusionsModerate residual mitral regurgitation after neochord repair was associated with increased anterior primary and secondary chordae forces in our ex vivo anterior valve prolapse model. This difference in chordal force profile may influence long-term repair durability, providing biomechanical evidence in support of obtaining minimal regurgitation when repairing mitral anterior valve prolapse.

Abstract 522: Computational Fluid Dynamics Analyses Of Geometric Incompatibility And Seal Zone Stability In Endovascular Aneurysm Repair

Introduction: Long-term durability of endovascular aneurysm repair (EVAR) is often compromised due to inadequate sealing of the endograft to the aorta. We hypothesize that geometric mismatch between the aorta and endograft can lead to the development of bird-beak regions, type Ia endoleaks, and endograft migration. Our novel computational model shows how geometric incompatibility at the seal zone contributes to endoleak formation and propagation. Methods: Using finite-element modeling, we simulated endograft crimping and deployment in pressurized aortic models with different degrees of curvature (0°, 30°, 60°) and oversizing (0%, 20%, 25%). We then performed computational fluid dynamics (CFD) modeling with a detailed pressure analysis of various regions along the length of each model. Results: Across our models, pressure gradients developed between the bulk flow and endoleak regions. For all degrees of curvature, the average total pressure in the endoleak region was higher than that of the bulk flow in the 20% and 25% oversized models. While oversizing decreased the aorta-endograft geometric mismatch in the 60° model and mitigated the volume of endoleak, too much oversizing in the 0° models worsened endoleak. Conclusions: We present one of the first computational models to study the sensitivity of seal zone mechanics to the degree of aorta-endograft mismatch. Our finding of pressure gradients that exist between the endoleak and bulk flow may represent regions of high mechanical instability that may further propagate the endoleak. Our results highlight the importance of shape and oversizing considerations when selecting the appropriate endovascular therapy for EVAR patients. Figure 1: CFD simulations of aorta-endograft models with different degrees of curvature and oversizing show endoleak formation as a function of geometric incompatibility.

Microinvasive mitral valve surgery: Current status and status quo.

Surgical mitral valve repair, performed either through median sternotomy or minimal invasive approach, presents the gold standard treatment for degenerative mitral valve disease. In dedicated centres, high repair and low complication rates have been established with excellent valve repair durability. Recently, new techniques have been introduced, that allow mitral valve repair to be performed through small surgical incisions and while avoiding cardio-pulmonary bypass. These new techniques, however, conceptually differ significantly when compared to surgical repair and it remains questionable whether they are capable of reproducing the results of surgical treatment.

Well Connected and Bloodtight, a Guarantee for Durable Endovascular Aneurysm Repair

Well Connected and Bloodtight, a Guarantee for Durable Endovascular Aneurysm Repair

Two-year target vessel-related outcomes following use of off-the-shelf branched endografts for the treatment of thoracoabdominal aortic aneurysms

ObjectiveThe aim of this study was to assess clinical outcomes and target vessel patency through 2 years following thoracoabdominal aortic aneurysms (TAAA) repair with the off-the-shelf Zenith t-Branch Thoracoabdominal Endovascular Graft (William Cook Europe). MethodsThis post-market observational study was conducted at three European sites with ambispective enrollment from 2012 to 2017. Patients underwent endovascular TAAA repair with the t-Branch graft and bridging stent grafts (BSGs) for the celiac (CA), superior mesenteric (SMA), left renal (LRA), and/or right renal (RRA) arteries. Follow-up was through 2 years, per sites’ standard of care. Procedural and 1-year results were reported previously. ResultsEighty patients (mean age, 71.0±7.4 years; 70.0% men) were enrolled; six patients had symptomatic TAAAs, and 15 patients had contained ruptures. Technical success was achieved in 98.8% of patients (79/80). Median follow-up was 22.2 months (interquartile range, 9.2-25.1 months). At 24 months, Kaplan-Meier (KM) freedom from all-cause and aneurysm-related mortality were 78.5% and 98.6%, respectively. Beyond 12 months, 38 adverse events occurred in 20 patients, including two aortic ruptures (one study aneurysm and one non-study aneurysm) and six deaths (none aneurysm-related, as reported by the site). Compared with postprocedure, maximum aneurysm diameter decreased (>5 mm) in 84.6% (44/52), remained unchanged in 3.8% (2/52), and increased (>5 mm) in 11.5% (6/52) of patients with imaging follow-up after 12 months. No conversions to open repair, and no t-Branch graft or other endograft component migration or integrity issues were reported. No loss of patency was reported in the t-Branch or iliac limb grafts throughout the study. Throughout study duration, four patients had five imaging-reported BSG compressions, none of which required secondary intervention. KM freedom from secondary intervention was 76.3% at 24 months. Fourteen target vessel-related secondary interventions were performed, primarily consisting of stent placement for endoleak, stenosis, or occlusion. KM freedom from loss of primary patency was 94.8%, 100%, 91.3%, and 89.3% for the CA, SMA, LRA, and RRA, respectively, at 24 months. KM freedom from loss of secondary patency in the CA, SMA, LRA, and RRA were 96.3%, 100%, 98.2%, and 98.3% at 24 months, respectively. A total of 298 vessels were targeted, of which 12 were occluded over the study period. ConclusionsPrimary and secondary target vessel patency rates through 2 years demonstrated durable repair with the t-Branch graft in patients treated for symptomatic or asymptomatic thoracoabdominal aortic aneurysms.

