Surgical Closure Group Research Articles

Patent ductus arteriosus management in very-low-birth-weight prematurity: a place for an early operation?

The goal was to evaluate neonatal outcomes based on treatment strategies and time points for haemodynamically significant patent ductus arteriosus (hsPDA) in very-low-birth-weight preterm infants, with a particular focus on surgical closure. This retrospective study included very-low-birth-weight infants born between 2014 and 2021 who received active treatment for hsPDA. Neonatal outcomes were compared between (i) primary surgical closure versus primary ibuprofen; (ii) early (<14th post-natal day) versus late primary surgical closure (≥14th post-natal day); and (iii) primary versus secondary surgical closure after ibuprofen failure. Further analysis using 1:1 propensity score matching was performed. Logistic regression was conducted to analyse the risk factors for post-ligation cardiac syndrome (PLCS) and/or acute kidney injury (AKI). A total of 145 infants with hsPDA underwent active treatment for closure. The in-hospital death rate and the incidence of severe bronchopulmonary dysplasia (BPD) were similar between the primary surgical closure group and the primary ibuprofen group in a 1:1 matched analysis. Severe BPD was significantly higher in the late surgical closure group than in the early primary surgical closure group with 1:1 propensity score matching (72.7% vs 40.9%, P=0.033). The secondary surgical closure group showed the mildest clinical condition; however, the probability of PLCS/AKI was highest (38.6%) compared to the early (15.2%) or the late primary surgical group (28.1%, P<0.001), especially in extremely premature infants (gestational age < 28 weeks). Surgical patent ductus arteriosus closure is not inferior to pharmacologic treatment. Considering the harmful effect of a prolonged patent ductus arteriosus shunt exposure, a timely decision and timely efforts should be made to minimize the risk of severe BPD and PLCS/AKI after surgical closure.

Addressing "immortal time bias" in the evaluation of treatment outcomes for post-infarction ventricular septal defect: implications for clinical practice and research

Abstract Introduction Post-infarction ventricular septal defect (VSD) is a rare but life-threatening complication of acute myocardial infarction (AMI). Surgical closure (SC) has traditionally been the standard treatment, but in recent years, percutaneous transcatheter (PC) closure has emerged as an alternative. This study aims to investigate the potential for "immortal time bias" in treatment selection for post-infarction VSD. Methods 8,022 patients who presented with STEMI, of whom 80 (1%) had a VSD. Among these: 26 SC, 20 underwent PC, and 34 received medical management (MM). The primary endpoint was in-hospital mortality. We used the Kaplan–Meier curves (Fig 1C) to plot survival, and to address immortal time bias, we used the time to closure as a time-dependent covariate and conducted a landmark analysis using time-dependent Cox proportional hazard regression. Significance was set at P≤0.05. Results The baseline and admission characteristics in the 3 groups are summarized in Table 1. The mean age was 64.4 years, and most were men (78.8%) with comorbidities such as DM(48.8%) and HTN(57.5%). At presentation, patients managed with MM were more likely to have high-risk features, including lower systolic blood pressure, LVEF; and higher right ventricular dysfunction. 21 patients (26.3%) presented with cardiogenic shock, which was more common in the MM group (SC 11.5%, PC 10%, vs MM 47.1%; P=0.001). The delay between the onset of AMI-arrival was similar in the SC and PC groups (P=0.95) but longer compared to MM (6 vs 5 vs 0.8 days, respectively, P&amp;lt;0.001). Patients managed with MM had a shorter time from onset of STEMI-VSD diagnosis (4 [2-9] SC, 4 [2-20] PC, and 2 [1-4] days for MM; P=0.03). The time from onset of STEMI-closure was 22 (12-45) days, with no significant difference in closure achievers (P=0.78) (Fig 1A). Only 19 patients (23.8%) received reperfusion therapy, most receiving thrombolytic treatment, and only 8 receiving pPCI. Inotropics, vasopressors, and invasive ventilation were used more frequently in the MM group. To evaluate the potential for survival bias, logistic regression was performed with the closure of VSD versus the time of AMI-event (closure or death) as the outcome variable for the entire cohort. The analysis showed a time-dependent gradient of reaching closure (P&amp;lt;0.001) with OR=1.15 (1.08-1.23) per day since AMI. This finding was corroborated by a spline that showed linearity df=1 X2=13.2 P&amp;lt;0.001. In the time-dependent analysis of the cohort, there were no significant differences in mortality (P=0.331) with a HR=1.69 (0.75-3.81; P=0.204) for SC and 0.78 (0.33-1.87; P=0.578) for PC vs MM (Fig1C). Conclusion Results showed a time-dependent gradient of reaching VSD closure, and a time-varying analysis showed no differences in mortality between SC or PC compared to MM. The findings of this study suggest that future studies evaluating outcomes for post-infarction VSD should take into account the potential for immortal time bias.Table 1Figure 1

Ultrasound-guided closure of the femoral artery during venoarterial decannulation using a large-bore closure device.

