Haemodynamic changes in visceral hybrid repairs of type III and type V thoracoabdominal aortic aneurysms.

The visceral hybrid procedure combining retrograde visceral bypass grafting and completion endovascular stent grafting is a feasible alternative to conventional open surgical or wholly endovascular repairs of thoracoabdominal aneurysms (TAAA). However, the wide variability in visceral hybrid configurations means that a priori prediction of surgical outcome based on haemodynamic flow profiles such as velocity pattern and wall shear stress post repair remain challenging. We sought to appraise the clinical relevance of computational fluid dynamics (CFD) analyses in the setting of visceral hybrid TAAA repairs. Two patients, one with a type III and the other with a type V TAAA, underwent successful elective and emergency visceral hybrid repairs, respectively. Flow patterns and haemodynamic parameters were analysed using reconstructed pre- and post-operative CT scans. Both type III and type V TAAAs showed highly disturbed flow patterns with varying helicity values preoperatively within their respective aneurysms. Low time-averaged wall shear stress (TAWSS) and high endothelial cell action potential (ECAP) and relative residence time (RRT) associated with thrombogenic susceptibility was observed in the posterior aspect of both TAAAs preoperatively. Despite differing bypass configurations in the elective and emergency repairs, both treatment options appear to improve haemodynamic performance compared to preoperative study. However, we observed reduced TAWSS in the right iliac artery (portending a theoretical risk of future graft and possibly limb thrombosis), after the elective type III visceral hybrid repair, but not the emergency type V repair. We surmise that this difference may be attributed to the higher neo-bifurcation of the aortic stent graft in the type III as compared to the type V repair. Our results demonstrate that CFD can be used in complicated visceral hybrid repair to yield potentially actionable predictive insights with implications on surveillance and enhanced post-operative management, even in patients with complicated geometrical bypass configurations.

Percutaneous decannulation of venoarterial extracorporeal membrane oxygenation using the Manta vascular closure device: A systematic review and meta-analysis.

OBJECTIVES: To perform a systematic review and meta-analysis of the techniques and outcomes associated with percutaneous decannulation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) using the Manta vascular closure device. BACKGROUND: Peripheral VA-ECMO can be used to treat critically ill patients with conditions such as refractory cardiogenic shock. After percutaneous implantation of VA-ECMO, VA-ECMO can also be decannulated completely percutaneously by using a vascular closure device. The Manta vascular closure device is a dedicated device used in the closure of large-bore arteriotomies by sandwiching the arteriotomy with an intra-arterial toggle and an extraluminal collagen plug. METHODS: We performed a thorough literature search using various electronic databases. We included studies that reported outcomes after peripheral femorofemoral VA-ECMO decannulation with the Manta vascular closure device. We performed a meta-analysis of proportions on outcome measures, including technical success, bleeding complications, vascular complications, wound complications, major amputation, and procedural-related deaths. RESULTS: We included seven studies with a total of 116 patients. The overall technical success of percutaneous decannulation of VA-ECMO with the Manta vascular closure device was 93.7%. The overall incidence of bleeding, vascular and wound complications was 1.7%, 13.8%, and 3.4%, respectively. No patient required lower limb amputation or died due to VA-ECMO decannulation. CONCLUSION: Percutaneous decannulation with the Manta vascular closure device is an effective and safe procedure that should be considered in suitable patients on VA-ECMO.

The Effect of Obesity on Outcomes After Arteriovenous Fistulae Creation: A Systematic Review.

BACKGROUND: Establishing reliable vascular access is critical for hemodialysis in end-stage renal disease (ESRD). In recent years, the global health burden of ESRD has grown, matched by a rise in prevalence of obesity. Currently, more and more arteriovenous fistulae (AVFs) are being created for obese patients with ESRD. This is a growing concern as creating arteriovenous (AV) access in obese ESRD patients can be more challenging and may be associated with poorer outcomes. METHODS: We performed a literature search with multiple electronic databases. We included studies that compared outcomes after autogenous upper extremity AVF creation between obese and nonobese patients. The relevant outcomes were postoperative complications, outcomes related to maturation, outcomes related to patency, and outcomes related to reintervention. RESULTS: We included 13 studies with a total of 305,037 patients. We found a significant association between obesity and poorer early and late AVF maturation. Obesity was also strongly associated with lower primary patency rates and a higher need for reintervention. CONCLUSIONS: This systematic review found that higher body mass index and obesity are associated with poorer AVF maturation outcomes, poorer primary patency, and higher reintervention rates.

