Patch Closure Research Articles

Does Fitzpatrick Score Predict Flap Loss? Microsurgical Breast Reconstruction Outcomes of Varying Skin Color.

This is a retrospective study conducted on patients who underwent any type of autologous flap breast reconstruction performed by the two senior authors at an academic center between January 2010 and December 2021. The sole primary outcome variable was flap loss. Patient skin tone was assessed using the Fitzpatrick scale on clinical photographs of patients. A total of 1115 pateints underwent autologous flap breast reconstruction, of which only 56 met both exclusion and inclusion criteria with 58 individual breasts being included in the final study population. The most common race of subjects was White (n = 33; 56.9%) while the most common Fitzpatrick score skin tone was type II (n = 22; 37.9%). The Cochran-Armitage test of trend showed a statistically significant linear trend, P = 0.006, with darker Fitzpatrick score skin tones associated with a higher proportion of flap loss in patients who had vascular compromise. A logistic regression showed that none of the predictor variables were significant. Patients with darker Fitzpatrick skin tones were associated with flap loss after vascular compromise. To prevent flap loss in patients who have darker Fitzpatrick score skin tones, more aggressive flap monitoring should be taken into consideration in the immediate postoperative setting.

Sinus of Valsalva aneurysm: Defining the optimal approach.

Sinus of Valsalva aneurysm (SVA) is relatively rare, especially in Western countries, and reports on long-term results after surgical SVA repair in a sizable patient cohort are scarce. In this issue of the Journal of Cardiac Surgery, Chaganti and colleagues publish their surgical experience over the past 30 years in 216 patients with SVA.SVAs were closed via a dual approach, with (1) patch closure (80%) or direct closure (20%) of the base of the fistula through aortotomy and (2) direct closure of the ruptured tip through the chamber of rupture. Aortic valve replacement (9.7%) or repair (6.5%) was performed for moderate to severe aortic regurgitation (AR). There was no hospital mortality. During a mean follow-up of 10 years, no patient had residual/recurrent shunting. The actual survival at 10 years was 99%, with only two deaths. Freedom from moderate or severe AR was 98.5% at 10 years. Early and long-term results after surgical repair of SVA were excellent in their 216 patients with a mean follow-up of 10 years. Their dual approach for SVA was effective in preventing residual/recurrent shunting. The need for AVR in 10% of the patients speaks to the importance of follow-up. The current report provides strong support for surgical repair being the preferred management for SVA.

Routine use of 3-dimensional zoom modality with 2-dimensional transesophageal echocardiography to decide the candidacy for transcatheter device closure of atrial septal defect

Abstract Background 2-dimensional transesophageal echocardiography (2D-TEE) and balloon sizing are commonly used for assessment of Ostium secundum atrial septal defect (OS-ASD) prior to device closure but complications do occur. Therefore, assessment of accurate morphology and anatomy of the defect in three-dimensional plane is essential for transcatheter device closure to be successful, which the 2D TEE fails to reveal. Purpose 2D TEE has long been used to decide size of the device required for transcatheter closure of OS-ASD and the appropriate candidates. However, complications like inadequate closure, leaving behind residual defect or device embolization often come into picture. The reason behind this is complex anatomy of some defects in the three-dimensional plane. Purpose of this study was to see if the routine use of 3D zoom with 2D TEE can better help to select the appropriate patients for device closure than that by 2 TEE alone. Methods We enrolled 71 OS-ASD patients from October 2020 to December 2021. All the patients underwent transesophageal echocardiography (TEE). Assessment of quantitative (number, shape and size of defect and size of residual rims) and qualitative (aneurysm, malalignment, fenestration) parameters was done by both 2D and 3D zoom. The measurements by 2D and 3D TEE clips were done by different operators. Transcatheter device closure was done for the patients with defect morphology and residual rims amenable for the same, with acceptable pulmonary pressure. Patients found to be adequate for the device closure by 2D TEE, when further found to have an unfavorable morphology by 3D TEE, were referred for surgical management. Follow up transthoracic echo was done after 1 month. Results Of the 71 patients, 65% were females and mean age was 26.23±10.75 years. By 3D TEE, 66% had circular defect,19% had oval defect and 14% had complex defect. 2 patients had spiral defect. Malalignment of the septum was seen in 4 (5.6%) patients by 2D TEE whereas in 13 (18.3%) patients by 3D TEE. Septal aneurysm was seen in 1 (1.4%) by 2D TEE whereas in 3 (4.2%) patients by 3D TEE. Mean largest size obtained by 2D was 24.82±9 mm and that by 3D was 26.23±8.42. By 3D TEE, 37 patients had at least one rim deficient (<5 mm). 3D Maximal diameter strongly correlated with 2D Maximal diameter (correlation coefficient 0.860; p<0.01). 9 (12.6%) patients found adequate for the device closure by 2D TEE were further found to have an unfavorable morphology by 3D TEE. 38 (53.5%) patients underwent device closure and 20 (28.2%) patients underwent surgical patch closure. At 1 month follow up all the 38 patients had device in-situ and had no residual shunt. Conclusions In OS-ASD patients, routine use of 3D zoom modality can complement 2D TEE in deciding appropriate patients for transcatheter device closure and help prevent many unforeseeable complications. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Jawaharlal Institute of Postgraduate Medical Education and Research

