Short-term safety and feasibility of a practical approach to combined atrial and ventricular physiological pacing: An initial single-center experience.

Background: Traditional right atrial appendage (RAA) pacing accentuates conduction disturbances as opposed to Bachmann bundle pacing (BBP). Objective: The purpose of this study was to evaluate the feasibility, efficacy, and safety of routine anatomically guided high right atrial septal (HRAS) pacing with activation of Bachmann bundle combined with routine left bundle branch area pacing (LBBAP). Methods: This retrospective single-center study included 96 consecutive patients who underwent 1 of 2 strategies: physiological pacing (PP) (n = 32) with HRAS and LBBAP leads and conventional pacing (CP) (n = 64) with traditional RAA and right ventricular apical leads. Baseline characteristics, sensing, pacing thresholds, and impedances were recorded at implantation and follow-up. Results: The PP and CP cohorts were of similar age (74.2 ± 13.8 years vs 73.9 ± 9.9 years) and sex (28.1% vs 40.6% female). There were no differences in procedural time (95.0 ± 31.4 minutes vs 86.5 ± 33.3 minutes; P = .19) or fluoroscopy time (12.1 ± 4.5 minutes vs 12.3 ± 13.5 minutes; P = .89) between cohorts. After excluding patients who received >2 leads, these parameters became significantly shorter in the CP cohort. The PP cohort exhibited higher atrial pacing thresholds (1.5 ± 1.1 mV vs 0.8 ± 0.3 mV; P <.001) and lower p waves (1.8 ± 0.8 mV vs 3.8 ± 2.3 mV; P <.001) at implantation and at follow-up. In the PP cohort, 72% of implants met criteria for BBP; of the ventricular leads, 94% demonstrated evidence of LBBAP. One lead-related complication occurred in each cohort. Conclusion: Routine placement of leads in the HRAS is a feasible and safe alternative to standard RAA pacing, allowing for BBP in 72% of patients. HRAS pacing can be combined with LBBAP as a routine strategy.

The incidence and impact of atrial fibrillation on hospitalized Coronavirus disease-2019 patients.

BACKGROUND: Since 2019, Coronavirus disease-2019 (COVID-19) has raised unprecedented global health crisis. The incidence and impact of atrial fibrillation (AF) on patients with COVID-19 remain unclearly defined. METHODS: We conducted a retrospective cohort study using ICD-10 codes to identify patients with a primary diagnosis of COVID-19 with or without AF in National Inpatient Sample Database 2020. We compared the outcome of COVID-19 patients with a concurrent diagnosis of AF with those without. HYPOTHESIS: AF will adversely affect the prognosis of hospitalized COVID-19 patients. RESULTS: A total of 211 619 patients with a primary diagnosis of COVID-19 were identified. Among these patients, 31 923 (15.08%) had a secondary diagnosis of AF. Before propensity score matching, COVID-AF cohort was older (75.8 vs. 62.2-year-old, p < .001) and had more men (57.5% vs. 52.0%, p < .001). It is associated with more comorbidities, mainly including diabetes mellitus (43.7% vs. 39.9%, p < .001), hyperlipidemia (54.6% vs. 39.8%, p < .001), chronic kidney disease (34.5% vs. 17.0%, p < .001), coronary artery disease (35.3% vs. 14.4%, p < .001), anemia (27.8% vs. 18.6%, p < .001), and cancer (4.8% vs. 3.4%, p < .001). After performing propensity score match, a total of 31 862 patients were matched within each group. COVID-AF cohort had higher inpatient mortality (22.2% vs. 15.3%, p < .001) and more complications, mainly including cardiac arrest (3.9% vs. 2.3%, p < .001), cardiogenic shock (0.9% vs. 0.3%, p < .001), hemorrhagic stroke (0.4% vs. 0.3%, p = .025), and ischemic stroke (1.3% vs. 0.7%, p < .001). COVID-AF cohort was more costly, with a longer length of stay, and a higher total charge. CONCLUSION: AF is common in patients hospitalized for COVID-19, and is associated with poorer in-hospital mortality, immediate complications and increased healthcare resource utilization.

Left bundle branch area pacing for heart failure patients requiring cardiac resynchronization therapy: A meta-analysis.

