Surgical Occlusion Research Articles

Outcomes of cardiac surgery with left atrial appendage occlusion versus no Occlusion, direct oral Anticoagulants, and vitamin K Antagonists: A systematic review with Meta-analysis.

Surgical left atrial appendage occlusion (LAAO) is being used increasingly in the setting of atrial fibrillation but has been associated with procedural complications. This systematic review and meta-analysis compared the outcomes of surgical LAAO with those of no LAAO and the use of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) using the PRISMA guidelines. A literature search was undertaken for relevant studies published between January 1, 2003, and August 15, 2021. Primary clinical outcomes were all-cause mortality, embolic events, and stroke. Secondary clinical outcomes included major adverse cardiac events (MACE), postoperative atrial fibrillation, postoperative complications, reoperation for bleeding, and major bleeding. There was a statistically significant 34% reduction in incidence of embolic events (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.57-0.77, p<0.001) and a significant 42% reduction in risk of MACE (OR 0.58, 95% CI 0.38-0.88, p=0.01) in patients who underwent LAAO.Surgical LAAO has the potential to reduce embolic events and MACE in patients undergoing cardiac surgery for atrial fibrillation. However, complete replacement of DOACs and warfarin therapy with surgical LAAO is unlikely despite its non-inferiority in terms of minimizing all-cause mortality, embolic events, MACE, major bleeding, and stroke in patients on oral anticoagulation therapies.

Evaluation of mandibular positional changes after orthognathic surgery in skeletal class II and class III surgery-first approach patients

PurposeThe aim of this study was to predict and compare postoperative changes of mandibular position between mandibular setback and advancement surgery in a surgery-first approach (SFA). Materials and methodsThe study population included patients who underwent mandibular setback or advancement surgery using bilateral sagittal split ramus osteotomy, those were divided into two groups: mandibular setback and advancement surgery. Surgical and postoperative mandibular positional changes were evaluated by lateral cephalograms and CTs taken within 2 months before surgery (T0), 1 week after surgery (T1), and after the debonding procedure (T2). The postoperative mandibular positional changes were predicted from the increase in vertical dimension (VD) in surgical occlusion and the counterclockwise rotation to the preoperative VD on the lateral cephalograms and CT at T1. Furthermore, resultant measurement on postoperative mandibular positional changes was performed. Finally, we compared the prediction with actual positional changes of the mandible after the debonding procedure. ResultsNine SFA patients with mandibular setback surgery and six with advancement surgery were evaluated and significant mandibular changes from T0 to T1 and from T1 to T2 were observed. Negative correlation between horizontal surgical changes and postoperative horizontal changes was present in both groups. The difference between the predicted and actual amount of postoperative mandibular movement was significant in the mandibular advancement surgery group. ConclusionPostoperative mandibular relapse appeared much larger in the mandibular advancement surgery group than in the setback group. Therefore, it is more important to consider the postoperative mandibular position change in mandibular advancement surgery in SFA.

Microsurgical clipping vs Woven EndoBridge (WEB) device for the management of unruptured wide-neck bifurcation aneurysms

The Woven EndoBridge device (WEB) was introduced in 2010 to treat wide-neck bifurcation aneurysms (WNBAs). Three landmark studies have been conducted to assess its safety and efficacy: WEBCAST, WEBCAST 2, and French Observatory Study. However, these studies have not compared its safety and efficacy to other treatment modalities. In this study, we compare WEB versus microsurgical clipping in the management of unruptured WNBA. We conducted a retrospective study of unruptured WNBA meeting the morphological criteria to be amenable for WEB treatment operated on at our institution. Surgical morbidity, mortality, and occlusion rates were assessed. We compared our results to those reported in the cumulative population of the three WEB landmark studies at 1 year. A total of 84 patients with 89 WNBA were included. The most common aneurysm location was the middle cerebral artery bifurcation (n = 67/89, 75%). No operative mortality was observed. Morbidity comprised small-vessel vasospasm (n = 1/89, 1%) resulting in hemiparesis vs. 3% morbidity for WEB (p = .324). All but one (n = 1/89, 1%) WNBA were completely occluded vs WEB occlusion rate of 53% at 1 year, statistically significantly worse (p < .001). In our analysis, we were not able to show superiority of WEB in terms of procedural morbidity in comparison to microsurgical clipping, defined as worsening in mRS. Microsurgical clipping achieves statistically significantly higher rates of complete aneurysm occlusion, thus posing the question of whether the WEB should be presented as a viable, comparable alternative to patients amenable to surgical treatment.

