Autologous breast reconstruction in low- and middle-income countries (LMICs): a systematic review of current practices and challenges.

INTRODUCTION: Efforts to improve global healthcare persist, yet LMICs face challenges accessing surgical care, especially breast reconstruction amidst rising breast cancer cases. This review evaluates the present state and challenges of autologous breast reconstruction in low- and middle-income countries (LMICs). EVIDENCE ACQUISITION: Utilizing the PRISMA guidelines and the Cochrane Collaboration's standards, databases such as EMBASE, MEDLINE, Cochrane, PubMed, and Google Scholar were examined for studies on breast reconstruction in LMICs (based on the World Bank's 2022-2023 definitions) up to August 2022. Articles and case reports focusing on autologous reconstruction following breast cancer surgery in these regions were incorporated. EVIDENCE SYNTHESIS: From an initial 288 articles, 19 met the criteria after thorough assessment. These articles documented 4899 patient cases from LMICs, with the breakdown being: 11 on LD flaps, nine on TRAM flaps, eight on DIEP flaps, two on TDAP flaps, and one on TMG flap. Flap necrosis emerged as the prevalent complication in four studies. CONCLUSIONS: While autologous breast reconstruction presents superior aesthetic benefits without notable long-term economic setbacks, its adoption in LMICs is limited. This is partly due to the domination of implant-based methods among patients and surgeons, selected due to convenience. The scarcity of concrete evidence and standardized metrics in LMICs clouds the understanding of this procedure. Despite its advantages, awareness is low, necessitating more training and awareness campaigns. Uniform reporting, quality data, and financial analysis can provide a comprehensive LMIC understanding, aiding future research.

Isocyanide-based multicomponent reactions for the synthesis of benzopyran derivatives with biological scaffolds.

Benzopyrans (BZPs) are among the most privileged and influential small O-heterocycles that form the core of many natural compounds, commercial drugs, biological compositions, agrochemicals, and functional materials. BZPs are divided into six general categories including coumarins, chromans, 2H-chromenes, 4H-chromenes, chromones, and 4-chromanones, each of which is abundant in many plants and foods. These oxygenated heterocyclic compounds are fascinating motifs and have extensive applications in biology and materials science. Hence, numerous efforts have been made to develop innovative approaches for their extraction and synthesis. However, most of them are step-by-step or multi-step strategies that suffer from waste material generation and a tedious extraction process. Isocyanide-based multicomponent reactions (I-MCRs) offer a highly efficient method for overcoming these problems. The I-MCR is a simple and environmentally friendly one-pot domino procedure that does not require intermediate isolation or workup and is generally more efficient in material usage. This review covers all research articles related to I-MCRs for synthesizing BZP derivatives from the beginning to the middle of the year 2023. This strategy will be useful for organic and pharmaceutical chemists to design new drugs and optimize the synthesis steps of biological compounds and commercial drugs with benzopyran cores.

Machine learning algorithms for the prognostication of abdominal aortic aneurysm progression: a systematic review.

INTRODUCTION: Abdominal aortic aneurysm (AAA), often characterized by an abdominal aortic diameter over 3.0 cm, is managed through screening, surveillance, and surgical intervention. AAA growth can be heterogeneous and rupture carries a high mortality rate, with size and certain risk factors influencing rupture risk. Research is ongoing to accurately predict individual AAA growth rates for personalized management. Machine learning, a subset of artificial intelligence, has shown promise in various medical fields, including endoleak detection post-EVAR. However, its application for predicting AAA growth remains insufficiently explored, thus necessitating further investigation. Subsequently, this paper aims to summarize the current status of machine learning in predicting AAA growth. EVIDENCE ACQUISITION: A systematic database search of Embase, MEDLINE, Cochrane, PubMed and Google Scholar from inception till December 2022 was conducted of original articles that discussed the use of machine learning in predicting AAA growth using the aforementioned databases. EVIDENCE SYNTHESIS: Overall, 2742 articles were extracted, of which seven retrospective studies involving 410 patients were included using a predetermined criteria. Six out of seven studies applied a supervised learning approach for their machine learning (ML) models, with considerable diversity observed within specific ML models. The majority of the studies concluded that machine learning models perform better in predicting AAA growth in comparison to reference models. All studies focused on predicting AAA growth over specified durations. Maximal luminal diameter was the most frequently used indicator, with alternative predictors being AAA volume, ILT (intraluminal thrombus) and flow-medicated diameter (FMD). CONCLUSIONS: The nascent field of applying machine learning (ML) for Abdominal Aortic Aneurysm (AAA) expansion prediction exhibits potential to enhance predictive accuracy across diverse parameters. Future studies must emphasize evidencing clinical utility in a healthcare system context, thereby ensuring patient outcome improvement. This will necessitate addressing key ethical implications in establishing prospective studies related to this topic and collaboration among pivotal stakeholders within the AI field.

