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Journal and News Scan
Button battery ingestion in children is associated with severe morbidity and mortality if not treated promptly, due to the coagulation necrosis that ensues. Formation of a tracheoesophageal fistula (TEF), due to tissue necrosis, is an exceedingly rare complication, albeit one that carries high mortality. This article reports on four cases of TEF, their presentation, perioperative management, the surgical treatment employed, and follow-up. The authors discuss the use of esophagectomy with cervical fistula, repair of the trachea with aortic homograft, and the use of latissimus dorsi pedicled interposition flaps to cover and reinforce large tracheobronchial defects. The authors also discuss their technique and rationale for using aortic homograft due to its stiffer mechanical properties compared to bovine or autologous pericardium, thus, theoretically, applying less stress to suture lines.
Surgical treatment of laryngotracheal stenosis remains challenging not only because of low case volumes, but also due to highly individualized approaches used, including use of different endoscopic approaches. This article discusses surgical approaches used in 45 patients, including standard cricotracheal resection (CTR) (11 percent), CTR with dorsal mucosal flap (49 percent), CTR with dorsal mucosal flap and lateral cricoplasty (24 percent) and single stage laryngotracheal reconstruction (16 percent). Although, these procedures were carried out with low morbidity, it appears that prior endoscopic approaches add to the complexity of subsequent surgical resection, and adversely affect metrics in functional evaluation. Thus, the authors make a case for earlier surgical referral in patients with laryngotracheal stenosis.
Surgical treatment of pleural mesothelioma remains challenging and carries high morbidity, especially in patients who develop post operative empyema. This interesting article retrospectively studied 400 patients of whom 50 developed postoperative empyema. Extrapleural pneumonectomy (EPP) was found to be the only risk factor associated with development of empyema, with an odds ratio of 2.8 after controlling for confounding factors. Of note, survival was significantly worse in patients who developed empyema compared to those who did not.
Atrial fibrillation (AF) increases the risk of stroke and systemic embolism. While oral anticoagulation is the current standard of care, there is a growing body of evidence supporting left atrial appendage closure (LAAC) as an alternative or complementary treatment approach to reduce the risk of stroke or systemic embolism in patients with AF. An increasing number of randomized clinical trials studying the efficacy and safety of catheter-based LAAC in comparison with medical noninterventional treatment are giving further insights into this topic. Furthermore, robust randomized data about surgical LAAC in patients with AF undergoing cardiac surgery showed a significant reduction of the risk of stroke on the background of continued anticoagulation therapy. In this review, the authors describe the rapidly evolving field of LAAC and discuss recent clinical data, ongoing studies, open questions, and current limitations of LAAC.
The aim of this study was to demonstrate the ability of the Versius Surgical System to successfully and safely complete a range of thoracic procedures aligned with phase 2a of the (Development) of the Idea, Development, Exploration, Assessment and Long-term follow-up (IDEAL) framework for surgical innovation.
This prospective study included the first 30 consecutive patients who underwent robotic surgery with Versius by two surgeons without prior robotic experience between 1 April 2023 and 30 December2023 (25 lung resections [i.e., wedge, segmentectomy, lobectomy] and 5 thymectomies). There were no specific predetermined selection criteria for each case. The primary outcome was safe completion of the procedure without unplanned conversion. Secondary outcomes included intraoperative and postoperative complications, intraoperative device-related outcomes, and pathology results.
Twenty-eight cases (93.3 percent) were completed without conversion. Both conversions were to thoracoscopy, one due to a console alarm and the other due to a pulmonary artery bleeding. In lung resections, the median console time was 103 (90–129) minutes. Five patients (20 percent) experienced postoperative complications, the most frequent was persistent air leak (16 percent). The median length –of stay was 3 (2–4) days. Neither readmissions nor mortality was observed. In thymectomies, no intraoperative or postoperative complications, readmissions, reinterventions or mortality were observed. The median console time was 77 (75–89) minutes and the median length of stay was 1 (1–1) day.
This phase 2a IDEAL-D study confirms lung resections and thymectomies are feasible with the use of Versius system, laying the foundation for larger phase 2b and 3 clinical studies within the IDEAL-D framework.
There is limited data about the impact of timing of pulmonary valve replacement (PVR) on right heart reverse remodeling in patients with pulmonary regurgitation following intervention for isolated pulmonary valve stenosis (PS). This study compared differences in postprocedural right heart reverse remodeling after early versus late PVR (defined as PVR before versus after attainment of the conservative consensus criteria proposed by Bokma et al, 2018) in patients with prior intervention for PS, using patients with tetralogy of Fallot as the reference group.
Right atrial reservoir strain and right ventricular free wall strain were measured at baseline, one and three years after PVR. There were 114 patients with PS (early PVR, 87 [76 percent]; late PVR, 27 [24 percent]) and 291 patients with tetralogy of Fallot (early PVR, 197 [67 percent]; late PVR, 96 [33 percent]). The PS group had greater improvement in right atrial reservoir strain at one year (12 percent ±4 percent versus 8 percent±4 percent; P<0.001) and three years (15 percent±6 percent versus 9 percent ±6 percent ; P<0.001), and a greater improvement in right ventricular free wall strain at one year (12 percent ±4 percent versus 7 percent ±3 percent , P=0.008) and three years (16 percent ±6 percent versus 12 percent ±5 percent ; P=0.01) after PVR compared with the tetralogy of Fallot group. There was no difference in right heart reverse remodeling between patients who underwent early versus later PVR within the PS group. In contrast, late PVR was associated with less right heart reverse remodeling within the tetralogy of Fallot group.
These data suggest that patients with palliated PS presenting pulmonary regurgitation have a more benign clinical course, hence, delaying PVR in this population may be appropriate.
