Potent Micrografting Using the Meek Technique for Knee Joint Wound Reconstruction.

Background: Efficient treatment of extensive skin defects by using skin grafting is a significant challenge because the skin available to use is limited. A mesh graft is usually used; however, the expansion ratio is small (up to 1:6) and inaccurate. The Meek technique is a method of skin grafting that processes the skin into micrografts by cutting. The advantage of the Meek technique is its efficient use of available skin, expanding its area by up to 9 times. In 2020, Japanese insurance companies began to cover treatment using the Meek technique. This report aimed to show the usefulness of the Meek technique for treating left leg necrotizing fasciitis. Methods: A 55-year-old male was referred to our hospital for treating necrotizing fasciitis of the left leg. Debridement was performed, and antibiotics were administered immediately. After 1 month, Meek micrografts were applied to the left knee wound. The expansion ratio of the Meek micrografts was 1:9. Results: The skin was processed 9 times using the Meek technique, enabling effective use of a small amount of skin. Epithelialization of the Meek micrograft area was completed 1 month after skin grafting. The scar after Meek micrografting was soft and not reddish. The range of motion of the knee joint was >90 degrees. Conclusions: The Meek technique allows expansion of limited skin efficiently. Meek micrografts can cover a larger wound with smaller skin grafts than is possible with mesh grafts. After healing with Meek micrografts, the scar was soft, and the knee joint flexed smoothly. The Meek technique is useful for treating large wounds requiring skin grafts.

Beneficial Impact of "Supercharged" Pectoralis Major Musculocutaneous Flap With Indocyanine Green Angiography on Reconstruction in a Patient at High Risk for Necrosis.

Background: The pectoralis major musculocutaneous (PMMC) flap is a versatile and commonly used technique for reconstruction of the head and neck in patients at high risk in free tissue transfer procedures. In this report, a "supercharged" PMMC flap, in which the lateral thoracic artery was cut, preserved, and anastomosed to the cervical vessels, was developed to stabilize blood flow. Methods: The supercharged PMMC flap was introduced in a patient who was at high risk for partial necrosis of the flap and underwent surgery for reconstruction of the tongue. Intraoperative perfusion monitoring using laser-assisted indocyanine green angiography (ICGA) was also performed to verify the status of blood flow in the flap. Results: ICGA monitoring of blood flow in the flap revealed instability. Subsequently, a supercharged PMMC flap was applied, which prevented partial necrosis of the flap. Conclusions: Combined with ICGA, a supercharged PMMC flap contributed to successful reconstruction in a patient at high risk for necrosis of the flap region.

A solitary giant neurofibroma of the left thigh: a case report.

A neurofibroma not associated with neurofibromatosis type 1 is termed solitary neurofibroma. A solitary giant neurofibroma of the thigh is an extremely rare tumor. A 44-year-old woman presented to us with a well-defined swelling on her left thigh for 10 years. On the basis of magnetic resonance image finding, we diagnosed the tumor as a neurofibroma. We excised the tumor and the pathological findings established the diagnosis of neurofibroma. There was no recurrence 8-months after surgery.

A novel technique for forehead and eyebrow reconstruction using a temporal hairline flap combined with a free forearm flap: a report of two cases.

We herein report a novel technique for managing large forehead skin defects that include the eyebrows and upper eyelid. Case 1 was of a 55-year-old woman with an eccrine carcinoma (T2N0M0) at the right forehead, resulting in a skin defect 15 cm in diameter. Case 2 was of an 81-year-old man with a malignant peripheral nerve sheath tumor (T1a N0M0) at the left forehead, resulting in a skin defect 18 cm in diameter. A pedicled temporal hairline flap and free forearm flap were combined and placed on the defect, and good eyebrows and forehead morphology was ultimately achieved.

Double-pedicle unaffected split-breast flap for unilateral breast reconstruction.