Surgical shunt ligation for a congenital extrahepatic portosystemic shunt with pulmonary hypertension: A case report.

Introduction and importanceCongenital extrahepatic portosystemic shunt (CEPS) presents with various symptoms due to abnormal communication between the portal venous system and inferior vena cava. And Klippel-Trenaunay-Weber syndrome is another rare congenital disorder characterized by vascular malformations.Case presentationA 16-year-old male with Klippel-Trenaunay-Weber syndrome was referred to our hospital for surgical treatment of pulmonary hypertension due to CEPS since childhood. Dyspnea had developed about two years before presentation at our hospital and gradually worsened. Right heart catheterization had revealed pulmonary hypertension and a high cardiac output state associated with a portosystemic shunt. Although pulmonary vasodilators improved the dyspnea, pulmonary hypertension remained. The patient was then referred to our hospital for surgical shunt occlusion. The results of the preoperative and intraoperative shunt occlusion tests were within acceptable limits. Therefore, primary shunt ligation was performed. There were no postoperative complications. Continuous intravenous vasodilator was tapered off four months after discharge. No additional or increased doses of medications were required for four years after surgery.Clinical discussionSurgical shunt ligation for CEPS is effective but can cause acute portal hypertension. Primary shunt ligation could be performed without complications according to the criteria for safe shunt occlusion.ConclusionSurgical portosystemic shunt ligation could be performed safely and ameliorated pulmonary hypertension. Patients with CEPS, especially young patients, should be referred to a tertiary center while asymptomatic, and early therapeutic intervention is necessary.

Long-Term Efficacy and Anticoagulation Strategy of Left Atrial Appendage Occlusion During Total Thoracoscopic Ablation of Atrial Fibrillation to Prevent Ischemic Stroke.

ObjectivesAtrial fibrillation (AF) is associated with an increased ischemic stroke, and the left atrial appendage (LAA) represents the main source of thrombus formation. We evaluated the long-term efficacy of surgical thoracoscopic LAA occlusion during total thoracoscopic ablation of AF to prevent the stroke and anticoagulation strategy after surgery.MethodsPatients who underwent total thoracoscopic ablation for AF, from February 2012 to May 2020, were included; Patients who did not receive LAA occlusion were excluded. We evaluated the development of thromboembolism in these patients.ResultsThe total number of 460 patients [mean age, 57.1 ± 9.2 years; 400 (87.0%) males] were included in the study. The mean follow-up duration was 44.8 months. The mean CHA2DS2-VASc score was 1.9 ± 1.6. Median OAC duration was 109.5 days after the surgery, and the final number of patients who discontinued OAC were 411 (89.3%) in total. Anticoagulation discontinuation rate according to CHA2DS2-VASc score are as follows; (i) 0 = 99.0%; (ii) 1 = 98.2%; and (iii) ≥2 = 81.3%. The annualized incidence rate of ischemic stroke was 0.78%/year, showing a 73% risk reduction compared with the CHA2DS2-VASc predicted rate without anticoagulation. The hazard ratio for ischemic stroke according to previous stroke history was 1.5 [95% confidential interval (CI) 0.3–7.3, p = 0.62], and that of remnant LAA was 5.1 (1.2–20.9, p = 0.02).ConclusionsThoracoscopic LAA occlusion during total thoracoscopic ablation of AF was effective to prevent ischemic stroke. Most patients could discontinue OAC therapy after the procedure. Patients who had a residual trabeculated LAA, or peri-occluder pouch in follow-up CT need to maintain OAC therapy even after LAA occlusion.

Skeletal stability after bimaxillary surgery with surgery-first approach for class III asymmetry is not related to virtual surgical occlusal contact.