Peripheral femoro-femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO) is viable for fast hemodynamic assistance during cardiogenic shock. Ultrasound-guided closure with a large-bore device (MANTA®) is a feasible option potentially replacing surgical arteriotomy closure in peripheral VA-ECMO decannulation. This retrospective study included patients weaning from percutaneously inserted femoro-femoral VA-ECMO at the Helsinki University Hospital, Finland in 2012-2020. The primary endpoints were access-site complications, a composite of hematomas/seromas/surgical site infections (SSIs), and the safety endpoint of vascular complications (VCs). A total of 100 consecutive percutaneously implanted and weaned VA-ECMO patients were stratified into two groups by decannulation strategy: percutaneous ultrasound-guided MANTA device (n = 21, 21.0%) or surgical approach (n = 79, 79.0%). The mean age of the cohort was 51 ± 13 years and females represented 25.0%. The technical success rate of the percutaneous ultrasound-guided MANTA technique was 95.2%. In multivariate analysis, surgical closure was associated with a higher incidence of combined access site hematomas/seromas/SSIs compared to percutaneous ultrasound-guided deployment of MANTA device (44.3% versus 9.5%, odds ratio (OR): 7.162, 95% confidence interval (CI): 1.544-33.222; p = 0.012). Similarly, access-site complications necessitating interventions were more frequent in the surgical closure group compared to US-MANTA (ultrasound-guided MANTA) group (26.6% versus 0.0%, p = 0.005). VCs were infrequent in both groups without any significant intergroup difference (p > 0.99). Percutaneous ultrasound-guided MANTA closure of the femoral artery after VA-ECMO decannulation was associated with high technical success rate and low incidence of VCs. Compared to surgical closure, access-site complications were significantly less frequent, along with access-site complications necessitating interventions.

Comparison of Short-Term Outcomes of Transcatheter versus Surgical Closure of Atrial Septum Defect at a Tertiary Cardiac Care Facility

Objective: To compare the short-term outcomes of transcatheter versus surgical closure of atrial septal defect (ASD) at a tertiary cardiac care facility in South Punjab, Pakistan.&#x0D; Study Design: Prospective comparative study.&#x0D; Place and Duration of the Study: Department of Paediatric Cardiology and Paediatric Cardiac Surgery, Chaudhary Pervez Elahi Institute of Cardiology, Multan Pakistan, from Jul 2019 to Jun 2021.&#x0D; Methodology: A total of 110 patients with moderate to large isolated secundum ASDs without severe pulmonary hypertension and planned to undergo closure of secundum ASD by either surgical approach or device closure were included. All surgical and transcatheter procedures were performed adopting standard techniques. Intra-procedural or post-procedural outcomes were noted.&#x0D; Results: In a total of 110 patients, 59(53.6%) underwent transcatheter closure of ASD, while surgical closure was done in the remaining 51(46.4%) patients. Post-procedural complications were significantly more in the Surgical Closure Group in comparison to the Transcatheter Closure Group, [14(27.5%) vs 5(8.5%) (p=0.026)]. None of the cases in the Transcatheter Closure Group required inotropes in the post-procedure period in comparison to 24(47.1%) cases (p&lt;0.001). The total cost of treatment was significantly higher in transcatheter closure patients compared to surgical closure patients (1504±60.4 US$ versus 1448±75.4 US$, p&lt;0.001). Overall, successful closure was noted in 108(98.2%) cases. No mortality was recorded.&#x0D; Conclusion: Overall, short-term outcomes of transcatheter ASD closure were comparable to the surgical approach, but patients with transcatheter ASD closure had significantly less duration of hospitalization and low rates of post-procedural complications.Keywords: Atrial septum defect, Mortality, Surgical closure, Transcatheter closure.

Outcomes following transcatheter closure or surgical repair of coronary-left ventricular fistula: A single-center study with 10-year experience

BackgroundCoronary arteries drain into the left ventricle, known as coronary-left ventricular fistula (CLVF), an extremely rare anomalous coronary artery disease. Little is known about the outcomes following transcatheter closure (TC) or surgical closure (SC) of CLVF. MethodThis was a single-center retrospective study including 42 consecutive patients who underwent either the TC or SC procedure from January 2011 to December 2021. The baseline and anatomic characteristics of the fistulas, procedural outcomes, and late outcomes were summarized and analyzed. ResultsThe mean age was 31.6 ± 16.2 years, with 28 male patients (66.7%). Fifteen patients underwent SC group and the remaining received TC group. There were no differences in age, comorbidities, clinical presentations, and anatomic characteristics between the 2 groups. The procedural success rate was similar (93.3% vs. 85.2%, P = 0.639) without operative and in-hospital mortality in both groups. Notably, patients who underwent TC had a significantly shorter postoperative in-hospital length of stay (2.11 ± 1.49 vs. 7.73 ± 2.37 days, P<0.001). The median follow-up time was 4.6 years (2.5-5.7 years, TC group) and 3.98 years (0.42-7.15 years, SC group), respectively. No difference was observed in the incidence of recanalization of the fistula (7.4% vs. 6.7%, P = 1) and myocardial infarction (0% vs. 0%). Cerebral infarction due to discontinuation of anticoagulants happened to two patients in the TC group. Importantly, thrombotic occlusion of the fistulous tract with patent parent coronary artery was found in 7 patients of the TC group. ConclusionBoth transcatheter and SC are safe and effective for patients with CLVF. Thrombotic occlusion is a noteworthy late complication, and its presence indicates the use of anticoagulants lifelong.

