Ring-related Complications Research Articles

Short-term safety and effectiveness of conversion from sleeve gastrectomy to Ring augmented Roux-en-Y gastric bypass

BackgroundWeight recurrence, suboptimal clinical response and functional disorder (such as reflux) after a Sleeve Gastrectomy (SG) are problems that may require conversional surgery. For reflux, conversion to Roux-en-Y Gastric Bypass (RYGB) is considered effective. Regarding treatment for suboptimal clinical response, the technique of choice remains a subject of debate. This study aims to evaluate the safety and effectiveness of conversion from SG to Ring-augmented RYGB ( RaRYGB).MethodsAll laparoscopic SG to RaRYGB conversions performed between January 2016 and January 2022 were included. Primary outcome was percentage total weight loss (%TWL) after 1-year follow-up. Secondary outcomes consisted of cumulative %TWL, complications (with a focus on ring-related complications), and resolution of medical-associated problems.ResultsWe included 50 patients of whom 44 were female. Mean pre-conversion BMI was 37.6 kg/m2. All patients have reached the 1-year follow-up point, however 10 were lost to follow-up. After 1-year mean TWL was 17.8% while mean cumulative TWL, calculated from primary SG, was 32%. A total of 10 complications occurred in 8 patients within 30 days, 6 of which were ≤ CD3a and 4 ≥ CD3b. One MiniMizer was removed for complaints of severe dysphagia. Of the 35 medical-associated problems present at screening 5 remained unchanged(14.2%), 15 improved(42.9%) and 15 achieved remission(42.9%).ConclusionOur series of 50 patients undergoing conversion from SG to RaRYGB is adequate and successful regarding additional weight loss 1 year after conversion, cumulative weight loss, complication rate and achievement of improvement or remission of medical-associated problems.

A Systematic Review of Banded vs. Non-Banded Sleeve Gastrectomy Regarding Long Term Results

Abstract Background Laparoscopic Non-Banded Sleeve Gastrectomy (NBSG) is a widely popular weight loss procedure that has been around since the start of the millennium. Another variant, the Laparoscopic Banded Sleeve Gastrectomy (LBSG) started to emerge later. Questions have arisen on whether NBSG or BSG have better outcomes on the long run regarding weight loss, weight regain and reflux disease. This study aims to analyse previous studies performed on this subject and devise a conclusion regarding this matter. Obesity is a worldwide health issue with an unfortunate impact on an individual‘s quality of life. As of 2016, 39% of the world population suffered from obesity. Bariatric surgery is currently considered to be an effective and sustainable solution with increasing worldwide prevalence. Laparoscopic sleeve gastrectomy was first performed as the first step in biliopancreatic diversion with duodenal switch. Objective To scrutinize all English language papers written on the subject of comparing NBSG and LBSG as primary bariatric procedures and furthermore seeks to determine the superior surgery between them regarding weight loss, post-operative morbidity and complications like regurgitation, vomiting, reflux, dysphagia, and finally resolution of comorbidities like T2DM and HTN. Methodology This systematic review was carried out according to the updated PRISMA 2020 statement. A thorough search was executed in the Medline (PubMed) database, Elsevier‘s Scopus, Web of Science and the Cochrane Library in December 2022. Search was restricted to articles written in English. Search terms will be broad to encompass Banded Sleeve procedures. Results Our review revealed that the existing literature suggests increased weight loss following LBSG compared to NBSG; however, there‘s an increased risk of regular regurgitation episodes and of device related complications leading to revision surgeries (such as band removal). Data Sources Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materials available in the Internet till 2023. Conclusion Laparoscopic banded sleeve gastrectomy provides apparent better outcomes than non- banded sleeve gastrectomy regarding sustainable weight loss results through 3-5 years of follow up as the studies we reviewed had demonstrated. Nonetheless, it poses a definite increase in the risk of regurgitation, vomiting and ring related complications that might require revision surgeries. More RCTs with longer follow up periods (>5 years) will significantly add to our understanding of the matter. Larger LBSG sample sizes are needed to further enhance our impression on efficacy and safety of the banded sleeve gastrectomy. Finally, larger T2DM and HTN patients‘ sample size is needed to form a conclusion on the relationship between banding and the resolution of these diseases.