Coping Strategies among Elderly Women with Knee Osteoarthritis Pain at Beni-Suef City: Impact of Socio-demographic Characteristics

Background: Given that optimization of management of the subscapularis is essential to ensuring an optimal outcome after shoulder arthroplasty, this review will focus on the ideal method of Lesser Tuberosity Osteotomy (LTO) repair and the methods by which this is assessed. Specifically, we will review the existing literature to determine how suture configuration, number of sutures, type of sutures, and osteotomy size all influence the biomechanics of an LTO repair. Methods: A systematic review was performed in which one reviewer searched PubMed to find studies analyzing biomechanical strength of lesser tuberosity osteotomy repairs after a total shoulder arthroplasty. The following keywords were used to retrieve articles: (biomechanical) and (Lesser Tuberosity Osteotomy) or (LTO) or (subscapularis repair) and (total shoulder). Results: Nine studies met inclusion criteria. LTO was the strongest, most durable repair in most biomechanical studies. However, the biomechanical testing protocols and repair techniques widely varied throughout the literature. Dual row repair with sutures wrapped around the stem as well thin LTO fragments showed superior biomechanical outcomes. There has been minimal literature focusing on how the number, size and type of suture utilized in a repair affect biomechanical outcomes. Discussion: While the LTO repair technique has been demonstrated in multiple studies to be a biomechanically superior method of subscapularis repair in the setting of TSA, there has not been a single study which has analyzed the effects of repair technique, osteotomy size, as well as suture number/type/size using a standardized biomechanical testing protocol.

Trilayer temporalis fascia interposition graft: A reliable technique for nasal septal perforation repair

PurposeNasal septal perforation (NSP) repair is a complex procedure with variable techniques and success rates. In this study we describe NSP repair using a trilayer interposition graft of temporalis fascia and thin polydioxanone (PDS) plate without intranasal flaps and report outcomes in our patient population. Materials and methodsIRB-approved retrospective review of 20 consecutive patients presenting to a tertiary medical center with NSP from September 2018 to December 2020 and who underwent NSP repair via our trilayer temporalis fascia interposition graft. De-identified patient data was obtained from the medical record and stored on an encrypted secure server. Descriptive statistics were examined for each variable. ResultsAll 20 NSP repairs demonstrated durable repair with complete mucosal coverage at last follow-up (average 7 months). Complete resolution of preoperative symptoms was achieved in 85 % of patients, with partial resolution in the remaining 15 %. Of the 20 perforations 25 % were small (<1 cm), 50 % medium (1-2 cm), and 25 % large (>2 cm). The only surgical complication was a single intranasal synechiae. No graft harvest site complications were noted. ConclusionThe application of a trilayer temporalis fascia - PDS plate interposition graft without intranasal flaps is highly effective for repair of NSP.