Renal Function After Transcatheter Piccolo Patent Ductus Arteriosus Closure With Contrast Angiography in Extremely Premature Infants

Transcatheter patent ductus arteriosus (PDA) device closure is increasingly performed in extremely premature infants. Contrast angiography improves the procedural safety and effectiveness by precise anatomic delineation. Contrast nephropathy is a concern in clinically ill premature infants, especially with the presence of renal insufficiency. We hypothesized that the benefit of transcatheter PDA closure outweighs the harm of contrast nephropathy in extremely premature infants. A total of 160 infants underwent successful transcatheter (n=59) and surgical (n=101) PDA closure at a median age of 26 (7 to 78) days. The surgical group had a lower procedural weight (870 vs 960 g, p=0.014). In the transcatheter group, serum creatinine decreased from 0.48 to 0.45 mg/100 ml at 24 hours (p=0.003, n=59) and decreased further to 0.37 mg/100 ml at 5 to 7 days after closure (p &lt;0.001). Median contrast amount was 1.9 ml/kg (0.6 to 6.1). In 8 infants with pre-existing renal insufficiency who underwent transcatheter closure, serum creatine significantly improved from 1.44 to 1.36 mg/100 ml at 24 hours and 0.79 mg/100 ml at 5 to 7 days after closure (p &lt;0.001). There was no difference in improvement of serum creatinine between transcatheter and surgical closure groups. In conclusion, despite the use of contrast, serum creatinine significantly improved with transcatheter PDA closure even in infants with pre-existing renal insufficiency. Contrast angiography should not be discouraged for transcatheter PDA closure because of the concern for contrast nephropathy in extremely premature infants.

Short-term anti-TNF therapy with surgical closure versus anti-TNF therapy in the treatment of perianal fistulas in Crohn's disease (PISA-II): a patient preference randomised trial

Guidelines on Crohn's perianal fistulas recommend anti-tumour necrosis factor (TNF) treatment and suggest considering surgical closure for patients with surgically amenable disease. However, long-term outcomes following these two strategies have not been directly compared. The aim of this study was to assess radiological healing in patients who received short-term anti-TNF treatment and surgical closure compared with those who received anti-TNF treatment alone. The PISA-II trial was a multicentre, patient preference study done in nine hospitals in the Netherlands and one hospital in Italy. Adult patients with Crohn's disease and an active high perianal fistula with a single internal opening were eligible for inclusion. After counselling, patients with no treatment preference were randomly assigned (1:1) using random block randomisation (block sizes of six without statification), to 4-month anti-TNF therapy and surgical closure or anti-TNF therapy for 1 year, after seton insertion. Patients with a treatment preference received their preferred therapy. The primary outcome was radiological healing assessed by MRI at 18 months, defined as a complete fibrotic tract or a MAGNIFI-CD (Magnetic Resonance Index for Fistula Imaging in Crohn's Disease) score of 0, assessed according to the intention-to-treat principle. Secondary outcomes included clinical closure, number of patients undergoing surgical reintervention and number of reinterventions, recurrences, and impact on quality of life measured by the Perianal Disease Activity Index (PDAI). Analyses were performed on an intention-to-treat basis and additionally an as-treated analysis for radiological healing and clinical closure. This study was registered at the Dutch Trial Registry, NL7625, and with EudraCT, 2018-002064-15, and is closed to accrual due to completion. Between Sept 14, 2013, and Dec 7, 2019, 94 patients were enrolled onto the trial, of whom 32 (34%) were randomly assigned and 62 (66%) chose a specific treatment. 38 (40%) patients were assigned to the surgical closure group and 56 (60%) patients to the anti-TNF group. At 18 months, radiological healing was significantly more common in the surgical closure group (12 [32%] patients) than in the anti-TNF group (five [9%] patients; p=0·005). By contrast, clinical closure was not significantly different between the two treatment groups (26 [68%] patients in the surgical closure group vs 29 [52%] patients in the anti-TNF group; p=0·076). Significantly fewer patients required a reintervention in the surgical closure group than in the anti-TNF therapy group (five [13%] patients in the surgical closure group, median one reintervention [IQR one to three] vs 24 [43%] patients in the anti-TNF group, median two reinterventions [one to two]; p=0·005). Among patients who reached clinical closure during follow-up, four (14%) of 29 in the surgical closure group and five (16%) of 31 in the anti-TNF therapy group had a recurrence, which occurred only in patients without radiological healing. PDAI was significantly lower in the surgical closure group than in the anti-TNF group after 18 months (p=0·031). Adverse events and serious adverse events were similar in both treatment groups and mostly entailed reinterventions. Ten (11%) patients had side-effects associated with anti-TNF treatment. Two serious adverse events unrelated to study treatment occurred (appendicitis and myocardial infarction). One patient died from a tongue base carcinoma, unrelated to study treatment. Short-term anti-TNF treatment combined with surgical closure induces long-term MRI healing more frequently than anti-TNF therapy in patients with Crohn's perianal fistulas. These data suggest that patients with Crohn's perianal fistula amenable for surgical closure should be counselled for this therapeutic approach. Netherlands Organisation for Health Research and Development and Broad Medical Research Program.

