Trans-lateral decubitus radiograph of the hip: A new view to measure the anteversion of the femoral stem

BackgroundMalposition of the femoral stem is a risk factor for dislocation after total hip arthroplasty (THA). Currently, two radiological methods are available for the measurement of stem anteversion. However, one method is not applicable in patients with a stiff hip, and the other one cannot differentiate the anteversion and retroversion of the stem. Therefore, we developed a method to measure the stem anteversion and assessed its reliability as well as validity.MethodsTrans-lateral decubitus view of the proximal femur was taken with the patient in lateral decubitus position, the hip in extension and the knee in 90° flexion. Hip anteroposterior (AP) view, trans-lateral decubitus view and CT scan of the hip were taken in 36 patients, who underwent THA. Their mean age was 59.8 (27–84) years and the mean body mass index was 25.2 (18.8–30.9) kg/m². The stem neck-femoral shaft angle was measured on hip AP view and the trans-lateral decubitus view. Then, the stem anteversion was calculated using the Ogata-Goldsand formula. We assessed the intra- and inter-observer reliabilities and evaluated the validity by comparing with the measurements on CT scan.ResultsThe intra- and inter-observer reliabilities were 0.934 and 0.935, respectively. The calculated stem anteversion (23.72°±8.17°) correlated well with the stem anteversion on CT scan (23.91°±10.25°), especially when the radiological anteversion was <30° (correlation coefficient = 0.729, p = 0.001).ConclusionWe developed a reliable and valid method to measure stem anteversion using hip AP view and trans-lateral decubitus view of the femur. This method can replace conventional radiological methods.     

Acute total hip arthroplasty for older patients with acetabular fractures: A meta-analysis

ObjectiveMultiple treatment options for acetabular fractures in geriatric patients exist. However, no large-scale studies have reported the outcomes of acute total hip arthroplasty (THA) in this patient population. We systematically evaluated all available evidence to characterize clinical outcomes, complications, and revisions of acute THA for acetabular fractures in geriatric patients.MethodsMeta-analysis of 21 studies of 430 acetabular fractures with mean follow-up of 44 months (range, 17−97 months). Two independent researchers searched and evaluated the databases of Ovid, Embase, and United States National Library of Medicine using a Boolean search string up to December 2019. Population demographics and complications, including presence of heterotopic ossification (HO), dislocation, infection, revision rate, neurological deficits, and venous thromboembolic event (VTE), were recorded and analyzed.ResultsWeighted mean Harris Hip Score was 83.3 points, and 20% of the patients had reported complications. The most common complication was HO, with a rate of 19.5%. Brooker grade III and IV HO rates were lower at 6.8%. Hip dislocation occurred at a rate of 6.1%, 4.1% of patients developed VTE, deep infection occurred in 3.8%, and neurological complications occurred in 1.9%. Although the revision rate was described in most studies, we were unable to perform a survival analysis because the time to each revision was described in only a few studies. The revision rate was 4.3%.ConclusionsAcute THA is a viable option for treatment of acetabular fracture and can result in acceptable clinical outcomes and survivorship rates in older patients but with an associated complication rate of approximately 20%. Considering the limited treatment options, THA might be a viable alternative for appropriately selected patients.     

Acute total hip arthroplasty for older patients with acetabular fractures: A meta-analysis