Surgery-first orthognathic surgery is rarely used in class III asymmetry due to concerns of reduced skeletal stability from unstable surgical occlusion. This study aimed to evaluate if skeletal stability after surgery-first orthognathic surgery is related to virtual surgical occlusal contact or surgical change. We studied 58 adults with class III asymmetry, consecutively corrected by Le Fort I osteotomy and bilateral sagittal split osteotomy using a surgery-first approach. Dental casts were manually set to measure virtual surgical occlusal contact including contact distribution, contact number, and contact area. Cone-beam computed tomography taken before treatment, 1-week post-surgery, and after treatment was used to measure surgical change and post-surgical stability of the maxilla and mandible in translation (left/right, posterior/anterior, superior/inferior) and rotation (pitch, roll, yaw). The relationship between skeletal stability and surgical occlusal contact or surgical change was evaluated with correlation analysis. Significant instability was found in the mandible but not in the maxilla. No correlation was found between the maxillary or mandibular stability and surgical occlusal contact (all p > 0.01). However, a significant correlation was found between the maxillary (roll and yaw) or mandibular (shift, roll and pitch) stability and its surgical change (all p < 0.001). In correction of class III asymmetry with surgery-first bimaxillary surgery, the skeletal stability is not related to the virtual surgical occlusal contact, but surgical skeletal change. Planned over-correction is a reasonable option for correction of severe shift or roll mandibular asymmetry in bimaxillary surgery for class III deformity.

Surgical left atrial appendage occlusion in patients with left ventricular assist device.

Thromboembolic (TE) events are among the most common and devastating adverse events in patients with continuous-flow left ventricular assist device (cf-LVAD). Given the high burden of AF among cf-LVAD patients, we sought to evaluate the effect of concomitant surgical LAAO in patients receiving cf-LVAD. A systematic search using electronic databases was performed using the keywords: "left atrial appendage occlusion" and "left ventricular assist device." Statistical analysis was performed using metapackage for R version 4.0 and Rstudio version 1.2. Mantel-Haenszel risk ratio (RR) random-effects model was used to summarize data between two groups. The primary outcomes included: (a) stroke; (b) LVAD pump thrombosis; (c) all-cause mortality RESULTS: Three studies with a total of 305 patients (LAAO=68 and No-LAAO=237) were included in the analysis. HeartMate II (39%) and Heartware (27.5%) were the two most common cf-LVADs utilized, while only 5% received HeartMate III. At a mean follow up of 1.47 years, LAAO group had a lower risk of stroke (8.8%vs. 15.2%, RR 0.64; 95% CI 0.28-1.49), LVAD pump thrombosis (1.5%vs. 3.8%, RR 0.28; 95% CI 0.05-1.55) and all-cause mortality (5.9%vs. 20.2%, RR 0.69; 95% CI 0.19-2.52) when compared with no-LAAO group, but the difference did not reach statistical significance. Concomitant surgical LAAO at the time of cf-LVAD implantation demonstrated a trend toward positive outcomes and was not associated with adverse outcomes during the follow-up period, though the results were not statistically significant.

Abstract WP255: Cyfip2 Genotype Contributes To Variation In Stroke Vulnerability Among C57BL/6 Mouse Substrains

C57BL/6 mouse substrains of the N lineage derived from the NIH colony later than the separation of the Bailey line in the early 1960s show increased stroke vulnerability relative to C57BL/6J. A missense mutation in Cyfip2 , encoding cytoplasmic FMR1 interacting protein 2, is one of several known variants with a corresponding substrain distribution. This study evaluated reciprocal mouse lines in which the N Cyfip2 variant had been either introduced into C57BL/6J (J- Cyfip2 &lt;N&gt;) or corrected in C57BL/6NJ (NJ- Cyfip2 &lt;J&gt;) by CRISPR-Cas9 editing. Stroke was produced by permanent surgical occlusion of the middle cerebral and ipsilateral common carotid arteries under isoflurane anesthesia, and infarct volume was measured as the region of pallor in brain slices incubated with triphenyltetrazolium chloride at 24 hours. Figure illustrates mean ± SEM (group sizes in parentheses) for mice of the current study, along with prior data for parent substrains. Introduction of the N-lineage mutation markedly increased infarct size in both males and females (†) while maintaining the sex difference seen in J mice (*). Correction of the mutation in NJ had no significant effect. At face value these results establish Cyfip2 genotype as an important determinant of stroke vulnerability since the variant alone is sufficient to increase infarct volume in the J background. However, it is not the sole basis for differing stroke outcome among substrains, and at least one other variant must underlie the heterogeneity in sex difference. Cyfip2 encodes a protein with recognized functional roles in brain and the immune system, but the precise intersection with stroke pathology remains to be established.