A systematic review and meta-analysis of sirolimus-eluting stents for treatment of below-the-knee arterial disease.

OBJECTIVE: We performed a systematic review and meta-analysis to analyze the efficacy and safety of sirolimus-eluting stents (SESs) in the treatment of below-the-knee (BTK) arterial disease. METHODS: An electronic literature search was conducted from inception to July 24, 2021. Retrospective, prospective, and randomized studies that had used SESs to treat BTK arterial disease and had reported the primary patency, technical success, target lesion revascularization, and/or mortality were included. Meta-analyses of the proportions were conducted to derive pooled summary statistics of the outcomes. Where Kaplan-Meier curves were provided for primary patency, a meta-analysis of the individual patient data was conducted via a graphic reconstruction tool to estimate primary patency at various follow-up points. For studies comparing SESs and bare metal stents (BMSs), a two-stage meta-analysis was performed to compare the 6-month primary patency of SESs vs BMSs. RESULTS: Ten studies across 13 publications, including 995 patients, were retrieved for analysis. In the meta-analysis of proportions, across six studies (n = 339 patients), the pooled 6-month primary patency was 87.3% (95% confidence interval [CI], 81.6%-92.1%). Across seven studies (n = 283 patients), the pooled 6-month mortality was 5.4% (95% CI, 1.4%-11.2%). An individual patient data analysis of three studies (n = 282 patients) yielded a primary patency rate of 95.2% (95% CI, 92.7%-97.8%), 82.8% (95% CI, 78.3%-87.6%), 79.8% (95% CI, 75.0%-85.0%), and 79.8% (95% CI, 75.0%-85.0%) at 6, 12, 18, and 24 months, respectively. The 12-month target lesion revascularization rate across four studies (n = 324 patients) was 9.6% (95% CI, 6.4%-13.4%). In the two-stage meta-analysis of 6-month primary patency across three studies (n = 168 patients), the use of SESs was significantly favored over BMSs (risk ratio, 1.28; 95% CI, 1.12-1.46; P < .001). CONCLUSIONS: The overall evidence suggests that the use of SESs appears to be safe and offers favorable outcomes for BTK arterial disease compared with BMSs.

National Rates of Lower Extremity Amputation in People With and Without Diabetes in a Multi-Ethnic Asian Population: a Ten Year Study in Singapore.

OBJECTIVE: Population level data from Asia on amputation rates in people with and without diabetes are extremely limited. Hence it is unclear how the rising diabetes prevalence in Asia has affected the amputation burden. The present study examined national amputation rates in people with and without diabetes in Singapore from 2008 to 2017 in the context of increasing diabetes prevalence and health system changes. METHODS: This was a retrospective observational study using national population data for ages 16 - 100 years obtained from the Ministry of Health Singapore administrative datasets. Age sex standardised major and toe/ray amputation rates per 100 000 people with diabetes and per 100 000 people without diabetes were calculated. Rates were calculated overall and in each ethnic group (Chinese, Malay, Indian, Others), with trends over time calculated using joinpoint trend analysis. In addition, age specific rates, relative risk (RR) of amputation in diabetics compared with non-diabetics and proportion of amputations in the population attributable to diabetes were also calculated. RESULTS: Between 2008 and 2017, the database included 3.6 million unique individuals, of whom 75% were Chinese, 8.6% Malay, 7.9% Indian, and 8.4% Others. Of those, 413 486 (11%) had diabetes. Major amputation rates in people with diabetes remained stable (2008: 99.5/100 000; 2017: 95.0/100 000 people with diabetes, p = .91) as did toe/ray amputation rates. Rates in people without diabetes were substantially lower, with major amputation rates decreasing significantly (2008: 3.0/100 000; 2017: 2.1/100 000 people without diabetes, 3% annual reduction, p = .048). Diabetes related amputation rates were highest in Malays and lowest in Chinese. Diabetes related major amputation rates declined significantly among Chinese (3.1% annual reduction, p < .038). While the RR for amputations in diabetes remained stable, the proportion of major amputations attributable to diabetes increased from 63.6% in 2008 to 81.7% in 2017 (3% annual increase, p = .003). CONCLUSION: Diabetes related major and toe/ray amputation rates have remained stable but relatively high in Singapore compared with other countries, and the proportion of amputations attributable to diabetes has increased over time. More research is needed to understand the aetiopathological, sociocultural, and health system factors that may underlie the continued high rates of diabetes related amputations in this population.