Very long-term outcomes of twisted auto-pericardial mitral annuloplasty.

During mitral annuloplasty, we twisted the harvested auto-pericardium to enable adequate ring sizing and implanted it to prevent ring-related complications. Indication for twisted auto-pericardial band (APB) was limited to patients with less than severe annular dilation to ensure high reproducibility and durability. The aim of this study was to investigate the long-term outcomes of twisted APB annuloplasty. From 1999 to 2009, 107 patients (62 ± 12years, degenerative 92 and infective endocarditis 15) with isolated posterior mitral leaflet (PML) prolapse with inter-commissural distance of 32mm or smaller underwent twisted APB annuloplasty. Of these, 104 patients without early leaflet repair failure were studied. Leaflet repairs were predominantly performed by quadrangular resection. Median APB size was 28mm. Follow-up rate was 98.1% and duration was 10.9 ± 4.8years. There were two early and 34 late deaths. Survival and freedom from cardiac-related death at 15years were 61.7% ± 5.6% and 83.8% ± 4.7%, respectively. Age and male sex were independent predictors of mortality. There were four late reoperations for recurrent severe mitral regurgitation (MR), three of which were due to new chordal rupture. Freedom from reoperation and freedom from moderate or severe MR at 15years were 93.1% ± 3.5% and 81.3% ± 6.2%, respectively. No patients developed hemolysis, ring dehiscence, or infective endocarditis. The long-term outcomes of twisted APB for isolated PML prolapse without severe annular dilation are satisfactory. Twisted APB annuloplasty may be a preferable option to reduce ring-related complications with sufficient durability.

Plastibell circumcision: Comparison between neonates and infants.

Background:The Plastibell circumcision technique has gained popularity worldwide. It has a low bleeding risk which makes it suitable for a vulnerable population and in late circumcision. However, several problems resulting from prolonged retention of the Plastibell ring were reported.Objectives:The objectives of this study were to assess the outcomes of circumcision performed using Plastibell devices, report ring-related complications, and compare the complications of the technique between neonates and infants.Methods:This was a retrospective cohort study that was conducted in a total of 989 male neonates and infants who had Plastibell circumcision performed by a single surgeon between June 2006 and February 2018. Postoperative complications were reported and compared between the two age groups. The indications of the Plastibell technique were religious in 988 patients and urinary tract infection in 1 patient.Results:During the study period, Plastibell circumcision was performed in 633 neonates and 356 infants. The average ages of neonates and infants were 14 ± 2 days and 3 ± 0.5 months, respectively. Complications developed in 89 cases, 4.4% in neonates and 17% in infants (P < 0.001). The retained ring was the most common complication in 46 cases (4.6%), followed by excess skin in 21 cases (2%). Bleeding occurred in 10 cases (1%), infection in 7 cases (0.7%), and hematoma in 2 cases (0.2%).Conclusion:Complications of Plastibell circumcision are significantly higher in infants than in neonates, and ring retention is the most common complication in both the groups. However, the risk of severe hemorrhage is low making it a good option for infants in the outpatient setting.

Long-Term Results of Tricuspid Annuloplasty Using MC3 Ring for Functional Tricuspid Regurgitation.

