Validation of the Emory Risk Score in the Transcatheter Aortic Valve Implantation Population: A Canadian Perspective.

Background: Permanent pacemaker (PPM) implantation may be indicated post-transcatheter aortic valve implantation (TAVI). The Emory Risk Score (ERS) is a validated predictive risk score of the need for a PPM post-TAVI using a balloon-expandable valve. Our objectives were to determine the validity of the ERS in our local TAVI population with both balloon-expandable and self-expanding valves and to identify additional electrocardiographic (ECG) parameters predictive of the need for a PPM post-TAVI. Methods: Retrospective chart and electronic database reviews were performed to collect demographic and procedural information. Two expert readers reviewed all ECGs. Independent factors associated with PPM implantation were examined with multivariable logistic regression via a stepwise selection process with calculation of the area under the receiver operating characteristic curve to assess model discrimination. Results: The overall PPM implantation rate was 11.7%; rates were 9% for the Sapien 3 valves, 10% for the Evolut Pro valves, and 17% for the Evolut R valves. The ERS was found to not be predictive of need for PPM post-TAVI for the entire cohort. Right bundle branch block was the only ERS parameter independently associated with new PPM implant (8.5% vs 25%, odds ratio = 3.59, P = 0.01). No additional ECG parameters met the criteria for statistical significance. Conclusions: The poor predictive value of the ERS in determining the need for a PPM post-TAVI in our patient population suggests that further refinement of a formula (or risk-calculator) is warranted. Identification of a precise risk-calculator is likely to facilitate patient mobilization and reduce inpatient healthcare resource utilization.

Introduction: L'implantation d'un stimulateur cardiaque permanent (SCP) peut être indiquée après l'implantation valvulaire aortique par cathéter (post-IVAC). L'Emory Risk Score (ERS) est un score de prédiction du risque validé de la nécessité d'un SCP post-IVAC au moyen d'une valve expansible par ballonnet. Nous avions pour objectif de déterminer la validité de l'ERS auprès de notre population ayant eu une IVAC soit par valve expansible par ballonnet ou valve auto-expansible, et de déterminer d'autres paramètres électrocardiographiques (ECG) prédictifs de la nécessité d'un SCP post-IVAC. Méthodes: Nous avons réalisé des revues rétrospectives de dossiers et de bases de données électroniques pour collecter les données démographiques et interventionnelles. Deux experts ont lu et interprété tous les ECG. Les facteurs indépendants associés à l'implantation du SCP ont été examinés en effectuant la régression logistique multivariée par processus de sélection pas-à-pas au moyen du calcul de la surface sous la courbe caractéristique d'efficacité du récepteur afin d'évaluer la discrimination du modèle. Résultats: Le taux global d'implantation d'un SCP était de 11,7 % ; les taux étaient de 9 % pour les valves Sapien 3, de 10 % pour les valves Evolut Pro et de 17 % pour les valves Evolut R. Nous avons observé que l'ERS ne permettait pas de prédire si l'implantation d'un SCP post-IVAC était nécessaire pour la cohorte entière. Le bloc de branche droit était le seul paramètre de l'ERS indépendamment associé à la nouvelle implantation d'un SCP (8,5 % vs 25 %, rapport de cotes = 3,59, P = 0,01). Aucun autre paramètre ECG ne satisfaisait au critère de signification statistique. Conclusions: La faible valeur prédictive de l'ERS à déterminer la nécessité d'un SCP post-IVAC au sein de notre population de patients montre que des améliorations de la formule (ou calculateur de risques) sont justifiées. L'identification d'un calculateur de risques précis devrait favoriser l'adhésion des patients et réduire l'utilisation des ressources en soins de santé en milieu hospitalier.

Efficacy of Crosseal fibrin sealant (human) in rhytidectomy.

OBJECTIVE: To examine the potential efficacy of Crosseal (the human protein, bovine component-free fibrin sealant) (OMRIX Biopharmaceuticals, Ltd, Brussels, Belgium) to reduce ecchymoses and hematoma formation in patients undergoing rhytidectomy. METHODS: Before initiation of the study, approval was obtained from the US Food and Drug Administration for an Investigational New Drug Application and off-label use of Crosseal and from the Institutional Review Board of the University of California, Davis. Patients undergoing rhytidectomy with or without concomitant procedures were voluntarily enrolled without compensation in the study (N = 9). Patients were randomized according to which side of the rhytidectomy the tissue sealant was placed. In all patients in the study, 1 side of the rhytidectomy was treated with Crosseal; the other, untreated side was used as a control. Before closure of the skin, 2 mL of Crosseal was sprayed through a pressure regulator under the skin flap of the dissected area of the rhytidectomy only on 1 side. The skin was pretrimmed before placement and closed in standard fashion. A pressure dressing was left in place for 3 days before removal. Nine patients were originally enrolled in the study. On postoperative days 3 and 7, photographs were taken of the patients. The photographs were judged by 5 independent reviewers who were blinded as to which side had been treated with Crosseal. The judges rated the degree of ecchymoses on a scale of 1 (minimal) to 10 (severe) and were asked their opinion as to which side of the facelift had been treated with Crosseal. These results were compared using statistical analysis. Also on days 3 and 7, patients were examined for seroma or hematoma formation on each side of the face. RESULTS: Our study demonstrated efficacy of Crosseal in reducing ecchymoses and swelling in all patients. The mean score for ecchymosis on the Crosseal-treated side was 4.5 and on the untreated (control) side was 6.2 (P < .01, Wilcoxon rank sum test). The rate of hematoma or seroma formation was 22% (2 of 9 patients) for the untreated side vs 0% (0 of 9 patients) for the treated side. This did not reach statistical significance (P = .43, Fisher exact test). Small hematomas developed in 2 patients on the control side, which were needle aspirated. There were no known long-term complications from either the use of Crosseal or the rhytidectomy. CONCLUSION: Crosseal is efficacious in reducing ecchymoses after rhytidectomy.

