Need For Surgical Repair Research Articles

Determinants of surgical repair of patent ductus arteriosus in low-birth-weight infants.

To identify risk factors related to the failure of indomethacin therapy and the need for surgical repair in patent ductus arteriosus (PDA) in extremely low-birth-weight (<1000g) infants (ELBWI). Study subjects were 36 ELBWI with PDA born at a single tertiary perinatal center. They were classified into those who required surgery due to failure of indomethacin treatment (surgical group, n=21) and those with effective indomethacin treatment (non-surgical group, n=15). The odds ratios (ORs) and 95% confidence intervals (95% CIs) for the relationship between selected risk factors and surgical treatment of PDA were calculated. Gestational age of <28weeks and diameter of PDA of 2mm or more were independent and significant determinants of the need for surgical repair of PDA (adjusted ORs [95% CIs]=9.91 [1.16-84.48] and 24.80 [2.72-225.74], respectively). The need for surgical repair of PDA did not correlate with sex, birth weight, 1-min Apgar score, left atrium diameter/aortic diameter (LA/Ao), left ventricular internal dimension at end-diastole, prophylaxes with indomethacin, and total dosage of indomethacin. Gestational age at birth of <28weeks and diameter of PDA of 2mm or more are determinants of failure of indomethacin treatment for PDA and the need for surgical repair.

Complication Rates for Percutaneous Lower Extremity Arterial Antegrade Access

The antegrade access (AA) for percutaneous arterial interventions is associated with a higher complication rate than is the retrograde access (RA). Retrospective case review. A statewide consortium for peripheral vascular interventions consisting of 13 Michigan hospitals collecting data on their endovascular procedures. Demographic and procedure data on all patients receiving a percutaneous peripheral arterial intervention were entered prospectively by a full-time clinical nurse specialist in each hospital site. We evaluated vascular complications as a composite of retroperitoneal hematoma, pseudoaneurysm, hematoma requiring blood transfusion, arteriovenous fistula, acute thrombosis, or the need for surgical repair of the access site. In a 2-year period, we collected 6343 cases, of which 5918 had complete data regarding arterial access; of these, 745 (12.6%) were performed via an AA. There were fewer women and smokers (P < .001) in the AA group but more diabetic patients (P < .001). The indications for intervention were more frequently rest pain (P < .001) and limb salvage (P < .001) in the AA group. Multivariate regression analysis showed that the odds of complications were significantly higher with a larger sheath (95% confidence interval, 1.53-4.06; P < .001). Also, the incidence of blood transfusion and subsequent amputation was significantly higher in the AA group (P < .001). Endovascular procedures performed via an AA are more likely to result in perioperative complications and therefore should be used cautiously.

Perfil clínico, epidemiológico y pronóstico de la endocarditis infecciosa en un hospital de tercer nivel

Objectives To analyse the clinical, epidemiological profile and prognosis of infective endocarditis in a tertiary hospital. Methods A retrospective study of infective endocarditis was performed between 2004 and 2009. The main end-points were death due to infective endocarditis and the composite one of death and need of surgical repair. Results Sixty four patients with infective endocarditis were included (39% women), with 45 months of follow-up. Fifty six percent of the infective endocarditis occurred due to prosthetic valves. The most common isolated organisms were S.Aureus (22%), and coagulase-negative Staphylococcus (16%). Twenty five percent of patients died during the follow-up (81% at hospital admission), and 64% reached the composite end-point. Only Diabetes Mellitus and negative gram bacilli infection were associated with mortality ( P<0.05). Conclusions There have been changes in clinical, epidemiological and microbiological profile in infective endocarditis in recent years. Despite the improvement in diagnostic and therapeutic process, the morbidity-mortality in this disease is still very high.