This study aimed to evaluate the long-term results of tricuspid annuloplasty using the MC3 ring for functional tricuspid regurgitation (TR). Methods and Results: Between 2004 and 2014, 249 patients underwent tricuspid ring annuloplasty using the MC3 ring for functional TR (FTR). Main etiologies of FTR were left-sided valvular disease (n=211) and left-to-right shunt (n=34). Based on the interval between the operation and last echocardiographic scan, patients were divided into short-term and long-term follow-up groups. Mean follow-up duration was 84.4±37.1 months. Operative death occurred in 8 patients (3.2%). Predischarge echocardiography showed that both TR grade and systolic pulmonary artery pressure were significantly decreased compared with preoperative values, and these values were sustained during follow-up in both the short-term and long-term follow-up groups. There were no ring-related complications in either the postoperative or follow-up period, except for permanent pacemaker implantation in 2 patients. The freedom from TR ≥moderate and tricuspid valve (TV)-related events at 10 years were 92.1% and 92.8%, respectively. TV annular size was a risk factor for the recurrence of TR ≥moderate (P=0.001), and 42 mm was the cutoff value for predicting the recurrence of TR ≥moderate. Tricuspid annuloplasty using the MC3 ring for FTR provides satisfactory early results that are sustained during long-term follow-up. Preoperative TV annular size was associated with the recurrence of TR ≥moderate.

Early Clinical Outcomes of Tricuspid Valve Repair with a Tri-Ad Annuloplasty Ring in Comparison with the Outcomes Using an MC3 Ring.

BackgroundWe evaluated the early clinical outcomes of tricuspid valve annuloplasty (TAP) with the Tri-Ad annuloplasty ring for functional tricuspid regurgitation (TR).MethodsFrom January 2015 to March 2017, 36 patients underwent TAP with a Tri-Ad ring for functional TR. To evaluate the early clinical outcomes of TAP with the Tri-Ad ring, we conducted a propensity score-matched analysis comparing the Tri-Ad and MC3 tricuspid annuloplasty rings (n=34 in each group). The follow-up duration was 11.0±7.07 months.ResultsThere was 1 case of operative mortality (2.8%) and no cases of late mortality. Postoperative complications occurred in 15 patients (41%), including acute kidney injury in 6 patients (16%), bleeding requiring reoperation in 4 patients (11%), and low cardiac output syndrome in 4 patients (11%). There were no ring-related complications, such as atrioventricular block or ring dehiscence. The TR grade decreased significantly (from 2.03±1.06 to 1.18±0.92, p<0.01), as did the systolic pulmonary artery pressure (from 43.53±13.84 to 38.00±9.72 mm Hg, p=0.03). There were no cases of severe residual TR, but moderate TR was observed in 3 patients, all of whom had severe TR preoperatively. Severe preoperative TR was also associated with moderate in the univariate analysis (p<0.01). In the propensity score-matched analysis comparing the Tri-Ad and MC3 rings, there was no significant difference in early clinical outcomes.ConclusionTAP with the Tri-Ad ring corrected functional TR effectively and provided good early clinical and echocardiographic results without ring-related complications. However, severe preoperative TR was associated with moderate or severe residual TR in the immediate postoperative period. A follow-up study is necessary to confirm the stability of this procedure.

Early Clinical Outcomes of Tricuspid Ring Annuloplasty Using the New Three-dimensional Annuloplasty Ring, Tri-Ad

We evaluated the early clinical outcomes of tricuspid ring annuloplasty using the Tri-Ad ring and compared the results of the Tri-Ad ring with those of MC3 ring, a widely used three-dimensional (3D) ring. From 2007 to 2017, 227 patients underwent tricuspid ring annuloplasty (TAP) for functional tricuspid regurgitation using the new 3D ring, Tri-Ad. In total, 191 patients underwent TAP with a MC3 ring and 36 patients underwent TAP with a Tri-Ad ring. Tri-Ad rings have been used since January 2015. Propensity score-matched analysis was performed (n = 36 in each group). Mean ± SD duration of follow-up was 67 ± 37 months. Operative mortality occurred in nine patients and postoperative complications in 39, which included atrial fibrillation (n = 9), low cardiac output syndrome (n = 15), and bleeding requiring reoperation (n = 15). There were no significant differences in operative mortality and postoperative complications (p = .650 and p = .423, respectively). In the Tri-Ad group, both tricuspid regurgitation grade and systolic pulmonary artery pressure significantly decreased compared with its preoperative values in predischarge echocardiography (from 2.00 ± 1.19 mmHg to 1.17 ± 0.81 mmHg [p < .001] and from 43.11 ± 13.21 mmHg to 38.58 ± 8.61 mmHg [p < .001], respectively). There were no ring-related complications, such as atrioventricular block or ring dehiscence during follow-up in Tri-Ad group. In matched patients, there were no significant differences in in-hospital mortality, postoperative complications, or tricuspid valve-related events (p = .310, p = .502, and p = .1.00, respectively). The Tri-Ad ring, a new 3D ring, showed comparable early clinical outcomes and echocardiographic results to the MC3 ring. However, a long-term follow-up study is required to confirm the safety and efficacy of this new device.