ObjectiveMultiple treatment options for acetabular fractures in geriatric patients exist. However, no large-scale studies have reported the outcomes of acute total hip arthroplasty (THA) in this patient population. We systematically evaluated all available evidence to characterize clinical outcomes, complications, and revisions of acute THA for acetabular fractures in geriatric patients.MethodsMeta-analysis of 21 studies of 430 acetabular fractures with mean follow-up of 44 months (range, 17−97 months). Two independent researchers searched and evaluated the databases of Ovid, Embase, and United States National Library of Medicine using a Boolean search string up to December 2019. Population demographics and complications, including presence of heterotopic ossification (HO), dislocation, infection, revision rate, neurological deficits, and venous thromboembolic event (VTE), were recorded and analyzed.ResultsWeighted mean Harris Hip Score was 83.3 points, and 20% of the patients had reported complications. The most common complication was HO, with a rate of 19.5%. Brooker grade III and IV HO rates were lower at 6.8%. Hip dislocation occurred at a rate of 6.1%, 4.1% of patients developed VTE, deep infection occurred in 3.8%, and neurological complications occurred in 1.9%. Although the revision rate was described in most studies, we were unable to perform a survival analysis because the time to each revision was described in only a few studies. The revision rate was 4.3%.ConclusionsAcute THA is a viable option for treatment of acetabular fracture and can result in acceptable clinical outcomes and survivorship rates in older patients but with an associated complication rate of approximately 20%. Considering the limited treatment options, THA might be a viable alternative for appropriately selected patients.     

How is quality of life after total hip replacement related to the reconstructed anatomy? A study with low-dose stereoradiography

PurposeThe purpose of this study was to evaluate the relationships between the three-dimensional anatomy of operated hip in standing position using low-dose stereo-radiography imaging system and postoperative hip disability and osteoarthritis outcome score (HOOS) after total hip arthroplasty (THA).Material and methodsA total of 123 patients who underwent THA during a one-year period were included. There were 50 men and 73 women with a mean age of 67.3 ± 13.6 (SD) years (range: 19–89 years). All patients underwent pre- and postoperative low-dose stereo-radiography examination and completed a HOOS form (score from 0 to 100, 100 for full satisfaction). We recorded 16 anatomical parameters before THA, and 15 after THA. After binary transformation of HOOS score using 70 as threshold value, outcome was assessed using logistic or generalised linear models.ResultsA total of 103 patients (103/123; 83.7%) had a HOOS score ≥ 70 and were considered as the satisfied group. A significant difference in pelvic incidence (the angle between a line perpendicular to the sacral plate at its midpoint and a line connecting the same point to the centre of the bicoxofemoral axis) was found between the satisfied 56.4 ± 10.4 (SD)° (range: 31–85°) and the unsatisfied group 48.7 ± 8.9 (SD)° (range: 40–65) (P = 0.006). The relative variation of offset (distance from the centre of rotation of the femoral head to a line bisecting the long axis of the femur) compared to the contralateral hip was ?7% in the satisfied group and 7.2% in the unsatisfied group (P = 0.01).ConclusionPelvic incidence, a parameter independent of the reconstructed anatomy, probably influences the quality of life of patients with THA, via pelvic compensatory capabilities. A loss of femoral offset negatively influences the satisfaction of patients.     

Short to long term outcomes of 154 cemented total hip arthroplasties in ankylosing spondylitis

BackgroundLong-term outcome of Total Hip arthroplasty (THA) in Ankylosing Spondylitis (AS) remains unreported. Literature suggests a higher overall failure rate in ankylosing spondylitis as compared to osteoarthritis. Concern has been expressed regarding joint survival, given that recipients are generally young. The results of cemented THA in patients with ankylosing spondylitis were studied to determine the utility of THA for these patients.MethodsConsecutive series of 96 patients (77 males (80%) and 19 females (20%)) with ankylosing spondylitis who underwent 154 cemented THAs at a tertiary referral orthopaedic centre between January 1990–September 2015 were retrospectively analyzed for clinical and radiological outcomes; 58 patients (60.4%) underwent bilateral surgery.ResultsMean age at surgery was 48 years. Average follow up was 12.8 (2.1–24.8) years. 95% of the patients had a good or excellent post-operative outcome.Out of the total 154 hips operated on, 11% (17 hips) developed post-operative complications. Overall, 15 hips (9.7%) required a revision of the procedure, with the most common indication being aseptic loosening of the acetabulum. Average time to revision was 8.5 years (2–15). Survivorship analysis revealed probability of survival of both components at the end of 10 years, with revision due to any reason as the end point to be 92% (with 95% confidence intervals).21 hips (14%) developed heterotopic ossification post-operatively, of which 4 patients (2%) had clinically significant ossification (Brooker III or IV).ConclusionThis is one of the largest series of patients with ankylosing spondylitis with long term follow up available. Cemented THA in patients with ankylosing spondylitis provided consistently good and predictable long term results, with low rate of complications and revisions.     