Right ventricular remodeling in restrictive ventricular septal defect

Restrictive ventricular septal defect (rVSD) presents with little/no hemodynamic aberrations despite a patent septal defect. Clinically, these patients are observed with the hope that the defect will functionally close over time without the need for surgical repair and development of heart failure. Without evidence supporting a definitive therapeutic strategy, rVSD patients may have increased risk of a poor outcome. We tested the hypothesis that rVSD results in subclinical RV diastolic dysfunction and molecular remodeling. Five pigs underwent surgical rVSD creation. Echocardiography, hemodynamics, myocyte contractility experiments, and proteomics/Western blot were performed 6-weeks post-rVSD and in controls. * p < 0.05. LV and RV hemodynamics in rVSD were comparable to controls. The tricuspid valve early/late diastolic inflow velocity ratio (TV E/A ratio) decreased from 1.6 ± 0.05 in controls to 1.0 ± 0.08* in rVSD, indicating RV diastolic dysfunction. rVSD RV myocytes showed abnormalities in contraction (departure velocity (Vd) − 51%*, Vd time + 55%*) and relaxation (return velocity (Vr) − 50%*, Vr time + 62%*). Mitochondrial proteins (fatty acid, TCA cycle) increased 2-fold*, indicating heightened RV work. Desmin protein upregulated 285%* in rVSD RV myocardium, suggesting cytoskeletal remodeling. rVSD causes RV diastolic dysfunction, myocyte functional impairment, and mitochondrial/cytoskeletal protein upregulation in our model. Desmin upregulation may hinder sarcomeric organization/relaxation, representing a key subclinical early marker for future RV dysfunction. TV E/A measurements are a non-invasive modality to assess rVSD patients for diastolic dysfunction. Translational research applications may lead to fundamental changes in the clinical management of rVSD by providing evidence for early repair of the defect.

Manejo endovascular de las complicaciones agudas de la disección aórtica tipo B

Type B aortic dissection is usually managed by intensive care medical therapy and surgery is reserved for treating the complications that can occur during the evolution of a case. To assess the endovascular management of acute complications of type B aortic dissection and the closure of the intimal defect and aortic false lumen. Retrospective analysis of 8 consecutive patients aged 40 to 57 years (seven males) treated for acute complications in the initial episode of a type B aortic dissection between August 2006 and July 2008. Six/eight were known hypertensive patients. The indications for surgery were intractable pain in one, hypertension refractory to treatment in two and distal hypoperfusion in five. Five patients required covering of the left subclavian artery ostium, without need for surgical repair. One patient was subjected to renal angioplasty and stenting. Technical success was achieved in all cases, with complete closure of the proximal aortic tear and thoracic aortic false lumen, although 7 of patients had a persistent distal aortic false lumen. One case had a transient lower limb paraparesis. No patient died. Endovascular treatment is effective in closing the aortic tear as well as the thoracic aortic false lumen in aortic type B dissections with a low complication rate. Due to the high frequency of distal aortic false lumen persistence, it is not a definitive treatment for this condition but it is useful for the acute complications of the initial phase of type B aortic dissection.

Ulcerlike Projections Developing in Noncommunicating Aortic Dissections: CT Findings and Natural History

Aortic ulcerlike projections are focal, contrast-filled outpouchings projecting from the aortic lumen. Our aim was to document the CT findings and natural history of ulcerlike projections developing in patients with preexisting noncommunicating aortic dissection, including intramural hematoma or false lumen thrombosis. By searching the radiology information system, we found 38 ulcerlike projections arising in an underlying noncommunicating aortic dissection that were identified at CT in 24 patients. Clinical factors were determined from patient records. CT scans were reviewed to determine aortic pathology type and appearance time of ulcerlike projections and to measure the diameters of the aorta and ulcerlike projections for comparison over time. Complications were defined as an increase of at least 20% in the diameters of the ulcerlike projections or aorta, the need for surgical repair, or both. Comparisons of ulcerlike projections with and without complications were performed using various statistical tests. The underlying aortic disease of the 38 ulcerlike projections was intramural hematoma in 26, false lumen thrombosis in nine, and unknown in three. The mean time of ulcerlike projection appearance was 2.4 months (SD, 1.8) for intramural hematoma and 19.3 months (SD, 18.1) for false lumen thrombosis. Nine of the 28 ulcerlike projections with follow-up scans showed stability, size decrease, or resolution; 10 increased in size; and nine were incorporated into an expanded aortic lumen. Four of 36 ulcerlike projections with imaging or clinical follow-up (or both) required surgical repair. The only clinical or imaging feature significantly associated with the development of complications was false lumen thrombosis (p = 0.04). Ulcerlike projections forming in noncommunicating dissections may enlarge over time, although they rarely require surgical repair. Given the potential for critical complications, these lesions should be followed with serial CT scans.

