Transcatheter Systemic AV Valve-in-Valve Implantation in a Patient With LTGA and Ebstein Anomaly.

We present the first in-human transcatheter systemic atrioventricular valve-in-valve implantation in a 37-year-old patient with Ebstein anomaly, levo-transposition of the great arteries, and prior systemic valve replacement. She had severe bioprosthetic valve regurgitation and reduced systolic function. She had high surgical risk and was planned for transcatheter intervention. (Level of Difficulty: Advanced.).

The complication rate of intravascular ultrasound (IVUS) in a multicenter pediatric heart transplant population: A study of the international pediatric IVUS consortium.

BACKGROUND: Our purpose was to determine the complication rate from intravascular ultrasound (IVUS) in a large, multicenter cohort of pediatric heart transplant (PHT) patients. METHODS: We retrospectively reviewed all PHT who underwent IVUS at 5 institutions (2006-2014). Rates of major and minor complications were calculated. All adverse events (AE) were graded from 1 to 5 using a previously published AE severity scale. RESULTS: There were 1380 catheterizations in 505 patients and 32 AE (2.3%); 9 major (0.6%) and 23 AE (1.7%). The major AE attributed to IVUS were all coronary artery vasospasm (7). Major and minor AE rates directly related to IVUS were 0.5% and 0.7%, respectively. Minor AE possibly attributable to IVUS included excessive fluoroscopy (3) and transient ST segment changes (7). Of AE related to IVUS, only 3 were of moderate severity. The rest were ≤ minor in severity. There were no reports of coronary artery dissection or death. CONCLUSION: Most AE during routine PHT coronary evaluation with IVUS were minor and not directly related to the use of IVUS. The number of coronary related AE was similar to a registry-based report of coronary angiography alone. Efforts to minimize IVUS-related complications should be focused on preventing coronary artery vasospasm.

Primary Transplantation for Congenital Heart Disease in the Neonatal Period: Long-term Outcomes.

BACKGROUND: Primary transplantation was developed in the 1980s as an alternative therapy to palliative reconstruction of uncorrectable congenital heart disease. Although transplantation achieved more favorable results, its utilization has been limited by the availability of donor organs. This review examines the long-term outcomes of heart transplantation in neonates at our institution. METHODS: The institutional pediatric heart transplant database was queried for all neonatal heart transplants performed between 1985 and 2017. Follow-up was obtained from medical records and an annually administered questionnaire. Overall survival and time to development of complications were estimated using the Kaplan Meier method. Univariate and multivariate analyses were performed to identify independent predictors of survival. RESULTS: Heart transplantation was performed in 104 neonates. Median age was 17 days. Hypoplastic left heart syndrome (classic or variant) was the primary diagnosis in 77.8% of patients. Survival at 10 years and 25 years was 73.9% and 55.8%, respectively. At 20 years, freedom from allograft vasculopathy and lymphoproliferative disease was 72.0% and 81.9%, respectively. Freedom from re-transplantation was 81.4% at 20 years. Eight patients (7.6%) developed end-stage renal disease. By multivariate analysis, lower glomerular filtration rate and allograft vasculopathy were the only significant predictors of death. CONCLUSIONS: Neonatal heart transplantation remains a durable therapy with very acceptable long-term survival. Children transplanted in the newborn period have the potential to reach adulthood with minimal need for reintervention.

Toward an understanding of the development of time preferences: Evidence from field experiments.

Time preferences have been correlated with a range of life outcomes, yet little is known about their early development. We conduct a field experiment to elicit time preferences of over 1,200 children ages 3-12, who make several intertemporal decisions. To shed light on how such primitives form, we explore various channels that might affect time preferences, from background characteristics to the causal impact of an early schooling program that we developed and operated. Our results suggest that time preferences evolve substantially during this period, with younger children displaying more impatience than older children. We also find a strong association with race: black children, relative to white or Hispanic children, are more impatient. Finally, assignment to different schooling opportunities is not significantly associated with child time preferences.

Xiphoidectomy for Intractable Xiphodynia.