Diagnostic accuracy of ultrasonography for occult femoral neck fracture

BackgroundA delay in the diagnosis and treatment of an occult femoral neck fracture (OFNF) can negatively affect the subsequent quality of life. We investigated the diagnostic accuracy of ultrasonography for OFNF in patients confirmed with this condition by magnetic resonance imaging (MRI), and compared these results with other clinical findings.MethodsNinety-four outpatients aged above 70 years with acute hip pain but without radiographic abnormal findings who were suspected of having an occult femoral neck fracture (11 men and 83 women with a mean age of 81.8 ± 6.0 years) were enrolled. Both ultrasonography and MRI were performed in all cases within 24 h. The ultrasonographic distance between the anterior aspect of the femoral neck and the anterior joint capsule (ultrasound joint swelling) was measured.ResultsBy MRI findings, 27 patients were assigned to an occult femoral neck fracture (OFNF) group (1 man, 26 women) and 67 patients to a non-OFNF group (10 men, 57 women). The mean ultrasound joint swelling in both groups was 7.53 ± 1.52 mm and 3.45 ± 0.89 mm, respectively (p = 0.006, 95% CI, 3.58–4.59). A cut-off value of 5.3 mm showed a sensitivity of 0.96 (0.89–0.96) and a specificity of 0.98 (0.92–1.00).ConclusionsUltrasonography shows very high diagnostic accuracy for occult femoral neck fracture. This modality can thus contribute to initial bed-side examinations for this condition in patients over 70 years with acute hip pain.     

Transient inferior over-reduction after open reduction in walking-age DDH: A retrospective analysis of 42 Hips

BackgroundDue to various policy and health infrastructure issues, it is not uncommon to present developmental dysplasia of hip(DDH) at walking-age in India. The purpose of this study was retrospective analysis of operated cases of walking-age DDH with “inferior over-reduction”.Methods“Inferior over-reduction” was defined as break in the Shenton's arc inferiorly in an operated hip which otherwise appears reduced. After Ethical Committee approval, we searched children operated for walking-age DDH. Children suggestive of syndromic association were excluded. We collected demographic data, follow-up, procedures performed, inferior over-reduction and complications. The IHDI grade, Acetabular Index(AI), Smith's ratio for superior (h/b) & lateral displacement(c/b) of femur, and clinical outcome (Modified McKay criteria) were evaluated. The outcomes of cases with inferior over-reduction(Group A) were compared with those without(Group B).Results42 patients with average follow-up of 23 months were enrolled. 21 hips belonged to Group A. By 6 months follow up, all these cases recovered. On comparison of Smith's ratio, group A had significantly higher c/b for the operated hip at 3-month follow-up(p < 0.05). Patients undergoing acetabuloplasty had significantly lower c/b versus all other groups(p < 0.05). Correlation between h/b or c/b with age did not show any significant finding. 15 cases in group A and 14 cases in group B had excellent outcome as per modified McKay's criteria. None of the patients had inferior over-reduction, inferior or obturator dislocation at final follow-up. Three patients with group B had re-dislocation with poor outcome. we recorded 3 hips with AVN (7%).ConclusionsThis study highlights that after OR of walking-age DDH, the inferior over-reduction may be noted in as much as 50% of the cases. However, this is transient, and all cases recover by the 6 months follow up. There is no significant difference between group A & B in functional outcome, AVN rate. Long-term studies are required to see outcome differences between two groups.     

