Procedure Time Research Articles

Effects of morning versus afternoon surgery on peri‐operative disturbance of sleep–wake timing: An observational study

AbstractIntroductionThe circadian timing system regulates diurnal sleep–wake rhythm. Previously, we showed that, in patients undergoing elective surgery, sleep–wake timing is altered and post‐operative sleep quality is reduced. However, how the timing of the surgical procedure affects the disturbance and what other factors affect this disturbance remain unknown.MethodsSingle‐centre prospective observational study investigating the influence of surgery timing on post‐operative sleep in adult patients (≥18 years) undergoing elective surgery. Sleep–wake timing was measured from three nights before until seven nights after surgery with a daily sleeping log. Primary outcome was post‐operative midpoint of sleep shift between patients undergoing morning and afternoon surgeries. Secondary outcomes included factors affecting sleep timing disturbance and changes in subjective sleep quality.ResultsWe included 259 patients: 144 patients underwent morning procedures (08:00 h–12:00 h) and 115 underwent afternoon procedures (12:00 h–17:00 h). Both groups had significant phase advance of midpoint of sleep on the night after surgery when compared with three nights before surgery (mean − 00:41 h, 95% CI −00:27 h to −00:54 h, p < .001, for morning surgery and mean − 00:28 h, 95% CI −00:09 h to −00:46 h, p = .003, for afternoon surgery). However, there was no between‐group difference (mean − 00:13 h, 95% CI −00:35 h–00:09 h, p = .25). Reduction of sleep quality was also similar. Phase advance was larger for patients with an evening chronotype or with lower pre‐operative sleep quality. Decline of sleep quality after surgery was larger for patients with an evening chronotype, longer procedures or better pre‐operative sleep quality.ConclusionOur results suggest that the timing of surgery between 08:00 h and 17:00 h does not modulate the effect of anaesthesia and surgery on phase of the sleep–wake rhythm in patients undergoing elective surgery with a low pre‐operative risk of delirium.Editorial CommentTiming of surgery may impact post‐operative sleep. However, in this prospective cohort study of elective surgical patients, sleep–wake timing and post‐operative sleep quality did not differ between those undergoing morning versus afternoon surgery.

Intraoperative ultrasound for uterine septum resection: a systematic review and meta-analysis.

Septate uterus is one of the most common uterine malformations. Recent studies suggest that uterine septa may negatively affect fertility. In cases of recurrent pregnancy loss (RPL) or infertility, hysteroscopic metroplasty has been considered the primary treatment for septate uterus. This systematic review and meta-analysis aims to evaluate whether intraoperative ultrasound monitoring may improve the efficacy of hysteroscopic metroplasty compared to other types of intraoperative monitoring or to unguided resections. An electronic database search was performed to identify articles published until June 15, 2023. Five studies (two randomized clinical trials, two prospective studies and one retrospective cohort study) fulfilled the inclusion criteria. The primary outcome was the rate of residual septum > 10mm after hysteroscopic metroplasty in the ultrasound (US) monitoring group compared to the rate of residual septum using other types of intraoperative monitoring/no monitoring (control group). The secondary outcomes were any residual septa, surgical time, complications, uterine perforations and reproductive outcomes. Intraoperative ultrasound for uterine septum resection significantly reduced the rate of residual septum > 10mm and the rate of any residual septa compared to the control group. There was no statistically significant difference in the procedure time between women undergoing intraoperative US monitoring versus the control group. A trend toward reduction of surgical complications was observed in the intraoperative US group compared to the control group. In conclusion, intraoperative ultrasound during metroplasty may reduce the rate of the residual septum with no surgical time differences. Further studies are warranted to understand how this may improve reproductive outcomes.

Racial and Ethnic Disparities in Epidural Blood Patch Utilization Among Obstetric Patients in the United States: A Nationwide Analysis, 2016–2020

