Wound Infection after CABG Using Internal Mammary Artery Grafts: A Meta-Analysis.

BACKGROUND: Internal mammary arteries show better long-term patency rates than venous grafts. The use of both mammary arteries is associated with a higher risk of sternal wound infections. This meta-analysis was designed to assess the incidence of a wound healing disorder after bilateral compared with single mammary artery bypass grafting. Compared with existing meta-analysis this paper includes more current literature and one randomized controlled trial. METHODS: A literature search was performed using PubMed and the Cochrane Library. The quality of the articles was assessed by the Newcastle Ottawa Scale. The odds ratio was used as a measure of the chance of developing a wound healing disorder after bilateral internal mammary artery (BIMA) surgery. Meta-analyses were performed for different subgroups. RESULTS: Twenty studies met the quality criteria, including one randomized controlled trial. The use of both mammary arteries significantly increased the risk of superficial (odds ratio [OR] 1.72) and deep (OR 1.75) wound healing disorder in the total population (OR 1.80) as well as in the diabetic subgroup (OR 1.38) and with both preparation techniques. The increased risk with BIMA grafting was present independently of the preparation technique (pedicled: OR 1.89, skeletonized: OR 1.37). CONCLUSION: Bilateral internal mammary artery grafting, especially in high-risk and diabetic patients, is associated with an increased risk of wound healing impairment. Skeletonized preparation does not eliminate the elevated wound healing disorder risk after BIMA use.

Clinical and Functional Characteristics of Patients with Unclassifiable Interstitial Lung Disease (uILD): Long-Term Follow-Up Data from European IPF Registry (eurIPFreg).

(1) Aim of the study: In spite of extensive research, up to 20% of interstitial lung diseases (ILD) patients cannot be safely classified. We analyzed clinical features, progression factors, and outcomes of unclassifiable ILD (uILD). (2) Methods: A total of 140 uILD subjects from the University of Giessen and Marburg Lung Center (UGMLC) were recruited between 11/2009 and 01/2019 into the European Registry for idiopathic pulmonary fibrosis (eurIPFreg) and followed until 01/2020. The diagnosis of uILD was applied only when a conclusive diagnosis could not be reached with certainty. (3) Results: In 46.4% of the patients, the uILD diagnosis was due to conflicting clinical, radiological, and pathological data. By applying the diagnostic criteria of usual interstitial pneumonia (UIP) based on computed tomography (CT), published by the Fleischner Society, 22.2% of the patients displayed a typical UIP pattern. We also showed that forced vital capacity (FVC) at baseline (p = 0.008), annual FVC decline ≥10% (p < 0.0001), smoking (p = 0.033), and a diffusing capacity of the lung for carbon monoxide (DLco) ≤55% of predicted value at baseline (p < 0.0001) were significantly associated with progressive disease. (4) Conclusions: The most important prognostic factors in uILD are baseline level and decline in lung function and smoking. The use of Fleischner diagnostic criteria allows further differentiation and accurate diagnosis.

Stentless Bioprostheses for Aortic Valve Replacement in Octogenarians: The Influence of Coronary Artery Disease.

BACKGROUND: We sought to determine the long-term results of stentless biological heart valve replacement in octogenarians to find out whether coronary artery disease or the coronary artery bypass grafting (CABG) procedure itself influences survival in these aged patients. METHODS: From 4,012 patients undergoing aortic valve replacement (AVR) with a stentless prosthesis (Freestyle, Medtronic) at a single center, 721 patients were older than 80 years. They had a mean age of 83 ± 2 (2,320 patient years), the male/female ratio was 42:58, NYHA (New York Heart Association) class I and II was prevalent in 22.8%, preoperative atrial fibrillation (AF) in 20.6%, coronary artery disease in 56.1%, mitral valve disease in 12.5%, and aortic disease in 3.5%. Follow-up included a total of 11,546 patient years (mean follow-up time: 74 ± 53 months); follow-up mortality data were 96.3% complete. RESULTS: In these aged patients, 30-day mortality in the isolated AVR group (10.3%) was similar to that in the AVR + CABG group (13.4%). Although long-term survival (15 years) in the octogenarian population is low (9% in the AVR group and 6% in the AVR + CABG group), it was not different (p = 0.191) between patients with and without coronary artery disease. The stroke rate and the myocardial infarction rate, respectively, in the AVR + CABG group (0.43%/100 patient years and 0.17%/100 patient years) were only insignificantly higher than that in the isolated AVR group (each 0.01%/100 patient years). The actuarial freedom from reoperation was 99% in both the groups. CONCLUSION: Use of the Freestyle stentless valve prosthesis for AVR is feasible also in octogenarians. The existence of coronary artery disease leads to concomitant bypass surgery, but not a higher level of perioperative or long-term mortality.

Comparison between flat-panel volume computed tomography and histologic assessments of bone invasion of maxillofacial tumors: utility of an instantaneous radiologic diagnostic tool.