Intermittent Roxithromycin for Preventing Progression of Small Abdominal Aortic Aneurysms: Long-Term Results of a Small Clinical Trial

Antibodies against Chlamydia pneumoniae are associated with an increased rate of expansion of small abdominal aortic aneurysms (AAAs). Short-term follow-up trials have shown a transient reduction AAA growth rate, in macrolide treated compared with placebo. Therefore we analysed the influence of intermittent, long-term roxithromycin treatment on AAA expansion and referral for surgery. Eighty-four patients with small AAAs were randomized to either an annual 4 weeks' treatment with roxithromycin or placebo, and followed prospectively. Intermittent, long-term Roxithromycin-treatment reduced mean annual growth rate by 36% compared with placebo after adjustment for potential confounders. Long-term roxithromycin-treated patients had a 29% lower risk of being referred for surgical evaluation, increasing to 57% after adjusting for potential confounders. Annual 4 week treatment with 300 mg roxithromycin daily may reduce the progression of small AAAs, and later need for surgical repair. However, more robust studies are needed for confirmation.

ALCAPA Syndrome: Not Just a Pediatric Disease

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) syndrome is a rare congenital coronary artery anomaly. There are two types of ALCAPA syndrome: the infant type and the adult type, each of which has different manifestations and outcomes. Infants experience myocardial infarction and congestive heart failure, and approximately 90% die within the 1st year of life. Rarely, ALCAPA syndrome manifests in adults; it may be an important cause of sudden cardiac death. Historically, ALCAPA syndrome was diagnosed at conventional angiography. However, the development of electrogardiographically gated multidetector computed tomographic (CT) angiography and magnetic resonance (MR) imaging enables accurate noninvasive imaging. At MR imaging and multidetector CT angiography, findings include direct visualization of the left coronary artery arising from the main pulmonary artery. Reversed flow from the left coronary artery into the main pulmonary artery may be seen at steady-state free-precession cine and fast cine phase-contrast MR imaging. Because of its ability to assess myocardial viability, which can be used as a prognostic factor to direct the need for surgical repair, MR imaging plays an important role in patient treatment. Restoration of a dual-coronary-artery system is the ideal surgical treatment for ALCAPA syndrome.

Preventing Parastomal Hernia with a Prosthetic Mesh: A Five Year Follow Up of a Randomised Study

SocieteInternationale de Chirurgie 2008 Definitive colostomy formation has become less frequent during the last two decades since abdominoperineal resection can now be omitted in many patients with rectal cancer, and Hartmann's operation for sigmoid diverticulitis is increasingly replaced by resection with primary anasto- mosis—with a loop ileostomy, if necessary. Nevertheless, there are still a number of patients who will receive a definitive colostomy due to different reasons. Long-term quality of life in those patients is significantly correlated to a ''good'' colostomy that comprises a proper localization in the abdominal wall, a non-impaired evacuation, and finally an easy management of the ostomy devices. While patients with a well functioning colostomy have few restrictions in their daily live, patients with ostomy problems may be heavily disturbed in their individual quality of life. Fur- thermore, patients with parastomal hernia often need additional ostomy devices, i.e. specially shaped faceplates, and repeated use of health care resources, both causing a significant increase of cost. Development of parastomal hernia is a common prob- lem that occurs after definitive colostomy creation. The reported incidence ranges up to 50%. Surgical repair is performed in at least 30% of all patients with parastomal hernia, whereby the postoperative recurrence rate is high. Colostomies are at particular risk to develop parastomal hernia since intraoperatively it is impossible to exactly determine the precise diameter of the hole; in reality it is always a compromise between keeping the opening narrow versus not impairing blood flow as well as stool evacuation. The passage of the colon through the abdominal wall represents therefore a kind of a ''planned'' weakness her- alding hernia formation. This is in contrast to ''normal'' incisions of the abdominal wall that are tightly closed after the intervention. The high incidence of parastomal hernia with its sub- sequent adverse effects on quality of life, the need for surgical repair, and increased cost provide the impetus to prevent parastomal hernia formation instead of just repairing the defect. In accordance to the convincing results of incisional hernia repair by using a prosthetic mesh, it seems logical to insert a prosthetic mesh during the index operation in order to obviate parastomal hernia for-