BACKGROUND: Racial and ethnic disparities in health care delivery can lead to inadequate peripartum pain management and associated adverse maternal outcomes. An epidural blood patch (EBP) is the definitive treatment for moderate to severe postdural puncture headache (PDPH), a potentially debilitating neuraxial anesthesia complication associated with significant maternal morbidity if undertreated. In this nationwide study, we examine the racial and ethnic disparities in the inpatient utilization of EBP after obstetric PDPH in the United States. METHODS: In this retrospective observational study, we used the National Inpatient Sample, a nationally representative database of discharge records for inpatient admissions in the United States, from 2016 to 2020. We analyzed delivery hospitalizations of women of childbearing age (15–49 years) diagnosed with PDPH. Adjusting for maternal and hospitalization characteristics as confounders, we used a multilevel mixed-effects logistic regression model to compare the rates of EBP utilization by race and ethnicity. Secondarily, among hospitalizations with an EBP, we examined the association between race and ethnicity and the timing of the EBP procedure. RESULTS: We analyzed 49,300 delivery hospitalizations with a diagnosis of PDPH. An EBP was performed in 24,075 (48.8%; 95% confidence interval [CI], 47.8%–49.9%) of these hospitalizations. EBP was performed in 52.7% (95% CI, 51.3%–54.1%) of White non-Hispanic patients with PDPH. Compared to White non-Hispanic patients, Black non-Hispanic (adjusted odds ratio [aOR] = 0.69; 99% CI, 0.56–0.84), Hispanic (aOR = 0.80, 99% CI, 0.68–0.95), and Asian or Pacific Islander patients (aOR = 0.74, 99% CI, 0.58–0.96) were less likely to receive an EBP. The median (interquartile range [IQR]) time to perform an EBP was 2 (1–3) days after admission, with 90% of EBP procedures completed within 4 days of admission. There was no significant association between race and ethnicity and the timing of EBP placement. CONCLUSIONS: In this nationwide analysis of delivery hospitalizations from 2016 to 2020 in the United States with a diagnosis of PDPH, we identified racial and ethnic disparities in the utilization of EBP. Minoritized patients identified as Black non-Hispanic, Hispanic, or Asian or Pacific Islander were less likely to receive an EBP for the treatment of PDPH compared to White non-Hispanic patients. Suboptimal treatment of PDPH may be associated with adverse long-term outcomes such as postpartum depression, posttraumatic stress disorder, and chronic headaches. Racial and ethnic disparities in EBP utilization should be further investigated to ensure equitable health care delivery.

Efficacy and safety of supraglottic jet oxygenation and ventilation to minimize sedation-related hypoxemia: a meta-analysis with GRADE approach.

Hypoxemia is a common complication of sedation. This meta-analysis aimed to evaluate the efficacy and safety of supraglottic jet oxygenation and ventilation (SJOV) in preventing hypoxemia during sedative procedures. Randomized controlled trials (RCTs) that compared SJOV with conventional oxygen therapy in sedated patients were searched in five databases (MEDLINE, EMBASE, Cochrane Library, China National Knowledge Infrastructure [CNKI], and Google Scholar) from their inception to March 2024. The primary outcome was the proportion of patients who developed hypoxia (SpO2 < 90%). The secondary outcomes included subclinical respiratory depression (90% ≤ SpO2 < 95%), severe hypoxemia (SpO2 < 75%), airway interventions, adverse events, hemodynamics, propofol dosage, and procedure time. The certainty of evidence was determined using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Twelve trials (n = 3058) were included in the analysis. The evidence suggests that SJOV results in a large reduction in the risk of hypoxemia (risk ratio [RR], 0.26; 95% confidence interval, 0.19-0.36; low certainty) and subclinical respiratory depression (RR, 0.40; low certainty) compared with the control. SJOV likely resulted in a large reduction in the risk of severe hypoxemia (RR, 0.22; moderate certainty). In addition, it may result in a large reduction in the need for jaw lift (RR, 0.22; low certainty) and mask ventilation (RR, 0.13; low certainty). The risk of sore throat probably increases with SJOV (RR, 1.71; moderate certainty), whereas SJOV may result in little to no difference in nasal bleeding (RR, 1.75; low certainty). Evidence is very uncertain regarding the effect of SJOV on hemodynamics (very low certainty) and procedure time (very low certainty). SJOV probably resulted in little to no difference in sedative doses between the groups (moderate certainty). According to the GRADE approach, SJOV likely results in a large reduction in the risk of severe hypoxemia but probably increases the risk of sore throat. Compared with the control, evidence suggests that SJOV results in a large reduction in the risk of hypoxemia, subclinical respiratory depression, and the need for airway manipulation, with little to no difference in nasal bleeding. The integration of SJOV into clinical practice may help minimize hypoxemic events in at-risk patients.

Evolving Methods and Application of a 3D Printed Model in the Current Deep Inferior Epigastric Perforator Flap Elevation.

