A meta-analysis on the effect of proximal landing zone location on stroke and mortality in thoracic endovascular aortic repair

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) involving the aortic arch may increase the opportunity for stroke owing to disruption of cerebral circulation and embolization. In this study, a systematic meta-analysis was performed to examine the impact of proximal landing zone location on stroke and 30-day mortality after TEVAR.

METHODS

MEDLINE and Cochrane Library were searched for all original studies of TEVAR reporting outcomes of stroke or 30-day mortality for at least two adjacent proximal landing zones, based on the Ishimaru classification scheme. Forest plots were created using relative risks (RR) with 95% confidence intervals (CI). An I2 of <40% was regarded as minimal heterogeneity. A P value of <.05 was considered significant.

RESULTS

Of the 57 studies examined, a total of 22,244 patients (male 73.1%, aged 71.9 ± 11.5 years) were included in the meta-analysis, with 1693 undergoing TEVAR with proximal landing zone 0, 1931 with zone 1, 5839 with zone 2, and 3089 with zone 3 and beyond. The overall risk of clinically evident stroke was 2.7% for zones ≥3, 6.6% for zone 2, 7.7% for zone 1, and 14.2% for zone 0. More proximal landing zones were associated with higher risks of stroke compared with distal (zone 2 vs ≥3: RR, 2.14; 95% CI, 1.43-3.20; P = .0002; I2 = 56%; zone 1 vs 2: RR, 1.48; 95% CI, 1.20-1.82; P = .0002; I2 = 0%; zone 0 vs 1: RR, 1.85; 95% CI, 1.52-2.24; P < .00001; I2 = 0%). Mortality at 30 days was 2.9% for zones ≥3, 2.4% for zone 2, 3.7% for zone 1, and 9.3% for zone 0. Zone 0 was associated with higher mortality compared with zone 1 (RR, 2.30; 95% CI, 1.75-3.03; P < .00001; I2 = 0%). No significant differences were found in 30-day mortality between zones 1 and 2 (P = .13) and between zone 2 and zones ≥3 (P = .87).

CONCLUSIONS

The risk of stroke from TEVAR is lowest in zone 3 and beyond, increasing significantly as the landing zone is moved proximally. Furthermore, perioperative mortality is increased with zone 0 compared with zone 1. Therefore, risk of stent grafting in the proximal arch should be weighed against alternative surgical or nonoperative options. It is anticipated that the risk of stroke will improve with further development of stent graft technology and implantation technique.

Interposition Technique for Pulmonary Valve Replacement

BACKGROUND

Stented bioprosthesis implant at surgical pulmonary valve replacement (PVR) ideally should be 25 to 27 mm to facilitate future percutaneous PVR. This often requires accommodating 35 to 37 mm diameter sewing ring in the pulmonary position and requires anterior patch augmentation of the right ventricular outflow tract (RVOT). We present a novel "interposition" technique of PVR that allows upsizing the valve without RVOT patch augmentation.

METHODS

Using standard cardiopulmonary bypass, the main pulmonary artery (MPA) is dissected and transected at an appropriate level. The remnants of pulmonary valve leaflets are excised. The valve stent posts are telescoped into distal MPA, the MPA continuity is restored by end-to-end anastomosis of the proximal and distal MPA, with the interposed prosthetic valve sewing ring in the suture line between the two edges of the MPA with the bulk of the sewing ring extravascular.

RESULT

A total of seven patients (tetralogy of Fallot, three; congenital pulmonary stenosis, four; age range: 15-33 years) underwent the procedure. No patient required RVOT patch augmentation, all patients were extubated in the operating room and were fast-tracked to recovery. Our proposed technique of PVR has the following advantages: accommodate larger size valve, eliminates risk of a paravalvar leak, coronary compression, and anterior tilting of the prosthesis.

CONCLUSION

The valve interposition technique avoids the need for RVOT patch, allows implantation of an adequate sized prosthetic valve, maintains native geometry of the pulmonary artery without the risk of tilting of the prosthesis, and eliminates the risk of paravalvular regurgitation and left coronary compression.

Modified Warden Operation With the Use of Femoral Vein Homograft for Repair of a Variant of Right-Sided Partial Anomalous Pulmonary Venous Connection

Surgical repair of right-sided partial anomalous pulmonary venous return (PAPVR) involves baffling the pulmonary vein across a naturally occurring or surgically created atrial septal defect without causing pulmonary venous or superior vena cava obstruction. A nine-year-old male presented to us with an unusual anatomical variant of right-sided partial anomalous pulmonary venous connection. The pulmonary veins draining the right upper and middle lobes connected to the azygous vein that drained in the usual fashion into the superior vena cava. The Warden operation was modified, with the use of femoral vein homograft, to avoid pulmonary venous obstruction.

Regenerative Medicine Strategies for Hypoplastic Left Heart Syndrome

Hypoplastic left heart syndrome (HLHS), the most severe and common form of single ventricle congenital heart lesions, is characterized by hypoplasia of the mitral valve, left ventricle (LV), and all LV outflow structures. While advances in surgical technique and medical management have allowed survival into adulthood, HLHS patients have severe morbidities, decreased quality of life, and a shortened lifespan. The single right ventricle (RV) is especially prone to early failure because of its vulnerability to chronic pressure overload, a mode of failure distinct from ischemic cardiomyopathy encountered in acquired heart disease. As these patients enter early adulthood, an emerging epidemic of RV failure has become evident. Regenerative medicine strategies may help preserve or boost RV function in children and adults with HLHS by promoting angiogenesis and mitigating oxidative stress. Rescuing a RV in decompensated failure may also require the creation of new, functional myocardium. Although considerable hurdles remain before their clinical translation, stem cell therapy and cardiac tissue engineering possess revolutionary potential in the treatment of pediatric and adult patients with HLHS who currently have very limited long-term treatment options.

Malignant hyperthermia during laparoscopic adjustable gastric banding

Malignant hyperthermia is a rare, but potentially fatal, problem. Bariatric surgeons and anesthesiologists need be aware of the early signs of this complication.

Background:

We report a rare case of malignant hyperthermia during laparoscopic adjustable gastric banding.

Case Description:

A 32-y-old female with no previous history of adverse reaction to general anesthesia underwent laparoscopic adjustable gastric banding. Intraoperative monitoring revealed a sharp increase in end-tidal carbon dioxide, autonomic instability, and metabolic and respiratory acidosis, along with other metabolic and biochemical derangements. She was diagnosed with malignant hyperthermia. Desflurane, the anesthetic agent was discontinued, and the patient was started on intravenous dantrolene.

Results:

The surgery was completed, and the patient was brought to the surgical intensive care unit for continued postoperative care. She developed muscle weakness and phlebitis that resolved prior to discharge.

Conclusion:

Prompt diagnosis and treatment of malignant hyperthermia leads to favorable clinical outcome. This clinical entity can occur in the bariatric population with the widely used desflurane. Bariatric surgeons and anesthesiologists alike must be aware of the early clinical signs of this rare, yet potentially fatal, complication.