Mid-Term Outcome of Left Ventricle Reverse Remodeling After Atrial Septal Defect Closure: A Comparison Between Surgical and Device Groups.

Right ventricular (RV) volume overload occurs in patients with significant atrial septal defect (ASD II) shunts, which can impair left ventricle (LV) filling, thus decreasing LV indices. However, after ASD II closure, the left ventricle regains near normal dimensions. The purpose of this study was to compare the long-term outcomes of LV reverse remodeling between device and surgical closure. We retrospectively reviewed the echocardiographic data of 222 patients with isolated ASD II who underwent surgical (95 patients) or device closure (127 patients) between January 2012 and December 2017. The ASD II was significantly larger in the surgical closure group (p < 0.001.) leading to a higher degree of paradoxical interventricular septal (IVS) movement. In contrast, the LV volume was larger in the device closure group (p < 0.001). After a median follow-up period of 19.5months, the maximum LV systolic and diastolic volumes were reached at 1year in the device closure group and 2years in the surgical closure group. IVS motion normalized in 91% of the device closure group compared to 57% of the surgical closure group (p = < 0.001). There was significant improvement in left ventricular indices and IVS motion after ASD II closure in both groups but more favorable in patients after device closure.

OP18 Treatment of perianal fistulas in Crohn’s Disease: Surgical closure after anti-TNF induction treatment versus anti-TNF without surgery (PISA II) - A patient preference RCT

Abstract Background Current guidelines on Crohn’s perianal fistulas recommend anti-TNF treatment and suggest to consider surgical closure in amendable patients. However, long-term outcome of both treatments have not been directly compared. The aim of this study was to assess MRI healing in a patient preference RCT comparing both treatment modalities. Methods This multicentre, international trial compared surgical closure following anti-TNF induction (4 months) to anti-TNF therapy without surgery. Patients were counselled for both treatment arms and randomised if there was no preference. Due to the combination of a preference and randomised cohort, the appropriate sample size to detect a clinically relevant increase of 25% closure (from 15% to 40%) was flexible and adjusted for a possible skewed distribution (86 patients in case of 1:1 treatment allocation). All Crohn’s patients ≥ 18 years with a (re)active high perianal fistula and a single internal opening were eligible. Exclusion criteria were previous failure of anti-TNF, recto-vaginal fistula, proctitis, or stoma. Patients received seton placement prior to treatment. Primary outcome was MRI healing after 18 months (defined as a complete fibrotic fistula or MAGNIFI-CD score of 0–5). Secondary outcomes included clinical healing, re-interventions and fistula recurrence. Results Between September 2013 and December 2019, 7 hospitals in the Netherlands and Italy included 93 patients (59% females, median age 34 years) of which 32 were randomised. Thirty-seven patients were treated in the surgical closure group and 56 in the anti-TNF group, with comparable baseline characteristics. After 18 months, MRI healing was significantly higher after surgical closure (41% vs 11%; P=0.002). Although a trend was seen in favour of surgical closure, clinical healing rates and surgical re-interventions were not significantly different between groups (65% vs 45%, P=0.07 and 19% vs 34%, P=0.1). After median 38 months follow-up, 12 patients in the anti-TNF group crossed over to surgical closure. Both long-term MRI healing and clinical closure in the per protocol analysis remained significantly higher for the surgical closure group (46% vs 11%, P=0.002 and 65% vs 29%, P=0.006). One patient (4%) with a MAGNIFI-CD score ≤5 developed a recurrent fistula after 46 months, whereas recurrences occurred in 37% of patients with MAGNIFI-CD score &amp;gt;5 (P=0.004). Conclusion These results demonstrate that surgical closure following anti-TNF induction treatment induces MRI healing more frequently than anti-TNF alone. This is associated with increased long-term clinical closure and reduced recurrences. These data suggest that Crohn’s perianal fistula patients amendable for surgical closure should be counselled for this therapeutic approach.