The choice of the deep inferior epigastric perforator (DIEP) flap for breast reconstruction has increased. Three-dimensional (3D) models of DIEP flaps have been introduced with advances in 3D technology to assist the tedious intramuscular dissection of the pedicle. This study presents the process of creating an ideal 3D model for a DIEP flap. Collaboration among various professionals, including surgeons, radiologists, and 3D-printing model makers, is essential for manufacturing suitable 3D-printing DIEP models. Our team facilitated the collaboration process by sharing the virtual 3D model via a uniform resource locator (URL) using an online platform accessible on mobile devices. During collaboration in 3D DIEP model-making, we continuously upgraded the model to a better version. The model was modified according to the surgeon's preference from a 1:1 ratio size to a handheld size. Additionally, we achieved significant advancements over conventional methods, including improved visualization of detailed vessel pathways with separation of arteries and veins, tissue transparency, and superficial inferior epigastric vein (SIEV). Through 3D model-making collaborations, our team successfully developed a 3D DIEP model with translucency and visualized arteries and veins separately with accentuation of the perforators, including SIEV tracing, which is more accurate. This ideal 3D model for the DIEP flap enables the selection of a perforator vessel that is safe and easy to dissect to lower complications and procedure time and will be of great help to less experienced surgeons.

Prolonged intracranial catheter dwell time exacerbates penumbral stress and worsens stroke thrombectomy outcomes

BackgroundThe duration of mechanical thrombectomy (MT) is a negative predictor of outcomes in acute ischemic stroke (AIS), yet the precise mechanisms are unclear. We investigated whether the placement of large-bore...

In vivo evaluation of complex polyps with endoscopic optical coherence tomography and deep learning during routine colonoscopy: a feasibility study.

Standard-of-care (SoC) imaging for assessing colorectal polyps during colonoscopy, based on white-light colonoscopy (WLC) and narrow-band imaging (NBI), does not have sufficient accuracy to assess the invasion depth of complex polyps non-invasively during colonoscopy. We aimed to evaluate the feasibility of a custom endoscopic optical coherence tomography (OCT) probe for assessing colorectal polyps during routine colonoscopy. Patients referred for endoscopic treatment of large colorectal polyps were enrolled in this pilot clinical study, which used a side-viewing OCT catheter developed for use with an adult colonoscope. OCT images of polyps were captured during colonoscopy immediately before SoC treatment. A deep learning model was trained to differentiate benign from deeply invasive lesions for real-time diagnosis. 35 polyps from 32 patients were included. OCT imaging added on average 3:40min (range 1:54-8:20) to the total procedure time. No complications due to OCT were observed. OCT revealed distinct subsurface tissue structures that correlated with histological findings, including tubular adenoma (n = 20), tubulovillous adenoma (n = 10), sessile serrated polyps (n = 3), and invasive cancer (n = 2). The deep learning model achieved an area under the receiver operating characteristic curve (AUROC) of 0.984 (95%CI 0.972-0.996) and Cohen's kappa of 0.845 (95%CI 0.774-0.915) when compared to gold standard histopathology. OCT is feasible and safe for polyp assessment during routine colonoscopy. When combined with deep learning, OCT offers clinicians increase confidence in identifying deeply invasive cancers, potentially improving clinical decision-making. Compared to previous studies, ours offers a nuanced comparison between not just benign and malignant lesions, but across multiple histological subtypes of polyps.

Comparison of Therapeutic Effects Between Pulsed Field Ablation and Cryoballoon Ablation in the Treatment of Atrial Fibrillation: A Systematic Review and Meta-analysis

Pulsed field ablation (PFA) is a novel nonthermal ablation technique for the treatment of atrial fibrillation (AF) patients, with safety comparable to traditional catheter ablation surgery. The present study aims to evaluate and compare the procedural efficiency and safety profiles of PFA and cryoballoon ablation (CBA) in the management of AF. We performed a systematic search across PubMed, the Cochrane Library, and Embase databases, encompassing the literature up to February 2024, to inform our systematic review and meta-analysis. When assessing outcome indicators, the risk ratio and its corresponding 95% confidence interval (CI) were calculated for dichotomous variables. For continuous variables, the mean difference (MD) and the associated 95% CI were determined. In this scenario, a relative risk (RR) value of less than 1 and an MD value of less than 0 are deemed favorable for the PFA group. This could translate to a reduced likelihood of procedural complications or enhanced procedural performance within the PFA group. In this analysis, 9 observational studies encompassing 2875 patients with AF were included. Among these, 38% (n = 1105) were treated with PFA, while 62% (n = 1770) received CBA. The results indicated that PFA was associated with a significantly shorter procedural duration compared with CBA, with an MD of −10.49 minutes (95% CI, −15.50 to −5.49; P &lt; 0.0001). Nevertheless, no statistically significant differences were observed when comparing the 2 treatment cohorts concerning fluoroscopy time (MD, 0.71; 95% CI, −0.45 to 1.86; P = 0.23) and the recurrence of atrial arrhythmias during follow-up (RR, 0.95; 95% CI, 0.78–1.14; P = 0.57). In terms of perioperative complications, the PFA group showed a significantly decreased risk of phrenic nerve palsy (RR, 0.15; 95% CI, 0.06–0.39; P &lt; 0.0001) and an increased risk of cardiac tamponade (RR, 3.48; 95% CI, 1.26–9.66; P = 0.02) compared with the CBA group. No significant differences were noted between the PFA and CBA groups regarding the incidence of stroke/transient ischemic attack (RR, 0.99; 95% CI, 0.30–3.22; P = 0.99), vascular access complication (RR, 0.87; 95% CI, 0.36–2.10; P = 0.76), atrial esophageal fistula (RR, 0.33; 95% CI, 0.01–8.13; P = 0.50), and major or minor bleeding events (RR, 0.39; 95% CI, 0.09–1.74; P = 0.22). Our research results indicate that compared with CBA, PFA not only shortens the procedure time but also demonstrates noninferiority in terms of fluoroscopy duration and the recurrence rate of atrial arrhythmias. PFA and CBA have both demonstrated their respective advantages in perioperative complications.