Intraoperative Spinal Angiography during Microsurgical Occlusion of Spinal Dural Arteriovenous Fistula within the Hybrid Operation Room.

Spinal dural arteriovenous fistula (SDAVF) is a rare cause of progressive myelopathy in predominantly middle-aged men. Treatment modalities include surgical obliteration and endovascular embolization. In surgically treated cases, failure of obliteration is reported in up to 5%. The aim of this technical note is to present a safe procedure with complete SDAVF occlusion, verified by intraoperative digital subtraction angiography (DSA). We describe four patients with progressive leg weakness who underwent surgical obliteration of SDAVF with spinal intraoperative DSA in the prone position after cannulation of the popliteal artery. All surgeries took place in our hybrid operating room (OR) and were accompanied by electrophysiologic monitoring. Surgeries and cannulation of the popliteal artery were performed in the prone position. Ultrasound was used to guide the popliteal artery puncture. A 5-Fr sheath was inserted and the fistula was displayed using a 5-Fr spinal catheter. Spinal intraoperative DSA was performed prior to and after temporary clipping of the fistula point as well after the final SDAVF occlusion. The main feeder of the SDAVF fistula in the first patient arose from the right T11 segmental artery, which also supplied the artery of Adamkiewicz. The second patient initially underwent endovascular treatment and deteriorated 5 months later due to recanalization of the SDAVF via a small branch of the T12 segmental artery. The third and fourth cases were primarily scheduled for surgical occlusion. Access through the popliteal artery for spinal intraoperative DSA proved to be beneficial and safe in the hybrid OR setting, allowing the sheath to be left in place during the procedure. During exposure and after temporary and permanent occlusion of the fistulous point, intraoperative indocyanine green (ICG) video angiography was also performed. In one case, the addition of intraoperative DSA showed failure of fistula occlusion, which was not visible with ICG angiography, leading to repositioning of the clip. Complete fistula occlusion was documented in all cases. Spinal intraoperative DSA in the prone position is a feasible and safe intervention for rapid localization and confirmation of surgical SDAVF occlusion.

Current trends in orthognathic surgery.

Orthognathic surgery has steadily evolved, gradually expanding its scope of application beyond its original purpose of simply correcting malocclusion and the facial profile. For instance, it is now used to treat obstructive sleep apnea and to achieve purely cosmetic outcomes. Recent developments in three-dimensional digital technology are being utilized throughout the entire process of orthognathic surgery, from establishing a surgical plan to printing the surgical splint. These processes have made it possible to perform more sophisticated surgery. The goal of this review article is to introduce current trends in the field of orthognathic surgery and controversies that are under active discussion. The role of a plastic surgeon is not limited to performing orthognathic surgery itself, but also encompasses deep involvement throughout the entire process, including the set-up of surgical occlusion and overall surgical planning. The authors summarize various aspects in the field of orthognathic surgery with the hope of providing helpful information both for plastic surgeons and orthodontists who are interested in orthognathic surgery.

Advances in Neurocardiology: Focus on Atrial Fibrillation.

Advances in Neurocardiology: Focus on Atrial Fibrillation.

Epicardial left atrial appendage clip occlusion in patients with atrial fibrillation during minimally invasive cardiac surgery

ObjectiveThe left atrial appendage is a major source of stroke in patients with atrial fibrillation, and clinical benefits of left atrial appendage occlusion have been demonstrated in previous studies. Complete exclusion of the left atrial appendage has been recently available with an epicardial clipping device in the setting of minimally invasive cardiac surgery. MethodsThe study enrolled consecutive patients who received surgical left atrial appendage occlusion using an epicardial clipping device in a minimally invasive cardiac surgery setting from December 2015 to December 2018. The minimally invasive cardiac surgery included cardiac surgeries performed through a minithoracotomy. The procedural success of left atrial appendage complete exclusion was examined with cardiac computed tomography. Complete exclusion of the left atrial appendage was defined when the distance from circumflex artery to the device was less than 10 mm without contrast leakage. ResultsAmong 108 patients (age, 58.5 ± 11.5 years; 61 female, 56.5%) who were finally enrolled in the study, postoperative cardiac computed tomography was available in 103 patients. All patients had preoperative atrial fibrillation. Of these, 88 patients (81.5%) underwent simultaneous mitral valve procedure, and 3 (2.8%) and 6 (5.6%) received stand-alone procedure of left atrial appendage clipping and primary surgical ablation, respectively. There were no early deaths or device-related complications. For the procedural success rate, complete exclusion of the left atrial appendage was achieved in 95 patients (92.2%). During a median follow-up of 19 months (interquartile range, 11.7-28.3 months), there were no thromboembolic events or device-related reoperations. ConclusionsLeft atrial appendage occlusion using an epicardial clipping device during cardiac surgery can be performed successfully in a minimally invasive cardiac surgery setting in selected patients.