Early outcomes of a myofascial repair technique for fetal myelomeningocele

PurposeFetal repair of myelomeningocele (MMC) and myeloschisis leads to improved neurologic outcomes compared to postnatal repair, but the effects of modifications in closure techniques have not been extensively studied. Previous work has suggested that a watertight repair is requisite for improvement in hindbrain herniation (HBH) and to decrease postnatal hydrocephalus (HCP). Our institution adopted the myofascial closure technique for open fetal MMC repair in July 2019, which we hypothesized would result in decreased need for patch closure, improved HBH, and decreased rate of surgically-treated HCP. MethodsA single-center retrospective study of patients who underwent fetal MMC or myeloschisis repair between March 2013 and February 2022 was performed. Outcomes were evaluated (n = 70 prior to July 2019, n = 34 after July 2019). Statistical significance was determined by Fisher's exact and Chi square tests (p < 0.05 significant). ResultsPatients who underwent myofascial closure were less likely to require a patch for skin closure (14.7% vs 58.6%, p < 0.0001). Myofascial closure was also associated with an increased rate of HBH improvement on two-week postoperative fetal MRI (93.9% vs 65.7%, p = 0.002). Surgically-treated HCP at one year was lower in the myofascial closure group (n = 21), however this did not reach statistical significance (23.8% vs 41.9%, p = 0.19). ConclusionsWe conclude that the myofascial closure technique for repair of fetal MMC and myeloschisis is associated with significantly decreased need for patch closure and improvement in hindbrain herniation compared to our previous skin closure technique. These results support a surgical approach that employs a multilayer watertight closure.

A case series of rare pathologies of the aorta and the aortic arch in adolescents and younger adults: Transfer of experience for an individualized approach.