Comparative Efficacy and Safety of Anesthetic and Sedative Regimens for Endoscopic Retrograde Cholangiopancreatography: A Network Meta-analysis.

This study evaluates the efficacy and safety of various anesthetic and sedative regimens for Endoscopic Retrograde Cholangiopancreatography (ERCP) procedures. A systematic search was conducted across PubMed, Web of Science, Scopus, and Embase to identify randomized controlled trials (RCTs) published until March 2024. Primary outcomes included procedure time, patient satisfaction, oxygen saturation (SpO2), incidence of SpO2 below 90%, and adverse events. The analysis was performed using R software, analyzing continuous outcomes with mean differences and dichotomous outcomes with risk ratios. 42 RCTs were included. Combination therapies such as remifentanil plus tramadol and propofol plus midazolam plus pethidine demonstrated significantly shorter procedure times. Propofol plus oxycodone yielded higher patient satisfaction. Oxygenation results indicated that propofol plus fentanyl, oxycodone, and ketamine improved SpO2. Propofol plus oxycodone (RR<0.01), dexmedetomidine plus fentanyl (RR<0.01), propofol plus nalbuphine (RR=0.01), Mg sulfate plus propofol (RR=0.01), and propofol plus fentanyl (RR=0.02), showed a significant lower rate of patients with SpO2 below 90% compared to propofol. Midazolam plus pethidine plus dexmedetomidine (RR=0.01), propofol plus oxycodone (RR=0.09), and dexmedetomidine plus fentanyl (RR=0.2) exhibited lower rates of adverse events compared to propofol. This study provides comprehensive evidence to guide clinical decision-making and optimize anesthetic management for ERCP procedures.

The Impact of Systemic Inflammation on Recurrence in Patients with Congenital Nasolacrimal Duct Obstruction

Background/Objective: Congenital nasolacrimal duct obstruction (CNLDO) is commonly treated by probing, but recurrence remains a clinical issue. This study investigates the potential role of inflammatory biomarkers, such as the neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR), in predicting recurrence after probing in children with CNLDO. Methods: This retrospective cohort study included 172 patients who underwent initial probing for unilateral CNLDO. The patients were then categorized into two groups: those who experienced the complete resolution of symptoms after primary probing, and those who required Ritleng tube intubation due to recurrence following primary probing. Blood samples for calculating inflammatory biomarkers in all subjects were collected during general anesthesia preparation prior to initial probing. NLR, MLR, and PLR values were compared between the groups using the independent samples t-test. The predictive performance of the inflammatory biomarkers for recurrence was assessed using Receiver Operating Characteristic (ROC) curve analysis. Results: A total of 110 patients were included in the probing group, while 62 patients were in the recurrence group. The mean age at the time of the initial probing procedure was 15 ± 4.06 months in the probing group and 15.83 ± 4.02 months in the recurrence group. There was no difference in the duration of the probing procedure between the groups. The mean age at the time of Ritleng tube intubation in the recurrence group was 37.80 ± 13.34 months. The recurrence group exhibited significantly higher values in all analyzed inflammatory markers compared to the probing group, including the NLR (1.12 ± 0.56 vs. 0.86 ± 0.39, p = 0.002), MLR (0.16 ± 0.06 vs. 0.14 ± 0.06, p = 0.005), and PLR (95.13 ± 24.34 vs. 82.23 ± 22.77, p &lt; 0.001). ROC curve analysis indicated that these inflammatory biomarkers demonstrated moderate performance in predicting recurrence. Conclusions: Recurrence following probing in children with CNLDO was associated with complete blood cell count-derived inflammatory biomarkers. The preoperative assessment of these biomarkers may aid in the individualization of disease management and inform the development of new therapeutic strategies.

