Pledgeted Sutures Research Articles

LET'S MEET IN THE MIDDLE: SIMULTANEOUS ENDOSCOPIC AND BRONCHOSCOPIC SUTURE REPAIR TO CLOSE A LEFT MAIN-STEM MALIGNANT BRONCHO-ESOPHAGEAL FISTULA

TOPIC: Procedures TYPE: Fellow Case Reports INTRODUCTION: This case highlights a unique approach to manage broncho-esophageal fistula which is refractory to esophageal stenting. CASE PRESENTATION: We describe the case of a 68 year old female with stage IV squamous cell carcinoma of the esophagus status post chemotherapy, immunotherapy and radiation complicated by esophageal stricture requiring a fully covered 18mmx12.3cm WallFlex stent. Approximately three months after stent placement, she developed coughing with oral intake. Swallow study revealed contrast refluxing into the trachea, and CT scan showed presence of left mainstem broncho-esophageal fistula. Bronchoscopy demonstrated thick purulent secretions and a 1-1.5 cm defect of the left main, 5mm distal to the main carina. The esophageal stent was visualized through the defect. She underwent EGD with removal of the stent and was also found to have a large 3cm deep defect in the proximal esophagus and ulceration throughout the mid-esophagus. Due to high risk of perforation, the esophagus was not stable enough to safely allow stent replacement. Her defect was deemed non-operable. Bronchial stenting was considered; however, there was increased risk of pressure necrosis and mediastinits plus proximity of the fistula to the main carina made stenting difficult to size. We opted to pursue simultaneous flexible endoscopy with rigid bronchoscopy to close her broncho-esophageal fistula. We utilized an X-Tack Endoscopic HeliX Tacking System with one running suture as well as placed two 2.0 36 inch braided non-absorbable pledgeted sutures from the esophageal side with closure on the bronchial side with a Cor-Knot device. There was no evidence of saline leak over the fistula. Post-closure, she tolerated bedside swallow and was able to drink liquid without coughing. Follow up esophagram is pending. DISCUSSION: The current standard of care for management of malignant tracheal-esophageal fistula is esophageal with/without broncho-tracheal stent and is palliative in intent. Stenting was not a safe option in our patient. The use sutures placed via rigid scopes from the esophageal side to tracheal side with closure with a Cor-Knot device for management of tracheo-esophageal fistula has been described in one prior case report.(1) Our case further demonstrates the feasibility of this technique for management of airway-esophageal fistula. Our case is unique as it treats a fistula in the left mainstem bronchus as opposed to the trachea. Due to the distal location of the defect, we were unable to use the rigid esophageal tube to pass the sutures, so we straightened the sutures and successfully passed them through a flexible EGD scope. Our case also used an X-Tack running suture device to further stabilize our closure. CONCLUSIONS: This case demonstrates an effective alternative approach and potentially more viable solution to treat broncho-esophageal fistulas when endoscopic/endobronchial stenting is not permissible. REFERENCE #1: Mozer AB, Michel E, Gillespie C, Bharat A. Bronchoendoscopic Repair of Tracheoesophageal Fistula. Am J Respir Crit Care Med. 2019 Sep 15;200(6):774-775. doi: 10.1164/rccm.201812-2255IM. PMID: 30973758; PMCID: PMC6775884. DISCLOSURES: No relevant relationships by Navtej Buttar, source=Web Response No relevant relationships by Sangita Goel, source=Web Response No relevant relationships by Ryan Kern, source=Web Response No relevant relationships by John Mullon, source=Web Response No relevant relationships by Darlene Nelson, source=Web Response Research grant relationship with Intuitive Surgical Please note: $5001 - $20000 by Janani Reisenauer, source=Web Response, value=Grant/Research Support No relevant relationships by Linh Vu, source=Web Response

The art of aortic valve repair

The art of aortic valve repair

Doubly committed subarterial ventricular septal defect closure through tricuspid approach: a clinical analysis.