ObjectiveWhile aneurysm of the aortic root, interrupted aortic arch, and aortic coarctation are the most frequent aortic diseases in adolescents and younger adults, there are a number of rare pathologies of the thoracic aorta that need individualized treatment.PatientsWe present a small case series of unusual aortic pathologies in patients presenting with a broad spectrum of symptoms: tiredness, dysphagia, dyspnea, arterial hypertension, renal failure, and claudication. (1). Segmental agenesia of the descending aorta. (2). Balanced double aortic arch with complete vascular ring. (3). Right descending aortic arch, left lusorian artery with Kommerell diverticulum. (4). Large patent ductus (2.5 cm) and ventricular septal defect. (5). Aneurysm of the aortic arch in the presence of tuberous sclerosis. (6). Pseudo-aneurysm of the proximal descending aorta following coarctation patch plasty. (7). Supravalvular aortic stenosis combined with severe aortic valve stenosis. (8). Pseudo-aneurysm following ascendens-to-descendens bypass because of recurrent coarctation. (9). Takayasu arteriitis with severe stenosis in the thoraco-abdominal aorta.ResultsThe following procedures were performed, using individualized cardiopulmonary bypass, canulation and cerebral protection strategies. (1). Ascending to supraceliac extra-anatomic bypass. (2). Division of the ductus ligament and of the anterior aortic arch distally to the left subclavian artery. (3). Excision of the Kommerell diverticulum and translocation of the left subclavian artery. (4). Patch closure of the aorto-pulmonary window (patent ductus) and closure of the ventricular septal defect. (5). Complete aortic arch replacement combined with debranching of the supra-aortic vessels. (6). Graft interposition of the proximal descending aorta. (7). Enlargement of the ascending aorta and aortic valve replacement. (8). Exclusion of the pseudo-aneurysm, end-to-side graft interposition. (9). Ascending aorta to infrarenal aorta or ascending to bi-iliac artery bypass (planned). All patients were operated on without operative mortality. One patient died in-hospital from pulmonary complications one week after surgery. One patient is still awaiting surgery. All other patients recovered very well from the operation and did not show any residual symptoms.ConclusionRare pathologies of the thoracic aorta in younger patients may cause a broad spectrum of unusual symptoms; in some of them, diagnosis is delayed. Cross-sectional imaging is mandatory for optimal operative planning Surgical treatment can be performed with very satisfying results. The prognosis of these patients is usually favorable following surgery.

P9.24: An Alternative Abdominal Closure Technique After Pediatric Liver Transplant: Bogota-Bag Technique

Introduction: In conditions such as large for size, postreperfusion hepatic edema, and intestinal edema, primary closure of the abdominal wall can cause respiratory complications, thrombosis of vascular structures due to compression of graft vascular structures, ischemia of the graft, and intestinal complications. In this study, we aimed to compare the results of primary abdominal closure (PAC) and temporary patch closure (bogoto-bag technique) (BB) in pediatric liver transplant recipients. Material and Methods: The first liver transplant in 1988 was performed by our team. Between 8 December 1988 and 31 December 2021, we performed 701 liver transplant. Of these liver transplants 334 were pediatric and 367 were adults. We performed PAC in 295 recipients. In 39 pediatric liver transplant recipients, we preferred BB technique as the abdominal closure technique in patients with suspected intra-operative tense abdominal closure or intra-abdominal hypertension. In these patients we used this technique, we sutured the sterilized saline bag to the skin at the edge of the defect continuously with a 3/0 polypropylene suture by shaping the defect so as not to cause abdominal hypertension. PAC was achieved in patients after control laparotomies at 48-hour intervals. Results: The mean age of the PAC group was 8.38 years, while the mean age of the BB group was 2 years. The average weight of the PAC group was 26.38 kg, and the average weight of the BB group was 7.93 kg. Biliary atresia was the most common indication in both groups. The mean length of hospital stay was 21 days in PAC group and 24 days in BB group. Six patients in the BB group were died due to sepsis or bleeding in the early postoperative period. Wound closure was achieved within 2 weeks in 25 patients and within 8 patients in three weeks. Conclusion: Temporary patch closure technique can be used safely in experienced centers in low weight and young children, large for size and increased intra-abdominal pressure.

987 Protocol Driven Reduction of Haematoma Following Symptomatic Carotid Endarterectomy (CEA) – a Prospective Cohort Study

Abstract Aim Stroke is the third leading cause of death in developed nations and the leading cause of long-term disability. Carotid artery stenosis accounts for 20 to 30% of ischaemic strokes. Carotid Endarterectomy, has proven highly effective in preventing the development of strokes, TIAs and reducing death among patients with symptomatic carotid artery stenosis of 50–99%. The most common complication of CEA is wound haematomas. This study evaluates a protocol driven haemostasis pathway aimed to address the findings of a recent QI project that identified a significantly high neck haematoma rate as well as a high return to theatre rate for the complication. Method A prospective cohort outcome study between June 2019 and June 2020 was conducted, with the introduction of this stepwise pathway introduced as a quality improvement measure. This was implemented at the end of successful patch closure, for each CEA. Results Post-CEA haematoma rates decreased from 7% to 3.6%. Return to theatre rates reduced from 6% to 0.9% with no increase in peri-operative stroke rates. Conclusion Our protocol appears to reduce post-CEA haematoma rates. Return to theatre rates had also dropped without an increase in peri-operative stroke rates despite using protamine and tranexemic acid when needed.