INTRODUCTION: Left bundle branch area pacing (LBBP) is a novel conduction system pacing method to achieve effective physiological pacing and an alternative to cardiac resynchronization therapy (CRT) with biventricular pacing (BVP) for patients with heart failure with reduced ejection fraction (HFrEF). We conduted this meta-analysis and systemic review to review current data comparing BVP and LBBP in patients with HFrEF and indications for CRT. METHODS: We searched PubMed/Medline, Web of Science, and Cochrane Library from the inception of the database to November 2022. All studies that compared LBBP with BVP in patients with HFrEF and indications for CRT were included. Two reviewers performed study selection, data abstraction, and risk of bias assessment. We calculated risk ratios (RRs) with the Mantel-Haenszel method and mean difference (MD) with inverse variance using random effect models. We assessed heterogeneity using the I2 index, with I2 > 50% indicating significant heterogeneity. RESULTS: Ten studies (9 observational studies and 1 randomized controlled trial; 616 patients; 15 centers) published between 2020 and 2022 were included. We observed a shorter fluoroscopy time (MD: 9.68, 95% confidence interval [CI]: 4.49-14.87, I2 = 95%, p < .01, minutes) as well as a shorter procedural time (MD 33.68, 95% CI: 17.80-49.55, I2 = 73%, p < .01, minutes) during the implantation of LBBP CRT compared to conventional BVP CRT. LBBP was shown to have a greater reduction in QRS duration (MD 25.13, 95% CI: 20.06-30.20, I2 = 51%, p < .01, milliseconds), a greater left ventricular ejection fraction improvement (MD: 5.80, 95% CI: 4.81-6.78, I2 = 0%, p < .01, percentage), and a greater left ventricular end-diastolic diameter reduction (MD: 2.11, 95% CI: 0.12-4.10, I2 = 18%, p = .04, millimeter). There was a greater improvement in New York Heart Association function class with LBBP (MD: 0.37, 95% CI: 0.05-0.68, I2 = 61%, p = .02). LBBP was also associated with a lower risk of a composite of heart failure hospitalizations (HFH) and all-cause mortality (RR: 0.48, 95% CI: 0.25-0.90, I2 = 0%, p = .02) driven by reduced HFH (RR: 0.39, 95% CI: 0.19-0.82, I2 = 0%, p = .01). However, all-cause mortality rates were low in both groups (1.52% vs. 1.13%) and similar (RR: 0.98, 95% CI: 0.21-4.68, I2 = 0%, p = .87). CONCLUSION: This meta-analysis of primarily nonrandomized studies suggests that LBBP is associated with a greater improvement in left ventricular systolic function and a lower rate of HFH compared to BVP. There was uniformity of these findings in all of the included studies. However, it would be premature to conclude based solely on the current meta-analysis alone, given the limitations stated. Dedicated, well-designed, randomized controlled trials and observational studies are needed to elucidate better the comparative long-term efficacy and safety of LBBP CRT versus BIV CRT.

Sarcoid Heart Disease: Review of Current Knowledge.

Sarcoidosis is a granulomatous disease with the potential of multiple organ system involvement and its etiology remains unknown. Cardiac involvement is associated with worse clinical outcome, and has been reported to be 20-30% in white and as high as 58% in Japanese populations with sarcoidosis. Clinical manifestations of cardiac sarcoidosis highly depend on the extent and location of granulomatous inflammation. The most frequent presentations include heart block, tachyarrhythmia, or heart failure. Endomyocardial biopsy is the most specific diagnostic test, but has poor sensitivity due to often patchy involvement. The diagnosis of cardiac sarcoidosis remains challenging due to nonspecific imaging findings. Both 18 F-fluorodeoxyglucose-positron emission tomography (FDG-PET) and cardiac magnetic resonance imaging can be used to evaluate cardiac sarcoidosis, but evaluate different stages of the disease process. FDG-PET detects metabolically active inflammatory cells while cardiac magnetic resonance imaging with late gadolinium enhancement reveals areas of myocardial necrosis and fibrosis. Aggressive therapy of symptomatic cardiac sarcoidosis is often sought due to the high risk of sudden death and/or progression to heart failure. Prednisone 20-40 mg a day is the recommended initial treatment. In refractory or severe cases, higher doses of prednisone, 1-1.5 mg/kg/d (or its equivalent) and addition of a steroid-sparing agent have been utilized. Methotrexate is added most commonly. Long-term improvement has been reported with the use of a combination of weekly methotrexate and prednisone versus prednisone alone. After initiation of treatment, a cardiac FDG-PET scan may be performed 2-3 months later to assess treatment response.