Left Atrial Appendage Occlusion for Stroke Prevention in Nonvalvular Atrial Fibrillation.

The majority of embolic strokes in patients with nonvalvular atrial fibrillation are caused by thrombi in the left atrial appendage. It is projected that strokes related to atrial fibrillation will markedly increase in the future unless effective mitigation strategies are implemented. Systemic anticoagulation has been known to be highly effective in reducing stroke risk in patients with atrial fibrillation. However, bleeding complications and nonadherence are barriers to effective anticoagulation therapy. Surgical and percutaneous left atrial appendage occlusion devices are nonpharmacologic strategies to mitigate the challenges of drug therapy. We present a contemporary review of left atrial appendage occlusion for stroke prevention in nonvalvular atrial fibrillation. A thorough review of the history of surgical and percutaneous left atrial appendage occlusion devices, recent trials, and US Food and Drug Administration milestones of current left atrial appendage occlusion devices are discussed.

Feasibility of the AtriClip Pro Left Atrium Appendage Elimination Device via the Transverse Sinus in Minimally Invasive Mitral Valve Surgery.

BackgroundAchieving external access to and manual occlusion of the left atrial appendage (LAA) during minimally invasive mitral valve surgery (MIMVS) through a small right thoracotomy is difficult. Occlusion of the LAA using an epicardial closure device seems quite useful compared to other surgical techniques.MethodsFourteen patients with atrial fibrillation underwent MIMVS with concomitant surgical occlusion of the LAA using double-layered endocardial closure stitches (n=6, endocardial suture group) or the AtriClip Pro closure device (n=8, AtriClip group) at our institution. The primary safety endpoint was any device-related adverse event, and the primary efficacy endpoint was successful complete occlusion of blood flow into the LAA as assessed by transthoracic echocardiography at hospital discharge. The primary efficacy endpoint for stroke reduction was the occurrence of ischemic or hemorrhagic neurologic events.ResultsAll patients underwent LAA occlusion as scheduled. The cardiopulmonary bypass and aortic cross-clamp times in the endocardial suture group and the AtriClip group were 202±39 and 128±41 minutes, and 213±53 and 136±44 minutes, respectively (p=0.68, p=0.73). No patients in either group experienced any device-related serious adverse events, incomplete LAA occlusion, early postoperative stroke, or neurologic complication.ConclusionEpicardial LAA occlusion using the AtriClip Pro during MIMVS in patients with mitral valve disease and atrial fibrillation is a simple, safe, and effective adjunctive procedure.

Treatment Strategies for Cryptogenic Stroke Patients with Patent Foramen Ovale: What Do We Choose?

ImportanceThe treatment of cryptogenic stroke patients with patent foramen ovale to prevent recurrence of stroke, especially when patients consider drug prevention alone, has caused serious treatment dilemmas in clinical practice.ObjectiveTo study the safety and efficacy of different treatment strategies using a network meta-analysis of randomized controlled trials in this population with cryptogenic stroke and patent foramen ovale.Study SelectionPUBMED, EMBASE, The Cochrane Library, WangFang, and China National Knowledge Infrastructure were searched to identify RCT comparing different treatment strategies. Eleven randomized studies were included (n = 5706).Main OutcomesThe primary efficacy outcome was recurrence of ischemic stroke, including fatal and non-fatal ischemic strokes. The primary safety outcome was major hemorrhage, but closure surgery includes systemic thrombotic events, persistent atrial fibrillation, surgical deaths and other major events.ResultsIn terms of efficacy and safety events, compared with antiplatelet, the OR of vitamin K antagonists for stroke recurrence was 0.81 (95% CI, 0.41–1.6), the OR of surgical closure was 0.38 (95% CI, 0.16–0.63), and the OR of NOAC was 0.79 (95% CI, 0.27–2.3). Compared with antiplatelet, the safety event OR of vitamin K antagonists was 1.7 (95% CI, 0.65–4.8), the OR of surgical closure was 1.7 (95% CI, 0.68–3.8), and the OR of NOAC was 2.2 (95% CI, 0.67–7.6).ConclusionIn terms of effectiveness, surgical occlusion has the best performance, while anticoagulation is the second best. Vitamin K antagonists and non-vitamin K antagonists are difficult to distinguish between the best in effectiveness. Antiplatelet drugs are considered the worst option. Regarding the safety results, it is generally believed that there are no obvious beneficial interventions, but antiplatelet drugs are considered to be relatively best, followed by surgical intervention and vitamin K antagonists, and non-vitamin K antagonists are considered to be the least safe.