OGC SO41 - Omentopexy Technique in Robotic Assisted Minimally Invasive Oesophagectomy

Abstract Background Laparoscopic omentopexy has been shown to reduce the rates of post-oesophagectomy diaphragmatic hernia (PODH) in a retrospective cohort study in a UK specialist centre. We aimed to demonstrate the technique during robotic-assisted minimally invasive oesophagectomy (RAMIE) with video capture. Method The Versius (CMR Surgical) robotic system was used in the abdominal stage of RAMIE performed on a 63 year old male with a poorly differentiated oesophageal adenocarcinoma. No previous abdominal surgery had been performed on this patient. Video capture was used to record this part of the procedure. Results Ports were inserted in standard configuration to allow fashioning of a gastric conduit. Following this the greater omentum was secured to the anterior abdominal wall around the jejunostomy site. No immediate complications were observed. Conclusion The Versius system can be used to successfully perform omentopexy with standard port positioning. Omentopexy was successfully performed with no immediate complications, did not significantly prolong procedural time and may reduce risk of PODH. The authors support the use of this technique in robotic-assisted surgery for reducing risk of PODH and support further work to validate this technique in cohort studies.

Comparative study of the therapeutic effects of radiofrequency ablation of ganglionated plexi guided by high-frequency stimulation and anatomical localization methods in the treatment of vagal syncope in young people.

To investigate the differences in safety and efficacy between high-frequency stimulation (HFS) and anatomically guided endocardial catheter ablation (AA) of the ganglionated plexi (GPs) for treating vasovagal syncope (VVS) in individuals engaged in high-intensity physical training. Forty-five patients (age 22.5 ± 4.4 years) undergoing high-intensity physical training were included from January 2020 to January 2023 at our hospital. Patients underwent GP ablation for recurrent syncope. Comprehensive evaluations, including head MRI, cardiac ultrasound, electrocardiogram (ECG), ambulatory ECG (Holter), ambulatory blood pressure monitoring, plate motion tests, and head-up tilt tests (HUT), were conducted to exclude other systemic disorders causing syncope. HFS and AA-guided GP ablation were performed on 10 and 35 patients, respectively, all of whom tested positive for HUT. Differences between the two groups were compared regarding ablation sites, ablation time, safety, and effectiveness. The ablation time was significantly shorter in the AA group compared to the HFS group (P < 0.001). The number of GPs selected for ablation using the AA method was reduced (P < 0.001). All patients in the HFS group experienced palpitations and discomfort, whereas only 31.43% of patients in the AA group reported these symptoms (P = 0.001). Fentanyl analgesia was administered in both groups, and no significant complications arose from the ablation. The longest follow-up duration was 52 months, while the shortest was 15 months. One case of pre-syncope occurred in the HFS group 8 months post-ablation, and one case of pre-syncope and two cases of syncope occurred in the AA group at 1 and 3 months post-ablation, respectively. There were no statistically significant differences in heart rate variability (HRV) and cardiac deceleration capacity (DC) between the two groups after ablation (P > 0.05). Two cases in the AA group still exhibited type II second-degree atrioventricular block during sleep. Both groups of patients were able to complete high-intensity physical training and showed significant symptom improvement post-ablation. Young individuals with VVS engaged in high-intensity physical training can benefit from GP ablation using both HFS and AA methods. The AA method requires relatively simple equipment, shorter procedure time, and results in less discomfort during the ablation.

Induction of supraventricular tachycardias in patients undergoing pulmonary vein isolation for paroxysmal atrial fibrillation is safe and reasonable.

Patients with atrial fibrillation (AF) may experience other supraventricular tachycardias (SVT) that can trigger AF and cause similar symptoms. The aim of this study was to assess the safety and effectivity of inducing SVT in patients undergoing catheter ablation (CA) for AF. In 61 patients with paroxysmal AF undergoing CA between January 2022 and March 2023, an electrophysiological study was performed after pulmonary vein isolation (PVI) to induce SVT. Induced arrhythmias were mapped and ablated. All patients were followed up at 3, 6, and 12 months after the procedure; seven-day ECG Holter monitoring was carried out 6 and 12 months after the procedure. In 24 patients (39%) an SVT was induced during the stimulation protocol. There was no significant difference in procedure time (P=0.408) or fluoroscopy dose (P=0.458) between patients with and without inducible arrhythmia. Further, none of the echocardiographic variables such as left atrial volume index (LAVI) (P=0.936), left ventricular ejection fraction (LVEF) (P=0.586), or right atrial (RA) area (P=0.716), differed significantly in these subgroups. Age was a significant factor in patients with arrhythmia inducibility compared with those without (64.5 ± 7.6 and 58.2 ± 10.5, P=0.04). SVT inducibility after successful PVI was 39%. Ablation of nonclinical arrhythmia is safe and did not prolong the total procedure or fluoroscopy time.