Bovine Pericardial Patch Closure during Femoral Artery Endarterectomy

Bovine Pericardial Patch Closure during Femoral Artery Endarterectomy

Patch angioplasty versus primary closure for carotid endarterectomy.

Carotid patch angioplasty may reduce the risk of acute occlusion or long-term restenosis of the carotid artery and subsequent ischaemic stroke in people undergoing carotid endarterectomy (CEA). This is an update of a Cochrane Review originally published in 1995 and updated in 2008. To assess the safety and efficacy of routine or selective carotid patch angioplasty with either a venous patch or a synthetic patch compared with primary closure in people undergoing CEA. We wished to test the primary hypothesis that carotid patch angioplasty results in a lower rate of severe arterial restenosis and therefore fewer recurrent strokes and stroke-related deaths, without a considerable increase in perioperative complications. We searched the Cochrane Stroke Group trials register, CENTRAL, MEDLINE, Embase, two other databases, and two trial registries in September 2021. Randomised controlled trials and quasi-randomised trials comparing carotid patch angioplasty with primary closure in people undergoing CEA. Two review authors independently assessed eligibility and risk of bias; extracted data; and determined the certainty of evidence using the GRADE approach. Outcomes of interest included stroke, death, significant complications related to surgery, and artery restenosis or occlusion during the perioperative period (within 30 days of the operation) or during long-term follow-up. We included 11 trials involving 2100 participants undergoing 2304 CEA operations. The quality of trials was generally poor. Follow-up varied from hospital discharge to five years. Compared with primary closure, carotid patch angioplasty may make little or no difference to reduction in risk of any stroke during the perioperative period (odds ratio (OR) 0.57, 95% confidence interval (CI) 0.31 to 1.03; P = 0.063; 8 studies, 1769 participants; very low-certainty evidence), but may lower the risk of any stroke during long-term follow-up (OR 0.49, 95% CI 0.27 to 0.90; P = 0.022; 7 studies, 1332 participants; very low-certainty evidence). In the included studies, carotid patch angioplasty resulted in a lower risk of ipsilateral stroke during the perioperative period (OR 0.31, 95% CI 0.15 to 0.63; P = 0.001; 7 studies, 1201 participants; very low-certainty evidence), and during long-term follow-up (OR 0.32, 95% CI 0.16 to 0.63; P = 0.001; 6 studies, 1141 participants; very low-certainty evidence). The intervention was associated with a reduction in the risk of any stroke or death during long-term follow-up (OR 0.59, 95% CI 0.42 to 0.84; P = 0.003; 6 studies, 1019 participants; very low-certainty evidence). In addition, the included studies suggest that carotid patch angioplasty may reduce the risk of perioperative arterial occlusion (OR 0.18, 95% CI 0.08 to 0.41; P < 0.0001; 7 studies, 1435 participants; low-certainty evidence), and may reduce the risk of restenosis during long-term follow-up (OR 0.24, 95% CI 0.17 to 0.34; P < 0.00001; 8 studies, 1719 participants; low-certainty evidence). The studies recorded very few arterial complications, including haemorrhage, infection, cranial nerve palsies and pseudo-aneurysm formation, with either patch or primary closure. We found no correlation between the use of patch angioplasty and the risk of either perioperative or long-term stroke-related death or all-cause death rates. Compared with primary closure, carotid patch angioplasty may reduce the risk of perioperative arterial occlusion and long-term restenosis of the operated artery. It would appear to reduce the risk of ipsilateral stroke during the perioperative and long-term period and reduce the risk of any stroke in the long-term when compared with primary closure. However, the evidence is uncertain due to the limited quality of included trials.

Triple-valve replacement for Rhizobium radiobacter endocarditis with septic shock in an adult with ventricular septal defect. A case report.