Outcomes of catheter ablation for ventricular tachycardia in patients with sarcoidosis: Insights from the National Inpatient Sample database (2002-2018).

INTRODUCTION: Data on utilization, major complications, and in-hospital mortality of catheter ablation (CA) for sarcoidosis-related ventricular tachycardia (VT) are limited. We sought to determine the outcomes of sarcoidosis-related VT, and incidence and predictors of complications associated with the CA procedure. METHODS: We queried the 2002-2018 National Inpatient Sample database to identify patients aged ≥18 years with sarcoidosis admitted with VT. A 1:3 propensity score-matched (PSM) analysis was used to compare patient outcomes between CA and medically managed groups. Multivariable regression was performed to determine independent predictors of in-hospital mortality and procedural complications associated with the CA procedure. RESULTS: Of 3220 sarcoidosis patients with VT, 132 (4.1%) underwent CA. Patients who underwent CA were younger, male predominant, more likely Caucasian, had differences in baseline comorbidities including more likely to have heart failure, less likely to have prior myocardial infarction, COPD, or severe renal disease, had a higher mean household income, and more likely admitted to a larger/urban teaching hospital. After PSM, we examined 106 CA cases and 318 medically managed cases. There was a trend toward a lower in-hospital mortality rate in the CA group when compared to the medically managed group (1.9% vs. 6.6%, p = 0.08). The most common complications were pericardial drainage (5.3%), postoperative hemorrhage (3.8%), accidental puncture periprocedure (3.0%), and cardiac tamponade (2.3%). Independent predictors of in-hospital mortality and procedural complications among the CA group included congestive heart failure (odds ratio [OR], 13.2; 95% confidence interval [CI], 1.7-104.2) and mild to moderate renal disease (OR, 3.9; 95% CI, 1.1-13.3). CONCLUSIONS: Compared to patients with sarcoidosis-related VT who received medical therapy alone, those who underwent CA have a trend for a lower mortality rate despite procedure-related complications occurring as high as 9.1%. Additional studies are recommended to better evaluate the benefits and risks of VT ablation in this group.

Takotsubo syndrome and respiratory diseases: a systematic review.

Takotsubo syndrome (TTS) is a rare cardiovascular condition characterized by reversible ventricular dysfunction and a presentation resembling that of acute myocardial infarction. An increasing number of studies has shown the association of respiratory diseases with TTS. Here, we comprehensively reviewed the literature and examined the available evidence for this association. After searching PubMed, EMBASE, and Cochrane Library databases, two investigators independently reviewed 3117 studies published through May 2021. Of these studies, 99 met the inclusion criteria (n = 108 patients). In patients with coexisting respiratory disease and TTS, the most common TTS symptom was dyspnoea (70.48%), followed by chest pain (24.76%) and syncope (2.86%). The most common type of TTS was apical, accounting for 81.13% of cases, followed by the midventricular (8.49%), basal (8.49%), and biventricular (1.89%) types. Among the TTS cases, 39.82% were associated with obstructive lung disease and 38.89% were associated with pneumonia. Coronavirus disease 2019 (COVID-19), which has been increasingly reported in patients with TTS, was identified in 29 of 42 (69.05%) patients with pneumonia. The overall mortality rate for patients admitted for respiratory disease complicated by TTS was 12.50%. Obstructive lung disease and pneumonia are the most frequently identified respiratory triggers of TTS. Medications and invasive procedures utilized in managing respiratory diseases may also contribute to the development of TTS. Furthermore, the diagnosis of TTS triggered by these conditions can be challenging due to its atypical presentation. Future prospective studies are needed to establish appropriate guidelines for managing respiratory disease with concurrent TTS.

Impact of family history of coronary artery disease on clinical outcomes in Takotsubo cardiomyopathy.