Comparison of local pain and tissue reaction between conventional pneumatic tourniquet and disposable silicone ring tourniquet during Total Knee Arthroplasty

BackgroundTo study the comparison of conventional pneumatic and disposable silicone ring tourniquet in Total Knee Arthroplasty.Material and methodsThis is a prospective randomized control trial. We used conventional pneumatic tourniquet on one side of leg and disposable silicone ring tourniquet on the other side in consecutive 50 simultaneous bilateral TKR patients. Patients having peripheral vascular disease of the lower limb were excluded from the study. The patient demographics & characteristics are identical being the same patient with two different legs. We started the study with null hypothesis. An independent observer assessed the local tourniquet site pain (VAS score 1–10) and local tourniquet site skin reaction at 24 h and 48 h after the TKA. P value < 0.05 was considered significant.ResultsThere were no local skin complication with disposable tourniquet (0%). 8 out of 50 patients in whom the conventional tourniquet was applied showed local bruising, and two patients had blister formation making the local skin site complication rate 20% (statistically significant, p value0.0196, chi-squared test). The VAS score at 24 h was 4.3 ± 1.5 for disposable tourniquet group as against 5.6 ± 2.1 for conventional tourniquet group (statistically significant, p value = 0.0152, t statistic test for comparison of means). The VAS score at 48 h was 2.1 ± 1.5 and 3.3 ± 1.2 for disposable tourniquet group and conventional tourniquet group respectively (statistically significant p value = 0.003, student’s t-test).ConclusionUse of disposable tourniquet has better outcome than the conventional tourniquet with minimal or no local complications. The advantages of the disposable tourniquet are: 1 less local pain, 2. no local skin problems, 3. accurate tourniquet pressure at the application site, 4.0% local contamination. Hence, we recommend use of the disposable tourniquet during the Total Knee Arthroplasty.     

Prognostic factors for progression-free survival of the filum terminale ependymomas in adults

ObjectiveTo define the prognostic factors for progression and to determine the impact of the histological grading (according to the World Health Organization) on the progression-free survival (PFS) of filum terminale ependymomas.MethodsA retrospective chart review of 38 patients with ependymoma of the filum terminale was performed, focusing on demographic data, preoperative symptoms, tumor size, quality of resection, presence of a tumor capsule, and histological grade.ResultsGross total resection (GTR) was achieved in 30 patients (78.9%). Histopathological analysis found 21 (55.3%) myxopapillary grade I ependymoma (MPE), 16 (42.1%) ependymoma grade II (EGII), and 1 (2.6%) ependymoma grade III. There was no significant difference between the mean ± SD volume of MPE (5840.5 ± 5244.2 mm³) and the one of EGII (7220.3 ± 6305.9 mm³, p = 0.5). The mean ± SD follow-up was 54.1 ± 38.4 months. At last follow-up, 30 (78.9%) patients were free of progression. In multivariate analysis, subtotal resection (p = 0.015) and infiltrative tumor (p = 0.03) were significantly associated with progression. The PFS was significantly higher in patients with encapsulated tumor than in patients with infiltrative tumor (log-rank p = 0.01) and in patients who had a GTR in comparison with those who had an incomplete resection (log-rank p = 0.05). There was no difference in PFS between patient with MPE and EGII (p = 0.1).ConclusionThe progression of ependymoma of the filum terminale highly depends on the quality of resection, and whether the tumor is encapsulated. Except for anaplastic grade, histopathological type does not influence progression.     

Breast ultrasound in breast cancer surveillance; incremental cancers found at what cost?