MP07-07 ROBOTIC SACROCOLPOPEXY WITH UTERUS PRESERVATION: SURGICAL TECHNIQUE AND 12 YEAR EXPERIENCE FOR WOMEN WITH COMPLETE VAGINAL VAULT EVERSION

You have accessJournal of UrologyCME1 Apr 2023MP07-07 ROBOTIC SACROCOLPOPEXY WITH UTERUS PRESERVATION: SURGICAL TECHNIQUE AND 12 YEAR EXPERIENCE FOR WOMEN WITH COMPLETE VAGINAL VAULT EVERSION Cassandra Schuster, Benjamin Behers, Spencer Kortum, Genesis Dolgetta, Karim Ghazli, Victoria Bird, and Robert Carey Cassandra SchusterCassandra Schuster More articles by this author , Benjamin BehersBenjamin Behers More articles by this author , Spencer KortumSpencer Kortum More articles by this author , Genesis DolgettaGenesis Dolgetta More articles by this author , Karim GhazliKarim Ghazli More articles by this author , Victoria BirdVictoria Bird More articles by this author , and Robert CareyRobert Carey More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003222.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic sacrocolpopexy with uterus preservation (RASCP-UP) is a transabdominal approach for repair of pelvic organ prolapse (POP) that avoids placement of transvaginal mesh and preserves female sexual organs. Although hysterectomy may be performed at the time of POP repair, many women choose to preserve their uterus for reasons of sexuality, female identity, religion, maintenance of maximal vaginal length and undisturbed vaginal blood supply, and resistance to removal of a normal organ. METHODS: Data was collected from an IRB-approved prospectively maintained database of robotic POP repair in a tertiary care hospital. The surgery is performed with a da Vinci Si or Xi system with 4 robotic ports and 1 assistant port. Commercially available 4×24 cm Y-shaped wide pore polypropylene mesh is modified to accommodate >10 cm anterior and posterior dissections of the vaginal walls. The anterior vaginal wall component is brought through the broad ligament and joined with the posteriorly placed component for attachment to the anterior longitudinal ligament with GoreTex sutures. The mesh is then completely covered by peritoneum. Mid-urethral slings were placed at the time of sacrocolpopexy to prevent de novo stress incontinence. All patients for RASCP-UP had stage 4 prolapse with maximal anterior, posterior, and apical descent with the cervix at the apex of the descent. All patients had normal Pap smears and pelvic ultrasounds. RESULTS: Between 2010 and 2022, a total of 450 patients underwent RASCP at the same institution. Of these, 65 presented with complete vaginal vault eversion requesting RASCP-UP. Mean age was 65.9 years and mean BMI 28.0. Cases were completed with robotic console time between 59 and 123 minutes and all patients discharged within 24-48 hours. At mean 78-month (12 – 140 month) follow-up, there were no mesh erosions, hernias, or reoperations for prolapse. There was one reoperation for hysterectomy at 6 year follow up for suspected endometrial carcinoma and two reoperations for small bowel obstruction in patients with extensive lysis of adhesions. CONCLUSIONS: RASCP-UP is feasible for patients with severe POP who desire uterus preservation. The surgery restores normal vaginal axis and length without placement of mesh material through vaginal mucosa. Long-term results show durable functional repair. Women presenting with vaginal vault eversion and maximal descent of cervix can undergo repair of pelvic floor prolapse with concomitant hysterectomy. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e86 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Cassandra Schuster More articles by this author Benjamin Behers More articles by this author Spencer Kortum More articles by this author Genesis Dolgetta More articles by this author Karim Ghazli More articles by this author Victoria Bird More articles by this author Robert Carey More articles by this author Expand All Advertisement PDF downloadLoading ...

Comparison of flexible and rigid annuloplasty rings in isolated mitral regurgitation

Objectives: The aim of this study was to examine the early and midterm results of various annuloplasty rings in terms of residual mitral regurgitation (MR) in patients undergoing mitral valve repair. Patients and methods: In the retrospective study, 298 patients (157 males, 141 females; mean age: 58.8±14.3 years; range, 16 to 82 years) underwent repair between September 2009 and April 2012. Two hundred eleven were assigned to the flexible ring group (Group 1), whereas 87 were included in the rigid ring group (Group 2). Mitral pathologies were divided into three subgroups: ischemic, degenerative, and rheumatic. Results: The causes of mitral pathology were ischemic in 36.2%, degenerative in 54.4%, and rheumatic in 9.4%. Concomitant surgical procedures were present in 87%. The follow-up period ranged from 2 days to 33 months, with a mean of 15.8±7.5 months. The 30-day mortality rate was 9.2% and 10.4% in Groups 1 and 2, respectively. There was a high rate of successful repair in the rigid group with 88.5% and acceptable rate of repair in the flexible group with 72%. Mitral regurgitation was significantly reduced after intervention regardless of the ring type (p&lt;0.01). Significant improvement in NYHA class was observed in both groups. Recurrent regurgitation was detected in 27.9% of patients in Group 1 and 11.5% in Group 2. Recurrence occurred within three to nine months following the surgery. Reoperation rates for residual MR were 3.3% (n=7) vs. 1.1% (n=1) in Groups 1 and 2, respectively (p=0.293). Conclusion: Saddle-shaped rings provide a mechanical benefit through a low and uniform force distribution and improve repair durability compared to flat rings. As a result, the rigid ring had a significant advantage, particularly in degenerative and rheumatic subgroups, but there was a loss of superiority in late ischemic MR due to left ventricle remodeling.