Postoperative pain and vomiting after orbital wall surgery in trauma

Postoperative pain and vomiting after orbital wall surgery in trauma

Conservative Management of Postoperatively Diagnosed Cystotomy

Bladder injury is a common complication of hysterectomy that is often not recognized at the initial surgery. The conventional approach to intraperitoneal cystotomy is surgical repair. The goal of this case series was to introduce an alternative conservative treatment of posthysterectomy cystotomy. We present 3 cases of posthysterectomy cystotomy that were unrecognized at the initial surgery and were treated with assisted bladder drainage. The treatment of iatrogenic intraperitoneal cystotomy with bladder drainage facilitated complete healing and eliminated the need for surgical repair. We suggest that conservative management be considered as the first-line treatment option in appropriately selected patients.

Spontaneous Meningoencephalocele of the Temporal Bone

To describe the clinical presentation and the radiological and surgical findings in patients with spontaneous meningoencephalocele of the temporal bone. Retrospective case series. Academic, tertiary care medical center. Fifteen consecutive patients with surgically confirmed meningoencephalocele of the mastoid and middle ear, without a history of trauma, tumor, cholesteatoma, or surgery of the mastoid or cranium, who were treated at our institution between January 1, 1999, and December 31, 2006. Ten of the 15 patients were women. Ages ranged from 31 to 77 years, with 12 patients 50 years or older. The most common presenting complaint was new-onset hearing loss in 14 patients, followed by aural fullness and headache. Cerebrospinal fluid formed an effusion in the middle ears of 13 patients and was most commonly identified when myringotomy resulted in continuous clear otorrhea. Four subjects had a history of adult-onset recurrent acute otitis media with intermittent otorrhea, which in 1 case was complicated by brain abscess. At least 1 full-thickness defect of the tegmen associated with cortical thinning of the middle fossa floor was identified in all cases on high-resolution computed tomography. At surgery, herniations of meningeal and cerebral tissue were seen through 1 (7 cases) or 2 (8 cases) defects in the middle fossa floor. Obstruction of antral aeration by the meningoencephalocele was present in all 4 cases associated with otitis media. The onset of otitis media, including middle ear effusions at 40 years or older, warrants the consideration of a meningoencephalocele of the ear. The appearance of tegmental defects and cortical thinning of the middle fossa floor on computed tomography provides a strong indication of the diagnosis and of the need for surgical repair.

Iatrogenic Aortocoronary Dissection: The Case for Immediate Aortoostial Stenting

Aortoostial dissection is a serious but rare complication of coronary intervention that may require surgical aortic repair. Here we present four cases which were immediately sealed with stenting of the coronary ostium abruptly terminating spread of the aortic dissection and obviating the need for surgical repair. Long-term outcome in this small series was universally event free. Review of the literature suggests that such a strategy is frequently successful without major added risk. We propose that immediate ostial stenting (irrespective of whether the dissection starts from the ostium or further downstream in the coronary) should be strongly considered in all cases as it may prevent the need for high-risk emergent surgical aortic repair.

Isolated cleft of the posterior mitral valve leaflet

Fig. 1. A: Late-systolic still-frame of a transthoracic short axis view depicts the cleft (⁎) of the mildly thickened posterior mitral leaflet. AML denotes anterior mitral leaflet. B: Colour Doppler showing a moderate mitral regurgitation. A 64-year-old lady was referred for evaluation of a recently detected heart murmur. The patient was completely asymptomatic and an avid tennis player. Auscultation revealed a loud midto late systolic click followed by a grade III midto late systolic regurgitant murmur. Transthoracic echocardiography showed an isolated cleft of the mildly thickened posterior mitral valve leaflet with a moderate late systolic mitral regurgitation (Fig. 1). The anterior mitral valve leaflet and the subvalvular apparatus were normal, especially the insertion of the papillary muscles. No other cardiac anomalies were present. Isolated cleft posterior mitral valve leaflet is a very rare congenital malformation that is usually diagnosed in early childhood. The cleft is more commonly found in the anterior leaflet and in association with other cardiac anomalies such as atrioventricular septal defects and anomalies of the papillary muscles [1,2]. A retrospective analysis of more than 13,000 children revealed only ten isolated cleft mitral valve leaflets with none of them affecting the posterior leaflet [3]. Cleft mitral valve leaflet may result in severe mitral regurgitation and the need for surgical repair [4]. Our patient was diagnosed with the malformation at age sixty-four, had only moderate mitral regurgitation and remained asymptomatic.

