Y-Peg-in-a-Round-Hole Closure for Immediate Periareolar Mastectomy Expander Reconstruction.

INTRODUCTION: Mastectomies closed with a linear scar can distort the resulting shape of the breast. We present our novel Y-peg-in-a-round-hole closure method of the mastectomy scar, which improves the shape of the reconstructed breast while maintaining reliable healing, implant coverage, and minimum scar size for covering by tattoo. MATERIALS AND METHODS: A retrospective review of all breast reconstruction cases performed by the senior surgeon during the period from January 2010 to January 2017 was undertaken. Data were analyzed for wound healing problems, infection rates and mastectomy skin flap necrosis. RESULTS: Data were extracted for 126 consecutive patients with 154 breast reconstructions. Twelve breasts (7.7%) experienced wound healing problems, for which 7 (4.5%) required revisionary surgery. Eighteen breasts (11.7%) developed an infection requiring antibiotics, of which 8 (5.2%) needed a further operation. Four breasts (2.6%) needed removal of the implant. No patients were lost to follow-up. CONCLUSION: After nipple resecting mastectomy, the Y-peg-in-a-round-hole scar minimizes radial size and contour deformity but allows for reliable wound healing.

Normalized cardiopulmonary exercise function in patients with pectus excavatum three years after operation.

BACKGROUND: During exercise cardiac function is often limited in patients with pectus excavatum. Therefore, we hypothesized that cardiopulmonary exercise function would improve after the Nuss procedure. METHODS: Seventy-five teenagers (49 patients, 26 controls) were investigated at rest and during bicycle exercise before surgery, and 1 year and 3 years postoperatively (after pectus-bar removal). Echocardiography and lung spirometry were performed at rest. Cardiac output, heart rate, and aerobic exercise capacity were measured using a photoacoustic gas-rebreathing technique during rest and exercise. RESULTS: Forty-four patients and 26 controls completed 3 years follow-up. Preoperatively, patients had lower maximum cardiac index, mean ± SD, 6.6 ± 1.2 l·min(-1)·m(-2) compared with controls 8.1 ± 1.0 l·min(-1)·m(-2) during exercise (p = 0.0001). One year and 3 years postoperatively, patients' maximum cardiac index had increased significantly and after 3 years there was no difference between patients and controls (8.1 ± 1.2 l·min(-1)·m(-2) and 8.3 ± 1.6 l·min(-1)·m(-2), respectively [p = 0.572]). The maximum oxygen consumption was unchanged. Left ventricular dimensions increased in patients over 3 years; however, no difference was seen between the 2 groups. Preoperatively, patients had lower forced expiratory volume in the first second of expiration (FEV1; 86% ± 13%) as compared with controls (94% ± 10%), p = 0.009. Postoperatively, no difference was found in FEV1 between the 2 groups. CONCLUSIONS: Before operation, FEV1 and maximum cardiac index were lower in patients compared with healthy, age-matched controls. One year after, both parameters had increased, although only FEV1 had normalized. After 3 years and bar removal, cardiopulmonary function in patients during exercise had normalized.

Aortic regurgitation after transcatheter aortic valve implantation of the Edwards SAPIEN ™ valve.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) is established as an attractive treatment option for high-risk patients with aortic valve stenosis. One concern is the high risk of prosthetic valve regurgitation. This study aimed to examine for potential preoperative risk factors for postprocedural transcatheter heart valve regurgitation and to quantify the risk, degree, and consequences of postprocedural regurgitation. MATERIALS AND METHODS: 100 consecutive patients who underwent femoral (n = 22) or transapical (n = 78) TAVI were retrospectively reviewed. Echocardiographic valve regurgitation and clinical parameters were analyzed over the first year after TAVI. RESULTS: Seventy-five percent of all patients had prosthetic valve regurgitation. It was, however, only mild or absent in 64% of patients and did not require re-intervention in any of the patients in the series. The severity of the regurgitation appeared unchanged over the one-year follow-up period. Moderate to severe regurgitation was associated with significant yet stable dilatation of the left ventricle over one year and lesser NYHA class improvement three months after TAVI. Asymmetrical native valve calcification increased the risk of paravalvular regurgitation non-significantly. CONCLUSION: Transcatheter heart valve regurgitation seems to be mild in the majority of cases and unchanged over a 12 months follow-up period. While affecting left ventricular dimensions in moderate or severe cases, we observed no obvious undesirable consequences of the prosthetic valve regurgitation within the first year.

Dynamic geometry of the left ventricular outflow tract of pigs with induced supravalvular aortic stenosis.