Lobar versus Sublobar Resection in the Elderly for Early Lung Cancer: A Meta-Analysis.

OBJECTIVES: We performed a systematic review and meta-analysis of outcomes of lobectomy versus sublobar resection in elderly patients (≥65) with stage 1 nonsmall cell lung carcinoma (NSCLC). METHODS: We searched for relevant articles using a set of inclusion and exclusion criteria. Meta-analytic techniques were applied. RESULTS: Twelve studies (n = 5834) were chosen. Our results indicate that in the elderly, lobectomy for stage 1 NSCLC confers a survival advantage over sublobar resection. Lobectomy patients had a lower risk of death within 5 years and lower odds of local cancer recurrence. Our results show that lobectomy had a better 5-year cancer-specific survival and 5-year disease-free survival that trended toward significance. The sublobar resection group showed better 30-day operative mortality that trended toward significance. Subgroup analysis of stage 1A cancer demonstrated no difference in 5-year overall survival rates. However, for stage 1B tumors 5-year overall survival favored lobectomy. CONCLUSION: Lobectomy for stage 1 NSCLC in elderly patients is superior to sublobar resection in terms of survival and cancer recurrence and should be afforded where possible. For stage 1A tumors, sublobar resection is noninferior and may be considered. Further randomized controlled trials in this topic is required.

Centrifugal and Roller Pumps in Neonatal and Pediatric Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis of Clinical Outcomes.

Extracorporeal membrane oxygenation (ECMO) is an invaluable means of supporting critically ill children with refractory respiratory or cardiac failure. Controversy remains; however, whether roller or centrifugal pumps are superior, particularly in infants. We performed a comprehensive search on PubMed, Embase, and Scopus for studies comparing the use of centrifugal and roller pumps in the pediatric and neonatal population from 1973 until March 1, 2020. All prospective and retrospective comparative studies were screened. Single-arm studies and those that included adult patients were excluded. The primary endpoint was survival to discharge. Secondary endpoints were complications (mechanical, cardiac, pulmonary, neurologic, renal, and hemolytic) and requirements for inotropic support. Random effects meta-analyses across all clinical endpoints were conducted. A total of four studies with 9111 patients were included. There was a statistically significant difference in in-hospital mortality, favoring the groups where roller pumps were used. Roller pumps were associated with fewer episodes of hemolysis, mechanical complications, cardiac complications, renal complications, and less inotropic support. ECMO with roller pumps may be associated with lower mortality in children. Roller pumps were associated with fewer complications, as well as reduced hemolysis and use of inotropes.

Partial Versus Complete Thymectomy in Non-Myasthenic Patients With Thymoma: A Systematic Review and Meta-Analysis of Clinical Outcomes.