Long-term results of annuloplasty in trivial-to-mild functional tricuspid regurgitation during mitral valve replacement: should we perform annuloplasty on the tricuspid valve or leave it alone?

The benefits of concomitant tricuspid annuloplasty (TAP) for non-significant functional tricuspid regurgitation (TR) during mitral valve replacement (MVR) are controversial. We evaluated the long-term outcomes-particularly the long-term tricuspid valve (TV) functional outcomes-of MVR with or without tricuspid ring annuloplasty. From 2004 to 2014, 256 patients (56.4 ± 12.1 years) with trivial or mild functional TR who underwent MVR were enrolled. Eighty-two patients underwent concomitant tricuspid ring annuloplasty (TAP group), and 174 patients did not undergo the TV procedure (nTAP group). Propensity score-matched analysis was performed (n = 72 in each group). The follow-up duration was 77.4 ± 42.4 months. The early clinical outcomes were similar between the 2 groups before and after propensity score matching with an early mortality rate of 3.5% (9 of 256). No patients experienced ring-related complications during follow-up. Eleven (6.3%) patients developed significant TR (≥moderate) in the nTAP group, while no patients developed significant TR in the TAP group. There were no significant differences in overall survival between the 2 groups before or after matching. However, propensity score-matched analysis revealed that the freedom from significant TR aggravation and freedom from TV-related event rates were significantly higher in the TAP group than in the nTAP group (P = 0.047 and P = 0.043, respectively). Patients with untreated trivial or mild functional TR accompanied by mitral valve disease can develop significant TR during follow-up. TV ring annuloplasty can be performed without complications and can be beneficial for patients with trivial or mild functional TR who are undergoing MVR.

LONG-TERM POSTOPERATIVE ENDOSCOPIC FINDINGS AFTER GASTRIC BYPASS PROCEDURE: a co-occurrence analysis.

A multitude of endoscopic findings post-gastric bypass procedures have been previously reported in the literature, but to our knowledge, no present rules exist that could guide clinicians regarding which findings should be actively sought, once an initial finding is identified. To identify co-occurrence patterns among endoscopic findings of patients having undergone past gastric bypass procedure. Our registry involves all consecutive patients undergoing an upper endoscopic evaluation after a gastric bypass procedure. We collected information on the presence of the endoscopic findings in post-gastric bypass surgery patients. Co-occurrence evaluation involved the use of intersection, cluster and item factor analyses. A total of 396 endoscopic evaluations were made on 339 patients. Most patients were female (81.1%), with an average BMI of 31.88±6.7 at the time of endoscopy. Esophagitis was the most common isolated finding (35.3%). Endoscopic findings clustered around two groups, (1) the ring-related complications involving ring displacement, ring slips and gastric pouch, while (2) stenosis-related findings involved dilation and stenosis (P<0.01). While most endoscopic findings after gastric bypass endoscopic procedures are isolated, ring and stenosis-related clusters should be used as a set of rules by clinicians, as it might enhance their probability of finding co-occurring conditions.