Abstract 4144517: Feasibility of Deep Sedation for Catheter Ablation of Atrial Fibrillation Using Pulsed Field Ablation

Introduction: General anesthesia is commonly utilized during catheter ablation of atrial fibrillation (AF) in the United States, providing patient immobility and permitting esophageal temperature management for radiofrequency ablation. Pulsed field ablation (PFA) is associated with shorter procedure time, less risk of esophageal injury, and less dependence on catheter stability compared with radiofrequency ablation. There are limited data available on performing the procedure with deep sedation as an alternative to general anesthesia with endotracheal intubation. Methods: Consecutive patients who underwent catheter ablation of AF at Endeavor Health (Chicago, IL) using pulsed field ablation (Farapulse, Boston Scientific, Marlborough, MA or PulseSelect, Medtronic, Minneapolis, MN) and deep sedation between March and May 2024 were retrospectively included in this study. Deep sedation (monitored anesthesia care) was administered by a certified registered nurse anesthetist and attending anesthesiologist, consisting of bolus and infusion dosing of propofol, dexmedetomidine, fentanyl, and midazolam at the discretion of the practitioner with continuous monitoring of vital signs and end-tidal CO2. The primary endpoint was the rate of airway complications or requirement for conversion to general anesthesia. Secondary endpoints were the rate of acute procedural success (all pulmonary veins isolated), total time in the EP lab, procedure time (from lidocaine to removal of sheaths), and non-procedure time (difference between total time in lab and procedure time). Results: A total of 40 patients (mean age 70.4 ± 13.6 years, BMI 30.2 ± 7.4, 60% females) were included in the analysis. There were no instances of airway complications or conversion from deep sedation to general anesthesia. There was a 100% rate of acute isolation of pulmonary veins. The average total time in the lab was 156.6 ± 41.5 minutes; consisting of a mean procedure time of 107.1 ± 39.7 minutes and non-procedure time 49.5 ± 10.3 minutes. Conclusions: In this initial experience at a single center, deep sedation (monitored anesthesia care) for PFA was associated with no instances of airway complications. The findings may not apply to patients with moderate or severe obstructive sleep apnea or other pulmonary diseases. Although patients generally were amnestic to the procedure, larger studies incorporating patient-reported outcomes are needed, as well as data regarding long-term clinical outcomes and cost.

Abstract 4135092: Prolonged Procedure Time and Its Association with Peri-Procedural Complications in Endovascular Therapy for Symptomatic Lower Extremity Arterial Disease

Background: Prolonged operative times in surgical procedures have been significantly associated with an increased risk of complications. However, the impact of prolonged procedure time of peri-procedural complications in patients undergoing endovascular therapy (EVT) for symptomatic lower extremity arterial disease (LEAD) has not been systematically evaluated. Aims: To determine the association between prolonged procedure time and peri-procedural complications in patients undergoing EVT for symptomatic LEAD. Methods: Data from a nationwide EVT registry in Japan (J-EVT) between 2021 and 2022 were analyzed. The outcome measure was peri-procedural complications defined as a composite of perioperative death, major bleeding, contrast nephropathy, myocardial infarction, ischemic stroke, and major amputation. Procedure time was categorized into four clinically relevant groups (≤59, 60–119, 120–179, and ≥180 minutes). The logistic regression model was developed to investigate the risk of peri-procedural complications across subgroups of procedure time with the shortest subgroup (≤59 minutes) set as the reference category. Results: A total of 47,301 patients (average age: 75±9 years, male: 69.0%, chronic limb-threatening ischemia [CLTI]: 51.0%) undergoing EVT for symptomatic LEAD were analyzed. Notable comorbidities included diabetes mellitus at 60.6% and dialysis at 29.9%, respectively. A history of coronary artery disease was noted in 40.7% of the participants. The median procedure time (interquartile range) was 110 (74–161) minutes. A total of 431 patients (0.9%) experienced perioperative complications. The perioperative complications included 48 deaths, 277 cases of major bleeding, 28 cases of contrast nephropathy, 10 myocardial infarctions, 16 ischemic strokes and 72 major amputations. After adjusting for patient and limb characteristics, and hospital and operator volumes, the odds ratios for perioperative complications were 1.21 (P=0.45) for 60–119 minutes, 2.36 (P=0.001) for 120–179 minutes, and 5.31 (P&lt;0.001) for ≥180 minutes with the shortest subgroup (&lt;59 min) set as the reference. Conclusions: Prolonged procedure time of EVT for symptomatic LEAD was significantly associated with an increased risk of perioperative complications.