Introduction and importanceTriple-valve replacement in active infective endocarditis has rarely been reported. This paper is the first report of a triple-valve replacement performed in endocarditis with septic shock and the first presentation of multivalvular endocarditis due to Rhizobium radiobacter.Case presentationA 26-year-old patient with a neglected ventricular septal defect referred to us in septic shock, with multiple organ failure, severe biventricular dysfunction, and pulmonary hypertension, due to Rhizobium radiobacter infective endocarditis affecting the aortic, tricuspid and pulmonary valves. Initially, he was deemed unfit for surgery. However, after clinical stabilization, triple-valve replacement, aortic annular abscess repair, membranous septum aneurysm resection, and ventricular septal defect patch closure were performed. The postoperative evolution was good; both ventricles showed functional recovery after six months.Clinical discussionAlthough surgery provides the best chances of survival in endocarditis with septic shock, reportedly, most cases are considered inoperable. Clinical stabilization under intensive care using specific therapies to manage septic shock, myocardial dysfunction, and pulmonary hypertension was crucial for surgery success. Custodiol® cardioplegia, and replacement of the right-sided valves using a beating-heart technique were used to reduce the myocardial ischemic time.ConclusionRhizobium radiobacter, an opportunistic gram-negative bacterium, potentially may cause multiple valve endocarditis. Patients with endocarditis and septic shock initially considered inoperable can still benefit from surgery after tenacious intensive care (cytokine hemoadsorption and levosimendan are helpful in this process). In complex multivalvular procedures, a beating heart technique to replace the right-sided valves should be considered to minimize the duration of myocardial ischemia.

Technical Details of Transwindow Fenestrated, Unidirectional, Valved, Aorticopulmonary Fabric Patch Closure of Aortopulmonary Window (UKC's Modification): A Video Presentation

AbstractA 10-year-old female patient diagnosed with isolated type I aortopulmonary window and severe pulmonary arterial hypertension who underwent repair of the aortopulmonary window via Johansson's transwindow approach using a unidirectional, fenestrated, valved, aorticopulmonary patch. The preoperative pulmonary vascular resistance was 9.0 Woods units/m2 that reduced to 4.0 Woods units/m2 after oxygen (100%) and nitric oxide (80 ppm) administration. The postoperative recovery was uneventful.

Perinatal Prognostic Factors for Congenital Diaphragmatic Hernia: A Korean Single-Center Study

Purpose: This study aimed to identify prognostic factors based on treatment outcomes for congenital diaphragmatic hernia (CDH) at a single-center and to identify factors that may improve these outcomes.Methods: Thirty-five neonates diagnosed with CDH between January 2011 and December 2021 were retrospectively analyzed. Pre- and postnatal factors were correlated and analyzed with postnatal clinical outcomes to determine the prognostic factors. Highest oxygenation index (OI) within 24 hours of birth was also calculated. Treatment strategy and outcome analysis of published literatures were also performed.Results: Overall survival rate of this cohort was 60%. Four patients were unable to undergo anesthesia and/or surgery. Three patients who commenced extracorporeal membrane oxygenation (ECMO) post-surgery were non-survivors. Compared to the survivor group, the non-survivor group had a significantly higher occurrence of pneumothorax on the first day, need for high-frequency ventilator and inhaled nitric oxide use, and high OI within the first 24 hours. The non-survivor group showed an early trend towards the surgery timing and a greater number of patch closures. Area under the receiver operating characteristic curve was 0.878 with a sensitivity of 76.2% and specificity of 92.9% at an OI cutoff value of 7.75.Conclusion: OI within 24 hours is a valuable predictor of survival. It is expected that the application of ECMO based on OI monitoring may help improve the opportunity for surgical repair, as well as the prognosis of CDH patients.

Aorto-Left Ventricular Tunnel - Prenatal Diagnosis and Outcome.