PurposeTo determine the diagnostic parameters of breast ultrasound (US) in the setting of routine radiological surveillance after a diagnosis of breast cancer and evaluate costs of the inclusion of breast US as well as any survival benefit of US detected cases of recurrence in surveillance.Methods622 patients underwent breast cancer surgery and follow up at Austin Health from July 2009 to December 2015. Retrospective data analysis was performed to determine; diagnostic parameters, financial costs of US and survival outcomes of US detected cases of recurrence.ResultsPatients underwent 1–9 years of breast cancer surveillance, with a median of 4.24 years. 390 (62.7%) patients underwent additional breast US surveillance to mammography. 232 (38.3%) fit criteria for use of additional breast US. 199 abnormal imaging episodes occurred, leading to 16 screen detected-cases of locoregional recurrence. US alone generated 107 abnormal images and found 9 cancers. US had a sensitivity of 44.1%, specificity of 95.2% and positive predictive value of 11.7% in comparison to mammography; 20.6%, 97.4% and 9.9% respectively. US had a biopsy rate of 4.0% and lead to an incremental cancer detection rate of 0.38%. The cost of incremental cancer found was $31,463.72 AUD. Survival outcomes based on method of detection of recurrence were insignificant (p value = 0.71).ConclusionsBreast US has a sensitivity of 44.1% and detected seven recurrences that were mammographically occult. Breast US has a similar PPV to mammography in surveillance. Breast US generated considerable biopsy rates and costs. Survival analysis was not able to detect any benefit of US detected cases of recurrence.     

A novel unidirectional-valved shunt approach for end-stage pulmonary arterial hypertension: Early experience in adolescents and adults

ObjectivesDespite advances in treatment of idiopathic pulmonary arterial hypertension (IPAH), there remains no medical cure, and patients can experience disease progression leading to right heart failure, progressive exercise intolerance, and death. The reversed Potts shunt (left pulmonary artery to descending aorta) was reintroduced for treatment of end-stage IPAH to permit decompression of the suprasystemic right ventricle by right to left shunting, with preservation of upper body oxygenation. The shunt has the potential to delay the need for lung transplantation and offer a treatment for those who are transplant ineligible. To optimize shunt design and avoid the potential complications of bidirectional shunting, we developed a novel approach using a unidirectional-valved shunt (UVS) in patients with IPAH with suprasystemic pulmonary arterial pressure and poor right ventricular function.MethodsA single-center retrospective review was performed of UVS cases done at Columbia University Medical Center–New York Presbyterian between November 1, 2016, and May 1, 2019.ResultsFive patients (4 female; ages 12-22 years) underwent UVS. All had suprasystemic pulmonary arterial pressure, poor right ventricular function, and World Health Organization functional class IV symptoms at baseline. All patients are alive and transplant-free at latest follow-up (range 3-33 months; median 6 ± 11 months).ConclusionsThe UVS may offer an alternative solution to lung transplantation in adolescents and young adults with IPAH. Longer-term follow-up is needed to determine the ultimate impact of unidirectional unloading of the right ventricle in these patients and to determine whether the UVS will enable a broader approach to the treatment of patients with IPAH.     

Association between intravesical prostatic protrusion and clinical outcomes in prostatic artery embolization

PurposeTo evaluate the influence of intravesical prostatic protrusion (IPP) on clinical outcomes after prostatic artery embolization (PAE) in patients with lower urinary tract symptoms due to benign prostatic hyperplasia.Materials and methodsAll consecutive patients who underwent PAE for lower urinary tract symptoms between January 2017 and January 2019 were retrospectively included. IPP was evaluated on pre-treatment magnetic resonance imaging examination and symptoms were assessed at follow-up consultations using the international prostate symptom score (IPSS) and quality of life (QOL) questionnaire. IPPs were classified as grade 1 (< 5 mm), grade 2 (5–10 mm), or grade 3 (> 10 mm).ResultsA total of 160 consecutive men (mean age 65 ± 7.8 [SD] years; range: 45–89 years), underwent PAE. The mean IPSS was 21 ± 7.3 (SD) (range: 5–35) and prostate volume 87 ± 38 (SD) mL (range: 30–200 mL). The IPP grade was 1 for 28 (28/160; 18%), 2 for 52 (52/160; 33%), and 3 for 80 (80/160; 50%) patients. There were no significant differences in IPSS at baseline between the three IPP grades. Patients with severe (grade 3) IPP had a significantly higher reduction in IPSS than those with non-severe IPP (grade 1 or 2), with estimated mean reductions of 12 ± 2.5 (SD) (range: ?4–28) and 8.3 ± 1.9 (SD) (range: ?8–21) (P = 0.02), respectively. The mean reduction in the QOL score was 3.0 for grade 3 and 2.0 for grade 1 or 2 IPP (P = 0.02).ConclusionsThe degree of IPP does not limit the efficacy of PAE in patients with lower urinary tract symptoms due to benign prostatic hyperplasia.     