Abstract 4137267: A novel reproducible low-cost model of acute myocardial infarction in swine

Background: Traditional open- and closed-chest methods for inducing acute myocardial infarction (AMI) in pigs typically require extensive and expensive instrumentation, including ventilators and inhalation anesthesia. This study aims to evaluate a reproducible and low-cost model for AMI in pigs using lower hemisternotomy. Methods: Twenty Yorkshire swine (15-20 kg, 45-50 days of age) underwent permanent ligation of the roots of the first and second diagonal branches of the left anterior descending coronary artery. The procedure was performed under intramuscular anesthesia (1ml 0.5mg/kg Zoletil™ and 2ml 10mg/kg xylazine hydrochloride) with spontaneous respiration. Cardiac function was assessed via echocardiography and cardiac PET/MRI scans at 1 and 4 weeks post-MI. Heart tissue was collected for pathological analysis to evaluate the establishment of the AMI model. Results: All animals exhibited ECG changes, including premature ventricular complexes and ST-segment elevation immediately after ligation. No ventricular tachycardia and fibrillation was observed during the operation. No animals (0%) died during infarct creation. The "Skin-to-Skin" procedure time was 18±3.3 minutes. this procedure produced an infarction that occupies ~10% of the left ventricular mass accompanied with the decrease of LV heart function and LV anterior wall thickness 4 weeks post-MI. Conclusions: This novel low-cost technique provides reproducible acute coronary artery occlusion at a selected location with subsequent AMI. It avoids ventilation, inhalation anesthesia, major surgery and does not require expensive instrumentation for intracoronary intervention.

Abstract 4140163: Initial Experience with Mini-Crush Versus Double Kissing Crush in Bifurcation Percutaneous Coronary Intervention: Insights from PROGRESS-BIFURCATION registry

Background: There is limited data on use of the mini-crush technique in two-stent bifurcation percutaneous coronary intervention (PCI). Methods: This retrospective, observational, cohort study was performed across 6 centers in the United States, Russia, and Turkey between 2013-2024, as part of the Prospective Global Registry of Percutaneous Coronary Intervention in Bifurcation Lesions (PROGRESS-BIFURCATION, NCT05100992). We evaluated procedural characteristics of patients who underwent bifurcation stenting using the mini-crush technique and compared it with those who were treated with double kissing (DK) crush. Results: Of 1,138 PCIs involving 1,499 lesions, 46 (4.04%) were performed using the mini-crush technique and 147 lesions (12.91%) using the DK crush technique. Baseline characteristics of the patients were similar in both groups. There was no difference between mini-crush versus DK-crush in technical success (100.0% versus 98.6%; p=0.99), procedural success (95.1% versus 97.1%, p=0.62), procedural complications (10.9% versus 14.7%, p=0.51), or in-hospital major adverse cardiovascular events (MACE) (6.5% versus 5.7%, p=0.73). In contrast, mini-crush technique was associated with shorter procedure time (79.00 vs 116.50 minutes; p&lt;0.001; Figure 1A), fluoroscopy time (23.50 vs 30.35 minutes, p=0.002; Figure 1A), and lower contrast volume (150 versus 109 milliliters; p&lt;0.001; Figure 1B), and air kerma radiation dose (1.11 vs 1.71 gray; p=0.024; Figure 1C). Conclusion: In patients undergoing PCI for bifurcation lesions, the mini-crush technique had similar rates of procedural complications and in-hospital MACE as compared with the DK crush technique but required less contrast volume, fluoroscopy time, radiation dose, and procedural time.

Abstract 4143224: Feasibility of Left Atrial Appendage Occlusion with Dual-Seal Technology without Pre-Procedural CT: Early Single-Center Experience