Aorto-left ventricular tunnel (ALVT) is an extremely rare, albeit prenatally detectable, extracardiac channel that connects the ascending aorta to the cavity of the left ventricle. All ALVTs diagnosed prenatally (2006-2020) in five tertiary referral centers were retrospectively assessed for prenatal ultrasound findings, intrauterine course, postnatal outcome, and surgical treatment. We focused on the size of the tunnel and alterations of perfusion of the left ventricular outflow tract and aortic arch. 11 fetuses were diagnosed with ALVT at a mean gestational age of 24.8 weeks. All cases were associated with severe dilatation of the left ventricle and a to-and-fro flow in the left outflow tract. Signs of congestive heart failure were present in five fetuses, four of which were terminated and one of which died in the neonatal period. One fetus died in utero at 34 weeks without prior signs of cardiac failure. Of the five survivors, two underwent the Ross procedure. In both cases the prenatal left ventricular outflow was exclusively via a large tunnel. The remaining three neonates underwent patch closure of the tunnel. In these cases, the prenatal outflow of the left ventricle was via the aortic valve and simultaneously over the tunnel. Prenatal diagnosis of ALVT should be considered in the presence of left ventricular hypertrophy, dilatation of the aortic root, and to-and-fro flow in the aortic outflow tract. Signs of heart failure are associated with an unfavorable outcome. Large tunnels, particularly in combination with the absence of flow over the aortic valve, may be an unfavorable predictor of surgical repair.

25, 50 &amp; 75 years ago

25, 50 &amp; 75 years ago

An Alternative Abdominal Closure Technique After Pediatric Liver Transplant: Bogota Bag Technique.

In conditions such as large-for-size syndrome, postreperfusion hepatic edema, and intestinal edema, primary closure of the abdominal wall can cause respiratory complications and thrombosis of vascular structures. Here, we compared results of primary abdominal closure versus a temporary patch closure technique (the Bogota bag technique) in pediatric liver transplant recipients. We performed primary abdominal closure in 295 recipients. In 39 pediatric liver transplant recipients, the Bogota bag technique was used as the abdominal closure technique because of suspected intraoperative tense abdominal closure. In patients who had the Bogota bag technique, we sutured the sterilized saline bag to the skin at the edge of the defect by shaping the defect so as not to cause abdominal hypertension. Primary abdominal closure was achieved in patients after control laparotomies at 48-hour intervals. The mean age of the primary abdominal closure group was 8.38 years, whereas the mean age of the Bogota bag group was 2 years. The average weight of patients in the primary abdominal closure group was 26.38 kg, and the average weight of patients in the Bogota bag group was 7.93 kg. Biliary atresia was the most common indication in both groups. Mean length of hospital stay was 21 days in the primary abdominal closure group and 24 days in Bogota bag group. Six patients in the Bogota bag group died from sepsis or bleeding in the early postoperative period. In the Bogota bag group, wound closure was achieved within 2 weeks in 25 patients and within 3 weeks in 8 patients. Temporary patch closure techniques can be used safely in low-weight and young children, children with large-for-size grafts, and those who display increased intra-abdominal pressure.

Aortic root reinforcement in aortic valve endocarditis with annular abscess: The Calamari procedure.

Treatment of infective endocarditis can often prove challenging due to its wide range of anatomical presentations. When complicated by an aortic root abscess, patients may require extensive root surgery, which on its own leads to a worse outcome. We present our experience with a surgical technique for reinforcing the aortic annulus with a ring from a Dacron aortic prosthesis placed in the left ventricular outflow tract to avoid the need for root replacement procedures or patch closures of the defect. The technique described in this paper provides a viable alternative to the standard techniques used for the treatment of annular abscesses in aortic valve endocarditis. Due to the relative simplicity and ease of use, this approach may present a means of reducing operation time and possibly postoperative complications of this severe condition.

Five-year outcome of non-shunting and primary closure technique during carotid endarterectomy: a longitudinal cohort study.

ObjectiveThe long-term outcomes of primary carotid artery closure after carotid endarterectomy (CEA) have not been sufficiently studied. This prospective study was performed to analyze the 5-year outcomes of the non-shunting and primary arterial repair technique for CEA.MethodsThis study involved 150 patients who underwent CEA with the primary arterial closure technique without arterial shunting and completed 5 years of follow-up.ResultsThe patients comprised 107 men and 43 women. The 30-day postoperative course was uneventful in 147 (98.0%) patients; however, cerebrovascular accidents occurred in 3 (2.0%) patients. With respect to the long-term results, most cases of restenosis at 5 years were <50%. Two patients developed asymptomatic total internal carotid artery occlusion. Eleven deaths occurred (mortality rate of 7.3%); one death (0.7%) occurred in the first 30 days.ConclusionPrimary arteriotomy closure provides very good long-term patency. Routine use of patch closure is unnecessary.