Evaluation of a Clinical Decision Support System for the most evidence-based approach to managing perioperative anticoagulation

Study objectiveWe explored the feasibility of a Clinical Decision Support System (CDSS) to guide evidence-based perioperative anticoagulation.DesignProspective randomised clinical management simulation multicentre study.SettingFive University and 11 general hospitals in Germany.ParticipantsWe enrolled physicians (anaesthesiologist (n = 73), trauma surgeons (n = 2), unknown (n = 1)) with different professional experience.InterventionsA CDSS based on a multiple-choice test was developed and validated at the University Hospital of Frankfurt (phase-I). The CDSS comprised European guidelines for the management of anticoagulation in cardiology, cardio-thoracic, non-cardio-thoracic surgery and anaesthesiology. Phase-II compared the efficiency of physicians in identifying evidence-based approach of managing perioperative anticoagulation. In total 168 physicians were randomised to CDSS (PERI-KOAG) or CONTROL.MeasurementsOverall mean score and association of processing time and professional experience were analysed. The multiple-choice test consists of 11 cases and two correct answers per question were required to gain 100% success rate (=22 points).Main resultsIn total 76 physicians completed the questionnaire (n = 42 PERI-KOAG; n = 34 CONTROL; attrition rate 54%). Overall mean score (max. 100% = 22 points) was significantly higher in PERI-KOAG compared to CONTROL (82 ± 15% vs. 70 ± 10%; 18 ± 3 vs. 15 ± 2 points; P = 0.0003). A longer processing time is associated with significantly increased overall mean scores in PERI-KOAG (≥33 min. 89 ± 10% (20 ± 2 points) vs. <33 min. 73 ± 15% (16 ± 3 points), P = 0.0005) but not in CONTROL (≥33 min. 74 ± 13% (16 ± 3 points) vs. <33 min. 69 ± 9% (15 ± 2 points), P = 0.11). Within PERI-KOAG, there is a tendency towards higher results within the more experienced group (>5 years), but no significant difference to less (≤5 years) experienced colleagues (87 ± 10% (19 ± 2 points) vs. 78 ± 17% (17 ± 4 points), P = 0.08). However, an association between professional experience and success rate in CONTROL has not been shown (71 ± 8% vs. 70 ± 13%, 16 ± 2 vs. 15 ± 3 points; P = 0.66).ConclusionsCDSS significantly improved the identification of evidence-based treatment approaches. A precise usage of CDSS is mandatory to maximise efficiency.     

Complications of percutaneous image-guided screw fixation: An analysis of 94 consecutive patients

PurposeThe purpose of this study was to retrospectively assess the safety profile of percutaneous image-guided screw fixation (PIGSF) for insufficiency, impending or pathological fractures.Materials and methodsFrom July 2012 to April 2020, all consecutive patients who underwent PIGSF were retrospectively included in the study. Patient characteristics, fracture type, procedural data and complications were analyzed. Complications were divided into per-procedural, early (< 24 hours) and delayed (> 24 hours) and classified into minor (grade 1-2) and major complications (grade 3-5) according to Common Terminology Criteria for Adverse Events (CTCAE) v5.0.ResultsA total of 110 fractures (40 insufficiency [36%], 53 pathological [48.5%] and 17 impending [15.5%] fractures) in 94 patients (48 women, 46 men; mean age, 62.7 ± 12.7 [SD] years; age range: 32–88 years) were treated with PIGSF during 95 procedures. Twenty-four-hours follow-up was available for all patients, and > 24-hours follow-up was available for 79 (79/110; 71.8%) fractures in 69 (69/94; 73.4%) patients. Per-procedural complications occurred in 3/110 fractures (2.7%, all minor). Early complications were reported in 4/110 fractures (3.6%, 1 major and 3 minor) and delayed ones in 14/79 fractures (17.7%, 5 major and 9 minor). The most frequent major delayed complication was infection (3/79; 3.8%).ConclusionThe rate of per-procedural and early (within 24 hours) complications following PIGSF is extremely low with most complications being minor, with major complications being delayed ones (> 24 hours).     