OBJECTIVES: Detailed information about the dynamic geometry of the left ventricular outflow tract (LVOT) is of great importance for transcatheter aortic valve implantation (TAVI), since these valves utilize the LVOT as a landing zone for optimum placement and fixation. The LVOT is generally considered circular in shape and stable in its conformation. However, recent studies indicate that this may not be the case. METHODS: Twenty-two 5-kg pigs (± 0.47 kg) were randomly allocated to either aortic banding (n = 14) or sham operation (n = 8). LVOT dynamic geometry was assessed using cardiovascular-magnetic resonance imaging, 9 weeks after banding of the ascending aorta. RESULTS: All the banded animals developed significant left ventricular hypertrophy (P = 0.01) compared with controls. All the animals demonstrated significant reduction in eccentricity index (P(intervention) < 0.01, P(control) < 0.05) and longest internal diameter (P(intervention) < 0.01, P(control) = 0.02) when comparing measurements from end-diastole to end-systole. No significant systolic or diastolic differences were found between the two groups. CONCLUSIONS: The main findings were: the LVOT (i) undergoes substantial geometric alterations throughout the cardiac cycle and (ii) is ellipsoid throughout the cardiac cycle, (iii) geometric changes during the cardiac cycle stems from compression of the long-axis of the LVOT and (iv) dynamic geometry did not change significantly after induction of significant LV hypertrophy. Thus, our data suggest that assumptions made in daily practice, of a circular and stable LVOT geometry, need to be revised.

Improved cardiopulmonary exercise function after modified Nuss operation for pectus excavatum.

OBJECTIVES: Patients with pectus excavatum have compromised cardiac function during exercise. We hypothesized that the Nuss technique would improve cardiopulmonary function during exercise. METHODS: We investigated 75 teenagers (49 patients and 26 controls) at rest and during bicycle exercise prior to surgery and 1 year postoperative. RESULTS: Prior to surgery, patients had a lower cardiac index 6.6 ± 1.1 l/min/m(2) when compared with controls 8.1 ± 1.0 l/min/m(2) during submaximal exercise, P = 0.0001. There was no difference in heart rate or increase in heart rate between the two groups. One year after surgery, cardiac index had significantly increased in the pectus group, P = 0.0054 although cardiac index was still significantly lower 7.2 ± 1.0 l/min/m(2) when compared with the control subjects (8.5 ± 1.6 l/min/m(2), P = 0.0008). Both the patients and the controls increased their VO(2) max during the one-year study period although the controls increased most. Right ventricular diastolic dimension increased in both groups over the one-year study period and left ventricular dimensions increased in the patients. Before operation, the patients had lower forced expiratory capacity FEV(1) 86 ± 13% when compared with controls 94 ± 10%, P = 0.009. Patients increased FEV(1)/forced vital capacity over the one-year long study course although there were no differences between groups. CONCLUSION: Patients with pectus excavatum have lower cardiac index at submaximal exercise when compared with healthy age-matched controls. Their cardiac index and FEV(1) are increased one year after the modified Nuss operation.

Transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) was introduced experimentally in 1989, based on a newly developed heart valve prosthesis - the stentvalve. The valve was invented by a Danish cardiologist named Henning Rud Andersen. The new valve was revolutionary. It was foldable and could be inserted via a catheter through an artery in the groin, without the need for heart lung machine. This allowed for a new valve implantation technique, much less invasive than conventional surgical aortic valve replacement (SAVR). Surgical aortic valve replacement is safe and improves symptoms along with survival. However, up to 1/3 of patients with aortic valve stenosis cannot complete the procedure due to frailty. The catheter technique was hoped to provide a new treatment option for these patients. The first human case was in 2002, but more widespread clinical use did not begin until 2006-2010. Today, in 2011, more than 40,000 valves have been implanted worldwide. Initially, because of the experimental character of the procedure, TAVI was reserved for patients who could not undergo SAVR due to high risk. The results in this group of patients were promising. The procedural safety was acceptable, and the patients experienced significant improvements in their symptoms. Three of the papers in this PhD-thesis are based on the outcome of TAVI at Skejby Hospital, in this high-risk population [I, II and IV]. Along with other international publications, they support TAVI as being superior to standard medical treatment, despite a high risk of prosthetic regurgitation. These results only apply to high-risk patients, who cannot undergo SAVR. The main purpose of this PhD study has been to investigate the quality of TAVI compared to SAVR, in order to define the indications for this new procedure. The article attached [V] describes a prospective clinical randomised controlled trial, between TAVI to SAVR in surgically amenable patients over 75 years of age with isolated aortic valve stenosis. The study was terminated prematurely, as patients undergoing TAVI showed a statistically non-significant trend towards more complications than SAVR patients. Although non-significant the study was closed for ethical reasons. At present, scientific evidence supports TAVI as being superior to standard medical treatment, in patients who cannot undergo SAVR due to high- predicted risk. However, in patients who are surgically amenable, current publications suggest that TAVI using presently available devices is not competitive to SAVR, with regards to procedural safety and outcome.

Compromised cardiac function in exercising teenagers with pectus excavatum.