The research was to introduce the experience of doubly committed subarterial ventricular septal defect (DCVSD) repaired through tricuspid approach. From January, 2015 to September, 2019, 86 consecutive DCVSD paediatrics underwent repair via right subaxillary vertical incision (RAVI) through tricuspid approach. Perioperative and follow-up data were collected. The age and weight at operation were 28.1 ± 18.5 (range: 7-101) months and 12.2 ± 4.2 (6-26.5) kg. There were two patients combined with discrete subaortic membrane, two patients with patent ductus arteriosus, one patient with atrial septal defect, and two patients with abnormal muscle bundle in right ventricular outflow tract. The mean size of ventricular septal defect was 7.0 ± 2.4 (3-13) mm. The defect was repaired with a piece of Dacron patch in 68 patients or directly with 1-2 pledgetted polypropylene sutures in 18 patients. The cardiopulmonary bypass time and aortic cross-clamp time were 46.2 ± 13.3 (23-101) minutes and 29.2 ± 11.5 (12-84) minutes. After 3.1 ± 2.4 (0-14) hours' ventilator assist and 23.2 ± 32.1 (0-264) hours' ICU stay, all patients were discharged safely. At the latest follow-up (27.9 ± 14.6 months), echocardiography showed trivial residual shunt in two patients. There was no malignant arrhythmia occurred and there was no chest deformity or asymmetrical development of the breast was found. DCVSD repaired via right subaxillary vertical incision through tricuspid approach was safe and feasible, providing a feasible alternative to median sternotomy, and it can be performed with favourable cosmetic results.

Ruptured sinus of Valsalva aneurysm: diagnosis by community echocardiography

SummaryA 71-year-old man was referred to a general practitioner with specialist interest (GPSI) in cardiology due to exertional breathlessness. Examination revealed a continuous murmur but no signs of heart failure. Echocardiography revealed significant aortic root enlargement (63 mm) with aneurysmal dilatation of the right sinus of Valsalva (Fig. 1A, Video 1) and severe aortic regurgitation (Fig. 1B). Parasternal short-axis images suggested rupture of the aneurysmal right aortic sinus (Fig. 1C, Video 2) with colour Doppler imaging suggestive of a shunt from the aorta into the right atrium (Fig. 1D, Video 3). The study was uploaded to a cloud-based server (Ultralinq Healthcare Solution Inc, New York, USA) and the GPSI contacted the local tertiary centre urgently. On image review, the suspicion was confirmed of an aorto-atrial fistula secondary to the ruptured sinus of Valsalva aneurysm and the patient was hospitalized the same day. At surgery, the aortic root had significantly thinned walls in all sinuses with the presence of a large aneurysm extending from the right coronary sinus towards the right ventricular outflow tract. The fistulous communication was identified and led into the right atrium — this was repaired with pledgeted sutures. A modified Bentall procedure was performed, with a 27 mm Perimount, bioprosthesis sewn into a 34 mm Valsalva Gelweave graft for the aortic root replacement. Sinus of Valsalva aneurysm is a rare abnormality (population incidence 0.09%) that occurs due to a weakening of the layers of the aortic wall (principally the aortic media). This may be due to a congenital abnormality in the aortic wall or may be acquired following bacterial endocarditis or connective tissue disorders. Most aneurysms arise from the right coronary sinus and at least 1/3 will rupture. Rupture into the right heart chambers can lead to a significant intra-cardiac shunt and acute heart failure. In recent years, there has been a significant expansion of community cardiology clinics, including the provision of echocardiography. The method of storage of echocardiographic studies is variable — this case highlights not just the potential value of skilled community echocardiography operators but also the value of cloudbased servers that can facilitate rapid expert review of images performed remotely so that timely management decisions can be made.