Neonatal transcatheter closure of a large pulmonary arteriovenous fistula

A congenital fistulous connection between the right pulmonary artery and the left atrium is a rare condition, resulting in early cyanosis and cardiac failure. These patients usually required urgent surgery. We present a neonate in whom we successfully closed such a large fistula via catheterization with an Amplatzer Duct Occluder, resulting in rapid clinical improvement, and obviating the need for surgical repair.

The Intraluminal Thrombus as a Source of Proteolytic Activity

Most abdominal aortic aneurysms (AAAs) with a diameter indicating need for surgical repair contain intraluminal thrombus (ILT). The development of AAA is linked to degradation of elastin and collagen. These changes are more pronounced in the aneurysm wall covered by the ILT, which also shows more signs of inflammation and is thinner compared to the aneurysm wall exposed to flowing blood. The rate of increase in diameter of AAA correlates with increased thrombus growth and rupture. CT examinations of patients with rupture have demonstrated contrast appearing in the thrombus suggesting bleeding into it. Studies using gene array of human aneurysm specimens have shown that most matrix metalloproteinases (MMP) were upregulated in the thrombus-free wall. Analyses by zymography, however, demonstrate gelatinase activity in the interface between the thrombus and the underlying wall and in the media of the wall not covered by a thrombus. The thrombus contains large amounts of neutrophils. Neutrophil gelatinase associated lipocalin (NGAL) is involved in the regulation of MMP-9 activity and prevents its inactivation, thus augmenting the proteolytic effect. It has been identified in all layers of the ILT. The presence of NGAL/MMP-9 complexes throughout the thrombus and in the thrombus-covered wall may contribute to the increased proteolytic degradation seen in this wall segment. In conclusion, the presence, growth, and thickness of the ILT have been shown to be associated with growth and risk of rupture. The wall underlying the thrombus is thinner and shows more signs of proteolytic degradation. Increased proteolytic activity by MMP-9 may be mediated by binding to NGAL.

CORRELATION BETWEEN BANKART AND HILL‐SACHS LESIONS IN ANTERIOR SHOULDER DISLOCATION

Bankart lesions and Hill-Sachs lesions are commonly associated with anterior shoulder dislocations. The presence of Bankart lesion indicates the need for surgical repair. Magnetic resonance imaging (MRI) has been shown to be sensitive in detecting these two lesions. The aim of this study is to investigate the correlation between Bankart lesions and Hill-Sachs lesions on MRI for patients with traumatic anterior shoulder dislocations. Between 2003 and 2005, 61 patients from Alfred and Sandringham Hospitals had an MRI as part of the investigation for traumatic anterior shoulder dislocations. The MRI scans were reviewed and subsequently confirmed by a radiologist to show the presence or absence of Bankart and Hill-Sachs lesions. The data were then analysed by a statistician. Although patients with one of these lesions were more than two-and-a-half times as likely to have the other, small study numbers precluded this result from achieving statistical significance. (odds ratio, 2.67 (0.83-8.61), P = 0.10). Younger age was a strong predictor of a recurrence of shoulder dislocation (odds ratio, 0.93 (0.89-0.98), P = 0.005). The presence of Bankart or Hill-Sachs lesions on MRI for the primary shoulder dislocation group was similar to the recurrent group (73% vs. 72% for Bankart lesion and 67% vs. 70% for Hill-Sachs lesion). There is a strong correlation between both lesions. This apparent trend can be useful in predicting the presence of a Bankart lesion when a Hill-Sachs lesion is identified on a plain radiograph. This study suggests the consideration of surgical repair after identification of a Hill-Sachs lesion on plain radiographs, especially for younger patients where the rate of re-dislocation is high.