Atrial fibrillation in partial anomalous pulmonary venous return: right atrial drainage from one vein and epicardial conduction from another vein.

A 72-year-old man with a history of patch closure of sinus venosus atrial septal defect (ASD) and uncorrected partial anomalous pulmonary venous return (PAPVR) of the right superior pulmonary vein (RSPV) draining to right superior vena cava (Figure 1A) presented for atrial fibrillation (AF) ablation. In addition to the PAPVR of the RSPV, computed tomography angiography showed four veins draining into the left atrium (LA): a right middle pulmonary vein (RMPV), a right inferior pulmonary vein, and two left-sided pulmonary veins. Mapping showed the RSPV was electrically silent but pulmonary vein potentials were present in all other pulmonary veins. An irrigated radiofrequency ablation catheter was used to perform wide antral circumferential ablation of the pulmonary veins in the LA. After completion of the line as well as a carinal line, an entrance block was seen in all pulmonary veins except the RMPV. Mapping while pacing the posterior LA showed earliest activation was deep within the RMPV 1 cm from the antrum. Pacing within the pulmonary vein at the low output (ensuring absence of direct RA capture) showed earliest activation in the posterior right atrium (RA) even prior to LA activation (Figure 1B). These findings were consistent with bidirectional conduction across an epicardial electrical connection between RMPV and RA. The site of earliest RA activation was directly adjacent to the phrenic nerve as delineated by high output pacing. As such, ablation was not undertaken to isolate this vein out of concern for phrenic nerve injury. Recurrence of AF has not been seen at a 6-month follow-up.

Comparison of Omental Patch Closure Versus Simple Closure for Laparoscopic Repair of Perforated Peptic Ulcer: A Systematic Review and Meta-Analysis.

To evaluate comparative outcomes of laparoscopic repair of perforated peptic ulcer with omental patch versus without omental patch. A systematic search of multiple electronic data sources was conducted, and all studies comparing laparoscopic repair of perforated peptic ulcer (PPU) with and without omental patch were included. Operative time, postoperative complications, re-operation and mortality were the evaluated outcome parameters for the meta-analysis. Revman 5.3 was used for data analysis. Four observational studies reporting a total number of 438 patients who underwent laparoscopic repair of PPU with (n = 268) or without (n = 170) omental patch were included. Operative time was significantly shorter in no-omental patch group (NOP) when compared to omental patch group (P = .02). There was no significant difference in the risk of postoperative ileus (Odd ratio (OR) .76, P = .61), leakage (OR 1.17, P = .80), wound infection (OR 1.89, P = .34), intra-abdominal abscess (OR 1.17, P = .87), re-operation (OR .00, P = .94) and mortality (OR .55, P = .48). Moreover, length of hospital stay was comparable between the two groups (P = .81). Laparoscopic repair of PPU with or without omental patch have comparable postoperative complications and mortality rate. However, considering the shorter operative time, no-omental patch approach is an attractive and more favourable choice. Well-designed randomized controlled trials are needed to investigate this comparison.

Drug-induced duodenal perforation in the paediatric patient with thalassemia major, an unreported side effect of iron- chelating agent- a case report

Duodenal ulcer disease is uncommon in paediatric age group. Its perforation is even rarer. However, it should be kept in mind when examining children with acute abdomen especially if there are signs of shock or possibility of upper gastrointestinal bleed. We report a case of a 6 years old female child, a known case of thalassemia major and taking oral Deferasirox since two years of age. She had atypical presentation as there was no previous history of peptic ulcer disease and she only suffered epigastric pain and vomiting for a week but due to lack of proper diagnosis at a local clinic developed duodenal ulcer perforation, which was ultimately diagnosed at a tertiary care hospital and managed with Graham Patch Closure.