Abstract 16979: Hemodynamic Comparison of Tricuspid Ring Annuloplasty vs. Hetzer Annuloplasty Technique to Repair Functional Tricuspid Regurgitation

Introduction: Surgical repair of functional tricuspid regurgitation (FTR) is increasingly performed, and the techniques are evolving. Annuloplasty is currently the technique of choice, with different techniques yielding varied results, and thus require optimization. Objective: In this study, we sought to compare tricuspid valve function and kinematics after ring annuloplasty and Hetzer’s double orifice repair in an ex vivo model of FTR. Methods: Ten pig hearts were mounted into a right heart simulator, and studied at 70 bpm while maintaining the total volume of working fluid. FTR was created by increasing afterload, which caused acute right ventricular dilation and TV tethering. Tricuspid valve annuloplasty (TVA) was performed with a 26mm MC 3 ring. Hetzer procedure was performed with pledgeted sutures that approximated the anteroposterior and septal annular segments. Flow probes were used to measure FTR, and leaflet kinematics with echocardiography. Results: FTR of 17.7±9.2mL(p<0.0001) after RV dilation. Repair with TVA and Hetzer reduced FTR to 8.8±6.8ml(p=0.7142) and 7.8±6.9ml(p=0.0919), respectively, but did not eliminate it. Septal leaflet excursion angle decreased by 48.1% with FTR (p=0.04 vs. baseline ) . Repair with TVA and Hetzer increased the angle to 17.3±6.7°(p=0.0312) and 21.5±8.3°(vs FTR, p=0.0034), respectively. The Hetzer improved septal leaflet mobility better than TVA (p=0.0145). The posterior leaflet excursion angle decreased by 49.2% compared to baseline to 18.4±10.5° (p=0.0060) and both TVA and Hetzer significantly improved mobility to 33.6±8.4° (p=0.0081) and 31.6±15.6° (p=0.0256), respectively. Anterior leaflet mobility decreased after FTR by 60.7% to 18.1±8.2°. The effect of these repairs on the sub-valvular apparatus was negligible. Conclusion: TVA and Hetzer both reduced regurgitation but did not eliminate it. Septal and posterior leaflet mobility was improved, while the anterior leaflet remained tethered.

Hemodynamic outcomes after undersizing ring annuloplasty and focal suture annuloplasty for surgical repair of functional tricuspid regurgitation.

Surgical annuloplasty for functional tricuspid regurgitation (FTR) is on the rise and can be performed in several ways with varied outcomes. In this study, we sought to compare the hemodynamic outcomes of tricuspid annuloplasty performed with a commercially available annuloplasty ring (tricuspid valve annuloplasty [TVA]) compared with focal suture annuloplasty (Hetzer) in an experimental FTR model. An exvivo FTR model was developed by inducing right ventricular dilatation by acute afterload elevation, causing severe tricuspid valve tethering and annular dilatation, leading to regurgitation. Ten porcine hearts in which FTR was induced underwent TVA with a 26-mm Edwards MC3 ring and Hetzer annuloplasty with a pledgeted suture cinching the anteroposterior and septal annulus. FTR was measured before after each repair, and tenting geometry, valve kinematics, and subvalvular geometry were measured with echocardiography. At baseline, none of the hearts had FTR, but upon afterload elevation an FTR volume of 17.7±9.2mL (26.38±17.47% regurgitant fraction) was measured (P<.0001). TVA reduced regurgitation by 50% and Hetzer annuloplasty by 56% , respectively, but both left persistent FTR. Anteroseptal tenting area was 279.0±158.9mm2 before repair and decreased significantly to 147.2±134.8mm2(P=.0195) with Hetzer but not with TVA. Posteroseptal tenting area was 425.1±169.2mm2 before repair and was significantly reduced by both techniques (TVA: 200.3±102.9mm2 [P=.0012]; Hetzer: 237.6±127.6mm2 [P=.0270]). Tricuspid annuloplasty with a ring or a focal suture can reduce FTR but not eliminate it. Annular approaches did not relieve tricuspid valve tethering and reduced leaflet mobility persisted. Either subannular repairs or judicious use of valve replacement may be necessary.

Retrospective analysis of tricuspid valve repair using a novel surgical technique: A 7-year single-surgeon experience.