RECURRENT HEMOPTYSIS IN UNILATERAL PULMONARY ARTERY AGENESIS

TOPIC: Signs and Symptoms of Chest Diseases TYPE: Fellow Case Reports INTRODUCTION: Unilateral pulmonary artery agenesis (UPAA) is a rare condition that is typically from a defect during birth. It may remain asymptomatic and only be diagnosed in adulthood. Symptoms may include dyspnea on exertion, recurrent pulmonary infections, and pleural effusion. Hemoptysis has been described in 10% of patients. Imaging modalities include pulmonary angiography and aortography to localize and embolize collaterals for a therapeutic approach. This case presents a patient with known UPAA with recurrent hemoptysis with difficulty in localization of bleed. CASE PRESENTATION: A 27-year-old female with history of factor 5 Leiden deficiency, von Willebrand's disease, polycystic ovarian syndrome, morbid obesity, absent right pulmonary artery, atrial septal defect, and patent ductus arteriosus presented to the emergency department after experiencing an episode of hemoptysis. She denied any chest pain, fever, or chills, however, since her recent diagnosis with COVID-19, she has had ongoing shortness of breath. In the emergency room, she had a temperature of 98.6°F, heart rate of 123bpm, respiratory rate of 18 breaths/min, blood pressure of 186/113mmHg and Spo2 of 100% on ambient air. Physical exam was unremarkable. Her labs consisted of a normal PT and INR, unremarkable CMP, Hemoglobin of 13.8 g/dL, platelets of 250,000/uL. A CT angiogram was done showing no pulmonary embolism but confirming absence of the right pulmonary artery and showing a hypoplastic right lung (Figure1). She was subsequently admitted under observation. A 2D echo did not show any evidence of pulmonary hypertension. She had additional small episodes of hemoptysis and therefore underwent a bronchoscopy, however, was completely obscured by blood upon entry and was withdrawn. She underwent a repeat bronchoscopy in the operating room which showed a slow ooze from the posterior segment of the right upper lobe. She did not have any further episodes of hemoptysis and was therefore discharged. She presented again with significant hemoptysis requiring intubation followed by a bronchoscopy where a large thrombus and blood was removed. Due to her complex pathology, she was flown to a tertiary care center where her hemoptysis eventually subsided. DISCUSSION: Unilateral pulmonary artery agenesis has a prevalence of 1 in 200,000 patients caused by failure in connection of the sixth aortic arch and pulmonary trunk. It may be accompanied with other congenital heart abnormalities. Therapeutic options include surgical reconstruction of the pulmonary artery early in childhood. In adulthood, one may consider surgical occlusion of collateral vessels or pneumonectomy to avoid hemoptysis. CONCLUSIONS: Outcomes are not well-described given the rare condition, however, routine surveillance in the development of pulmonary hypertension is important. Given our patient's known diagnosis, she was referred to her congenital cardiologist for close follow up. REFERENCE #1: Steiropoulos P, Archontogeorgis K, Tzouvelekis A, Ntolios P, Chatzistefanou A, Bouros D. Unilateral pulmonary artery agenesis: a case series. Hippokratia. 2013;17(1):73-76. REFERENCE #2: Johnson, T.R.C, Thieme, S.F, Deutsch, M.A, et al. Circulation. 2021. Unilateral Pulmonary Artery Agenesis. [online] Available at: https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.108.777698 [Accessed 13 April 2021 DISCLOSURES: No relevant relationships by Tokunbo Matthews, source=Web Response No relevant relationships by Awan Rahman, source=Web Response No relevant relationships by Nitasa Sahu, source=Web Response

Woven EndoBridge Embolized Aneurysm Clippings: 2-Dimensional Operative Video.