Comparison of interventional and surgical treatment of paravalvular leak after cardiac valve replacement

Objective: To assess the immediate and mid-term outcomes and hospital costs of patients who underwent trans-catheter closure (TC) or surgical closure (SC) of perivalvular leakage (PVL). Methods: Patients who underwent treatment of TC and SC of PVL in our center between January 2016 and December 2019 were enrolled. Baseline characteristics, procedure success, in-hospital and mid-term outcomes and hospital costs were compared. Results: A total of 141 patients were enrolled (TC, n=65 and SC, n=76). The patients in TC group were elder ((56.8±12.8) years vs (50.1±12.8) years, t=-3.124, P=0.002). Technical success was significant higher in the SC group (83.1% vs 98.7%, χ²=10.960, P<0.001). And the residual PVLs were less in SC group (33.3% vs 13.3%, χ²=-2.525, P=0.012). One patient in SC group had procedure-related death. Procedure room time ((93±38) min vs (395±132) min, t=19.065, P<0.001), intensive care unit time (0 h vs 28 (21, 74)h, Z=-10.738, P<0.001), length of stay from hospitalization to discharge (7 (4, 10) days vs 21 (15, 25) days, Z=-8.075, P<0.001) and costs (¥46 073 (36 837, 52 448) vs ¥130 798 (104 048, 186 188), Z=-10.059, P<0.001) were significantly less in TC group. After risk adjustment, there was no significant difference in 30 days survival between TC group and SC group. At a median follow-up of 21 months, there was a trend towards reduced all-cause death following TC versus SC (OR = 0.054, 95%CI: 0.07 to 0.445, P= 0.007). Conclusions: SC for PVL is associated with higher technical rates and less residual shunt compared with TC approach. But, the shorter length of stay and lower resources use with TC group significantly reduce hospital costs. In addition, TC achieve a better mid-term results in survival.

Congenital coronary artery fistula in pediatric patients: transcatheter versus surgical\xa0closure

ObjectivesTranscatheter closure (TCC) and surgical closure (SC) are the two main approaches for congenital coronary artery fistula (CCAF), but data on the comparisons of the efficacy and safety of these two approaches are limited.MethodsWe retrospectively reviewed pediatric patients with CCAF in Guangdong Cardiovascular Institute between January 2002 and December 2017. Patients who were qualified into our criteria were included into final analysis. The rate of successful closure and complications during hospitalization and at follow-up were compared between SC and TCC groups.ResultsIn total, 121 pediatric patients (male, n = 69; female, n = 52) with CCAF were divided to TCC (n = 63) and SC groups (n = 58) according to the indications. The mean age was 5.3 ± 1.4 years. The baseline characteristics of these two groups were similar except for the fistula anatomic feature. After adjusted for the fistula anatomy, compared to SC, TCC was associated with higher risk of major complications (p = 0.013). Proportions of patients requiring blood transfusion and intra-operative blood loss were higher in SC versus TCC groups, as were longer duration of hospital and ICU stay during hospitalization. In contrast, myocardial ischemia (10.2% vs 0.0%, p = 0.028), residual shunts (16.9% vs 3.6%, p = 0.045) and new-onset moderate-to-severe valve regurgitation (11.9% vs 0.0%, p = 0.013) were higher in TCC group versus SC groups during follow-up.ConclusionsTCC has less invasive and faster recovery. However, SC had a higher successful rate and lower risk of major complications in pediatric patients.

Comparison of trans-catheter closure of paravalvular leak versus surgical approach-outcomes and cost analysis

Abstract Background The outcomes and costs of trans-catheter closure (TC) of paravalvular leak (PVL) compared with surgical closure (SC) are rarely described. Purpose The aim of the study was to assess the outcomes and hospital costs of patients who underwent TC or SC of PVL in our center. Methods Patients who underwent TC and SC of PVL between Jan. 2016 and Dec. 2019 were enrolled. Baseline characteristics, procedural, in-hospital and mid-term outcomes and hospital costs were compared. Results A total of 141 patients were studied (TC, n=65 and SC, n=76). The patients were elder in TC group (56.8±12.8 years vs. 50.1±12.8 years, p=0.002). Technical success was higher in SC group (83.1% vs. 98.7%, p&amp;lt;0.001). Procedure room time (93±38 min vs. 395±132 min, p&amp;lt;0.001), intensive care unit time (0 h vs. 25 h, p&amp;lt;0.001), length of stay from hospitalization to discharge (7 days vs. 21 days, p&amp;lt;0.001) and costs (¥45090±19343 vs. ¥164165±94300, p&amp;lt;0.001) were significantly less in TC group. After risk adjustment, there was no significant differences between in 30 days survival between TC group and SC group. However, the residual PVLs were less in SC group (43.1% vs. 12.0%, p=0.012). At a median follow-up of 21 months, there was a trend towards reduce all-cause death following TC versus SC (OR=0.054, 95% CI: 0.070 to 0.445, p=0.007). Conclusions SC for PVL is associated with higher technical rates and less residual shunt. But, the shorter length of stay and lower resources use with TC group significantly reduce hospital costs. In addition, TC achieve a better mid-term results in survival. Funding Acknowledgement Type of funding source: None

Assessment of the Right and Left Atrial Functions at Midterm After Surgical and Device Atrial Septal Defect Closure: A 2-Dimensional Speckle-Tracking Echocardiographic Study.