Objectives:Tricuspid annuloplasty is the optimal surgical repair technique for tricuspid regurgitation which improves mortality and morbidity. Ring annuloplasties is the techniques of choice. Here, we evaluate the efficacy and durability of a new method of interrupted pledgeted suture annuloplasty.Methods:Between 2011 and 2018, 39 eligible patients underwent tricuspid valve repair using this novel technique. Indication for repair was a grade of regurgitation at moderate or greater, or an annular diameter >40 mm. Patients were assessed both preoperatively and postoperatively by echocardiogram. Follow-up results were split into the first postoperative echocardiogram and most recent postoperative echocardiogram undertaken.Results:There were two in-hospital mortalities and two patients required permanent pacemaker implantation following surgery. At the time of the first postoperative echocardiogram undertaken (median 3 months postoperatively), freedom from moderate-severe regurgitation was 92.3%. At the time of the most recent postoperative echocardiogram undertaken (median 11 months postoperatively); none or mild regurgitation was detected in 24 patients (61.5%), mild-moderate in 11 (28.2%) and moderate-severe in 4 (10.3%) patients. Freedom from moderate-severe regurgitation was 89.7%. Postoperative grade of regurgitation was significantly reduced from preoperative grades (p < 0.001).Conclusion:Initial and midterm results of our technique show a good durability of repair. We have demonstrated recurrence rates of regurgitation equal and superior to current forms of suture annuloplasty published in the literature. This novel method of suture annuloplasty can be considered in the surgical repertoire of tricuspid valve repair techniques.

Right Ventricular Device HeartWare Implant to the Right Atrium with Fixation to the Chest Wall in Patient with Biventricular Support.

Right Ventricular Device HeartWare Implant to the Right Atrium with Fixation to the Chest Wall in Patient with Biventricular Support.

Interventricular septal hematoma complicating placement of a ventricular assist device in an infant and support with bi-atrial cannulation.

Interventricular septal hematoma complicating placement of a ventricular assist device in an infant and support with bi-atrial cannulation.

Discussion

Discussion

Penetrating thoracic wound with cardiac trauma

A young male whippet presented in hypovolaemic shock with a penetrating thoracic wound. Point-of-care ultrasound documented a moderate volume of pleural effusion and a hyperechoic mass adjacent to the right...

Invited Commentary

Invited Commentary

Short-term results after laparoscopic repair of giant hiatal hernias with pledgeted sutures: a retrospective analysis

PurposeThis study investigates if pledgeted sutures for hiatal closure could be an alternative to mesh for the surgical treatment of large hiatal hernia.MethodsForty-one patients who underwent laparoscopic 270° Toupet fundoplication with pledgeted sutured crura between September 2014 and April 2017 were evaluated with regard to recurrence of hiatal hernia at 3 months and 1 year after surgery. Indication for pledgets was a hiatal surface area of at least 5.60 cm2, or migration of more than 1/3 of the stomach into the thorax or preoperative hernia size > 5 cm. The integrity of repair was assessed using a barium swallow test 3 months and 1 year after surgery.ResultsAll operations could be completed laparoscopically with no intraoperative complications. Until study end no complications related to the pledgets have occurred. Forty-four of 50 patients (88.0%) completed the follow-up radiographic examination 3 months (mean 12.7 weeks) after surgery, and 37 patients (74.0%; mean 55.1 weeks) 1 year after surgery. Postoperative recurrence was diagnosed in 3/44 patients (6.8%) at 3 months, and in 4/37 patients (10.8%) at 1 year follow-up. Only one patient was symptomatic, 1 year after surgery (2.7%). All other patients with reherniations were asymptomatic at time of the study.ConclusionsUtilization of pledgets to reinforce hiatal sutures seems safe and shows a quite low early recurrence rate compared to other methods. Long-term data will allow firm conclusions as to whether pledgeted sutures are an appropriate solution for the treatment of giant hiatal hernias.