Conversion of Vertical Sleeve Gastrectomy to a Functional Single-Anastomosis Gastric Bypass: Technique and Preliminary Results Using a Non-Adjustable Ring Instead of Stapled Division

BackgroundRecent data show that some patients will have insufficient weight loss or experience weight regain after sleeve gastrectomy. Dilation of the sleeve over time or use of an inadequate technique may contribute to relapse of morbid obesity. Repeat sleeve gastrectomy is the most obvious option but requires stapling of scarred tissue, has a higher risk of leakage, and is prone to re-enlargement with time. We herein describe a simple and innovative technique with which to revise vertical sleeve gastrectomy (VSG) into functional single-anastomosis gastric bypass (f-SAGB).Materials and MethodsTwelve VSGs were converted to f-SAGB by placing a GaBP Ring (Bariatec Corp., Palos Verdes Peninsula, CA, USA) at the base of the “sleeve” and performing the anastomosis above the ring. The length of the biliopancreatic loop was chosen according to the volume of the pouch and the patient’s residual eating capability.ResultsAll procedures were completed by laparoscopy and were uneventful. The average decrease in the body mass index was from 41.0 to 29.5 kg/m2 at the 12-month follow-up. No ring-related complications were reported.Conclusionf-SAGB is a low-risk and effective option with which to revise VSG in patients with inadequate weight loss. Avoiding detachment of the pouch from the antrum assures full reversibility of the procedure and preserves the chance to explore the remnant stomach and biliary tree.

Laparoscopic Revision of Banded Roux-En-Y Gastric Bypass: Pouch Resizing and Redo of Gastrojejunal Anastomosis for Ring Migration and Pouch Dilation

Introduction: The Roux-en-Y gastric bypass (RYGB) is a surgical procedure to induce and maintain weight loss. It was first reported for the treatment of obesity in 1967.1 Since then, this surgery has undergone many modifications, such as the placement of a silastic ring around the gastroenterostomy site.2 This procedure, known as banded RYGB, was performed to restrict the rate of emptying of the pouch. Some patients develop serious ring-related complications, such as nausea, vomiting, regurgitation, and even malnutrition, requiring revision of their bariatric operation.3 The stenosis due to the ring migration leads to gastric pouch dilation and weight regain after distal obstruction resolution. A pouch resizing may be necessary to prevent obesity relapse. We present a video of a revisional laparoscopic surgery for the treatment of ring migration with gastric pouch dilation. Materials and Methods: A 48-year-old female with hypertension and type 2 diabetes underwent open-banded RYGB in 2007. The maximum weight was 119 kg (body mass index [BMI] = 44 kg/m2). The patient remained with stable weight until 2012. After 5 years of surgery, the patient weighed 62.1 kg (BMI = 23 kg/m2) with complete resolution of hypertension and diabetes. However, the patient started presenting gastroesophageal reflux symptoms, postprandial vomiting, and progressive weight loss. Seven years after surgery, the patient weighed 55 kg (BMI = 20.7 kg/m2). The patient was subjected to investigation. Endoscopy revealed Los Angeles grade C esophagitis and stenosis of the gastrojejunal anastomosis, upper gastrointestinal contrast study demonstrated ring migration, and computed tomography showed pouch volumetry of 110 mL. The patient underwent multiple upper endoscopies with dilations without substantive relief of symptoms. Laparoscopic approach was performed with gastrojejunostomy resection along with the ring, pouch resizing, and redo of gastrojejunal anastomosis within a 210 minutes procedure. Results: The postoperative period was uneventful. The patient started with fasting at postoperative day 1, presented good liquid diet acceptance, and had hospital discharged 4 days after surgery. No early complication was observed. After 2 years, the patient is without gastroesophageal reflux and no weight regain. Conclusion: Ring migration along with pouch dilation after banded RYGB can be safely managed through laparoscopic gastrojejunostomy resection and pouch resizing with immediate and long-term symptomatic improvement. This video was presented at the IFSO Congress 2014 in Montreal, Canada. No competing financial interests exist. Runtime of video: 4 mins 58 secs