Improved Outcomes of Reimplantation vs Remodeling in Marfan Syndrome: A Propensity-Matched Study

BackgroundValve-sparing root replacement (VSRR) has excellent outcomes when performed in experienced centers in well-selected patients. It is suggested that reimplantation of the aortic valve may have better durability than remodeling in patients with Marfan syndrome (MFS), although long-term comparative data are limited.MethodsBetween 1988 and 2018, 194 patients with MFS underwent VSRR at our institution. From these, we derived a propensity-matched cohort of 68 patients (44 who underwent reimplantation and 24 who had remodeling). Early outcomes included death and perioperative complications. Late outcomes were survival, probability of aortic insufficiency, and reintervention up to 20 years of follow-up. Median follow-up was 17.8 years (interquartile range, 12.0-20.6 years) for the entire matched cohort.ResultsBaseline variables were similar between reimplantation and remodeling patients after matching: age (39 ± 12 vs 40 ± 13 years, P = .75) and male sex (28 [64%] vs 15 [63%], P = 1.0). Similar 20-year survival was observed after reimplantation compared with remodeling (82% vs 72%, P = .20), whereas the probability of developing greater than mild aortic insufficiency at 20 years was increased after remodeling (5.8% vs 13%, P = .013). More patients underwent reoperation on the aortic valve after a remodeling procedure than after reimplantation of the aortic valve (18% vs 0%, P = .018).ConclusionsVSRR provides excellent long-term survival and freedom from valve-related complications outcomes in patients with MFS. Reimplantation of the aortic valve was associated with a lower risk of aortic valve reoperation and aortic insufficiency than the remodeling procedure after 2 decades of follow-up.     

Late results of aortic valve repair for isolated severe aortic regurgitation

ObjectivesThe objectives were to analyze the long-term outcomes of tricuspid aortic valve repair for isolated severe aortic regurgitation and the impact of different annuloplasty techniques.MethodsThe study cohort consists of 127 consecutive patients who received aortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve between 1996 and 2019 in our institution. Exclusion criteria were aorta dilatation (≥45 mm), connective tissue disease, active endocarditis, type A dissection, and rheumatic disease. Mean age of patients was 55.6 ± 16 years, and 80% were male. Median follow-up was 6.4 years. Time-to-event analysis was performed, as well as risk of death, reoperation, and aortic regurgitation recurrence.ResultsCusp repair was performed in 117 patients (92%), and annuloplasty was performed in 126 patients (99%) with Cabrol stitch (73%), reimplantation technique (19.7%), or ring annuloplasty (6.3%). There was no hospital mortality. At 10 and 14 years, overall survival was 81% ± 5% and 71% ± 6%, respectively, and freedom from reoperation was 80% ± 5% and 73% ± 6%, respectively. Age and left coronary cusp repair were independent predictors of reoperation. Freedom from recurrent severe aortic regurgitation (>2+) was 73% ± 5% and 66% ± 7% at 10 and 12 years, respectively. Age, left ventricular end-diastolic diameter, and patch repair were independent predictors of recurrent aortic regurgitation. Type of annuloplasty had no impact on survival or reoperation.ConclusionsAortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve is a safe procedure, and durability at 14 years is acceptable. In this study, the annuloplasty technique did not influence repair durability as was found in bicuspid aortic valve repair or aortic valve–sparing surgery. Severity of cusp pathology seems to be the main determinant of repair durability.     