BACKGROUND: In some breast cancer patients with a contralateral unaffected hypertrophic and ptotic breast, autologous small-breast reconstruction with contralateral breast reduction is a good option. The current study is aimed to assess the efficacy of the double-pedicle unaffected split-breast (USB) flap harvested from the central half of the unaffected breast for unilateral breast reconstruction with contralateral transverse scar reduction mammoplasty. METHODS: Between February 2003 and May 2020, 14 patients underwent breast reconstruction using the USB flap. The mean patient age was 59.1 (range: 48-76) years, and the mean body mass index was 24.2 (range: 19.5-33.3) kg/m2 . This flap comprised half of the contralateral breast tissues with the 3rd or 4th internal mammary perforator (IMAP) and the lateral thoracic vessel (LTA/V). After USB flap elevation and LTA/V resection, flap perfusion from the IMAP was evaluated on indocyanine green (ICG) angiography. The medial pedicle USB flap was rotated 180° and was transferred to the affected site via the midline. The LTA/V was anastomosed to the recipient vessel to supercharge the distal part of the USB flap, which was then used for breast reconstruction. Then, the remaining contralateral upper and lower breast poles were used for transverse scar reduction mammoplasty. RESULTS: The mean flap size was 13.3 × 26.9 (range: 9.5 × 22 to 16 × 29) cm. All flaps and reduced breasts survived without serious complications such as flap necrosis, although there was one patient with hematoma and one patient with hypertrophic scar. ICG revealed poor perfusion in the distal, lateral part of the flap, ranging from 22.0% to 48.5% of the overall flap area. Final aesthetic evaluation was high, with 11 cases (78.6%) being "good" or "excellent" and 3 cases (21.4%) that were either poor or fair. The mean follow-up period for the patients was 53.8 (range: 15-84) months, with none of the patients presenting second primary breast cancer or recurrence in both breasts. CONCLUSION: USB flap breast reconstruction with contralateral reduction mammoplasty is a valuable option in breast cancer patients with a hypertrophic and ptotic breast.

Direct Flow Medical vs. Edwards Sapien 3 Prosthesis: A Propensity Matched Comparison on Intermediate Safety and Mortality.

Aims: To compare intermediate performance and mortality rates in patients, who underwent transcatheter aortic valve implantation (TAVI) with two different types of prostheses: Edwards Sapien 3 (ES3) and Direct Flow Medical (DFM). Methods and Results: 42 consecutive patients implanted with a DFM prosthesis for severe aortic stenosis were matched 1:1 with an equal number of patients, who received an ES3 during the same period. Primary endpoint was mortality. MACE, as a composite of all-cause death, stroke, and re-do-procedure (valve-in-valve), was defined as secondary endpoint. Moreover, we compared NYHA class, NT-proBNP-levels and the extent of restenosis. Patients were followed for 2 years. DFM patients showed echocardiographic elevated mean pressure gradients compared to ES3 patients before discharge (11.2 mmHg ± 5.3 vs. 3.5 mmHg ± 2.7; p < 0.001) and upon 6-months follow-up (20.3 mmHg ± 8.8 vs. 12.3 mmHg ± 4.4; p < 0.001). ES3 candidates showed superior NYHA class at follow-up (p = 0.001). Kaplan-Meier analysis revealed significantly worse survival in patients receiving a DFM prosthesis compared to ES3 (Breslow p = 0.020). MACE occurred more often in DFM patients compared to ES3 (Breslow p = 0.006). Conclusions: Patients receiving DFM valve prostheses showed worse survival and higher rates in MACE compared to ES3. Prosthesis performance regarding mean pressure gradients and patients' NYHA class also favored ES3.

Immediate one-stage breast reconstruction for an 85-year-old breast cancer patient using deep inferior epigastric perforator flap surgery.

The deep inferior epigastric perforator (DIEP) flap is widely recognized as safe for use as a first-choice option in autologous tissue breast reconstruction; however, DIEP is often not performed for breast reconstruction in the elderly. We report a case of an 85-year-old woman who underwent DIEP flap reconstruction. Immediate reconstruction was performed after mastectomy. The patient successfully underwent DIEP flap reconstruction with no complications. Other options for reconstruction include a latissimus dorsi flap, a transverse rectus abdominis flap and implant-based reconstruction. DIEP flap reconstruction was performed, which does not cause muscle damage and provides sufficient volume. To our knowledge, this study is the first to report DIEP breast reconstruction in a patient over 85 years of age. This case demonstrates the usefulness of DIEP flap reconstruction for elderly patients.

Natural course of tricuspid regurgitation and prognostic implications.

OBJECTIVE: Functional tricuspid regurgitation (TR) is a frequent finding in echocardiography. Literature suggests significant TR is associated with poor prognosis. Still, data remain limited. This study aimed to evaluate long-term prognostic implications in patients with TR. METHODS: In this observational cohort study, data from 1650 consecutive patients were analysed. Primary endpoint was all-cause mortality. Mean follow-up time was 1090 days. TR grades at baseline and follow-up were compared. Survival analyses were performed to identify prognostic factors. RESULTS: At baseline, 14.1% patients showed no, 63.8% mild, 17.4% moderate and 4.7% severe TR. 359 patients (21.8%) died within the study period. TR at baseline was associated with excess mortality. Moderate and severe TR were of prognostic implication in all subgroups irrespective of systolic pulmonary artery pressure (sPAP) (

Right Ventricular Longitudinal Strain Predicts Survival in Patients With Functional Tricuspid Regurgitation.