The Woven EndoBridge (WEB) device (MicroVention, Aliso Viejo, California) is an intrasaccular flow disruptor used for the treatment of both unruptured and ruptured intracranial aneurysms. WEB has been shown to have 54% complete and 85% adequate aneurysm occlusion rates at 1-yr follow-up.1 Residual and recurrent ruptured aneurysms have been shown to have a higher risk of re-rupture than completely occluded aneurysms.2 With increased utilization of WEB in the United States, optimizing treatment strategies of residual aneurysms previously treated with the WEB device is essential, including surgical clipping.3,4 Here, we present an operative video demonstrating the surgical clip occlusion of previously ruptured middle cerebral artery and anterior communicating artery aneurysms that had been treated with the WEB device and had sizable recurrence on follow-up angiography. Informed consent was obtained from both patients. Lessons learned include the following: (1) the WEB device is highly compressible, unlike coils; (2) proximal WEB marker may interfere with clip closure; (3) no evidence of WEB extrusion into the subarachnoid space; (4) no more scarring than expected in ruptured cases; and (5) clipping is a feasible option for treating WEB recurrent or residual aneurysms.

Choice of X-ray surgical tactics for the treatment of venogenic erectile dysfunction in patients with pelvic varicose veins

The aim of the study was to develop an interventional approach for X-ray endovascular occlusion of the periprostatic plexus veins in patients with venogenic erectile dysfunction by systematizing X-ray phlebographic images obtained by standard dynamic pharmacocavernosography and dynamic multispiral computed cavernosography.Materials and methods. A comprehensive examination was carried out in 192 patients with venous erectile dysfunction. The age of the patients ranged from 19 to 66 (36.5 ± 0.73) years. The indication for occlusion of the veins of the periprostatic plexus was a combination of erectile dysfunctions on the IIEF-5 scale from 5 to 20 points and pathological venous drainage from the proximal cavernous bodies of the penis.Results. According to the Doppler ultrasound of the scrotum organs, TRUS of the prostate and the veins of the periprostatic plexus, all patients were diagnosed with pelvic varicose disease as a simultaneous combination of varicose veins of the gonadal veins and veins of the pelvic organs. Standard dynamic pharmacocavernosography was performed in 96 patients with erectile dysfunction. Pathological venous drainage was detected in 79 patients: proximal type - in 68 (86.0 %) of cases, distal type - in 4 (5.1 %) of cases and mixed type - in 7 (8.9 %) of cases. Periprostatic plexus vein occlusion was performed in 20 patients with venogenic erectile dysfunction with proximal pathological venous drainage. Complete disappearance of complaints of erectile dysfunction 6 months after X-ray surgical occlusion of the periprostatic plexus veins was noted in 81.0 % of cases (an increase in the index on the IIEF-5 scale from 12.7 ± 0.9 to 19.8 ± 0.9 points). The discrepancy between the data on the presence of venous leakage according to the results of standard pharmaco-Doppler sonography and the data on its absence according to the results of dynamic pharmacocavernosography in 19 patients determined the indications for dynamic multispiral computed pharmacocavernosography. The implementation of dynamic multispiral computed pharmacocavernosography made it possible to improve the visualization of variants of pathological venous outflow into the periprostatic venous plexus and the veins of the small pelvis from the cavernous bodies of the penis and to offer our own X-ray anatomical classification.Conclusion. The most common type of pathological venous drainage is its proximal type (86.0 % of cases). X-ray surgical occlusion of the veins of the periprostatic plexus is an effective method for the treatment of venogenic erectile dysfunction. Visualization of X-ray phlebographic images of the small pelvis during dynamic multispiral computed cavernosography with 3D reconstruction surpasses the results of standard dynamic pharmacocavernosography in the diagnosis of proximal, distal and mixed types of pathological venous drainage from the corpora cavernosa of the penis. Dynamic multispiral computed pharmacocavernosography with 3D reconstruction allows to determine the shape of the pathological venous drainage of the proximal type and determines the choice of antegrade or retrograde method of X-ray endovascular occlusion of the peripheryprostatic plexus veins in patients with venogenic erectile dysfunction.