OBJECTIVE: The optimal extent of surgical resection for non-myasthenic patients with thymoma is controversial. The objective of this meta-analysis was to compare complete to partial thymectomy in non-myasthenic patients for oncological and postoperative clinical outcomes. METHODS: We performed a PubMed and EMBASE search (from inception to January 2020) for English-language studies directly comparing partial thymectomy (thymomectomy) to complete thymectomy for thymoma resection. Clinical endpoints studied included overall and disease-free survival, Masaoka and World Health Organization staging, adjuvant therapy, postoperative complications, postoperative drainage, length of hospital stay, thymoma-related deaths, postresection development of myasthenia gravis, incomplete resection, and recurrence. Random effects meta-analyses across all clinical endpoints was done. RESULTS: There was no statistically significant difference between the two approaches with regard to recurrence (odds ratio [OR], 1.22; 95% confidence interval [CI], 0.78-1.92), completeness of resection (OR, 1.17; 95% CI, 0.66-2.10), adjuvant therapy (OR, 0.71; 95% CI, 0.40-1.26), or thymoma-related deaths (OR, 0.76; 95% CI, 0.12-4.66). There was a statistically significant decrease in postoperative complications (OR, 0.61; 95% CI, 0.39-0.97), drainage (mean difference [MD], -0.99; 95% CI, -1.98 to -0.01), and length of hospital length (MD, -1.88; 95% CI, -3.39 to -0.36) with partial thymectomy. CONCLUSIONS: The evidence appeared to suggest that partial thymectomy is oncologically equivalent to complete thymectomy for non-myasthenic patients with early-stage thymoma. There is an additional advantage of reduced postoperative complications and decreased length of hospital stay with partial thymectomy.

A scoping review on the changes in vascular surgical practice during the early phases of the COVID-19 pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has had a profound effect on the delivery of vascular surgery to patients around the world. In order to conserve resources and reduce the risk of COVID-19 infection, many institutions have postponed or cancelled surgical procedures. In this scoping review, we aim to review current literature and recapitulate the significant changes in elective and emergency vascular surgery during the COVID-19 pandemic. We conducted this scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews. We included all articles that had reported the effects of the COVID-19 pandemic on elective or emergency vascular surgery. A total of 28 articles were included in this scoping review. We identified eight distinct themes that were relevant to our study topic. We report global, regional, and local data on vascular surgical cases. We also discuss the adoption of vascular surgery triage systems, emergence of global collaborative vascular surgery research groups, increased use of endovascular techniques and locoregional anesthesia, delayed presentation of vascular surgery conditions, and poorer outcomes of patients with chronic limb threatening ischemia. This scoping review provides a snapshot of the impact of the COVID-19 pandemic on elective and emergency vascular surgery.

A scoping review of vascular surgery education in the medical school curriculum.

OBJECTIVE: Despite the high burden of vascular disease that is assessed, investigated, and managed by generalists, no specific medical school curriculum is in use for vascular surgery (VS). In the present scoping review, we aimed to map the available evidence on the provision of VS education in the medical school curriculum worldwide. METHODS: The present review was conducted in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analysis) extension for scoping reviews. The inclusion criterion was reported research studies on VS education in the medical curriculum. RESULTS: A total of 20 studies were included. Three main themes were identified. VS was perceived as an essential part of the general medical student curriculum by VS applicants. Exposure to VS varied considerably, and students generally expressed a need for an increase in VS coverage. The most important positive determinants when choosing VS as a career were having a VS mentor, the technical aspects of VS, and participation in a VS rotation. Frequently cited deterrents were the long training time and demanding lifestyle potentially compromising family life. CONCLUSIONS: The present scoping review has provided a starting point to better understand the provision of VS education in medical schools across the world. Our review has demonstrated the variability in VS exposure at medical school and described students' sentiments toward VS. We have highlighted the need to determine whether the current curricula are adequate from the perspective of multiple stakeholders (eg, vascular surgeons, educators, general practitioners, a variety of specialists) with a crucial role in the treatment of patients with vascular conditions.

The association between fluoroquinolones and aortic dissection and aortic aneurysms: a systematic review and meta-analysis.

Previous studies have drawn causal associations between fluoroquinolone use and collagen pathologies including tendon rupture and retinopathy. This meta-analysisattempted to assess the association between fluoroquinolone use and the risk of aortic dissection or aortic aneurysm. A systematic search was performed on Medline, EMBASE, and the Cochrane library. 9 studies were included in final analysis. Primary random-effects meta-analysis of 7 studies, excluding 2 pharmacovigilance studies demonstrated statistically increased odds of aortic dissection (OR, 2.38; 95% CI, 1.71-3.32) aortic aneurysm (OR, 1.98; 95% CI, 1.59-2.48), and aortic aneurysm or dissection (OR, 1.47; 95% CI, 1.13-1.89; I2 = 72%) with current use of fluoroquinolones compared to their nonuser counterparts. Based on the "number needed-to-harm" analysis, 7246 (95% CI: 4329 to 14,085) patients would need to be treated with fluoroquinolones for a duration of at least three days in order for one additional patient to be harmed, assuming a population baseline incidence of aortic dissection and aneurysm rupture to be 10 per 100,000 patient-years. With strong statistical association, these findings suggest a causal relationship, warranting future research to elucidate the pathophysiological and mechanistic plausibility of this association. These findings however, should not cease prescription of fluoroquinolones, especially when clinically indicated.