Family history of coronary artery disease (FHxCAD) is a critical risk factor for CAD, underscoring the contribution of genetic factors to disease pathogenesis and susceptibility. Takotsubo cardiomyopathy (TCM) simulates the clinical features of and frequently coexists with CAD. However, the association between FHxCAD and TCM is unclear. Here, we retrospectively examined the impact of FHxCAD on in-hospital outcomes of patients with TCM. Using the National Inpatient Sample database (2016-2018), we identified 4733 patients admitted to hospital with a primary diagnosis of TCM. We compared in-hospital outcomes and complications between TCM patients with (n=646, 13.7%) and without FHxCAD (n=646) in the unmatched and in a propensity-score matched cohort (1:1 ratio). TCM with FHxCAD patients had a reduced incidence of cardiogenic shock, acute kidney injury (AKI), and acute respiratory failure (ARF); lower mortality rates; shorter length of stay (LOS); and decreased total charge compared with TCM without FHxCAD patients (p<0.05). In the matched cohort, TCM with FHxCAD patients (vs TCM without FHxCAD patients) had a lower incidence of cardiogenic shock (2.2% vs 6.3%, p<0.001; OR 0.33, 95% CI 0.18 to 0.61), AKI (5.1% vs 8.7%, p=0.016; OR 0.57, 95% CI 0.36 to 0.88), and ARF (5.7% vs 12.7%, p<0.001; OR 0.42, 95% CI 0.28 to 0.63); decreased in-hospital mortality (<11% vs 3.1%, p=0.002; OR 0.2, 95% CI 0.07 to 0.57); shorter LOS (2.66±1.96 days vs 3.40±3.05 days, p<0.001); and a reduced total charge (p=0.001), respectively. FHxCAD was associated with favorable outcomes in both unmatched and propensity-matched cohorts.

A Comparison of In-Hospital Outcomes Between the Use of Impella and IABP in Acute Myocardial Infarction Cardiogenic Shock Undergoing Percutaneous Coronary Intervention.

BACKGROUND: The use of Impella ventricular support systems and intra-aortic balloon pump (IABP) in acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) has increased in recent years and expanded treatment options, although the comparative clinical outcomes and device safety remain unclear. METHODS: We used the Nationwide Inpatient Sample database (2012-2017) to identify adults who were admitted for AMI complicated by CS and received percutaneous coronary intervention (PCI). The study sample was divided into Impella and IABP groups. Patient characteristics, hospital characteristics, and comorbidities were balanced between groups using propensity-score matching. Regression analysis was utilized to study outcome differences between groups. RESULTS: We identified 51,150 patients, of whom 44,265 (86.54%) received IABP and 6885 (13.46%) received Impella. After propensity matching, compared with the Impella group (n = 1592), the IABP group (n = 8638) had lower rates of sepsis (6.44% vs 12.69%; P=.01), blood transfusion (8.92% vs 14.28%; P=.01), mortality (28.95% vs 49.59%; P<.01), and hospitalization costs ($49,420 vs $68,087; P<.001). The IABP group had similar rates of cardiac arrest (20.32% vs 22.22%; P=.32), in-hospital stroke (1.46% vs 1.59%; P=.37), and length-of-stay (8.56 days vs 8.64 days; P=.26) compared with the Impella group. CONCLUSION: In patients with CS complicating AMI who underwent PCI, Impella use compared with IABP was associated with higher mortality with no differences in in-hospital stroke and cardiac arrest rates, although study interpretation is limited by retrospective observational design and the potential for remaining confounders. Further prospective research is warranted to elucidate the optimal mechanical circulatory support device in these patients.

Anticoagulation for Atrial Fibrillation: A Review of Current Literature and Views.