The available literature lacks data on the comparison of the functions of the right atrium (RA) and left atrium (LA) between surgical atrial septal defect (ASD) closure and percutaneous device ASD closure at follow-up durations of longer than 1 year. We sought to evaluate the RA and LA functions in patients who underwent surgical or device ASD closure between 1 and 5 years postprocedurally. The study population included 30 patients who underwent device ASD closure and 30 who underwent surgical ASD closure, who were matched for the procedural time, age, and sex, in addition to 30 control participants. The RA and LA functions were evaluated with 2-dimensional speckle-tracking echocardiography. The LA systolic and early diastolic strain and strain rate values and the RA early diastolic strain rate in the device closure group were more likely to be abnormal than in the control group. The RA systolic and late diastolic strain and strain rate values, the RA early diastolic strain rate, and the LA early diastolic strain in the surgical closure group were more likely to be abnormal than in the control group. The RA systolic strain and strain rate in the surgical closure group were more likely to be abnormal than in the device closure group. The LA reservoir and conduit functions and the RA contraction function in the patients who underwent device ASD closure and all of the RA functions and the LA conduit function in the patients who underwent surgical ASD closure were more likely to be abnormal than those in the control participants. The RA reservoir function in the surgical closure group was more likely to be abnormal than that in the device closure group.

Management of post-myocardial infarction ventricular septal defects: A critical assessment.

Post-myocardial infarction (MI) ventricular septal defects (PIVSD) are an uncommon but life-threatening complication of acute MI. Although surgical closure has been the standard of care, mortality, and recurrence of VSD remain high even after emergent surgery. Transcatheter VSD closure (TCC) devices have become an alternative or adjunct to surgical closure. Online database search was performed for studies that included adults with PIVSD who underwent medical treatment (MT) alone, surgical closure (SC) (early or late), and TCC (early, late, or for post-surgical residual VSD). Twenty-six studies were included with a total of 737 patients who underwent either MT (N = 100), SC (early (n = 167), late (n = 100)), and TCC (early (n = 176), late (n = 115), or post-surgical residual VSD (n = 79)). The 30-day mortality among MT group was 92 ± 6.3%, among SC was 61 ± 22.5% (early 56 ± 23%, late 41 ± 30%), and for all TCC patients was 33 ± 24% (early 54 ± 32.7%, late 16 ± 26%), and TCC for post-surgical residual VSD 11 ± 34.9%. The mortality among overall SC, overall TCC and early TCC groups was significantly lower as compared with the MT (P < 0.001 for all comparisons). The overall mortality among all TCC, and late TCC groups was significantly lower when compared with the late SC (P < 0.0001, P < 0.0001, respectively). Closure of PIVSD decreases mortality as compared with MT alone and should be attempted as early as possible after diagnosis. Selection of TCC versus SC should be based on factors including complexity of the defect, availability of closure devices, expertise of the operator, and clinical condition of patient.

Transcatheter Vs. Surgical Closure of Atrial Septal Defects in Adults

Abstract Percutaneous transcatheter device closure of secundum atrial septal defects (ASD) has now largely replaced surgical closure in most centres. The aim of this study was to compare results of transcatheter and surgical ASD closure in adults in Latvia during the years 2002–2014 and to analyse long-term outcomes of transcatheter closure. We analysed data from 334 patients with secundum ASD who underwent ASD closure in Pauls Stradiņš Clinical University Hospital. Patients were included into device or surgical closure groups. In the device group, three follow-ups were made 1, 6, and 12 months after the procedure. No follow-up data were available for surgical arm patients beyond their hospitalisation period. The mean age of patients was 45.3 ± 19.9 years for the device group and 40.0 ± 16.9 years for the surgical group (p = 0.023). The mean secundum ASD size in the device and surgical groups was 14.2 ± 5.6 mm and 28.7 ± 10.0 mm, respectively (p &lt; 0.001). No differences were observed regarding procedure success rates: 99.2% in the device group and 100% in the surgical group (p = 0.451). Periprocedural complications generally were more common in the surgical closure group. The study results show a successful introduction of the percutaneous ASD closure method in Latvia with good early and late outcomes and without significant differences in procedure success rate compared to surgical closure.

In-Hospital and 4-Year Clinical Outcomes Following Transcatheter Versus Surgical Closure for Secundum Atrial Septal Defect in Adults: A National Cohort Propensity Score Analysis.