Antifibrinolytics reduces blood loss in thoracic surgery: a systematic review and meta-analysis.

BACKGROUND: The purpose of this systematic review is to evaluate the efficacy of antifibrinolytics in non-cardiac thoracic surgery. METHODS: We searched for all randomized controlled trials on this topic. A set of strict inclusion and exclusion criteria was developed. Six studies were meta-analysed together then in subgroups of topical tranexamic acid and intravenous aprotinin. We compared postoperative chest drain output, transfusions requirements and duration of hospital stay where available to determine the efficacy of topical tranexamic acid or intravenous aprotinin in reducing blood loss. RESULTS: The use of antifibrinolytics reduces 24-h chest drain output (-290.21 mL [-524.75, -55.66], P = 0.02, I2  = 98%), red blood cell transfusion requirements (-1.27 units [-2.24, -0.30], P = 0.01, I2  = 100%) and shortened duration of hospital stay (-1.81 days [-3.25, -0.36], P = 0.01, I2  = 96%). The subgroup analysis also supported this trend. CONCLUSION: We conclude that the use of antifibrinolytics appears to reduce postoperative blood loss by reducing chest drain output, transfusion requirements and length of stay after thoracic surgery.

Diabetes-related lower extremity complications in a multi-ethnic Asian population: a 10 year observational study in Singapore.

AIMS/HYPOTHESIS: Diabetes progression and complication risk are different in Asian people compared with those of European ancestry. In this study, we sought to understand the epidemiology of diabetes-related lower extremity complications (DRLECs: symptomatic peripheral arterial disease, ulceration, infection, gangrene) and amputations in a multi-ethnic Asian population. METHODS: This was a retrospective observational study using data obtained from one of three integrated public healthcare clusters in Singapore. The population consisted of individuals with incident type 2 diabetes who were of Chinese, Malay, Indian or Other ethnicity. We examined incidence, time to event and risk factors of DRLECs and amputation. RESULTS: Between 2007 and 2017, of the 156,593 individuals with incident type 2 diabetes, 20,744 developed a DRLEC, of whom 1208 underwent amputation. Age- and sex-standardised incidence of first DRLEC and first amputation was 28.29/1000 person-years of diabetes and 8.18/1000 person-years of DRLEC, respectively. Incidence of both was highest in individuals of Malay ethnicity (DRLEC, 36.09/1000 person-years of diabetes; amputation, 12.96/1000 person-years of DRLEC). Median time from diabetes diagnosis in the public healthcare system to first DRLEC was 30.5 months for those without subsequent amputation and 10.9 months for those with subsequent amputation. Median time from DRLEC to first amputation was 2.3 months. Older age (p < 0.001), male sex (p < 0.001), Malay ethnicity (p < 0.001), Indian ethnicity (p = 0.014), chronic comorbidities (nephropathy [p < 0.001], heart disease [p < 0.001], stroke [p < 0.001], retinopathy [p < 0.001], neuropathy [p < 0.001]), poorer or missing HbA1c (p < 0.001), lower (p < 0.001) or missing (p = 0.002) eGFR, greater or missing BMI (p < 0.001), missing LDL-cholesterol (p < 0.001) at diagnosis, and ever-smoking (p < 0.001) were associated with higher hazard of DRLEC. Retinopathy (p < 0.001), peripheral vascular disease (p < 0.001), poorer HbA1c (p < 0.001), higher (p = 0.009) or missing (p < 0.001) LDL-cholesterol and missing BMI (p = 0.008) were associated with higher hazard of amputation in those with DRLEC. Indian ethnicity (p = 0.007) was associated with significantly lower hazard of amputation. CONCLUSIONS/INTERPRETATION: This study has revealed important ethnic differences in risk of diabetes-related lower limb complications, with Malays most likely to progress to DRLEC. Greater research efforts are needed to understand the aetiopathological and sociocultural processes that contribute to the higher risk of lower extremity complications among these ethnic groups.