Patients with pectus excavatum complain about fatigue, tachypnea, discomfort and dyspnea, but the existence of an equivalent underlying pathophysiology has been questioned. We investigated 75 teenagers (49 pectus excavatum patients and 26 age matched controls) at rest and during bicycle exercise at submaximal exercise levels. At rest cardiac function was determined using echocardiography. During rest and exercise, cardiac output, heart rate and aerobic exercise capacity were measured using photo-acoustic gas-rebreathing technique for non-invasive determination of the cardiopulmonary function. At rest, no cardiac differences were found between control subjects and patients with pectus excavatum. During submaximal exercise, cardiac index was lower 6.6(6.3-7.0) l/min/m(2) among the pectus patients as compared to the control subjects 8.0(7.3-8.8) l/min/m(2), P=0.0001. The lower cardiac output among the pectus patients was due to a lower stroke index 42(39-45) ml/beat/m(2) as compared to controls 54(44-64) ml/beat/m(2), P=0.0022, whereas heart rate was unchanged. Cardiac function is significantly impaired at submaximal exercise level compared to healthy age matched controls.

Transatrial stent-valve implantation in a stenotic tricuspid valve bioprosthesis.

A 69-year-old man presented with symptoms of right heart failure due to stenosis of a tricuspid valve bioprosthesis. Echocardiography revealed right atrial dilatation and an estimated tricuspid valve area of 0.4 cm2. Because of advanced poor general condition and comorbidities, he was found unfit for conventional reoperation. Instead, transcatheter transatrial stent-valve implantation through a right thoracotomy was scheduled. The procedure resulted in a markedly improved clinical condition and an increased valve area measured to 2.5 cm2. In conclusion, transcatheter transatrial stent-valve implantation in stenotic valves is technically feasible and may lead to substantial improvement of the clinical condition.

Single center experience with transcatheter aortic valve implantation using the Edwards SAPIEN™ Valve.

OBJECTIVES: The use of transcatheter aortic valve implantation (TAVI) for high-risk patients was introduced in the early 2000s for treatment of aortic valve stenosis patients with too high surgical risk. During the last years, there has been a dramatic increase in TAVI procedures. TAVI programs are implemented in numerous cardiac centers. This paper describes a single center experience with its first 100 TAVI procedures. METHODS: This study included the first 100 patients who were scheduled for either transfemoral (F-TAVI) or transapical (A-TAVI) aortic valve implantation at Aarhus University Hospital, Skejby, using the Edwards SAPIEN™ valve. The indication for TAVI was unacceptable high predicted risk associated with conventional surgery. Patients with adequate diameter of iliac arteries were scheduled for F-TAVI, otherwise A-TAVI was preferred. RESULTS: The patients were treated between February 2006 and June 2010. Of these were 44% males and 56% females with a mean (S.D.) age of 81 (7.0). Thirty-days mortality rate was 8%, and decreased from 12% among the first 50 patients to 4% for the last 50 patients. Successful implantation was achieved in 92% patients. Major non-fatal complications were seen in 5% of 76 A-TAVI and in 0% of 24 F-TAVI patients. Mean (S.D.) EuroSCORE in the F-TAVI and A-TAVI groups was 15.9 (9.4) and 21.5 (14), respectively (p = 0.06). Post-procedural leakage of cardiac biomarkers was significantly higher in the A-TAVI group as compared to in the F-TAVI group. Mean (S.D.) NYHA class improved from 2.9 (0.6) to 1.8 (0.7) p < 0.001, with no significant difference between A-TAVI and F-TAVI patients. CONCLUSION: In surgically non-amenable patients, TAVI can be performed with acceptable mortality and morbidity and results in marked functional improvement. A decrease in 30-day mortality over time indicated a learning curve when implementing this treatment.

[Catheter-based aortic valve substitution. Initial experiences with stent valve implantation]. / Kateterbaseret aortaklapsubstitution. Initiale erfaringer med implantation af stentklap.

INTRODUCTION: Recent years have seen the introduction of catheter-based aortic valve substitution with stent valves to treat aortic valve stenosis in patients who were deemed inoperable via conventional open heart surgery. We here report our initial experience. MATERIAL AND METHODS: Register-based study with prospective registration of prespecified parameters. A total of 26 patients were treated with an aortic stent valve, 12 via transfemoral (TFA-AVI) and 14 via transapical (TAP-AVI) access. In the TFA-AVI group, 75% were women and the average age was 85 4.5 years; in the TAP-AVI group, 71% were women and the average age was 79 8.4 years. RESULTS: In the TFA-AVI group, successful stent valve implantation was performed in 9/12 (75%) and TAP-AVI in 13/14 (93%) patients. Mortality after 30 days was 25% in the TFA-AVI and 7% in the TAP-AVI group. The aortic valve area increased from 0.6 0.13 cm(2) to 1.6 0.39 (2) in the TFA-AVI group and from 0.7 0.2 (2) to 1.6 0.37 (2) in the TAP-AVI group. 91% of patients showed clinical improvement after treatment. CONCLUSION: Transcatheter aortic valve implantation of conventional unresectable patients requires close cooperation between different specialities. The treatment seems to be a realistic alternative to medical treatment for inoperable patients and may even be used in operable high-risk patients.