Renorrhaphy Using Pledgeted Sutures for Grade IV Renal Trauma

Renorrhaphy Using Pledgeted Sutures for Grade IV Renal Trauma

Simultaneous hepatic and portal vein ligation induces rapid liver hypertrophy: A study in pigs

BackgroundLiver hypertrophy induced by partial portal vein occlusion (PVL) is accelerated by adding simultaneous parenchymal transection (“ALPPS procedure”). This preclinical experimental study in pigs tests the hypothesis that simultaneous ligation of portal and hepatic veins of the liver also accelerates regeneration by abrogation of porto-portal collaterals without need for operative transection. MethodsA pig model of portal vein occlusion was compared with the novel model of simultaneous portal and hepatic vein occlusion, where major hepatic veins draining the portal vein–deprived lobe were identified with intraoperative ultrasonography and ligated using pledgeted transparenchymal sutures. Kinetic growth was compared, and the portal vein system was then studied after 7 days using epoxy casts of the portal circulation. Portal vein flow and portal pressure were measured, and Ki-67 staining was used to evaluate the proliferative response. ResultsPigs were randomly assigned to portal vein occlusion (n = 8) or simultaneous portal and hepatic vein occlusion (n = 6). Simultaneous portal and hepatic vein occlusion was well tolerated and led to mild cytolysis, with no necrosis in the outflow vein–deprived liver sectors. The portal vein–supplied sector increased by 90 ± 22% (mean ± standard deviation) after simultaneous portal and hepatic vein occlusion compared with 29 ± 18% after PVL (P < .001). Collaterals to the deportalized liver developed after 7 days in both procedures but were markedly reduced in simultaneous portal and hepatic vein occlusion. Ki-67 staining at 7 days was comparable. ConclusionThis study in pigs found that simultaneous portal and hepatic vein occlusion led to rapid hypertrophy without necrosis of the deportalized liver. The findings suggest that the use of simultaneous portal and hepatic vein occlusion accelerates liver hypertrophy for extended liver resections and should be evaluated further.

Neonatal quadricuspid truncal valve repair with left coronary artery unroofing

Neonatal quadricuspid truncal valve repair with left coronary artery unroofing

PS02.056: TIMELY LIGATION OF THORACIC DUCT IN POST ESOPHAGECTOMY CHYLE LEAK: KEY TO SUCCESSFUL MANAGEMENT

Abstract Background Chyle leak after esophagectomy for carcinoma esophagus is a rare but life threatening condition with reported an incidence of 1–6%. Mortality rate of up to 50% have been reported. Management of chyle leak is controversial. We reviewed our experience with iatrogenic chylothorax after esophagectomy for carcinoma esophagus. Methods From 2003 to 2017, 560 patients underwent esophagectomy for cancer at our department of oncosurgery. Eight patients developed post operative chyle leak. Transthoracic or transabdominal ligation of duct was done in six patients with in first week. 100 ml of cream was given 30 min before induction to visualize the leak intraoperatively. We used 4–0 prolene pledgeted suture to ligate the duct. Results Six patients who underwent early ligation could be salvaged and the two who were managed conservatively succumbed. Oringer et al. pointed towards conservative treatment having little place in the management of chylothorax in nutritionally depleted patients. Hence, prompt ligation of thoracic duct decreases morbidity and mortality of chylothorax. Thus the role of early surgery needs to stressed. There is a wide difference of mortality rate of conservative management of 82% with respect to the mortality rate of surgery of 10–16%. Though no conclusion data are available regarding the indication and time point of surgical ligation of the thoracic duct, it is important not to procrastinate while the condition deteriorates to a level at which surgery would be detrimental.Administration of cream to the patient (through feeding jejunostomy) around half an hour before surgery makes identification of site of leak simpler.The importance of pledgeted sutures cannot be denied as the thoracic duct is paper thin and chyle contains no fibrin. Thus non pledgeted sutures will tear it further. Infact, stitching should not be done through the duct but into the surrounding tissue around the duct and should allow the pledgets to close the duct. Conclusion Disclosure All authors have declared no conflicts of interest.