Atrial fibrillation is a common supraventricular tachyarrhythmia with uncoordinated atrial activation and ineffective atrial contraction. This leads to an increased risk of atrial thrombi, most commonly in the left atrial appendage, and increased risks of embolic strokes and/or peripheral thromboembolism. It is associated with significant morbidity and mortality. To meet the concerns of thrombi and stroke, anticoagulation has been the mainstay for prevention and treatment thereof. Historically, anticoagulation involved the use of aspirin or vitamin K antagonists, mainly warfarin. Since early 2010s, direct oral anticoagulants (DOACs) including dabigatran, rivaroxaban, apixaban, and edoxaban have been introduced and approved for anticoagulation of atrial fibrillation. DOACs demonstrated a dramatic reduction in the rate of intracranial hemorrhage as compared to warfarin, and offer the advantages of absolution of monitoring therefore avoid the risk of hemorrhages in the context of narrow therapeutic window and under-treatment characteristic of warfarin, particularly in high-risk patients. One major concern and disadvantage for DOACs was lack of reversal agents, which have largely been ameliorated by the approval of Idarucizumab for dabigatran and Andexanet alfa for both apixaban and rivaroxaban, with Ciraparantag as a universal reversal agent for all DOACs undergoing Fast-Track Review from FDA. In this article, we will be providing a broad review of anticoagulation for atrial fibrillation with a focus on risk stratification schemes and anticoagulation agents (warfarin, aspirin, DOACs) including special clinical considerations.

Machine learning predicting mortality in sarcoidosis patients admitted for acute heart failure.

Background: Sarcoidosis with cardiac involvement, although rare, has a worse prognosis than sarcoidosis involving other organ systems. Objective: We used a large dataset to train machine learning models to predict in-hospital mortality among sarcoidosis patients admitted with heart failure (HF). Method: Utilizing the National Inpatient Sample, we identified 4659 patients hospitalized with a primary diagnosis of HF. In this cohort, we identified patients with a secondary diagnosis of sarcoidosis using International Statistical Classification of Disease, Tenth Revision (ICD-10) codes. Patients were separated into a training group and a testing group in a 7:3 ratio. Least absolute shrinkage and selection operator regression was used to select variables to prevent model overfitting or underfitting. For machine learning models, logistic regression, random forest, and XGBoosting were applied in the training group. Parameters in each of the models were tuned using the GridSearchCV function. After training, all models were further validated in the testing group. Models were then evaluated using the area under curve (AUC) score, sensitivity, and specificity. Results: A total of 2.3% of sarcoidosis patients died in HF admission. Our machine learning model analysis found the RF model to have the highest AUC score and sensitivity. Feature analysis found that comorbid arrhythmias and fluid electrolyte disorders were the strongest factors in predicting in-hospital mortality. Conclusion: Machine learning methods can be useful in identifying predictors of in-hospital mortality in a given dataset.

Carcinoid Heart Disease: Pathophysiology, Pathology, Clinical Manifestations, and Management.

Carcinoid heart disease (CHD) is a rare and potentially lethal manifestation of an advanced carcinoid (neuroendocrine) tumor. The pathophysiology of CHD is related to vasoactive substances secreted by the tumor, of which serotonin is most prominent in the pathophysiology of CHD. Serotonin stimulates fibroblast growth and fibrogenesis, which can lead to cardiac valvular fibrosis. CHD primarily affects right heart valves, causing tricuspid and pulmonic regurgitation and less frequently stenosis of these valves. Left heart valves are usually spared because vasoactive substances such as serotonin are enzymatically inactivated in the lung vasculature. The pathology of CHD is characterized by plaque-like deposition of fibrous tissue on valvular cusps, leaflets, papillary muscles, chordae, and ventricular walls. Symptomatic CHD usually presents between 50 and 70 years of age, initially as dyspnea and fatigue. Echocardiography is the mainstay of imaging and demonstrates thickened right heart valves with limited mobility and regurgitation. Treatment focuses on control of the underlying carcinoid syndrome, targeting subsequent valvular heart disease and managing consequent heart failure. Surgical valve replacement and catheter-directed valve procedures may be effective for selected patients with CHD.

The impact of atrial fibrillation on outcomes in patients undergoing radical prostatectomy.