Advances in scalp reconstruction.

PURPOSE OF REVIEW: The present review summarizes traditional and advanced techniques used to reconstruct defects of the scalp. These deformities range from small defects that can be closed primarily to significant defects, which require free tissue transfer. RECENT FINDINGS: Increased use of tissue expanders, advancement rotational flaps, and hair transplantation has resulted in improved cosmetic outcomes for larger defects of the scalp. Free tissue transfer has provided a revolutionary method of reconstructing subtotal and total defects of the scalp, in particular those associated with neoplasms. SUMMARY: New advances in techniques of scalp reconstruction have provided improved outcomes in terms of cosmetic appearance and decreased morbidity for scalp reconstruction.

Quantitative assessment of nasal changes after maxillomandibular surgery using a 3-dimensional digital imaging system.

OBJECTIVE: To evaluate nasal changes after maxillomandibular surgery by means of images taken with a 3-dimensional digital camera. DESIGN: Thirty-two patients (26 female and 6 male) with preoperative and postoperative 3-dimensional photographs were studied. The patients underwent maxillary movement with impaction (upward rotation), maxillary movement with lengthening (downward rotation), or maxillary movement without rotation. With the 3-dimensional imaging software, preoperative and postoperative calculations were performed for interalar width, internostril width, nasal tip projection, and columellar length from the 3-dimensional digital images. The nasolabial angle was also measured. RESULTS: Postoperative interalar and internostril widening was significant (P<.05) for all 3 categories of maxillary movement. However, there was no statistically significant change in nasal tip projection and columellar length. Interestingly, movement of the maxilla with upward rotation did show a statistically significant decrease in the nasolabial angle. CONCLUSIONS: Changes to the nose clearly occur after orthognathic surgery. There was a statistically significant increase in postoperative interalar width and internostril width with maxillary movement. However, no clear correlation could be determined between amount of change and maxillary movement. Interestingly, maxillary advancement did not show any significant change in nasal tip projection or columellar length, with data showing both increases and decreases in measurements. The nasolabial angle in patients who underwent maxillary advancement with impaction (upward rotation) was the only measurement that showed a statistically significant increase.

Porous high-density polyethylene for orbital reconstruction.

OBJECTIVE: To determine the safety and efficacy of using porous high-density polyethylene (PHDPE) in the repair of orbital defects. DESIGN: Retrospective case series. SETTING: Academic tertiary care trauma center. Patients One hundred seventy patients with orbital defects requiring surgical repair. Intervention Orbital defect repair with PHDPE. Main Outcome Measure Our review documents surgical results and complications associated with the use of PHDPE. RESULTS: There was a 6.4% complication rate associated with the use of PHDPE. The infection rate was 1.8%. The persistent orbital malposition rate was 3.5%. The extrusion rate was 0%. CONCLUSIONS: This report represents the largest case series in the literature using PHDPE for orbital reconstructions. The use of PHDPE resulted in a low complication rate and excellent functional and cosmetic reconstructive results. Because of our success with the use of PHDPE, we have changed our clinical practice to minimize the use of autologous graft material, thereby eliminating donor site morbidity in cases involving orbital reconstruction.

Barbed polypropylene sutures for midface elevation: early results.

BACKGROUND: In the past decade, the popularity of minimally invasive procedures for midface rejuvenation has greatly increased. We describe a new technique using percutaneous barbed polypropylene sutures to specifically address midface aging. It can be performed in a closed or open approach, depending on the degree of tissue repositioning required. OBJECTIVE: To determine the efficacy of the barbed polypropylene suture in the elevation of the aging midface and the rate of associated early complications. METHODS: Examination of the results obtained in 44 patients in whom we used the barbed polypropylene suture in a private practice plastic surgery facility. Of these patients, 34 underwent an open-approach and 10 a closed-approach procedure. Attention was focused on improvement of the aging midface, including the infraorbital hollow, lower lid position, nasolabial and melolabial creases, and nasojugal groove. Attention was also focused on improvement of the jowls. RESULTS: All patients demonstrated improvement in the midfacial area and jowls, with minimal complications. CONCLUSION: The suture evaluated in this article provides another technique that can be used by facial plastic surgeons in selected patients to address, in particular, ptosis of the midface.

Gorham Stout syndrome (disappearing bone disease): two additional case reports and a review of the literature.

Gorham-Stout syndrome, or disappearing bone disease, is characterized by the proliferation of thin-walled vascular channels associated with regional osteolysis. There have been fewer than 150 cases reported in the literature. In this clinical report, we describe 2 additional cases of Gorham-Stout syndrome affecting the maxillofacial skeleton. We provide a review of the clinical diagnosis of this syndrome and describe treatment options.

A child with Saethre-Chotzen syndrome, sensorineural hearing loss, and a TWIST mutation.

OBJECTIVE: Patients with syndromic craniosynostosis may have associated hearing deficits. A review of hearing loss associated with syndromic craniosynostosis as well as implications of cochlear implantation in the craniosynostosis patients is presented. In the literature, patients with Saethre-Chotzen syndrome have been shown to have conductive or mixed hearing losses. This case report describes a patient with Saethre-Chotzen syndrome caused by a mutation in the TWIST gene who exhibits a severe to profound sensorineural hearing loss.