Sutureless aortic valve replacement in pure aortic regurgitation: expanding the indications.

BACKGROUND: In the era of transcatheter methods, patients presenting with a pure aortic regurgitation (AR) are not considered eligible for transcatheter treatment and therefore require another less invasive surgical option. We sought to review our experience with sutureless aortic valve replacement (SU-AVR) in patients presenting with symptomatic pure AR, which until now is a contraindication for implementation of sutureless valve prostheses in Europe. METHODS: Between April 2018 and June 2021, 80 consecutive patients underwent a SU-AVR for various indications at our institution. We analyzed the outcomes and postoperative complications of 12 patients presenting with a pure severe AR undergoing SU-AVR using Perceval (Corcym). RESULTS: The mean age of the patients was 67 ± 9.1 years old. All patients presented with symptomatic pure AR. Patients presented with multiple comorbidities as reflected by the mean EuroSCORE-II of 3.6 ± 2.6%. Six patients (50%) underwent a concomitant CABG procedure. The mean operating- and cross clamp time was 127.25 ± 45.9 and 40.33 ± 17.3 min respectively. All isolated SU-AVR were performed via J-sternotomy or right anterolateral thoracotomy. There were no cases of device dislocation. No patients presented with a paravalvular leakage. We observed excellent mean postoperative pressure gradient at follow-up 5.7 ± 1.5 mmHg. CONCLUSIONS: Our experience with SU-AVR shows the feasibility of sutureless technologies in the aortic valve surgery due to pure AR. Besides the great technical success and excellent hemodynamics, SU-AVR in severe AR offers a great opportunity of reducing the invasivity of the surgical procedure and potentially reducing hospital cost without compromising the postoperative outcomes and in-hospital length of stay.

Present and future of machine learning in breast surgery: systematic review.

BACKGROUND: Machine learning is a set of models and methods that can automatically detect patterns in vast amounts of data, extract information, and use it to perform decision-making under uncertain conditions. The potential of machine learning is significant, and breast surgeons must strive to be informed with up-to-date knowledge and its applications. METHODS: A systematic database search of Embase, MEDLINE, the Cochrane database, and Google Scholar, from inception to December 2021, was conducted of original articles that explored the use of machine learning and/or artificial intelligence in breast surgery in EMBASE, MEDLINE, Cochrane database and Google Scholar. RESULTS: The search yielded 477 articles, of which 14 studies were included in this review, featuring 73 847 patients. Four main areas of machine learning application were identified: predictive modelling of surgical outcomes; breast imaging-based context; screening and triaging of patients with breast cancer; and as network utility for detection. There is evident value of machine learning in preoperative planning and in providing information for surgery both in a cancer and an aesthetic context. Machine learning outperformed traditional statistical modelling in all studies for predicting mortality, morbidity, and quality of life outcomes. Machine learning patterns and associations could support planning, anatomical visualization, and surgical navigation. CONCLUSION: Machine learning demonstrated promising applications for improving breast surgery outcomes and patient-centred care. Neveretheless, there remain important limitations and ethical concerns relating to implementing artificial intelligence into everyday surgical practices.

Non-Inferiority of Sutureless Aortic Valve Replacement in the TAVR Era: David versus Goliath.

BACKGROUND: The rapid development of transcatheter treatment methods has made transcatheter aortic valve replacement (TAVR) a feasible alternative to conventional surgical aortic valve replacement (SAVR). Recently, indications for TAVR have been expanded to intermediate- and low-risk patients, although there still remains a portion of ineligible patients. We sought to evaluate and compare our experience with sutureless SAVR and transapical TAVR in the "grey-area" of patients unsuitable for transfemoral access. METHODS: Between April 2018 and June 2021, 248 consecutive patients underwent a sutureless SAVR (SU-SAVR) or TA-TAVR at our institution. We performed a pair-matched analysis and identified 56 patient pairs based on the EuroSCORE II. All transcatheter procedures were performed using SAPIEN XT/3™ prostheses, while all surgical procedures deployed the Perceval (LivaNova) aortic valve. RESULTS: All patients presented with multiple comorbidities as reflected by the median EuroSCORE-II of 3.1% (IQR 1.9-5.3). Thirty-four patients from the surgical group (60.7%) underwent a concomitant myocardial revascularization. There was no significant difference in major adverse events, pacemaker implantation or postoperative mortality during follow-up. Both interventions demonstrated technical success with similar mean postoperative pressure gradients at follow-up and no cases of paravalvular leakage. CONCLUSIONS: Sutureless aortic valve replacement constitutes a feasible treatment alternative for patients with aortic valve disease who are ineligible for transfemoral access route and/or require concomitant coronary revascularization. With its excellent hemodynamic performance, similar survival compared to TA-TAVR, and high cost-efficiency without compromising the postoperative outcomes and in-hospital length of stay SU-AVR might be considered for patients in the "grey-area" between TAVR and SAVR.