PURPOSE: To assess the role of atrial fibrillation (AF) on complicating inpatient outcomes of radical prostatectomy (RP). MATERIALS AND METHODS: We identified patients treated with RP during 2012-2014 within National Inpatient Sample (NIS) database. Length of stay, cost of hospitalization, and in-hospital complications were compared between patients with or without diagnosis of AF. Propensity score matching methods and multivariable regression analysis were used to adjust for potential confounders and a trend analysis was conducted. RESULTS: Patients with AF had a significantly longer hospital stay (coefficient 0.19, 95% CI 0.09-0.29, P < 0.001) and higher cost (coefficient 0.10, 95% CI 0.06-0.15, P < 0.001). Post-operative cardiac complications were significantly higher for patients with AF (OR 16.38, 95% CI 7.72-34.74, P < 0.001), while no differences were found in other complications between the two groups. Similar results were shown in propensity score matching methods. The cardiac complications after laparoscopic RP (OR: 37.71, 95% CI 1.85-768.73, P = 0.018) and open RP (OR: 16.78, 95% CI 1.41-199.51, P = 0.026) were significantly higher than robot-assisted RP (RARP) in patients with AF. The results of trend study indicated that postoperative cardiac complication rates showed a trend of decreasing year by year while the prevalence of AF was rising. CONCLUSIONS: Perioperative AF is associated with increased cardiac complications, longer hospital stay and higher cost in PCa patients undergoing RP. RARP may be a preferred choice for patients with AF. Attention should be paid to this special patient population. Reasonable pre-operative risk stratification and standardized management should be done to decrease perioperative complications.

Unique technique to relieve left ventricular assist device electromagnetic interference with an implantable cardioverter defibrillator.

We introduced a simple technique to eliminate electromagnetic interference between a left ventricular assist device (LVAD) and an implantable cardioverter defibrillator (ICD). A 43-year-old male with heart failure and a reduced ejection fraction who had an ICD presented with decompensated heart failure and received an LVAD as a bridge to transplant. Remote monitoring showed persistent atrial fibrillation causing an inappropriate ICD shock leading to a decision to disable shock therapies. However, an in-office interrogation was unsuccessful due to electromagnetic interference. Patient was instructed to extend his arm above his head on the ipsilateral side of the ICD, thus increasing the distance between LVAD and ICD, eliminating the interaction to allow reprogramming of the device.

Human Acellular Dermal Matrix Augmentation Phalloplasty Surgery.

INTRODUCTION AND OBJECTIVE: Many men often have the need to enlarge their penises for psychological gain and to satisfy or to impress their partners. Many surgical techniques have been reported. However, none is the gold standard. AIM: To evaluate the efficacy and safety of human acellular dermal matrix allograft in augmentation phalloplasty technique. METHODS: From March 2015 to September 2017, a total of 182 patients were prospectively recruited into our cohort after complete physical and psychological evaluation that deemed suitable for penile enhancement. Penis circumference was measured at the mid-length of the penis. Mean was 7.03 cm (6.93 ± 1.00 cm) and 12.1 cm (10.59 ± 1.15 cm) during flaccid and erection, respectively. All patients received human acellular dermal matrix graft under spinal or local anesthesia. The allograft was preconditioned in normal saline for 20 minutes, and mesh incisions were made to optimize blood flow. The width was equal to the circumference of both corpus cavernosa but without corpus spongiosum. The length of the graft was determined by measuring the length between the tip of the coronary sulcus and the root of penis. A complete incision below the coronary sulcus to the depth of the Buck's fascia was made. Then separate the dartos fascia from the Buck's fascia. The prepared graft was then placed on top of the Buck's fascia, with the blood-remained side facing the Buck's fascia. The graft was sutured using 4-0 absorbable polyglycolic acid suture to the Buck's fascia. Extra caution needed to be taken when fixing ventrally to avoid injuring the urethra. Once completed, the dartos fascia was restored, the dartos fascia and subcutaneous tissue were sutured with 4-0 absorbable suture, and skin closure is achieved subsequently. RESULTS: The post-operative course was without complications. At the follow-up after 1 year, the mean flaccid girth increased to 8.07 ± 1.06 cm (P < .05), while the mean erect girth increased to 12.79 ± 1.23 cm (P < .05). Sexual activity was allowed after 8 weeks of surgery. The majority reported that sexual self-esteem and functioning significantly improved. In addition, 59 patients reported alleviation of premature ejaculation. CONCLUSIONS: Compared to autologous dermis-fat graft and xenograft, augmentation phalloplasty using human acellular dermal matrix has several advantages: (1) it avoids harm harvesting site of the autograft; (2) the effects of dermis allograft can last at least 1 year; and (3) acellular dermal matrix is more likely to be accepted by people.