Valvular complex and tissue remodelling in ovine functional tricuspid regurgitation.

Pathophysiology of function tricuspid regurgitation (FTR) is incompletely understood. We set out to comprehensively evaluate geometric and tissue remodelling of the tricuspid valve complex in ovine FTR. Twenty adult sheep underwent left thoracotomy and pulmonary artery banding (PAB) to induce right heart pressure overload and FTR. After 8 weeks, 17 surviving animals and 10 healthy controls (CTL) underwent sternotomy, echocardiography and implantation of sonomicrometry crystals on right ventricle and tricuspid valvular apparatus. Haemodynamic and sonomicrometry data were acquired in all animals after weaning from cardiopulmonary bypass. Leaflet tissue was harvested for pentachrome histologic analysis and biomechanical testing. Animal weight was 62 ± 5 and 63 ± 3 kg for CTL and PAB, respectively (P = 0.6). At terminal procedure, systolic pulmonary artery pressure was 22 ± 3 and 40 ± 7 mmHg for CTL and PAB, respectively (P = 0.0001). The mean TR grade (+0-4) was 0.8 ± 0.4 and 3.2 ± 1.2 (P = 0.0001) for control and banded animals, respectively. Right ventricle volume (126 ± 13 vs 172 ± 34 ml, P = 0.0019), tricuspid annular area (651 ± 109 vs 865 ± 247 mm2, P = 0.037) and area between papillary muscle tips (162 ± 51 vs 302 ± 75 mm2, P = 0.001) increased substantially while systolic excursion of anterior leaflet decreased significantly (23.8 ± 6.1° vs 7.4 ± 4.5°, P = 0.001) with banding. Total leaflet surface area increased from 806 ± 94 to 953 ± 148 mm2 (P = 0.009), and leaflets became thicker and stiffer. Detailed analysis of the tricuspid valve complex revealed significant ventricular, annular, subvalvular and leaflet remodelling to be associated with ovine functional tricuspid regurgitation. Durable surgical repair of severe FTR may require a multi-level approach to the valvular apparatus.

Independent associations with early mortality after open repair of Crawford extent IV thoracoabdominal aortic aneurysms

ObjectiveWe aimed to identify outcomes and factors that independently associate with early mortality after open repair of Crawford extent IV thoracoabdominal aortic aneurysms, defined as aneurysms confined to the segment below the diaphragm. MethodsThis retrospective analysis included 721 extent IV thoracoabdominal aortic aneurysm repairs performed in our institution from 1986 to 2021. Indications for repair were aneurysm without dissection in 627 cases (87.0%) and aortic dissection in 94 cases (13.0%). Overall, 466 patients (64.6%) were symptomatic preoperatively; 124 (17.2%) procedures were performed in patients with acute presentation, including 58 (8.0%) ruptured aneurysms. ResultsOperative death occurred after 49 (6.8%) repairs. Persistent renal failure necessitating dialysis occurred after 43 (6.0%) repairs. Binary logistic regression modeling revealed that previous extent II thoracoabdominal aortic aneurysm repair, chronic kidney disease, previous myocardial infarction, urgent or emergency repair, and longer crossclamp times during surgery were independently associated with operative mortality. Among early survivors (n = 672), competing risk analysis revealed that cumulative incidence of mortality and reintervention rates at 10 years were 74.8% (95% confidence interval, 71.4%-78.5%) and 3.3% (95% confidence interval, 2.2%-5.1%), respectively. ConclusionsAlthough patient comorbidities contributed to operative mortality, factors associated with the repair, such as urgent or emergency status, the duration of aortic crossclamping, and certain types of complex reoperation, also played prominent roles. Patients who survive the operation can expect a durable repair that usually is free from late reintervention. Expanding our collective knowledge regarding patients who undergo open repair of extent IV thoracoabdominal aortic aneurysms will enable clinicians to establish best practices and improve patient outcomes.