Rescue extracorporeal life support as a bridge to durable left ventricular assist device.

BACKGROUND: The ideal timing of a durable assist device implantation in patients with end-stage heart failure presenting with INTERMACS profile I is still controversial. The data on extracorporeal life support (ECLS) bridge to durable left ventricular assist device (LVAD) in these patients is limited. MATERIALS AND METHODS: We retrospectively analyzed the outcomes of 35 patients in acute cardiogenic shock (CS) who, between December 2013 and September 2020, were bridged with ECLS to durable LVAD. The mean age was 52.3 ± 12.0 years. The primary endpoints of this study were in-hospital, 30-day, 6-month, and 1-year mortality. The secondary endpoint was the development of any postoperative adverse events and other characteristics during the follow-up period. We also assessed the impact of the rescue ECLS on the recovery of the end-organ function. RESULTS: In-hospital, 30-day, 6-month, and 1-year survival was 65.6%, 75.9%, 69.2%, and 62.7% respectively. The median time on ECLS was 7 days (IQR 5.0-13.0). We observed a high incidence of a severe right heart failure (22.9%), acute kidney injury on dialysis (68.6%), and respiratory failure (77.1%). Bridge with ECLS provided a significant recovery of liver and kidney function prior to durable LVAD implantation. CONCLUSION: The concept of bridging patients presenting in end-stage heart failure and cardiogenic shock with ECLS prior to durable LVAD implantation is a feasible method to ensure acceptable survival rates and significant recovery of the end-organ function.

Surgical and multimodality treatment of cardiac sarcomas: A systematic review and meta-analysis.

INTRODUCTION: Primary cardiac sarcomas (PCSs) are an extremely rare and aggressive type of malignancies that have been described only by a limited number of observational studies. This study aimed to evaluate the currently existing evidence comparing surgical to multimodality treatment of PCS. METHODS: We systematically reviewed Embase, MEDLINE, Cochrane Database, and Google Scholar, from inception to December 2020, for original articles about surgical and multimodality treatment of PCS. The outcomes included were mortality at various time points, resection margin status, and mean estimated survival. The pooled treatment effects were calculated using a random-effects model. RESULTS: Ten studies including a total of 1570 patients met our inclusion criteria. Surgery was associated with significantly lower mortality when compared to conservative treatment at 1, 2, and 3 years, whereas no significant difference was found at 5 years. Furthermore, multimodality treatment showed significantly lower mortality at 1 year when compared to surgery alone, but not at 2 and 5 years. We found no difference in mortality between angiosarcomas and other PCS subtypes. CONCLUSION: Overall, surgery was found to provide a significant mortality advantage to PCS patients up to 3 years following treatment. Multimodality treatment might be of additional benefit, although only within the first year. Prospective randomized studies are needed to further explore these differences in the treatment of PCS.

Gender and coronary artery bypass grafting in cardiogenic shock.

PURPOSE: Bypass surgery in patients undergoing cardiogenic shock caused by acute coronary syndrome is one of the most urgent and often performed cardiac operations. It remains unclear if patients gender independently influences the outcome. Literature reveals that females and males primarily differ from each other with regard to many important preoperative characteristics. Our objective was to compare the outcome and postoperative courses of both genders, using matched samples, eliminating these preoperative differences. METHODS: Between 2007 and 2015, 491 patients in cardiogenic shock underwent urgent bypass surgery in our institution. To assess the impact of gender on outcomes, we performed a propensity score matching to create two groups [males and females] which were matched for age, severity of shock, coronary artery disease morphology, and other comorbidities. Two groups were created: (1) 103 female and (2) 103 male patients. We analyzed the outcomes, complications and potential mortality predictors. RESULTS: Most of the patients had three-vessel disease (70.1%, n = 344) with proximal left anterior descending lesion (88%, n = 432). Our study showed no differences between female and male patients regarding choice of conduits, number of anastomosed vessels, and outcome. Acute kidney injury (AKI) occurred significantly more often in female patients and pericardial tamponade in their male counterparts. There were no differences regarding other major complications. CONCLUSION: Gender does not appear to influence long-term outcomes in the study sample. Female gender is an independent risk factor for postoperative AKI. Other complications occurred with comparable rates in both genders. Exertion tolerance in the follow-up period was similar between genders.