Background: Left Atrial Appendage (LAA) Occlusion with Amulet has shown promising results in achieving complete closure with minimal periprocedural leak. Amulet’s dual-sealed technology and numerous sizing options provide versatility for different LAA morphologies. Pre-procedural CT is routinely recommended for pre-procedural planning. However, this brings risks including use of contrast, risk of renal failure, radiation exposure, and patient inconvenience. Here, we share initial results of our Amulet implantation protocol without pre-procedural CT: 83 cases were reviewed; number of devices used, procedural time, periprocedural bleeding complications, success in coming off oral anticoagulation, and incidences of stroke and embolism were followed. Methods: We followed 83 AF patients who underwent LAA closure with Amulet, implanted with intraprocedural TEE, intracardiac left atrial echocardiography, and intraprocedural angiography. Pre-procedural CT was not used. Patients were followed to assess safety and efficacy of this protocol. Safety endpoints included rates of procedural and bleeding complications. Efficacy endpoints included rates of stroke and embolism, and number of devices used. Results: All 83 procedures were successfully completed with no perioperative procedural complications and no documented leaks on follow-up TEE. Patients had early ambulation with closure. On average, 1.14 devices were used per case: 88% of cases required 1 device, and nine cases required 2 devices; one case required 4 devices to fit as patient was noted to have an interrupted IVC, requiring implantation via right IJV. There were no cases of stroke or embolism following implantation, and all patients were safely able to come off oral anticoagulation. Conclusions: Results demonstrate that Amulet with its dual-sealed technology can be effectively and safely implanted without pre-procedural CT. No perioperative complications were observed. 88% of cases closed with single device usage. No post-procedure leaks were noted on follow-up TEE. Safety endpoints revealed minimal adverse events, with 2 cases of late pericardial effusion managed without long-term consequences. This protocol demonstrated high efficacy, as all patients were successfully able to come off oral anticoagulation with no reported strokes or embolic events. Intraprocedural TEE, intracardiac left atrial echocardiography, and intraprocedural angiography are typically appropriate for periprocedural sizing of the device.

Abstract 4125076: Catheter Ablation Alone Versus Catheter Ablation With Combined Percutaneous Left Atrial Appendage Closure For Atrial Fibrillation: A Systematic Review and Meta-analysis

Background: Combined catheter ablation (CA) with left atrial appendage closure (LAAC) may produce comprehensive treatment for atrial fibrillation (AF) whereby rhythm control is achieved and stroke risk is reduced without the need for chronic oral anticoagulation. However, the efficacy and safety of this strategy is still controversial. Aim: To investigate the efficacy and safety of a combined CA with LAAC approach to treat AF in patients moderate-to-high-risk for bleeding. Methods: This meta-analysis was reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Medline, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Risk of bias was assessed using the Modified Newcastle-Ottawa scale and Cochrane risk of bias tool. Eligible studies reported outcomes in patients with AF who underwent combined CA and LAAC versus CA alone. Studies performing CA without pulmonary vein isolation were excluded. Results: Eight studies comprising 1878 patients were included (2 RCT, 6 observational). Pooled results showed no difference in arrhythmia recurrence (risk ratio [RR] 1.05; 95% confidence interval [CI] 0.84-1.30), stroke or systemic embolism (RR 0.71; 95% CI 0.26-1.94), total procedure time (mean difference 31.45 minutes; 95% CI -5.91-68.81), or major periprocedural complications (RR 1.28; 95% CI 0.28-5.89) when comparing combined CA and LAAC versus CA alone. Conclusion: Combined CA with LAAC for AF is associated with similar rates of arrhythmia free survival, stroke, major periprocedural complications, and procedure time when compared to CA alone. A combined strategy may be as safe and efficacious for patients moderate-to-high-risk for bleeding events to negate the need for chronic oral anticoagulation.

Impact of Body Mass Index on the Outcomes of Cryoballoon Pulmonary Vein Isolation for Paroxysmal Atrial Fibrillation

Background: Atrial fibrillation (AF) is prevalent among obese patients, and cryoballoon ablation (CBA) is an effective strategy for the rhythm control of AF. The impact of body mass index (BMI) on the clinical outcomes of CBA for AF is not fully explored. Methods: 85 consecutive patients with paroxysmal AF were enrolled and were categorized into three groups as per their BMI: normal weight (BMI 18.5–25 kg/m2), overweight (BMI 25–30 kg/m2), and obese patients (BMI &gt; 30 kg/m2). The primary study endpoint was a late (12 month) recurrence of AF. Early recurrence of AF, symptom improvement, and procedural outcomes were some key secondary outcomes. Results: 20 patients had normal weight, 35 were overweight, and 30 were obese. Obese patients featured a higher prevalence of diabetes mellitus, heavier exposure to smoking, and worse baseline symptoms (as assessed through EHRA class at admission and 12 months before CBA) compared to overweight and normal weight patients. Both late and early (&lt;3 months) AF recurrence rates were comparable across the three groups. Of note, obese patients showed greater improvement in their symptoms post-CBA, defined as improvement by at least one EHRA class, compared to normal weight patients; this might be explained by improved diastolic function. Total procedure time and dose area product were significantly increased in obese patients. The multivariate logistic regression analysis indicated that early AF recurrence and the duration of hypertension are independent predictors of late AF recurrence. Conclusion: CBA is effective in overweight and obese patients with paroxysmal AF. Procedure time and radiation exposure are increased in obese patients undergoing CBA.