The incidence of pulmonary thromboembolism in COVID-19 patients admitted to the intensive care unit: a meta-analysis and meta-regression of observational studies.

OBJECTIVES: Coronavirus disease 2019 (COVID-19) infection is associated with a prothrombotic state. We performed a meta-analysis of proportions to estimate the weighted average incidence of pulmonary thromboembolism (PTE) in COVID-19 patients who were admitted to the intensive care unit (ICU). METHODS: We searched various medical databases for relevant studies from 31 December 2019 till 30 September 2020. We included observational studies that reported the incidence of PTE in COVID-19 patients admitted to the ICU. We extracted data related to study characteristics, patient demographics, and the incidence of PTE. Risk of bias was assessed by using the ROBINS-I tool. Statistical analysis was performed with R 3.6.3. RESULTS: We included 14 studies with a total of 1182 patients in this study. Almost all patients in this meta-analysis received at least prophylactic anticoagulation. The weighted average incidence of PTE was 11.1% (95% CI 7.7% to 15.7%, I2 = 78%, Cochran's Q test P < 0.01). We performed univariate and multivariate meta-regression, which identified the proportion of males as a significant source of heterogeneity (P = 0.03, 95% CI 0.00 to - 0.09) CONCLUSION: The weighted average incidence of PTE remains high even after prophylactic anticoagulation. PTE is a significant complication of COVID-19 especially in critically ill patients in the ICU.

A systematic review of brachial artery ligation as a safe and feasible option in the management of arteriovenous dialysis access infection.

OBJECTIVE: Creation of good long-term arteriovenous access is essential in patients requiring hemodialysis for end-stage renal failure. However, arteriovenous grafts or fistulae can be complicated by infection that may require emergency surgery. For infections that involve the brachial artery anastomosis, or if total graft explantation is indicated, brachial artery repair or reconstruction is often required. An alternative management strategy would be brachial artery ligation (BAL). We performed a systematic review to evaluate the outcomes of BAL that has been performed for infected arteriovenous grafts or fistulae. METHODS: A thorough literature search was conducted using various electronic databases. We included articles that reported outcomes of BAL performed for infected arteriovenous grafts or fistulae. The primary outcome was the incidence of upper limb ischemia after BAL. Secondary outcomes were the need for urgent revascularization, need for upper limb amputation, and incidence of postoperative neurological deficit after BAL. RESULTS: A total of five studies with a total of 125 patients were included in our systematic review. BAL was performed for infected arteriovenous grafts or fistulae for all studies. Follow-up period ranged from 1 to 27 months. The incidence of upper limb ischemia after BAL was low. Only a single study reported three patients who developed upper limb ischemia. Two patients required urgent revascularization, and one patient required forearm amputation after proximal ligation. All studies reported clearance of infection with no recurrence. CONCLUSIONS: Distal BAL may be performed safely for patients with infected arteriovenous fistulae or grafts with low risk of upper limb ischemia, postoperative neurological deficit, and recurrent infection.

Automated Fastener vs Hand-tied Knots in Heart Valve Surgery: A Systematic Review and Meta-analysis.