As long-term outcomes of congenital heart operations continue to improve, attention has turned toward neurocognitive development. As such, there is a need for clinical tools to predict neurologic outcomes in mid- and long-term follow-ups. In this article, the authors present an interesting study of 76 patients who had continuous EEG monitoring throughout this study. Researchers were able to identify key phenotypic patterns associated with cognitive, gross motor, and fine motor scores over a median one-year follow-up. Continuous EEG monitoring may prove to be a useful tool in the treatment team’s armamentarium to prognosticate infants and children undergoing congenital heart surgery from a neurologic standpoint.
Wearable Devices, Health Care Use, and Psychological Well‐Being in Patients With Atrial Fibrillation
Wearables are increasingly used by patients with atrial fibrillation (AF) for symptom monitoring and health management, but their impact on patient health care use and psychological well‐being is not well understood.
In this retrospective, propensity‐matched study of patients with AF, survey and electronic health record data were merged to compare AF‐specific health care use (outpatient/inpatient visits, rhythm‐related testing, and procedures) and informal health care use (telephone calls and patient portal messages) over a 9‐month period between wearable users and nonusers. The authors also examined the effects of wearable cardiac monitoring features (eg, heart rate alerts, irregular rhythm notification, and ECG) on patient behavior and well‐being. Of 172 patients with AF in this analysis (age, 72.6±9.0 years; 42 percent women), 83 used wearables. Compared with nonusers, wearable users reported higher rates of symptom monitoring and preoccupation (P=0.03) and more AF treatment concerns (P=0.02). Moreover, 20 percent of wearable users experienced anxiety and always contacted their doctors in response to irregular rhythm notifications. After matching, AF‐specific health care use was significantly greater among wearable users compared with nonusers (P=0.04), including significantly higher rates of ECGs, echocardiograms/transesophageal echocardiogram, and ablation. Wearable users were also significantly more likely to use informal health care resources compared with nonusers (P=0.05).
Wearables were associated with higher rates of symptom monitoring and preoccupation, AF treatment concerns, AF‐specific health care use, and use of informal health care resources. Prospective, randomized studies are needed to understand the net effects of wearables and their alerts on patients, providers, and the health care system.
The selection of valve prostheses for patients undergoing surgical aortic valve replacement (SAVR) remains controversial. In this study, the authors compared the long-term outcomes of patients undergoing aortic valve replacement with biological or mechanical aortic valve prostheses.
The authors evaluated late results among 5,762 patients aged 45-74 years who underwent biological or mechanical aortic valve replacement with or without concomitant coronary artery bypass from 1989 to 2019 at four medical centers. The Cox proportional hazards model was used to compare late survival; the age-dependent effect of prosthesis type on long-term survival was evaluated by an interaction term between age and prosthesis type. Incidences of stroke, major bleeding, and reoperation on the aortic valve following the index procedure were compared between prosthesis groups.
Overall, 61 percent (n=3,508) of patients received a bioprosthesis. The 30-day mortality rate was 1.7 percent (n=58) in the bioprosthesis group and 1.5 percent (n=34) in the mechanical group (P=0.75). During a mean follow-up of 9.0 years, the adjusted risk of mortality was higher in the bioprosthesis group (HR=1.30, P<0.001). The long-term survival benefit associated with mechanical prosthesis persisted until 70 years of age. Bioprosthesis (vs mechanical prosthesis) was associated with a similar risk of stroke (P=0.20), lower risk of major bleeding (P<0.001), and higher risk of reoperation (P<0.001).
Compared to bioprostheses, mechanical aortic valves are associated with a lower adjusted risk of long-term mortality in patients aged 70 years or younger. Patients <70 years old undergoing SAVR should be informed of the potential survival benefit of mechanical valve substitutes.
Pectus defects are a group of congenital conditions found in approximately 1 in 250 people, where the sternum is depressed back toward the spine (excavatum), protrudes forward (carinatum) or, more rarely, is a mixture of both (arcuatum or mixed defects). For the majority of patients, it is well tolerated, but some patients are affected psychologically, physiologically or both.
The deformity becomes apparent at a young age due to the growth of the ribs and the cartilage that links them to the sternum. The majority of defects are mild and are well tolerated, i.e. they do not affect activity and do not cause psychological harm. However, some young people develop lower self-esteem and depression, causing them to withdraw from activities, such as swimming and dancing, and from interactions that might “expose” them, such as sleepovers, dating, going to the beach, and wearing fashionable clothing. This psychological harm occurs at a crucial time during their physical and social development. A small number of patients have more extreme depression of their sternum that impedes their physiological reserve, which can occur when engaging in strenuous exercise, such as running, but can also limit moderate activity, such as walking and climbing stairs. The effects can be so extreme that symptoms occur at rest or cause life-threatening compression of the major blood vessels and organs. The group of patients with physiological impairment typically also suffer from low self-esteem and depression.
This paper summarizes the current evidence for the different treatment strategies for this condition, including supportive care, psychological support and nonsurgical techniques including bracing and vacuum bell therapy. The authors also consider surgical techniques including the Ravitch procedure, the Nuss procedure (minimally invasive repair of pectus excavatum), pectus implants, and other rare procedures such as Pectus Up.
For the majority of patients, supportive care is sufficient, but for a minority, a combination of the other techniques may be considered.
This paper also outlines best practice guidance for the delivery of such therapies, including standardized assessment, consent to treatment, audit, quality assurance, and long-term support.
All the interventions have risks and benefits that the patient, parents, and clinicians need to carefully consider and discuss when deciding on the most appropriate course. The authors hope this evidence review of “Best Practice for Pectus” will make a significant contribution to those considerations and help all involved—from patients to national policy makers—to deliver the best possible care.