Atrial septal defect (ASD) closure is major therapy for patients with secundum ASD. Although surgical closure (SC) and transcatheter closure (TC) are usually performed in such patients, data on the long-term outcomes comparing TC and SC in adults are limited. Data on the participants of this cohort study were retrieved from Taiwan's National Health Insurance Research Database from 2004 to 2011. Secundum ASD patients > 18 years of age who underwent TC or SC were initially enrolled, and those with associated comorbidities were excluded. After propensity score matching, the clinical outcomes between the TC and SC groups were analyzed. There were 595 patients recruited in the TC group and 308 patients in the SC group. The SC group had a higher incidence of systemic thromboembolism (P < 0.001), ischemic stroke (P = 0.002), and all-cause mortality (P = 0.013) when compared with those of the TC group at the index hospitalization, and similar phenomena could also be seen in a around 4-year follow-up period after the procedures (systemic thromboembolism (P < 0.001, HR = 11.48, 95% CI: 3.29-40.05), ischemic stroke (P = 0.005, HR = 9.28, 95% CI: 1.94-44.39), and all-cause mortality (P = 0.035, HR = 2.28, 95% CI: 1.06-4.89). In addition, atrial fibrillation (P = 0.005) and atrial flutter (P = 0.049) more frequently developed in the SC group than in the TC group at the index hospitalization. The adult secundum ASD patients had lower incidence rates of systemic thromboembolism, ischemic stroke, and all-cause mortality after TC than those after SC in the 4-year follow-up after procedures. Transcatheter ASD closure should therefore be given priority.

Early reconstruction of the leaking ileal pouch‐anal anastomosis: a novel solution to an old problem

The study aimed to determine the effectiveness and direct medical costs of early surgical closure of the anastomotic defect after a short course of Endo-sponge® therapy of the presacral cavity, compared with conventional treatment in patients with anastomotic leakage after ileal pouch-anal anastomosis (IPAA). Patients with anastomotic leakage after IPAA undergoing early surgical closure of the anastomotic defect after a short Endo-sponge® treatment were prospectively followed and compared with a consecutive cohort of patients with an anastomotic leak treated by creation of a loop ileostomy and occasional drainage of the presacral cavity. A total of 15 patients were treated with early surgical closure and 29 were treated conventionally. In the early surgical closure group, the Endo-sponge® treatment was continued for a median of 12days [interquartile range (IQR) 7-15days] with a median of 3 (IQR 2-4) Endo-sponge® changes. Secondary anastomotic healing was achieved in all patients (n=15) in the early surgical closure group compared with 52% (n=16) in the conventional treatment group (P=0.003). Closure of the anastomotic defect was achieved after a median of 48 (25-103)days in the early surgical closure group compared with 70 (IQR 49-175)days in the conventional treatment group (P=0.013). A functional pouch was seen in 93% and 86% of the patients in each group. There was no significant difference in direct medical cost. Early surgical closure after a short period of Endo-sponge® treatment is highly effective in treating anastomotic leakage after IPAA without increasing cost.

Long-Term (5- to 20-Year) Outcomes After Transcatheter or Surgical Treatment of Hemodynamically Significant Isolated Secundum Atrial Septal Defect

Truly long-term follow-up data after transcatheter closure (TC) of atrial septal defects (ASDs) are scarce. We report the 5- to 20-year outcomes of TC and surgical closure (SC) for typical secundum ASD. We reviewed the records of patients with isolated secundum ASD and right ventricular volume overload who underwent TC or SC (January 1, 1986 to September 30, 2005). Follow-up was obtained through a combination of chart review, physician records, and telephone survey. We identified 375 patients (207 SC and 168 TC) and obtained follow-up data >5 years (median follow-up 10 years) for 300 (152 SC, 148 TC). Nine patients have died (3%). The New York Heart Association functional class was unchanged in 227 patients, improved in 25, and was worse in 15. Clinically significant arrhythmia was found in 28 patients (9.3%); 21% aged >40 years developed arrhythmia. On multivariate analysis, the odds of significant arrhythmia tended to be greater in the SC group, but this was statistically insignificant (95% confidence interval 0.68 to 3.9, p = 0.27). Age and preprocedure arrhythmia, but not TC or SC, were independent risk factors for late arrhythmia (p <0.001). No difference was found in the incidence of late, probably embolic, stroke in the TC (3%) versus SC (2%) groups. In conclusion, long-term outcomes after secundum ASD closure using modern methods are excellent. No significant differences were found between TC versus SC with regard to survival, functional capacity, atrial arrhythmias, or embolic neurologic events. Arrhythmia and neurologic events remain long-term risks after ASD closure, especially if the patient had pre-existing arrhythmia.