OBJECTIVE: The aim of this study was to compare the accuracy of flat-panel volume computed tomography (fpVCT) to histopathologic evaluation of excised tumors of the jaws in the detection of the degree of tumor infiltration, the presence of tumor at the resection margins, and the sizes of lesions. STUDY DESIGN: This preliminary study included 47 patients undergoing jaw resection for tumor invasion of bone. The specimens were examined by histology and 3-dimensional fpVCT, and the parameters of bone infiltration, resection margins, and tumor size were determined. RESULTS: In 95.7% of cases, the fpVCT results of tumorous bone infiltration were in accordance with the histologic findings. An examination of the resection margins showed 100% concordance between the 2 methods, and all resection margins were found to be clear in both fpVCT and the histologic examination. Identical pathologic and nonpathologic results were seen with the use of both diagnostic methods. Radiologic estimates of tumor size were larger than histologic measurements in the case of small tumors but the true sizes of the larger lesions were underestimated. CONCLUSIONS: The intraoperative diagnostic gap can be closed by using fpVCT to investigate bone destruction, allowing one-step resections and reconstructions to become more reliable.

Freestyle stentless bioprosthesis for aortic valve therapy: 17-year clinical results.

BACKGROUND: Aortic valve replacement with stentless bioprostheses has been shown to produce lower aortic gradients than stented bioprostheses, thus facilitating left ventricular mass regression and preventing heart failure. We sought to determine the long-term results of stentless biological aortic valve replacement over a 17-year follow-up. METHODS: Between 1996 and 2012, 2551 patients underwent isolated aortic valve replacement with a stentless prosthesis (Medtronic Freestyle) at a single center. The mean patient age was 72 ± 10 years, 55% were male, 24.1% were in New York Heart Association class I and II, 9.6% had undergone previous surgery, 18.1% had coronary artery disease, and 23.1% had diabetes. For the long-term follow-up, patients were contacted in writing and by telephone; follow-up was 96.3% complete, resulting in 11,546 patient-years. RESULTS: At 30 days, mortality (5.4%), renal failure (3.9%), myocardial infarction (0.7%), and stroke (1.4%) rates were acceptable. During long-term follow-up of 1-17 years, the bleeding rate (2.9%) was higher than the thromboembolic event rate (0.7%) despite 18.1% of patients being on oral anticoagulants. New pacemaker implantation (4.5%; 0.87 events/100 patient-years), neurological disorders (5%; 0.52 events/100 patient-years), valve insufficiency (0.7%; 0.16 events/100 patient-years), paravalvular leakage (0.4%; 0.09 events/100 patient-years) and reoperation due to valvular complications (0.7%; 0.38 events/100 patient-years) were rare. Long-term survival was 41.8% ± 1.6 after 10 years, 21.3% ± 2.3 after 15 years, and 12.1% ± 3.9 after 17 years. CONCLUSION: Long-term results after aortic valve replacement with stentless biological prostheses compare favorably with those obtained with stented bioprostheses.

A prospective randomized trial on preventative methods for positional head deformity: physiotherapy versus a positioning pillow.

OBJECTIVE: To evaluate the impact of stretching exercises versus available bedding pillows on positional head deformities. STUDY DESIGN: Fifty children aged 5 months or younger with positional head deformity were included in this prospective clinical trial (n=20 plagiocephaly, n=10 brachycephaly, n=20 combination). A random distribution was performed for treatment with the bedding pillow alone (n=25) or with stretching exercises (n=25) for 6 weeks. Anthropometric caliper measurements were done before and after that interval. Cranial vault asymmetry index (CVAI) and cranial index (CI) were calculated and analyzed using a descriptive statistical general linear model. RESULTS: ΔCVAI in the stretching group was 2.09% for plagiocephaly and 2.34% for combined head deformities. Using the bedding pillow, ΔCVAI was 3.01% in plagiocephal children and 2.86% for combined head deformity. The ΔCI in the stretching group was 0.94% for isolated brachycephal children and 2.24% for combined head deformity. ΔCI in the pillow group was 3.63% for brachycephaly and 3.23% in children with combined head deformities, respectively. CONCLUSIONS: Bedding pillows and stretching exercises both resulted in improvements in positional cranial deformation. For children with combined plagiocephaly and brachycephaly, improvement in cranial asymmetry was slightly greater when using bedding pillows versus stretching.

Clinical classification of infant nonsynostotic cranial deformity.

OBJECTIVE: Based on a pilot study including >400 children and a comprehensive database analysis of >2500 children, we sought to define the craniofacial norm and to objectify the categorization of positional head deformity. STUDY DESIGN: A database was created containing clinical information on children assessed for nonsynostotic cranial deformity. The findings of standardized anthropometric measurements were compared with data from a group of 401 healthy children with a normal head shape collected in terms of a prospective pilot study. Using a statistical analysis of all anthropometric craniofacial measurements, cut-off percentiles for discriminating different groups of deformation and severity classes were generated. RESULTS: Normative percentiles for all dimensions in cranial vault anthropometric measurements during the first year of life were calculated. Children with definite nonsynostotic head deformity could be clearly allocated into 3 different groups: positional plagiocephaly (abnormal Cranial Vault Asymmetry Index), positional brachycephaly (abnormal Cranial Index), and combined positional plagiocephaly and brachycephaly (abnormal Cranial Vault Asymmetry Index and Cranial Index). Additionally, a reliable 3-level severity categorization (mild, moderate, and severe) for each group of cranial deformation could be obtained according to age and sex. CONCLUSIONS: Our results allow a meaningful and reliable classification of nonsynostotic early childhood cranial deformity.

