Comparison of outcomes between minimally invasive and median sternotomy for double and triple valve surgery: A meta-analysis

Background

Limited data exists demonstrating the efficacy of minimally invasive surgery (MIS) compared to median sternotomy (MS) for multiple valvular disease (MVD). This systematic review and meta-analysis aims to compare operative and peri-operative outcomes of MIS vs MS in MVD.

Methods

PubMed, Ovid, and Embase were searched from inception until August 2019 for randomized and observational studies comparing MIS and MS in patients with MVD. Clinical outcomes of intra- and postoperative times, reoperation for bleeding and surgical site infection were evaluated.

Results

Five observational studies comparing 340 MIS vs 414 MS patients were eligible for qualitative and quantitative review. The quality of evidence assessed using the Newcastle-Ottawa scale was good for all included studies. Meta-analysis demonstrated increased cardiopulmonary bypass time for MIS patients (weighted mean difference [WMD], 0.487; 95% confidence interval [CI], 0.365-0.608; P < .0001). Similarly, aortic cross-clamp time was longer in patients undergoing MIS (WMD, 0.632; 95% CI, 0.509-0.755; P < .0001). No differences were found in operative mortality, reoperation for bleeding, surgical site infection, or hospital stay.

Conclusions

MIS for MVD have similar short-term outcomes compared to MS. This adds value to the use of minimally invasive methods for multivalvular surgery, despite conferring longer operative times. However, the paucity in literature and learning curve associated with MIS warrants further evidence, ideally randomized control trials, to support these findings.

     

Temporalis myofascial flap in maxillofacial reconstruction: clinical and histological studies of the oral healing process

Objectives—To report our experience with temporalis myofascial flaps (TMF), describe the healing process of uncovered flaps in the mouth, and the histology of the repaired mucosa in the long term. Design—Prospective clinical and histological study. Subjects—36 patients who received a TMF over a 6.5 year period for serial assessment of the oral healing, 24 patients whose scars over the reconstructed area were assessed clinically, and 11 whose repaired mucosa was assessed histologically. Main outcome measures—To follow the clinical process of oral healing of the TMF and describe the repaired mucosa healed over the flap. Results—The uncovered TMF in the mouth healed gradually starting with an acute inflammatory phase, going through chronic inflammatory and proliferative phases with eventual epithelialisation of the oral mucosa. There were no major complications. The healed mucosa showed mild scarring in 70% of cases and the repaired mucosa had characteristic histological features that were distinct from the normal mucosa. Conclusion—The TMF is an extremely reliable and versatile flap for maxillofacial reconstruction which heals gradually with eventual coverage by mildly scarred repaired mucosa.     

The impact of COVID-19 on the provision of cardiac surgical services

The global pandemic caused by COVID-19 has had a significant global impact on healthcare systems. One implication of this pandemic is the cancellation of elective cardiac surgeries and the centralization of services. As a result, hospitals in Europe, North America, and the United Kingdom have had to alter the services offered to patients to be able to cope with service provision for COVID infected patients. Data should be collected during this period to provide a good insight following the lockdown period to understand the implication of such service alteration. Future research should also focus on the effects on long-term mortality and morbidity as well as financial implications on hospitals as a result of these changes.     

A novel problem,a tested solution: A case of an infected left ventricular titanium plug

Persistent infection of left ventricular-assisted devices are challenging to treat. We describe a case of a middle-aged man who presented with cardiogenic shock and profound heart failure from sarcoid myocarditis, necessitating the placement of a left ventricular assist device. After recovery of cardiac function, the device was decommissioned but complicated by infection in the implant bed, chest wall, and of the titanium plug left in situ. This to our knowledge is the first report of an infected titanium plug and we describe an option of using a latissimus dorsi flap using its vascularized tissues to treat the infected plug. This is another example where a multidisciplinary approach can yield rewarding results in cases such as these.