Randomized Multicenter Controlled Study of Endoscopic and Surgical Closure of a 4-cm Gaping Wide Colon Perforation in a Porcine Model

Introduction & Aims: Colonoscopic perforation is a serious complication that requires emergency surgery. How about immediate colonoscopic closure as an alternative? We have shown that endoscopic clip closure of colon perforation is technically feasible & results in excellent healing; peritonitis & adhesions could be prevented by endoscopic clip closure with the InScope MultiClip Applier (IMCA) in a controlled trial; gaping wide colon perforations not amenable to clip closure can be closed with full-thickness sutures using tissue apposition system (TAS) (Raju et al GIE 2005-07). Our aim is to report the results of a randomized, multi-center, 2 wk survival study comparing endoscopic closure of a 4-cm gaping wide colon perforation with surgery. Of the 50 studies, 20 were completed at this time. Methods: 20 pigs with a 4-cm long, freshly created, full-thickness, gaping wide, colon perforation were randomized to endoscopic or surgical closure groups (ECG vs SCG). Endoscopic closure was accomplished with TAS ± IMCA. Surgical suture closure was accomplished after laparotomy. Endpoints: a) Technical feasibility of closure; b) Clinical recovery to normalcy in 6 hrs; c) 2 wk survival; d) Necropsy - day 14 for peritonitis, abscesses, adhesions & other complications; & e) Healing of perforation by leak test. Results: All the perforations were closed successfully. Of the 20 animals, 16 survived for 2 wks without complications; 1 in the ECG required additional endoscopic closure of suspected leak 4 hrs later - recovered slowly (necropsy @ 2wks: partial bowel obstruction); 3 were euthanized within 1 wk: 1) fecal peritonitis in the ECG (n = 1); 2) bowel obstruction from adhesions & 3) urinary bladder rupture from urethral ligation in the SCG (n = 2). ECG animals resumed normal activity in 6 hours, while SCG animals required 48 hrs to recover. Results are summarized in table 1. Conclusions: Endoluminal closure of a 4-cm gaping wide colon perforation is comparable to surgical closure. Endoscopic TAS ± IMCA application can close large perforations, prevent peritonitis, and the animals survive without complications. Recovery is quick after endoscopic closure. Close monitoring & immediate endoscopic reintervention may seal any ongoing leak. Tabled 1Comparison of endoscopic and surgical closure of a 4-cm gaping wide colon perforation Closure groups Successful closure Clinical recovery within six hrs 2 wk survival Peritoneal cavity Adhesion of intestine to ventral abdominal wall Leak test - no leak Endoscopy n = 10 10 8 9† 1 (feces) 1 (fibrin) 1 (abscess) 2 9/10∗ Surgery n = 10 10 0 8†† 1 (urine) 1 (fibrin) 1 (abscess) 7 9/10∗∗ p-value NS 0.001 NS NS NS NS † fecal peritonitis; †† bowel obstruction; & †† bladder rupture; ∗1/10: colon wound dehiscence; ∗∗1/10: colon suture abscess - leaked. Open table in a new tab † fecal peritonitis; †† bowel obstruction; & †† bladder rupture; ∗1/10: colon wound dehiscence; ∗∗1/10: colon suture abscess - leaked.

Comparison between transcatheter and surgical closure of secundum atrial septal defect in children and adults: Results of a multicenter nonrandomized trial

ObjectivesThis study sought to compare the safety, efficacy and clinical utility of the Amplatzer septal occluder (ASO) for closure of secundum atrial septal defect (ASD) with surgical closure. BackgroundThe clinical utility of a device such as the ASO can only be judged against the results of contemporaneous surgery. MethodsA multicenter, nonrandomized concurrent study was performed in 29 pediatric cardiology centers from March 1998 to March 2000. The patients were assigned to either the device or surgical closure group according to the patients’ option. Baseline physical exams and echocardiography were performed preprocedure and at follow-up (6 and 12 months for device group, 12 months for surgical group). ResultsA total of 442 patients were in the group undergoing device closure, whereas 154 patients were in the surgical group. The median age was 9.8 years for the device group and 4.1 years for the surgical group (p < 0.001). In the device group, 395 (89.4%) patients had a single ASD; in the surgical group, 124 (80.5%) (p = 0.008) had a single ASD. The size of the primary ASD was 13.3 ± 5.4 mm for the device group and 14.2 ± 6.3 mm for the surgery group (p = 0.099). The procedural attempt success rate was 95.7% for the device group and 100% for the surgical group (p = 0.006). The early, primary and secondary efficacy success rates were 94.8%, 98.5% and 91.6%, respectively, for the device group, and 96.1%, 100% and 89.0% for the surgical group (all p > 0.05). The complication rate was 7.2% for the device group and 24.0% for the surgical group (p < 0.001). The mean length of hospital stay was 1.0 ± 0.3 day for the device group and 3.4 ± 1.2 days for the surgical group (p < 0.001). Mortality was 0% for both groups. ConclusionsThe early, primary and secondary efficacy success rates for surgical versus. device closure of ASD were not statistically different; however, the complication rate was lower and the length of hospital stay was shorter for device closure than for surgical repair. Appropriate patient selection is an important factor for successful device closure. Transcatheter closure of secundum ASD using the ASO is a safe and effective alternative to surgical repair.