Objectification of cranial vault correction for craniosynostosis by three-dimensional photography.

PURPOSE: Correction of craniosynostosis is necessary in predominant cases. Surgical planning usually requires a preoperative CT to estimate the bony and intracerebral structures. A postoperative CT scan would involve a significant dose of radiation, which carries an elevated risk of malignant tumor development in later life. This study was performed to demonstrate the quality of three-dimensional (3D) photogrammetry when objectifying perioperative changes in craniofacial surgery. PATIENTS AND METHODS: Twenty-eight patients with different premature craniosynostoses were analyzed photogrammetrically before and after surgical correction. 3D changes in cranial distances, symmetry and volumes were evaluated. A statistical covariance analysis excluded changes in cranial shape caused by physiological head growth. RESULTS: The Cephalic Index in Scaphocephaly changed from 75.1% to a median value of 77.4%. The anterior symmetry ratio for coronal synostoses improved from 0.943 to 0.949 (a value of 1.0 represents perfect symmetry). The posterior symmetry ratio improved from 0.733 to 0.808 postoperatively in one single lambdoidal synostosis. In trigonocephaly, the median anterior skull volume rose from 528 to 601 ml. CONCLUSIONS: 3D photogrammetry has great potential to track and objectify the clinical course of surgical correction of craniosynostoses. Craniofacial changes become highly reproducible and demonstrate clinical utility based on this technology.

Value and reliability of anthropometric measurements of cranial deformity in early childhood.

OBJECTIVES: Since the "back to sleep" campaign initiated by the American Pediatric Society in 1992, an increasing incidence of positional cranial deformity in early infancy has been widely observed. Anthropometric caliper measurements present the most practical tool for diagnosis and decision making although their value is being controversially discussed in literature. PATIENTS AND METHODS: Our study included 30 randomly chosen infants who had been diagnosed with plagiocephaly, brachycephaly, or a combination of both conditions. The 10 patients in each group were then measured anthropometrically by three examiners. The following parameters were measured six times in a standard manner and with a standard head position by each examiner: circumference, length, width, and oblique distance from the fronto-temporal area (ft) to the lambdoid suture on each side of the head (ld). Inter- and intra-observer variabilities for every value were statistically evaluated by a variance components estimation procedure. RESULTS: Both inter- and intra-observer agreement had very low variability. Overall, mean inter-observer variability was lower than 0.182mm(2), and mean intra-observer variability was lower than 1.131mm(2). Altogether, interobserver variability as well as intraobserver variability had a maximum of about 2 mm measurement variance. CONCLUSIONS: Standardized measurements are highly reproducible to quantify early childhood head deformity. Standard head position is indispensable for reliable measurement. Repeatability of anthropometric measurements is essential to define diagnoses and severity codes and to develop treatment concepts.

Three-dimensional photographic analysis of outcome after helmet treatment of a nonsynostotic cranial deformity.

Cranial asymmetries due to nonsynostotic deformation of the skull have been reported with increasing frequency during the last decade. Conservative approaches using helmets and physiotherapy have been shown to be effective in their treatment. Traditionally, documentation has been carried out using anthropometric caliper measurements. The present study evaluates the use of a new three-dimensional photographic system in the improved validation of changes in head deformities. This prospective analysis introduces a new technique for digital anthropometric measurement. The study series comprised 181 children with nonsynostotic head deformities. Three-dimensional photographs were obtained before and after treatment with an orthotic helmet device. The oblique head diagonals and head width and length were measured from three-dimensional photographs using 3dMD customer software. The cranial vault asymmetry index, cranial vault asymmetry, and cranial index were compared before and after treatment. The measurements obtained on three-dimensional images were able to demonstrate significant improvement in early infant cranial deformity after treatment with an orthotic helmet. The cranial vault asymmetry index in plagiocephaly was reduced by 7.16%, and cranial vault asymmetry was reduced by 0.86 cm. The cranial index in brachycephaly decreased by 7.32%. In children with combined plagiocephaly and brachycephaly, the cranial vault asymmetry index improved by 5.77%, cranial vault asymmetry improved by 0.71 cm, whereas the cranial index changed by 5.48%. Three-dimensional photogrammetry can support treatment control in patients with deformational plagiocephaly. This new technology offers several advantages such as easy acquisition of images, detection of landmarks without patient movement, repeatable measurements without patient discomfort, and the opportunity for unbiased evaluation.