BACKGROUND: Xiphodynia is a rare condition with hardly any data published regarding xiphoidectomy as a valid treatment option for intractable disease. It is necessary to bear this syndrome in mind after having filtered out other differential diagnoses. METHODS: Between 2003 and 2015, 11 patients underwent xiphoidectomy for intractable xiphodynia at our institution. Patients' charts were reviewed including preoperative workup, operative technique, and results. Every patient had routine follow-ups, 4 weeks after the procedure and 1 year after surgery. RESULTS: The main symptom was chest pain in the area of the xiphoid. Conservative treatment trials with different combinations of analgesics over at least 1 year did not lead to insufficient and long-term improvement, which is why the decision for a surgical xiphoidectomy was eventually made. No postoperative complications occurred. Significant pain relief was achieved in eight out of ten patients; one patient was lost to long-term follow-up. Both patients with insufficient pain relief have had previous surgery in form of a sternotomy and upper median laparotomy. CONCLUSIONS: Xiphodynia is a diagnostic conundrum, which is why reports on its treatment including surgical resection of the xiphoid are even sparser. So far, this is the largest reported series of surgically treated xiphodynia. Correct diagnosis remains the key factor for success. While tenderness over the tip of the xiphoid process combined with protrusion of the xiphoid with a xiphisternal angle of <160° are good indications for surgery, patients after previous operations affecting the xiphoid process are less likely to benefit from xiphoidectomy.

Arthroscopic Findings After Traumatic Shoulder Instability in Patients Older Than 35 Years.

BACKGROUND: Shoulder instability in the older patient traditionally has received less attention in the literature than in the younger patient population. However, when traumatic dislocation does occur, these patients often still have frequent pain, disability, and even continued instability. PURPOSE: To characterize the pathoanatomy of traumatic anterior shoulder instability in the older patient population and to discuss the correlating symptoms that ultimately led to operative treatment. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients with a history of an initial traumatic anterior shoulder instability event occurring after the age of 35 years who underwent arthroscopic surgical intervention were prospectively enrolled. Exclusion criteria included posterior instability, major fractures of the shoulder girdle, and multidirectional instability. All patients initially underwent a period of nonoperative rehabilitation. Operative treatment was performed if a patient continued to have pain and/or instability. Operative reports and arthroscopic pictures were reviewed for pathoanatomical findings. RESULTS: A total of 27 patients (28 shoulders) met the inclusion criteria and were analyzed in this study (22 men and 5 women; mean age, 55 years; age range, 35-74 years). Surgical intervention was performed for recurrent instability in 7 patients, pain for 8 patients, and pain with instability for 13 patients. Arthroscopic findings demonstrated 18 rotator cuff tears (RCTs) (64.3%) and 18 Bankart lesions (64.3%). Nine patients had both an RCT combined with a Bankart lesion (32.1%). Three humeral avulsion of the glenohumeral ligament (HAGL) lesions (10.7%) and 2 anterior labral periosteal sleeve avulsion (ALPSA) lesions (7.1%) were found. All shoulders demonstrated Hill-Sachs lesions of various size and depth. CONCLUSION: Traumatic shoulder instability in the older patient may result in a wide array of pathologic findings as well as a diversity of clinical presentations. These findings suggest that the clinical diagnostician should maintain a high index of suspicion for RCT, Bankart lesions, and HAGL lesions in older patients who remain symptomatic after traumatic anterior shoulder instability.

Acute elbow dislocations.

The elbow is the second most commonly dislocated major joint in the adult age group and the most commonly dislocated major joint in the pediatric population. The mechanism of injury and resultant ligamentous disruption pattern have been investigated and noted. Classification of elbow dislocation is well described, and allows for appropriate treatment and rehabilitation. For stable reductions, an aggressive early ROM protocol emphasizing active motion has been helpful for maximizing final range of motion and minimizing extension loss. Associated injuries with elbow dislocation are common and can result in significant morbidity if not diagnosed and treated.

Allografts in the treatment of anterior cruciate ligament injuries.

Symptomatic knee instability is a common complaint among athletic individuals after a torn anterior cruciate ligament (ACL) of the knee. Allograft ACL reconstruction has gained popularity for primary and revision reconstructions. This graft choice has become popular with good intermediate term results combined with decreased operative times, hospital costs, and improved immediate postoperative pain and function. Intermediate follow-up has demonstrated similar results with autograft reconstructions, without the addition of donor site morbidity. Multiple allograft options exist for ACL reconstruction. The most commonly selected grafts include patellar tendon, Achilles tendon, and tibialis allografts. The use of a tibialis allograft provides a stout graft for reconstruction, while minimizing bone tunnel size. Bone-patella-bone allografts provide bone to bone fixation options with flexibility in tunnel selection sizing.

Revision lateral ankle reconstruction.