INTRODUCTION ET OBJECTIF: De nombreux hommes ressentent le besoin de subir une augmentation du pénis pour des raisons psychologiques et pour impressionner leur conjointe. Il existe de nombreuses techniques chirurgicales, mais aucune n'est la norme de référence. BUT: Évaluer l'efficacité et l'innocuité de l'allogreffe par matrice dermique acellulaire dans la technique de phalloplastie. MÉTHODOLOGIE: De mars 2015 à septembre 2017, 182 patients ont fait l'objet d'un recrutement prospectif après une évaluation physique et psychologique complète jugée convenable pour l'augmentation pénienne. La circonférence du pénis était mesurée à mi-longueur. La moyenne était de 7,03 cm (6,93±1,00 cm) flasque et de 12,1 cm (10,59±1,15 cm) en érection. Tous les patients ont reçu une greffe de matrice dermique acellulaire humaine sous anesthésie spinale ou locale. L'allogreffe était préconditionnée 20 minutes dans une solution physiologique, et des incisions en treillis étaient pratiquées pour optimiser la circulation sanguine. La largeur était égale à la circonférence des deux corps caverneux, mais sans le corps spongieux. La longueur de la greffe était déterminée par la mesure de la longueur entre le bout du sillon coronaire et la racine du pénis. Une incision complète était pratiquée sous le sillon coronaire jusque dans la profondeur du fascia de Buck, puis le fascia du dartos était séparé du fascia de Buck. La face sur laquelle se trouve le sang de la greffe préparée était ensuite placée sur le fascia de Buck. La greffe était cousue au fascia de Buck à l'aide d'une suture d'acide polyglycolique absorbable 4-0. Il fallait faire preuve d'une extrême prudence pour la fixer sur la face ventrale afin d'éviter d'endommager l'urètre. Une fois l'intervention terminée, le fascia du dartos était restauré, le fascia du dartos et les tissus sous-cutanés étaient cousus à l'aide d'une suture absorbable 4-0, puis la peau était refermée. RÉSULTATS: L'évolution postopératoire s'est déroulée sans complications. Au suivi au bout d'un an, la circonférence flasque moyenne était passée à 8,07±1,06 centimètres (P < 0,05), et la circonférence en érection, à 12,79±1,23 centimètres (P < 0,05). L'activité sexuelle était autorisée huit semaines après l'opération. La majorité des patients ont constaté une amélioration importante de l'estime de soi sexuelle et du fonctionnement sexuel. De plus, 59 patients ont déclaré une atténuation de l'éjaculation précoce. CONCLUSIONS: Par rapport à la greffe autologue de derme et de graisse et à la xénogreffe, la phalloplastie d'augmentation par matrice dermique acellulaire humaine comportait plusieurs avantages : 1) elle évite les dommages au foyer de prélèvement de l'autogreffe; 2) les effets de l'allogreffe du derme peuvent durer au moins un an; 3) la matrice dermique acellulaire est plus susceptible d'être acceptée.

Perioperative hemorrhagic complications in pelvic floor reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: We sought to assess the incidence, symptoms, and risk factors of perioperative hemorrhagic complications in patients undergoing pelvic floor reconstructive surgery. METHODS: This is a retrospective study on 694 consecutive patients who underwent pelvic floor reconstructive surgery with or without using mesh in our hospital over a 3-year period. RESULTS: We identified 694 pelvic floor reconstructive procedures from 2014 to 2016, including complete/incomplete colpocleisis (176, 25.4%), sacral colpopexy/hysteropexy with mesh (140, 20.1%), colporrhaphy (77, 11.1%) or vaginal mesh repair (99, 43.1%). Two patients who received only sacrospinous ligament suspension were excluded. There were 68 (9.8%) and 3 (0.1%) patients whose blood loss reached 200 and 500 ml respectively. Procedures involving mesh and vaginal hysterectomy (VH) caused more intraoperative blood loss. Postoperative hemoglobin drop was least in colpocleisis (p < 0.05). All 6 of the patients (0.9%) who developed postoperative pelvic hematoma underwent concomitant VH, and 5 of them received mesh. CONCLUSIONS: Hemorrhagic complications during or after pelvic floor reconstructive surgery are rare. Mesh use and concomitant VH are two major surgical risk factors for hemorrhagic complications in pelvic floor reconstructive surgery.