Transapical Beating-Heart Mitral Valve Repair Using a Novel Artificial Chordae Implantation System

We reported a successful transapical beating-heart mitral valve repair in a 78-year-old patient with severemitral regurgitation with prohibitive surgical risk using the MitralStitch system (Hangzhou DeJinMedtech Co, Ltd, Hangzhou, China), a novel device distinguished by its implanted chordae mimicking the surgical pledgeted suture and the retrievable positioner facilitating leaflet capture. This technology would be a competitive option for high-riskpatients with severe mitral regurgitation due to leaflet prolapse.

Transatrial implantation of a transcatheter heart valve for severe mitral annular calcification

ObjectiveTo assess the outcomes of transatrial implantation of a transcatheter heart valve (THV) for the treatment of mitral valve disease with severe mitral annular calcification (MAC). MethodsImplantation of a balloon-expandable THV was performed on cardiopulmonary bypass via left atrial exposure in patients considered at risk for left ventricular outflow tract obstruction. The anterior mitral valve leaflet was systematically resected and pledgeted sutures were placed to enhance stability and reduce paravalvular leak. ResultsTwenty-six consecutive symptomatic patients with severe MAC (mean age, 78 ± 7 years; 92% female; mean Society of Thoracic Surgeons score, 9.4 ± 4.8) were included at 6 different centers. Two patients (8%) received an Edwards Sapien XT (Edwards Lifesciences, Irvine, Calif), and 24 (92%) an Edwards Sapien 3 bioprosthesis (Edwards Lifesciences). Concomitant aortic valve replacement was performed in 11 patients. Technical success according to the criteria of the Mitral Valve Academic Research Consortium was achieved in all patients. The mean transmitral gradient decreased from 10 ± 5 to 4 ± 2 mm Hg (P < .001) with trace or mild regurgitation in all patients. An elevated mean transaortic gradient (30 mm Hg) was observed in 1 patient (4%). Five patients died during hospital stay (19%) and 2 additional between discharge and 30 days (30-day mortality: 27%). Sustained functional improvement was observed in the remaining patients. ConclusionsTransatrial implantation of a THV for the treatment of MAC is associated with high technical success despite unfavorable anatomy. In this early experience of very high surgical risk patients, 30-day all-cause mortality was high. Patients at particular risk appear to be those with chronic kidney disease requiring multiple valve surgery.

Double ligation of portal and hepatic veins achieves hypertrophy comparable to ALPPS - a study in pigs

Background: Liver hypertrophy induced by partial portal vein ligation (PVL) is accelerated by adding parenchymal transsection (“ALPPS procedure”). Previous experiments suggested that transsection abrogates portal neocollateral formation between lobes. This preclinical experimental study in pigs tests the hypothesis that simultaneous ligation of portal and hepatic veins (PVL + HVL) of the liver functionally abrogates collateral formation as well and thereby also accelerates hypertrophy. Methods: Simultaneous PVL + HVL was performed in landrace pigs by simultaneously ligating portal veins and major hepatic veins with the help of intraoperative ultrasound and ligated using pledgeted transparenchymal sutures. Kinetic growth was compared to a model of PVL. The anatomy of the portal vein system was studied after 7 days using epoxy casts of the portal circulation. Portal vein flow and portal pressure were measured and Ki-67 staining was used to evaluate the proliferative response. Results: Pigs were randomized to PVL (n = 8) and PVL + HVL (n = 6). PVL + HVL was well tolerated, led to mild cytolysis and no necrosis in the portal vein deprived lobe. The portal vein supplied sector increases by 90 ± 22% after PVL + HVL compared to 29 ± 18% after PVL (p < 0.001). Collaterals to the deportalized liver developed after 7 days in both procedures, but were markedly reduced in PVL + HVL. Ki-67 staining at 7 days was comparable. Volume increase after PVL + HVL appeared comparable to a pig model of ALPPS estabablished before. Conclusion: This study shows that simultaneous PVL + HVL leads to accelerated hypertrophy comparable to ALPPS. The findings suggest that reduced collateral formation indeed is an important element of rapid hypertrophy. Simultaneous Bi-embolization of portal and hepatic veins may well replace ALPPS to increase the efficiency of regenerative liver surgery.