Invited Commentary

In the 1960s, Kay and colleagues [1Kay J.H. Egerton W.S. Zubiate P. The surgical treatment of mitral insufficiency and combined mitral stenosis and insufficiency with use of the heart-lung machine.Surgery. 1961; 50: 67-74PubMed Google Scholar] and Reed and colleagues [2Reed G.E. Tice D.A. Clauss R.H. Asymmetric exaggerated mitral annuloplasty: repair of mitral insufficiency with hemodynamic predictability.J Thorac Cardiovasc Surg. 1965; 49: 752-761PubMed Google Scholar] described methods to reduce the posterior annulus by plicating the annulus at the commissures. Anchoring sutures were placed on the anterior side of the annulus at the commissure, with considerably larger bites on the posterior annulus, which decreased the length of the posterior annulus. By contrast, annuloplasty is used to support or reduce in size the posterior portion of the mitral annulus and to provide a stable foundation for appropriate alignment of the leaflets. Some surgeons use the Kay suture plication technique only if abnormalities are localized solely at the commissures, which are not the majority of cases. Also, Kay and colleagues demonstrated good results with mitral repair for patients with ischemic mitral insufficiency, but no analyses were performed to examine the impact of confounding variables. Some studies demonstrated that complications after mitral valve repair, including annuloplasty, were affected by patients' preexisting comorbidities [3Grossi E.A. Goldberg J.D. LaPietra A. et al.Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications.J Thorac Cardiovasc Surg. 2001; 122: 1107-1124Abstract Full Text Full Text PDF PubMed Scopus (279) Google Scholar]. Sawazaki and colleagues [4Sawazaki M. Tomari S. Izawa N. Zaikokuji K. Tateishi N. Imaeda Y. Interrupted commissural band annuloplasty for degenerative mitral valve disease.Ann Thorac Surg. 2014; 97: 558-562Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar] modified the original Kay technique in order to avoid posterior annuloplasty to prevent hemolysis and prevent mitral stenosis secondary to pannus formation. The article by Sawazaki and colleagues [4Sawazaki M. Tomari S. Izawa N. Zaikokuji K. Tateishi N. Imaeda Y. Interrupted commissural band annuloplasty for degenerative mitral valve disease.Ann Thorac Surg. 2014; 97: 558-562Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar] reports a series of 63 patients with bilateral commissural band annuloplasty compared with 58 patients with a Cosgrove band, looking at the incidence of mitral stenosis and hemolysis that seems to favor the former technique. The incidence of these complications is generally low, and the attempt at improving the technique of Kay and colleagues does not seem to address prime considerations in the occidental setting of mitral valve repair. Definitive conclusions regarding the use of this technique can be derived only after a larger comparative study and by including numerous precisions on types of lesions, patients' preoperative characteristics, and associated procedures. Finally, on the basis of long-term studies, mitral valve repair at 10 years is durable, meaning that is carries better survival than do mechanical valves [4Sawazaki M. Tomari S. Izawa N. Zaikokuji K. Tateishi N. Imaeda Y. Interrupted commissural band annuloplasty for degenerative mitral valve disease.Ann Thorac Surg. 2014; 97: 558-562Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 5DiBardino D.J. ElBardissi A.W. McClure R.S. Razo-Vasquez O.A. Kelly N.E. Cohn L.H. Four decades of experience with mitral valve repair: analysis of differential indications, technical evolution, and long-term outcome.J Thorac Cardiovasc Surg. 2010; 139 (discussion 83–74): 76-83Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar]. Also, repair offers a better preservation of heart function, lower risk of thromboembolic events, and infection, and it does not require the use of anticoagulation. In the near future, the technique presented in this article could be added to the available methods of performing mitral repair. Interrupted Commissural Band Annuloplasty for Degenerative Mitral Valve DiseaseThe Annals of Thoracic SurgeryVol. 97Issue 2PreviewMitral annuloplasty is useful for treating degenerative mitral valve disease. Although the incidence of complications is low, prosthetic ring-related complications can occur. Hemolysis and mitral stenosis are serious complications requiring reoperation. Limited use of prosthetic material could decrease the risk for complications. Commissural annuloplasty has been reported by Kay and Reed; their techniques involve suture plication. To prevent dehiscence, we selected short bands and compared the echocardiographic changes between this method and the Cosgrove ring. Full-Text PDF