BACKGROUND: Functional tricuspid regurgitation (TR) is a frequent finding in echocardiography. Despite general consent that right ventricular (RV) dysfunction impacts outcome of patients with TR, it is still unknown which echocardiographic parameters most accurately reflect prognosis. In this study we aimed to evaluate the prevalence of RV dysfunction and its prognostic value in patients with TR. METHODS: Data from 1089 consecutive patients were analysed. Tricuspid annular plane systolic excursion (TAPSE), fractional area change, and right ventricular free wall longitudinal strain (RV strain) were used to define RV dysfunction. Patients were followed for 2-year all-cause mortality. For prediction of survival, reclassification and C statistics of RV functional parameters using TR grade as reference model were performed. RESULTS: Among the patients studied, 13.9% showed no TR, 61.2% had mild TR, 19.6% had moderate TR, and 5.3% had severe TR. The TR grade was associated with increased mortality (log rank, P < 0.001). Impaired RV strain and TAPSE were independent predictors for mortality (RV: hazard ratio [HR], 1.130; 95% confidence interval [CI], 1.099-1.160; P < 0.001; TAPSE: HR, 1.131; 95% CI, 1.085-1.175; P < 0.001). Both RV strain and TAPSE improved the reference model for survival prediction (RV: integrated discrimination improvement [IDI], 0.184; 95% CI, 0.146-0.221; P < 0.001; TAPSE: IDI, 0.057; 95% CI, 0.037-0.077; P < 0.001). CONCLUSIONS: Echocardiographic evaluation of RV function appears to useful for patients with TR. Assessment of RV strain provides additional value for prediction of 2-year mortality.

How low is "low-flow" in aortic stenosis? A retrospective analysis of patients with true low-flow/low-gradient aortic stenosis undergoing TAVI.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a valuable treatment option for patients with reduced left ventricular ejection fraction (LVEF) and low-flow/low-gradient (LF/LG) aortic stenosis (AS). According to current literature, the presence of severe AS is unlikely in case of severely reduced LVEF and mean pressure gradient (meanPG) below 30 mmHg. However, a considerable number of patients presenting with typical clinical symptoms of severe AS, show gradients below 30 mmHg. We hypothesized, that these patients undergoing TAVI do have a measurable clinical benefit and an improved LVEF. METHODS: In this single center retrospective cohort study, data from 1199 patients undergoing TAVI between 2013 and 2017 was analyzed. A 6-month follow-up was performed to assess changes in NT-proBNP, NYHA-class, and LVEF. RESULTS: Thirty patients presented with LVEF<35%, an aortic valve area (AVA<1 cm2), and a meanPG below 30 mmHg. Mean logistic EuroSCORE II was 24.05±10.9. Most patients (56%) showed improved NYHA-class upon follow-up. NT-proBNP-levels decreased from 3.901 pg/mL IQR 10.880 to 1.491 pg/mL IQR 2.245 (P<0.001). LVEF increased from 30% IQR 6.25 to 40% IQR 15 (P<0.001). CONCLUSIONS: Based on our findings TAVI represents a valuable treatment option even in patients with LF/LG AS and PGmean below 30mmHg.

Balloon-expandable transfemoral transcatheter aortic valve implantation with or without predilation: findings from the prospective EASE-IT TF multicentre registry.

Background: Predilation of the native valve has long been deemed necessary in transfemoral transcatheter aortic valve implantation (TF-TAVI), despite little trial evidence to support its clinical use. As most evidence is derived from retrospective analyses of observational studies, we conducted a two-armed, prospective multicentre registry. Methods: Patients undergoing TF-TAVI with the Edwards SAPIEN 3 valve, with or without balloon aortic valvuloplasty (BAV), were included and their procedural characteristics, short-term safety and short-term efficacy outcomes compared. We hypothesised that BAV may be safely omitted in many patients and omission could be associated with procedural benefits. Results: Overall, 196 consecutive patients underwent TF-TAVI, 56 with BAV and 140 without. The mean age was 81.2±6.2 years, and the mean logistic EuroSCORE I was 17.1±13.6. Device success according to Valve Academic Research Consortium-2 (VARC-2) was achieved in 96.4%. The median procedural duration was shorter without BAV (56 min vs 90 min; p=0.001), as was fluoroscopy time (10 min vs 13 min; p=0.001). The need for balloon postdilation was less frequent in patients without BAV (15.7% vs 30.4%, p=0.029). There was no difference in the proportion of patients meeting the VARC-2 defined composite safety endpoint at 30 days (9.3% without vs 8.9% with BAV; adjusted OR (adjOR) 2.55; 95% CI 0.56 to 18.84) and at 6 months (15.2% without vs 16.4% with BAV; adjOR 1.66; 95% CI 0.49 to 6.55). Conclusions: In the majority of patients, BAV can be safely omitted from the TAVI procedure without adverse effects. The omission of BAV is associated with shorter procedural duration and could be advantageous for the majority of patients. Trial registration number: NCT02760771.