BACKGROUND: Symptomatic lateral ankle instability is a common source of disability in an active population. While most incidences are successfully treated by conservative measures, some individuals require lateral ankle reconstruction. A commonly performed procedure is the Gould modification of the Broström lateral ankle reconstruction. Despite its success, some individuals experience recurrent instability through reinjury. Revision surgery often involves nonanatomic reconstruction using tendon grafts that may restrict normal ankle and subtalar motion and can result in persistent postoperative pain and disability. The purpose of this study was to demonstrate an equivalent success rate using a more anatomic revision lateral ankle reconstruction based on the Gould modification of the Broström concept. METHODS: We retrospectively reviewed 15 consecutive patients who had a revision lateral ankle reconstruction between 1992 and 2000. All procedures were done by a single surgeon (FGL). Patients who exhibited hindfoot varus and dynamic heel rollout had a valgus calcaneal osteotomy. Patients were asked to complete a 100-point questionnaire postoperatively. RESULTS: All patients reported improvement in ankle function, decreased pain, and no episodes of instability compared to preoperative assessments. Excellent results were achieved in 12 of 15 patients which was consistent with published data from index Broström reconstructions. Four patients who had fixed hindfoot varus and dynamic ankle rollout had valgus calcaneal osteotomies. All patients returned to an active lifestyles including sports and military service. CONCLUSION: Our findings suggest that a revision anatomic lateral ankle reconstruction is an effective option. A thorough clinical evaluation was mandatory to assess hindfoot valgus with dynamic ankle rollout for which a valgus calcaneal osteotomy was included in the procedure. We believe that tendon sacrificing procedures can be avoided in most patients, but soft-tissue structures must be assessed intraoperatively and the surgical approach planned to allow for conversion if necessary.

Blood flow to the metatarsal head after chevron bunionectomy.

BACKGROUND: Avascular necrosis (AVN) of the metatarsal head is a known, but infrequent, complication of a chevron bunionectomy. An increased incidence of AVN has been reported with the addition of an adductor tenotomy and lateral release. The purpose of this study was to document the vascular insult to the metatarsal head during a chevron bunionectomy with adductor tenotomy and lateral release through direct blood flow measurements during the procedure. METHODS: A prospective study of 20 patients was performed. A chevron bunionectomy was performed under regional anesthesia without tourniquet control by two surgeons. Blood flow recordings were documented during key portions of the procedure: baseline, medial capsulotomy, adductor tenotomy and lateral release, and chevron osteotomy. The Periflux PF3 laser Doppler probe (Perimed, Inc., North Royalton, OH) was used to record blood flow. Mauchly's test of Sphericity and a pairwise comparison were performed with significance defined as p < 0.05. All patients had radiographs 3 months postoperatively to assess AVN. RESULTS: There was a statistically significant decrease in blood flow to the metatarsal head at each portion of the procedure. The greatest insult occurred with the medial capsulotomy (45% decrease). The lateral release and adductor tenotomy caused a 13% decrease and the chevron osteotomy caused a 13% decrease, totaling 71% decrease from the baseline. There was no evidence of AVN at 3 months, and all patients had radiographic evidence of union without recurrence or over-correction. CONCLUSION: The addition of the adductor tenotomy with lateral release often is crucial to obtain the desired correction and avoid the complication of recurrence. The disruption of microvascular blood flow to the metatarsal head after a chevron bunionectomy with adductor tenotomy and lateral release was not complete, totaling 71% in the study population. The greatest insult occurred with the medial capsulotomy. There were no occurrences of AVN. Despite the fear of AVN, this study demonstrated that an adductor tenotomy and lateral release could be done safely completed with a chevron bunionectomy.

Fate of polytetrafluoroethylene monocusp pulmonary valves in an animal model.

Creation of a competent pulmonary monocusp valve facilitates transition from pressure to volume overload following right ventricular outflow tract reconstruction. To determine intermediate-term results and performance of the different types of polytetrafluoroethylene membrane used to construct monocusp valves and transannular patches, 12 infant lambs underwent excision of the native pulmonary valve and insertion of a monocusp valve and transannular patch made from one of 4 types of membrane. Echocardiography was performed after 3, 6, 9, and 12 months, and cardiac catheterization was carried out prior to animal sacrifice at 6 (n = 4) or 12 (n = 8) months. There was no postoperative morbidity or mortality. On echocardiography, 6 valves were mobile (50%), 4 had diminished mobility (33%), and 2 were fixed (17%) prior to sacrifice. At catheterization, mild, moderate, and severe pulmonary regurgitation was observed in 4 valves each (33%), with no stenosis. Right ventricular outflow tract reconstruction with polytetrafluoroethylene monocusp valves can be safely accomplished with good early competence, variable degrees of late insufficiency, and no stenosis. Compared to an open microstructure, the closed polytetrafluoroethylene microstructure showed a milder fibroinflammatory reaction and fewer foci of microcalcification, with sparing of the free edge of the monocusp; this correlated with better intermediate-term hemodynamic performance.