Frozen elephant trunk versus conventional proximal repair of acute aortic dissection type I.

Objective: The extent of surgery and the role of the frozen elephant trunk (FET) for surgical repair of acute aortic dissection type I are still subjects of debate. The aim of the study is to evaluate the short- and long-term results of acute surgical repair of aortic dissection type I using the FET compared to standard proximal aortic repair. Methods: Between October 2009 and December 2016, 172 patients underwent emergent surgery for acute type I aortic dissection at our center. Of these, n = 72 received a FET procedure, while the other 100 patients received a conventional proximal aortic repair. Results were compared between the two surgery groups. The primary endpoints included 30-day rates of mortality and neurologic deficit and follow-up rates of mortality and aortic-related reintervention. Results: Demographic data were comparable between the groups, except for a higher proportion of men in the FET group (76.4% vs. 60.0%, p = 0.03). The median age was 62 years [IQR (20), p = 0.17], and the median log EuroSCORE was 38.6% [IQR (31.4), p = 0.21]. The mean follow-up time was 68.3 ± 33.8 months. Neither early (FET group 15.3% vs. proximal group 23.0%, p = 0.25) nor late (FET group 26.2% vs. proximal group 23.0%, p = 0.69) mortality showed significant differences between the groups. There were fewer strokes in the FET patients (FET group 2.8% vs. proximal group 11.0%, p = 0.04), and the rates of spinal cord injury were similar between the groups (FET group 4.2% vs. proximal group 2.0%, p = 0.41). Aortic-related reintervention rates did not differ between the groups (FET group 12.1% vs. proximal group 9.8%, p = 0.77). Conclusion: Emergent FET repair for acute aortic dissection type I is safe and feasible when performed by experienced surgeons. The benefits of the FET procedure in the long term remain unclear. Prolonged follow-up data are needed.

Concomitant intra-atrial excision of the left atrial appendage during robotic-assisted minimally invasive cardiac surgery.

Objective: Surgical closure of the left atrial appendage (LAA) in patients with atrial fibrillation undergoing cardiac surgery can decrease the risk of stroke and thromboembolism and should therefore be considered. In minimally invasive, thoracoscopic, or robotic-assisted mitral valve surgery, however, external procedures such as clip application or epicardial resection are not feasible due to anatomic limitations and the reduced size of the access port. Internal suture closing techniques bear the risk of recurrent LAA reperfusion, so far. We present a novel surgical technique of LAA excision and subsequent defect closure from the interior aspect of the atrium. Methods: We developed this novel technique during robotic-assisted cardiac surgeries. In short, the LAA is invaginated into the left atrium, excised completely at the base using scissors and the stump is then closed from the inside with a two-layer looped PTFE suture. We give a detailed step-by-step description of the technique. Results: A total of 20 patients received intra-atrial LAA excision so far. Complete resection of the LAA without any residual stump or bleeding was achieved in all cases. There were no procedure-related complications. Conclusion: The intra-atrial LAA excision technique shows promising preliminary results regarding efficacy, safety, and reproducibility during robotic-assisted cardiac operations and could be recommended for all right-sided minimally invasive cardiac surgical procedures.

Refusing Medication Therapy in Involuntary Inpatient Treatment-A Multiperspective Qualitative Study.

Objective: Between June 2012 and February 2013, two decisions by the German Federal Constitutional Court restricted the so-far common practice to use involuntary medication in inpatients who were involuntarily hospitalized. Up to then, involuntary medication was justified by a judge's decision on involuntary hospitalization. It could be applied according to clinical judgment even against the declared will of a patient. Since then, all domestic laws related to involuntary treatment had to be revised. For several months, involuntary medication was allowed only in an emergency. We were interested in the impact of the changed legal framework on the experiences of inpatients, their relatives, and clinical professionals during that time. Methods: Thirty-two interviews were analyzed qualitatively using a grounded theory methodology framework. Results: As a consequence of the restrictions to involuntary medication, special efforts by nursing and medical staff were required concerning de-escalation, ward management, and the promotion of treatment commitment in inpatients who refused medication. Family caregivers were also under strong pressure. They wanted to help and to protect their relatives, but some also welcomed the use of coercion if the patient refused treatment. Most of the interviewed patients had not even noticed that their rights to refuse medication had been strengthened. They complained primarily about the involuntary hospital stay and the associated limitations of their everyday lives. While patients and family members evaluated the refusal of medication from a biographical perspective, the mental health care professionals' focus was on the patients' symptoms, and they understood the situation from a professional perspective. It was obvious that, in any of the four perspectives, the problem of feeling restricted was crucial and that all groups strived to gain back their scope of action. Conclusion: The temporary ban on involuntary medication questioned the hitherto common routines in inpatient treatment, in particular when patients refused to take medication. Each of the different groups did not feel good about the situation, for different reasons, however. As a consequence, it might be indispensable to increase awareness of the different perspectives and to focus the efforts on the establishment of nonviolent treatment structures and practices.