The application of a simplified system of criterions for audit to improve paediatric cardiologic and paediatric cardiac surgical care: evidence from a regional approach in Hungary

To evaluate the quality of cardiac and surgical care provided for children with congenital cardiac malformations in the eastern county of Hungary. We used the method of clinical audit based in selection of criterions, developing five such criterions concerning timely diagnosis, access to treatment, and outcome. To examine compliance with these criterions, we analysed retrospectively the routine data relating to children living in Hajdu-Bihar County. The period of observation lasted from January, 1994, until December, 2001, and was divided into two epochs in order to evaluate any changes over time. In the first epoch, 28 infants, representing 0.1% of all newborns, died of congenital cardiac disease, with one of the malformations being recognised post mortem. In the second epoch, 21 infants died, representing 0.09% of newborns. In this group, each malformation was diagnosed before death. In each period, 6 infants died without having undergone cardiac surgery, and having no other non-cardiac disease. The overall postoperative mortality was 9.2% for the first period, and 4.6% for the second. The number of patients waiting for non-urgent repair had reduced significantly by the end of the second epoch. The results show that the timely diagnosis of congenital cardiac malformations is in line with accepted international standards. Conversely, the access to invasive treatment was limited over the period of observation, albeit that the waiting list was reduced significantly by the end of the second epoch. The postoperative mortality for those suffering congenital cardiac malformations is also comparable with international standards, except for mortality during infancy for treatment of complex anomalies. Our audit highlights the need for surgical repair of the more complex malformations during infancy.

Shin Pain in a Runner

History A 35 year-old athletic female presents to a foot and ankle specialist for evaluation of a six month history of persistent, sharp, and non-radiating right ankle and shin pain with associated numbness. The patient is an avid runner and is currently training for her first marathon with a weekly average of greater than 25 miles. Rest improves her symptoms and activity exacerbates her pain, which occasionally wakes her up at night. Standard three view ankle films are negative for any acute injury, and the patient is diagnosed with shin splints and sent to physical therapy for treatment. Four months later, the patient presents to our clinic with worsening complaints since arduously completing a recent marathon, and she has recently noticed a small painful knot on the anterior portion of her tibia. Physical Examination The patient is a well-developed and well-nourished athletic female with an antalgic gait. On visualization there is no ecchymosis, erythema, or obvious prominence over either tibia. Her right tibia is tender along the anterior and posteromedial borders with focal tenderness over the midshaft. The patient has no neurological deficits or asymmetries in her lower extremities. Her distal pulses are 2+ and equal bilaterally. There is no pes planus or leg length discrepancy. Differential Diagnosis Tibial Stress Fracture Medial Tibial Stress Syndrome Tibial periostitis Chronic Anterior Compartment Syndrome Bone Cyst/Tumor Tests and Results AP and Lateral tib-fib X-rays show dual tibial stress fractures of the anterior cortex in the middle third of the tibia. Bone Densometry is normal. Final Working Diagnosis Dual Tibial Stress Fractures of the anterior cortex in the middle third of the tibia Treatment and Outcomes After extensive counseling and discussion with the patient concerning the need for surgical repair of her tibial stress fractures, she ultimately decided to forego surgical treatment at the time of diagnosis. The patient was made non-weight bearing with crutches and was placed in a pneumatic immobilizer. She was given a bone stimulator with instructions on its use and was sent for formal physical therapy. She was started on Fosamax, OsCal, and a multivitamin, and was given a prescription for a nonsteroidal to use as needed. The patient had two follow up appointments after her diagnosis, and her last follow up X-rays showed minimal interval healing of both fractures at two months.

The Clinical Development of Percutaneous Heart Valve Technology: A Position Statement of The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), and the Society for Cardiovascular Angiography and Interventions (SCAI)

The Clinical Development of Percutaneous Heart Valve Technology: A Position Statement of The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), and the Society for Cardiovascular Angiography and Interventions (SCAI)