BACKGROUND: Although several studies revealed that the Cor-knot automated fastener (LSI Solutions, Victor, NY) reduces aortic cross-clamp and cardiopulmonary bypass times, the influence of the device on postoperative morbidity and mortality still needs to be evaluated. The aim of this study was to verify the hypothesis that the use of the Cor-knot device for heart valve surgery reduces aortic cross-clamp and cardiopulmonary bypass times, and this time saving translates into reduced morbidity and mortality. METHODS: Retrospective cohort studies and randomized controlled trials reporting on the use of the automated fastener vs hand-tied knots were reviewed. The following end points were compared: aortic cross-clamp and cardiopulmonary bypass times, postoperative valvular regurgitation, postoperative ejection fraction, prolonged ventilator support, renal failure, and mortality. RESULTS: Eight studies reporting data on 942 patients were included in the final analysis. The Cor-knot device was associated with shorter cardiopulmonary bypass (mean difference [MD], -11.74; 95% confidence interval [CI], -14.54 to -8.93; P < .00001) and aortic cross-clamp times (MD, -14.36; 95% CI, -19.63 to -9.09; P < .00001) in minimally invasive heart valve procedures. Overall, lower rates of postoperative valvular regurgitation (risk ratio [RR], 0.40; 95% CI, 0.26 to 0.62; P < .0001) and prolonged ventilator support (RR, 0.29; 95% CI, 0.13 to 0.65; P = .003) were observed. No difference was observed in postoperative atrial fibrillation, ejection fraction, renal failure, and mortality. CONCLUSIONS: The use of the Cor-knot device in heart valve surgery reduced aortic cross-clamp and cardiopulmonary bypass times. Furthermore, as compared with hand-tie methods, the automated fastener may lead to decreased rates of prolonged ventilator support and valvular regurgitation while being noninferior in terms of other postoperative outcomes and mortality.

Anticoagulation After Isolated Mitral Valve Repair: A Systematic Review and Meta-Analysis of Clinical Outcomes.

Recommendations from international guidelines on optimal thromboprophylaxis after mitral repair are controversial and based on underpowered observational studies. This study aimed to evaluate the prophylactic use of warfarin after isolated mitral valve repair (MVr). A PubMed, EMBASE and Scopus search for studies in English on postoperative thromboprophylaxis for isolated MVr published to February 2020 was performed. The analysis excluded all studies with combined operations, mitral valve replacement and preoperative or postoperative atrial fibrillation. Clinical endpoints that were studied were thromboembolic events, bleeding complications and mortality. Random effects meta-analyses of the effect of postoperative warfarin use as compared with no warfarin use across all clinical endpoints was conducted. Warfarin use did not confer benefit in terms of thromboembolic prophylaxis after isolated MVr in patients without atrial fibrillation (OR, 0.97; 95% CI, 0.72-1.31). At the same time, it did not increase the risk of bleeding complications (OR, 1.10; 95% CI, 0.53-2.30) or affect overall survival during the follow-up period of the included studies (OR, 1.06; 95% CI, 0.28-4.05). To conclude, warfarin use is not necessary for patients after isolated MVr who remain in sinus rhythm. Recommendations from international guidelines may need to be revisited for this group of patients.

Longitudinal versus transverse incision for common femoral artery exposure: a systematic review and meta-analysis.

BACKGROUND: A longitudinal or a transverse incision is routinely used for common femoral artery (CFA) exposure. Some believe a transverse incision is associated with a lower incidence of postoperative complications. We performed a systematic review and meta-analysis to evaluate the risk of postoperative surgical site infection, lymphatic complications, wound dehiscence and haematoma formation when using a longitudinal or transverse incision for CFA exposure. METHODS: Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were adhered to. We searched various databases such as MEDLINE via PubMed and Embase for relevant studies from inception till 31 May 2020. Relevant search terms such as 'longitudinal', 'transverse', 'vertical', 'horizontal', 'femoral', 'incision' were used. We included both randomized controlled trials and case-controlled studies, and extracted data related to study characteristics and postoperative complications. We assessed risk of bias using the Cochrane risk of bias tool and the Newcastle-Ottawa scale. A random-effects meta-analysis was performed to obtain the pooled proportions and risk ratios (RR) for our study outcomes. RESULTS: We included seven studies with a total of 5922 groin incisions. A longitudinal incision was associated with a significantly higher incidence of wound infection (RR 2.93, 95% confidence interval (CI) 1.12-7.70, P = 0.03) and wound dehiscence (RR 2.87, 95% CI 1.06-7.77, P = 0.04). The risk of lymphatic complications (RR 1.09, 95% CI 0.39-3.05, P = 0.87) and wound haematoma (RR 2.85, 95% CI 0.88-9.21, P = 0.08) were similar. CONCLUSIONS: A longitudinal incision may be associated with a higher incidence of wound infection and wound dehiscence, as compared to using a transverse incision for CFA exposure.