Liver Cirrhosis After the Fontan Procedure: Impact of Atrioventricular Valve Failure

BackgroundLiver cirrhosis is now well recognized as a potential complication after the Fontan procedure, although associated risk factors and optimal timing of liver screening remain unclear.MethodsAll patients who underwent an extracardiac conduit Fontan procedure at The Royal Children’s Hospital, Melbourne, were identified using the Australia and New Zealand Fontan Registry. Cirrhosis was diagnosed based on liver biopsy, or a combination of imaging findings and clinical evaluation by a hepatologist.ResultsBetween 1997 and 2020, 398 patients underwent an extracardiac conduit Fontan procedure at our center, and 276 had ongoing follow-up in Victoria. Ninety-five patients (34%) underwent liver assessment at a mean age of 18.2 ± 6.7 years (11.8 ± 5.5 years post-Fontan). Fifteen patients (16%) were diagnosed with cirrhosis at a mean age of 22.7 ± 5.9 years (14.0 ± 5.2 years post-Fontan). The need for prior or concomitant atrioventricular valve repair or replacement was associated with an increased risk of cirrhosis (univariable hazard ratio [HR] 7.09, 95% confidence interval [CI] 2.13-23.61, P = .001). By multivariable analysis, factors associated with development of cirrhosis were atrioventricular valve failure prior to Fontan (HR 3.27, 95% CI 1.15-9.31, P = .026) and older age at Fontan operation (HR 1.13 per year increase, 95% CI 1.01-1.26, P = .034). The proportion of patients alive, nontransplanted, and without cirrhosis at 10, 15, and 20 years was 93.4% (95% CI 88.4%-98.7%), 79.6% (95% CI 69.7%-90.8%), and 64.6% (95% CI 51.0%-81.9%), respectively.ConclusionsEarly commencement of liver screening should be considered for patients with a history of atrioventricular failure during Fontan palliation.     

Ministernotomy compared with right anterior minithoracotomy for aortic valve surgery

ObjectivesMinisternotomy and right anterior minithoracotomy are the 2 main techniques applied for minimally invasive aortic valve replacement. The goal of this study is to compare early and long-term outcomes of both techniques.MethodsThe data of 2419 patients undergoing isolated minimally invasive aortic valve replacement between 1999 and 2019 were prospectively collected. Retrospectively, patients were divided into the ministernotomy group (n = 1352) and the minithoracotomy group (n = 1067).ResultsAfter propensity score matching, 986 patients remained in each group. Operation time and rate of conversion to full sternotomy were significantly higher in the minithoracotomy group than in the ministernotomy group (184.6 ± 45.2 vs 241.3 ± 68.6, relative risk, 2.54, P = .005 and .09 vs .23, relative risk, 1.45, P = .013, respectively). The 30-day mortality, excluding cardiac death, was lower in the ministernotomy group than in the minithoracotomy group (0.012 vs 0.028, relative risk, 1.41, P = .011, respectively); the intensive care unit length of stay (12.4 vs 16.5, relative risk, 1.62, P = .037, respectively) and hospital length of stay (5.4 vs 8.7, relative risk, 1.74 P = .028, respectively) were significantly longer in the minithoracotomy group. The minithoracotomy surgical approach was the strongest independent predictor of early mortality (odds ratio, 4.24 [1.67-7.35], P = .002). The actuarial survival by Kaplan–Meier analysis at 1, 3, 5, 10, and 20 years was significantly better in the ministernotomy group than in the minithoracotomy group (P = .0001). Actuarial freedom from reoperation at 5 years was 97.3% ± 4.4% in the ministernotomy group versus 95.8% ± 5.2% in the minithoracotomy group (P = .087).ConclusionsMinimally invasive aortic valve replacement using ministernotomy is associated with reduced operative time, intensive care unit stay, hospital length of stay, and postoperative morbidities and incisional pain, and improves early and long-term mortality.