Bailout bypass surgery for complications of coronary interventions.

BACKGROUND: Mechanical complications of percutaneous coronary interventions are treated percutaneously in most cases. If the rescue intervention is unsuccessful, bailout bypass surgery is necessary to restore the coronary flow. The surgical risk in these cases is higher than that of patients operated on for other indications. The aim of our study was to characterize patients who underwent surgical treatment at our institution and to compare their long-term outcomes with patients who underwent emergency bypass surgery for other indications. METHODS: We analyzed 707 consecutive patients who underwent isolated emergency bypass surgery at our institution from 2007 to 2015. In 44 of these cases, the surgery was necessitated by mechanical complications of percutaneous coronary interventions. There were 31 coronary dissections, 5 entrapped guidewires, and 8 coronary perforations. We compared patients in these three groups with one another. Follow-up was performed to assess long-term outcomes. RESULTS: The median age of the cohort was 68 years (range 59-75 years), and 36 (81.8%) patients presented in cardiogenic shock. Thirty-seven (84.1%) patients had history of a percutaneous coronary intervention. The courses were typical for bypass patients. The long-term survival was similar in all three subgroups (p = 0.16). The survival profiles within our sample did not differ significantly from that in patients who underwent emergency bypass surgery for other indications. CONCLUSIONS: Surgical risk and short- and long-term outcomes of patients undergoing emergency bypass surgery due to mechanical complications of percutaneous coronary interventions are similar to those of patients receiving the same surgery for other indications.

Transition metal- and catalyst-free one-pot green method for the synthesis of N-sulfonyl amidines via direct reaction of sulfonyl azides with amines.

In this report, a green synthesis of N-sulfonyl amidines via the direct reaction of tertiary or secondary amines with sulfonyl azides is described. Transition metal- and catalyst-free conditions were used for the synthesis of biologically important N-sulfonyl amidines. Further studies showed that the reaction proceeded via in situ aerobic oxidation of amines under reflux conditions.

Effects of cerebrolysin on functional outcome of patients with traumatic brain injury: a systematic review and meta-analysis.

BACKGROUND: Traumatic brain injury (TBI) remains a main public health problem being associated with high mortality and morbidity. The functional outcome of TBI remains unfavorable despite several surgical and medical therapies. Cerebrolysin is a neuropeptide with potential neuroregenerative entities. OBJECTIVE: The aim of the current systematic review and meta-analysis was to investigate the effects of cerebrolysin on functional outcome in patients with moderate and severe TBI. DATA SOURCES: Online databases used included Medline, Scopus, EMBASE, Google Scholar, Web of Science, and Cochrane Library. STUDY ELIGIBILITY CRITERIA: All the relevant studies with randomized clinical trial and cohort design evaluating the effects of intravenous cerebrolysin vs placebo on functional outcome of patients with TBI within the English literature up to October 2018 were included. STUDY APPRAISAL AND SYNTHESIS METHODS: The articles were reviewed by two independent authors and the data were extracted to a data sheet. I 2 and Cochran's Q-statistics were used to assess heterogeneity. Based on the presence of significant heterogeneity across included studies, data were pooled using random-effects model with Dersimonian-Laird method and presented as standardized mean differences (SMDs) and corresponding 95% CI. RESULTS: Five articles (5,685 participants) were included in the current meta-analysis. The overall pooled findings using random-effects models among patients with TBI indicated that intravenous administration of cerebrolysin significantly increased Glasgow Outcome Scale score (SMD =0.30; 95% CI: 0.18 to 0.42; P<0.001; I 2: 87.8%) and decreased modified Rankin Scale score (SMD =-0.29; 95% CI: -0.42 to 0.16; P=0.05; I 2: 89.6%). LIMITATIONS: The results are mainly based on cohort studies and there is a lack of clinical trials in the literature. There is also heterogeneity among the studies regarding the dosage and duration of administration and the measurement of functional outcome. CONCLUSION: The results of the current study revealed that intravenous administration of cerebrolysin is associated with improved functional outcome in patients with TBI measured by the Glasgow Outcome Scale and the modified Rankin Scale scores.

Surgical Treatment of Cardiac Metastases: Analysis of a 13-Year Single-Center Experience.