Effect of ascending aorta replacement on the long-term outcomes of bicuspid aortic valve repair

ObjectiveThe study objective was to determine the effect of sinutubular junction stabilization on long-term outcomes of bicuspid aortic valve repair. MethodsFrom January 1998 to January 2020, 419 patients underwent bicuspid aortic valve repair with ascending aorta replacement and 421 without (bicuspid aortic valve repair alone). Propensity score matching (97 pairs) was used to compare outcomes. ResultsBefore matching, prevalence of severe aortic regurgitation at 10 years was 5.4% after bicuspid aortic valve repair + ascending aorta replacement and 10% after bicuspid aortic valve repair alone; aortic valve gradient was 20 mm Hg after bicuspid aortic valve repair + ascending aorta replacement and 19 mm Hg after bicuspid aortic valve repair alone. Ten-year freedom from reoperation overall was 79% after bicuspid aortic valve repair + ascending aorta replacement and 75% after bicuspid aortic valve repair alone; freedom from late aortic regurgitation was 93% after bicuspid aortic valve repair + ascending aorta replacement and 92% after bicuspid aortic valve repair alone; and freedom from aortic stenosis was 87% after bicuspid aortic valve repair + ascending aorta replacement and 93% after bicuspid aortic valve repair alone. Ten-year survival was 95% after bicuspid aortic valve repair + ascending aorta replacement and 96% after bicuspid aortic valve repair alone. After matching, prevalence of severe aortic regurgitation at 10 years was 11% after bicuspid aortic valve repair + ascending aorta replacement and 9.1% after bicuspid aortic valve repair alone (P = .33); aortic valve gradient was 16 mm Hg after bicuspid aortic valve repair + ascending aorta replacement and 25 mm Hg after bicuspid aortic valve repair alone (P < .0001). Ten-year freedom from reoperation was 85% after bicuspid aortic valve repair + ascending aorta replacement and 72% after bicuspid aortic valve repair alone (P = .08) overall. Ten-year freedom from reoperation for late aortic regurgitation was 88% after bicuspid aortic valve repair + ascending aorta replacement and 86% after bicuspid aortic valve repair alone (P = .65). Freedom from aortic stenosis was 97% after bicuspid aortic valve repair + ascending aorta replacement and 91% after bicuspid aortic valve repair alone (P = .03). Ten-year survival was 96% after bicuspid aortic valve repair + ascending aorta replacement and 96% after bicuspid aortic valve repair alone (P = .16). ConclusionsBicuspid aortic valve repair with or without ascending aorta replacement is associated with good short- and long-term outcomes. Bicuspid aortic valve repair + ascending aorta replacement has a minimal effect on long-term repair durability. Sinutubular junction stabilization should not be performed for the sole purpose of long-term repair durability.

Repair concrete structures with high-early-strength engineered cementitious composites (HES-ECC): Material design and interfacial behavior

Aimed at realizing the effective strengthening and durable repair of concrete structures, particularly in emergencies like traffic interruption triggered by broken roads and damaged bridges, nine groups of specimens were designed and tested in this paper to develop the high-early-strength Engineered Cementitious Composites (HES-ECC) featured as both high early-strength and superior long-term-deformability. The high-early-strength effect of sulphoaluminate cement, silica fume, and Portland cement on HES-ECC was compared, as well as their influence on the deformation ability of HES-ECC. Moreover, the interfacial behaviors between HES-ECC and existing concrete structure were clarified, considering the effects of interfacial agents, interfacial treatment methods, and interfacial roughness. The results indicate that HES-ECC with 6% silica fume mixed could obtain both the high early-strength and superior long-term-deformability. The flexural strength at 3 h could reach 66.67% of that at 28d. The compressive strength could reach up to 28.7 MPa at 3 h, and the ultimate tensile strain could remain 4.21% at 28d. Cement paste interfacial agent could enhance the chemical adhesive bonding between HES-ECC and existing concrete while polymer modified interfacial agent was incompatible. The increased roughness of chiseled interface was beneficial to both the bearing capacity and the deformation ability. Interfacial shear performance of the grooved interface was scarcely deteriorated even if the roughness decreased by 54.18% compared with the chiseled interface. The recommended interfacial treatment is chiseled interface combined with grooved interface, as well as a thickness of 1–2 mm cement paste interfacial agent. This study provides valuable and credible experimental data for promoting the application of HES-ECC in repairing existing concrete structures in practice.