Interrupted Commissural Band Annuloplasty for Degenerative Mitral Valve Disease

Mitral annuloplasty is useful for treating degenerative mitral valve disease. Although the incidence of complications is low, prosthetic ring-related complications can occur. Hemolysis and mitral stenosis are serious complications requiring reoperation. Limited use of prosthetic material could decrease the risk for complications. Commissural annuloplasty has been reported by Kay and Reed; their techniques involve suture plication. To prevent dehiscence, we selected short bands and compared the echocardiographic changes between this method and the Cosgrove ring. Three sutures are placed in the commissures using two bands, which shortens the annular length by 60%. We performed this interrupted commissural band annuloplasty (iCBA) in 63 patients and used Cosgrove bands for 58 patients. Clinically, for iCBA and Cosgrove groups, respectively, hemolysis with mild mitral regurgitation occurred in 0 and 2 cases (p=0.084), and mitral stenosis due to pannus formation occurred in 0 and 1 case (p=0.224). There was a trend toward a lower ring-related complication rate in the iCBA group. On echocardiography, for the iCBA and Cosgrove groups, respectively, the maximum anterior-posterior distance of the annulus in diastole was 3.1±0.7 mm and 2.6±0.4 mm (p<0.001), maximum opening angle of the posterior leaflet was 85.7±17.3 degrees and 103.4±20.1 degrees (p<0.001), and coaptation distance was 11.6±3.7 mm and 8.4±2.6 mm (p<0.001). The iCBA method prevented posterior leaflet tethering, kept the coaptation distance deep on echocardiography, and was associated with lower trends of ring-related complications. Because the posterior side of the annulus was not reconstructed, iCBA is suitable for fibroelastic deficiency, rather than for Barlow's disease.

Assessment of Intrastromal Corneal Ring Segment Position With Anterior Segment Optical Coherence Tomography

To examine the exact position of implanted Keraring (Mediphacos, Belo Horizonte, Brazil) segments by high-resolution anterior segment optical coherence tomography (AS-OCT). This study included 17 eyes of 13 patients with keratoconus who underwent uneventful intracorneal ring segment implantation with the aid of femtosecond laser. Eyes were evaluated by AS-OCT at the third postoperative month. Distance from the apex of the triangular cross-section of the ring segment to the anterior corneal surface and distances from two basal corners to the posterior corneal surface were measured. Distance from apex to anterior corneal surface (263.1 ± 42.9 μm) was significantly smaller than target depth calculated intraoperatively (356.9 ± 35.7 μm, P < .001). Distance between outer basal corner and posterior corneal surface was significantly greater than distance between inner basal corner and posterior corneal surface. High-resolution AS-OCT is a rapid, convenient, and valuable technique in the follow-up of patients with implanted Keraring segments that may be helpful in predicting ring-related complications.