Technical aspects of a successful transvascular retrieval of an acutely dislodged WaveCrest® left atrial appendage occluder.

Percutaneous left atrial appendage (LAA) closure is an alternative therapy in patients with atrial fibrillation who are not suitable for anticoagulation. However, device embolization is one of the notable complications which inevitably requires catheter or surgical retrieval. In addition to previously reported Watchman® or AMULET® occluder embolization, here we report the first case of a WaveCrest® occluder dislodgement which was successfully removed by transcatheter technique. Instead of using the well-known snaring technique, we used a "wiring and ballooning technique" for retrieval. Considering its specific architecture without having hooks or feet where suitable for grasping, this technique is an option for retrieving WaveCrest® devices.

Post-procedural tricuspid regurgitation predicts long-term survival in patients undergoing percutaneous mitral valve repair.

BACKGROUND: Functional tricuspid regurgitation (TR) is frequently present in patients with severe mitral regurgitation and is associated with worse outcome. While percutaneous mitral valve repair (PMVR) is on the increase, the role of TR in those patients is unclear. This study aimed to compare pre- and post-procedural TR and investigated the impact of post-procedural TR and major clinical risk factors on long-term survival in patients undergoing PMVR. METHODS: In this retrospective observational cohort study, data from 213 consecutive patients at a tertiary care center undergoing PMVR from 2010 to 2016 were analyzed. Two different groups, dichotomized according to the degree of TR (none/mild and moderate/severe) were compared. Multivariable analyses were performed assessing predictors for long-term survival adjusting for major risk factors. RESULTS: Following PMVR TR was significantly reduced by at least 1 grade in 23.0% (p=0.001), while echocardiographic pulmonary pressure was decreased (TR Vmax 3.21±0.49m/s vs. 2.98±0.53m/s; p=<0.001). Patients with moderate or severe TR presented with worse New York Heart Association functional class and elevated N-terminal pro B-type natriuretic peptide levels compared to patients with none or mild TR. Median survival time was 1458 days. Proportional hazards model, adjusted for major risk factors, revealed post-procedural TR grade (HR 2.055, CI 1.317-3.206, p=0.02), severely impaired left ventricular function (HR 3.145, CI 1.199-8.250, p=0.020), and chronic kidney disease [glomerular filtration rate (GFR) 30-60ml/min HR 1.917, CI 1.109-3.314, p=0.020; GFR<30ml/min HR 3.969, CI 1.981-7.951, p<0.001] as independent predictors for long-term survival. CONCLUSION: Post-procedural moderate and severe TR predicts worsened long-term survival in patients undergoing PMVR and is associated with adverse clinical outcome. Whether outcome might be improved by interventional reduction of post-procedural TR has to be investigated in the future.

Predictive impact of previous coronary artery bypass grafting on mortality after MitraClip implantation for ischemic functional mitral regurgitation.

BACKGROUND: Many candidates with ischaemic functional mitral regurgitation (FMR) have previously undergone coronary artery bypass grafting (CABG), in which transcatheter mitral valve repair can be reasonable for ameliorating the deteriorated hemodynamic and heart failure symptoms. We sought to elucidate the outcomes of MitraClip (MC) implantation in patients with symptomatic ischaemic FMR after CABG. METHODS: We investigated clinical characteristics, outcomes and predictive impact of previous CABG on mortality in ischaemic FMR patients who underwent MC implantation from two high-volume centres in Germany. RESULTS: We enrolled 159 patients who previously underwent CABG. Compared with a reference group that did not previously undergo CABG (n = 182), the cohort consisted of more elderly patients (75.0, standard deviation [SD] 7.7 versus 72.9, SD 9.6 years, p = 0.028), more men (84% vs. 69%, p < 0.001), and reduced tricuspid annular plane systolic excursion (14.0, SD 4.0, vs. 16.6, SD 4.6 mm, p < 0.0001). The CABG group showed similar outcomes regarding procedural success (91% vs. 94%, p = 0.24) and 30-day mortality (5.0% vs. 6.0%, p = 0.68), but worse survival after MC implantation (log-rank p = 0.019, hazard ratio 1.56 [95% confidence interval (CI) 1.08-2.26]). After propensity score matching (n = 224), the hazard ratio was 1.18 [95%CI 0.76-1.84] without statistical significance (p = 0.46). CONCLUSIONS: Transcatheter mitral valve repair using the MC is a viable treatment option for patients with symptomatic ischaemic FMR after CABG. Although the baseline characteristics seemed to point to sick patients, CABG itself had only a modest impact on survival.