2021 Korean Heart Rhythm Society Guidelines for Stroke Prevention in Atrial Fibrillation

Atrial fibrillation (AF) is a strong risk factor for ischemic stroke and systemic embolism. To prevent thromboembolic events in patients with AF, anticoagulation therapy is essential. The anticoagulant strategy is determined after stroke and bleeding risk assessments using the CHA2DS2-VASc and HAS-BLED scores, respectively; both consider clinical risk factors. Vitamin K antagonists (VKAs) are the sole anticoagulant option in AF patients with a prosthetic mechanical valve or moderate-severe mitral stenosis; in all other AF patients VKA or non-vitamin K antagonist oral anticoagulants are therapeutic options. However, antiplatelet therapy should not be used for stroke prevention in AF patients. Anticoagulation is not needed in AF patients with low stroke risk but strongly recommended in those with a with low bleeding risk. Left atrial appendage (LAA) occlusion offers an alternative in AF patients in whom long-term anticoagulation is contraindicated. Surgical occlusion or the exclusion of LAA can be considered for stroke prevention in AF patients undergoing cardiac surgery. In this article, we review existing data for stroke prevention and suggest optimal strategies to prevent stroke in AF patients.

CineCT imaging platform for in-vivo and ex-vivo measurement of myocardial biomechanics post myocardial infarction and following intramyocardial delivery of theranostic hydrogel

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute of Health (NIH) Purpose Myocardial infarction (MI) induces acute regional changes in myocardial strain and stiffness in the infarct and the remote areas of the left ventricle (LV), which lead to adverse changes in LV geometry and function. We hypothesize that cineCT imaging could evaluate these biomechanical changes along with the effects of intramyocardial delivery of theranostic hydrogels. Introduction We present an experimental platform to assess changes in the deformation of the LV myocardium using contrast cineCT (CCT) imaging of the beating porcine heart (active deformation) before and after acute MI and intramyocardial delivery of an imageable theranostic hydrogel. We then assess the acute effects of hydrogel delivery early post-MI on biomechanics (passive deformation) using an ex vivo perfused heart preparation. Methods Contrast cineCT imaging was performed using 64-slice CT on 5 Yorkshire pigs without MI (n = 3) or with MI (n = 2). MI pigs had serial imaging performed before and 1 hour after acute surgical coronary occlusion to induce anterolateral MI. One MI pig was also imaged 1 hour after intramyocardial injection of a novel imageable theranostic iodinated hydrogel within the MI region. Post euthanasia, excised hearts were flushed with chilled UW cardioplegic solution and mounted on a custom inflation apparatus for cineCT imaging during LV inflation by external pump. LV pressure was cycled between 10 and 60 mmHg at 35 bpm. Dilute iohexol was injected into aortic root and UW perfusate (15 ml, 1 ml/sec). CineCT image series were reconstructed, contrast enhanced, resampled to the LV long axis (Z), and exported as a series of 10 CT volumes covering 0-90% of the cardiac/inflation cycle. Volumes were registered incrementally using nonlinear image registration (BioImageSuite) and the calculated displacement at each time point was exported at a resolution of 1 mm. A custom Matlab program was used to fit the displacement field to local trilinear polynomials and then calculate the displacement gradients and 3D Lagrangian strains. To estimate the accuracy of this approach, cardiac volumes were also numerically deformed using a 10 pixel translation and 5% triaxial stretch. Results We successfully acquired serial in-vivo and ex-vivo 3D CineCT images for assessment of the active and passive LV myocardial deformation and tracked deformation through the full cardiac/inflation cycle (Figure 2). Numerical deformation tests showed average tracking errors of &amp;lt; 0.2 mm (1/4 pixel) in the X,Y,Z directions of the volume. These resulted in Lagrangian strain errors of &amp;lt; 0.47% for the in-plane strains EXX and EYY (radial and circumferential plane) and &amp;lt; 0.5% for EZZ (long axis). Conclusions We have developed a novel CineCT imaging platform that allows for high resolution in-vivo and ex-vivo measurement of myocardial biomechanics post-MI and following intramyocardial delivery of imageable theranostic hydrogels, which may improve early active and passive biomechanics.