Tricuspid Annuloplasty Using the MC3 Ring for Functional Tricuspid Regurgitation

A recently introduced tricuspid annuloplasty ring, the MC(3) ring, has a 3-dimensional form that is designed to remodel the tricuspid valve annulus. The aim of this study was to investigate its clinical performance. From December 2004 to April 2008, 103 patients underwent tricuspid annuloplasty using the MC(3) ring (mean age, 52+/-13 years; 63.6% women). The average preoperative tricuspid regurgitation (TR) grade was 2.5+/-0.8, and the mean preoperative systolic pulmonary artery pressure was 48.4+/-15.0 (24-88) mmHg; the mean follow-up was 26.7+/-11.2 (0-52) months. One patient died after surgery (1.0%), because of cor pulmonale. No MC(3) ring-related complications, such as, atrioventricular block, ring dehiscence or thromboembolism, were encountered. Predischarge echocardiography showed a significant decrease in the TR grade (2.5+/-0.8 to 0.8+/-0.8, respectively; P<0.001). After a median 15 months, the mean TR grade was stable (0.9+/-0.8). The mean systolic pulmonary artery pressure was also lower than its preoperative value (33.9+/-7.9 vs 48.4+/-15.0 mmHg, respectively; P<0.001). The MC(3) ring provides good mid-term clinical and echocardiographic results for TR. However, long-term follow-up is mandatory to confirm the stability of this procedure.

Early clinical evaluation of the Cosgrove-Edwards prosthetic heart valve ring

We discuss the usefulness of the Cosgrove-Edwards ring from our early clinical results from 25 rings in 24 patients who underwent mitral annuloplasty (MAP) or tricuspid annuloplasty (TAP) between June 1999 and December 2000. In the MAP group, the posterior mitral annulus between the anterior and posterior fibrous trigones was reinforced with the prosthetic ring. In the TAP group, the annuli of the anterior and posterior leaflets were splinted with the ring. The prosthetic ring was attached by pledgeted U-sutures. Cardiologists performed echocardiography pre- and postoperatively. Thirteen of the 14 in the MAP group showed mitral valve regurgitation of grade 0 or I. Six of the 11 in the TAP group showed tricuspid regurgitation of grade 0 or I, and 5 patients with regurgitation equal to or greater than grade II who remained in atrial fibrillation postoperatively recovered without further clinical symptoms. No patient has required reoperation during a follow-up period of up to 2 years. Cosgrove-Edwards ring-related complications, such as valve stenosis, ring detachment, and arrhythmia, have been not recognized in these patients. In conclusion, for mitral and tricuspid annuloplasty, the Cosgrove-Edwards prosthetic ring showed excellent early clinical results, particularly in patients maintained in sinus rhythm.

Advance in mitral valve repair using a device flexible in three dimensions. The St Jude Medical-Séguin annuloplasty ring.

To allow remodeling of the annulus while respecting natural three dimensional annular movements during mitral valve repair, a new annuloplasty ring (St Jude Medical [SJM]-Séguin annuloplasty ring) was developed. This ring has variable flexibility; that is, it is sufficiently rigid on the anterior portion to maintain intercommissural distance, and sufficiently flexible on the posterior portion to respect left ventricular function and natural three dimensional annular mobility. Fifty patients operated on for pure mitral regurgitation between January, 1994 and June, 1995 were studied. Mean age was 58 years. The cause of mitral insufficiency was degenerative in 80% of the patients, rheumatic in 12%, ischemic in 4%, and infectious in 4%. The operative technique to restore normal valve coaptation was quadrangular resection in 31 cases, commissurotomy and chordal fenestration in 8, use of polytetrafluoroethylene chordae in 6, and chordal shortening or transposition in 5. Annuloplasty with a SJM-Séguin annuloplasty ring was realized in all 50 cases. Transesophageal echocardiographic mitral regurgitation decreased from 3.6 +/- 0.8 to 0.3 +/- 0.2 after repair (p < 0.005). Two post operative deaths due to non valve related complications, were observed. There were no ring related complications, especially no left ventricular outflow tract obstruction due to systolic anterior motion. Patients were all reviewed at a mean follow-up of 12.1 months (range, 9-27 months). All are well, in New York Heart Association functional Class I. Echocardiography showed a mean 0.4 +/- 0.3 mitral regurgitation, absence of any systolic anterior motion, and satisfactory mobility of the annuloplasty ring after the movements of the natural annulus, including non planar deviation. These preliminary results suggest that this annuloplasty ring 1) provides excellent correction of annular dilatation and remodeling of the annulus, 2) avoids systolic anterior motion observed with rigid rings, and 3) preserves physiologic three dimensional annulus motion.