Investigation of self-healing properties in concrete with Bacillus licheniformis isolated from agricultural soil

One of the best methods to enhance the strength and durability of concrete and repair the cracks is to use a self-healing mechanism, based on bacterial-induced calcite precipitation. The main goal of this study includes the isolation and identification of wild-type calcium carbonate precipitation bacteria compatible with concrete from agricultural soil as a bacterial self-healing agent. These bacteria were recognized as Bacillus licheniformis by molecular identification.The bacteria were immobilized inside lightweight expanded clay aggregate (LECA) to be protected bacteria against harsh concrete conditions. Five different bacterial concentrations (104, 105, 106, 107, and 108 cells/ml) were studied in the mixtures to evaluate the optimum concentration of bacteria.The mechanical properties and durability were tested to estimate the effectiveness of bacteria on the performance of concrete specimens at 7, 28, and 90 days. Furthermore, the physicochemical properties of precipitated calcium carbonate were characterized using field emission scanning electron microscopy (FESEM), energy dispersive spectroscopy (EDS), and X-ray diffraction (XRD).Test results showed that in the specimen containing 107 cells/ml Bacillus licheniformis, the compressive and tensile strength was 21% and 32% more than ordinary concrete, respectively. Also, the maximum decrease in water and chloride ion permeability was 45% and 55%, respectively. These results suggest that the wild-type strain can survive in the cement matrix and by producing calcium carbonate deposits, it has the potential to improve the mechanical properties and durability.

Laparoscopic Repair of a Right-Sided Diaphragmatic Hernia

Introduction: Blunt trauma may cause small occult diaphragmatic injuries that increase in size over the course of decades. The gradual increase is secondary to the pressure disparity between the abdominal and thoracic cavities. Over time, visceral contents may traverse the defect and become incarcerated within the thoracic cavity.1 Typically, the defect occurs on the left side with gastric herniation. Rarely, the defect occurs on the RIGHT side since the large right lobe of the liver may preclude herniation through a right-sided diaphragmatic defect.2,3 This video presents a repair of a symptomatic right-sided diaphragmatic hernia that occurred decades after blunt trauma. Materials and Methods: A 58-year-old man was admitted to the emergency department with a 2-day history of acute abdominal pain that was sharp and diffuse. He had vomited several times and denied flatus for 24 hours. He had a history of three prior motor vehicle accidents in the 1980s. He had a history of oropharyngeal cancer that was treated with radiation then a neck dissection 2 years before presentation. He had no history of abdominal or thoracic surgery but had a significant tobacco history for 40 years. His blood work was normal. A CT scan of the abdomen showed a right-sided diaphragmatic hernia defect that contained small intestine and colon. There was no dilated bowel or evidence of a pneumoperitoneum or free fluid. There was air in the rectum. A well-healed old nondisplaced pubic rami fracture was evident also on the scan. Surgical intervention included a laparoscopic possible thoracoscopic diaphragmatic repair. Operatively, he was placed in a semilateral position at 30°. A Veress needle was used to enter the abdomen and three 5 mm ports were placed along the subcostal border. One of the 5 mm ports was upsized to a 10 mm port. Diagnostic laparoscopy delineated the diaphragmatic defect containing bowel. Several adhesions were divided and the colon and small intestine were reduced from the defect. There was no hernia sac and the thoracic cavity was pristine. Once the bowel was reduced, the defect was measured at ~5 cm by 3 cm. The defect was closed with interrupted 0-silk sutures. The suture line was then buttressed with a 15 cm by 10 cm mesh. The mesh was secured with absorbable tacks. A 28F chest tube was placed. Results: The operative time was 90 minutes. The patient was started on a clear liquid diet on postoperative day 1 and advanced to a regular diet on postoperative day 2. Because of social issues, he was discharged on postoperative day 4. A chest CT at ~6 months postoperatively showed no evidence of a recurrent diaphragmatic defect. Conclusions: Minimally invasive techniques are well suited for diaphragmatic defects. If a right-sided symptomatic diaphragmatic hernia is diagnosed, a minimally invasive approach through the abdomen may be performed without a thoracic approach. Adhesions may warrant thoracic access to reduce the abdominal contents, so double lumen intubation is prudent. A durable repair may be obtained by suturing the defect and adding a mesh buttress. Patient consent has been obtained. Authors have received and archived patient consent for video recording/publication of the procedure. There are no conflict of interests associated with this video in terms of commercial or financial interests. Runtime of video: 5 mins 42 secs