BACKGROUND: Cardiac metastases are more common than primary malignant tumors of the heart and are usually treated surgically as a palliative approach. In this study, we reviewed our experience with the surgical treatment of patients with cardiac metastases of various types of malignant tumors. METHODS: Between 2003 and 2016, 10 patients underwent surgery for cardiac metastases at our institution. RESULTS: The mean age was 53.5 ± 19 years. Female patients made up 60% (n = 6) of the collective. The cohort included cardiac metastases of diverse origins (peripheral sarcomas, melanoma, rectal carcinoma, and hepatocellular carcinoma). The left side of the heart was more frequently affected (n = 7). In only six patients, the primary malignancy was known at the time of cardiac surgery. The interval between the first diagnosis of the primary tumor and cardiac metastases ranged from simultaneous diagnosis to up to 19 years. At the time of the diagnosis of the cardiac metastases, seven patients already had multiple metastases: all seven patients had pulmonary metastases, and three of them additionally had hepatic, cerebral, or osseous metastases. Only four patients were symptomatic (atrial fibrillation, pericardial effusion, tachycardia with chest pain, dyspnea). There was no in-hospital death. The postoperative course was uneventful overall. The one- and two-year survival rates were similar, that is, 76%. The median follow-up time was 5.4 years. CONCLUSIONS: Surgical intervention for treating cardiac metastases is associated with uneventful clinical outcome and acceptable survival in this critically ill population. Control of the primary malignancy, and maybe other metastases, determines the survival.

Surgery for Cardiac Papillary Fibroelastoma: A 12-Year Single Institution Experience.

BACKGROUND We reviewed our clinical experience with cardiac papillary fibroelastoma from 2005 to 2017. The objective of this study was to investigate the clinical and operative data, as well as the early survival rate and immediate postoperative complications. MATERIAL AND METHODS We performed a retrospective analysis of 11 patients (eight males and three females) who underwent resection of cardiac papillary fibroelastoma in our institution. RESULTS Mean age at tumor diagnosis was 60±14 years. The mean dimension of the tumor was 14±11 mm. The most common symptoms were dyspnea, palpitation, and angina pectoris, while one patient had recurrent fever attacks and another patient had a transient ischemic attack. Two patients had concomitant malignant tumors (cervical and colon carcinoma) and another two had concomitant benign neoplasms (liver cyst and thyroid adenoma). Bypass and cross clamp times were 77±32 minutes and 54±18 minutes, respectively. The tumors were found predominantly on cardiac valves (n=7). In eight cases, only tumor extirpation was performed, whereas in the other three cases, the valves had to be replaced. The mean intensive care unit length of stay was 1.1±0.3 days and there was no in-hospital mortality. All patients were alive at one-year follow-up and the survival rate was 91% in the mean follow-up period of 4.15 years. CONCLUSIONS The surgical treatment of cardiac papillary fibroelastoma was curative and safe. Thus, potential complications such as embolization or mechanical irritation of the valves can be avoided without high surgical risk.

Surgical Treatment of Cardiac Tumors: Insights from an 18-Year Single-Center Analysis.

BACKGROUND The aim of this study was to investigate the clinical presentation, operative data, and early and late outcomes of a large patient cohort undergoing surgical treatment for cardiac tumors in our institution. MATERIAL AND METHODS A total of 181 patients underwent surgery because of suspected cardiac tumor in our institution between 1998 and 2016. In 162 cases, the diagnosis was confirmed postoperatively and these patients were included in this study. Preoperative baseline characteristics, operative data, and postoperative early and long-term outcomes were analyzed. RESULTS Mean age at presentation was 56.6±17.6 years, and 95 (58.6%) patients were female. There were 126 (77.8%) patients with benign cardiac tumors, while the remaining patients had malignant tumors (primary and metastasized). The mean follow-up time was 5.2±4.7 years. The most frequent histologically verified tumor type was myxoma (63%, n=102). In terms of malignant tumors, various types of sarcomas presented most primary malignant cardiac tumors (7.4%, n=12). The mean ICU length of stay was 1.7±2.2 days and overall in-hospital mortality was 3.1% (n=5). Frequent postoperative complications included mediastinal bleeding (5.8%, n=9), wound infection (1.3%, n=2), acute renal failure (5.6%, n=9), and major cerebrovascular events (n=7, 4.6%). The overall cumulative survival after cardiac tumor resection was 94% at 30 days, 85% at 1 year, 72% at 5 years, and 59% at 15 years. CONCLUSIONS Surgical treatment of cardiac tumors is a safe and highly effective strategy associated with good early and long-term outcomes.