Aortic Outcome after Implementation of a Treatment Strategy for Type B Aortic Dissection Involving the Aortic Arch.

OBJECTIVE: To evaluate the outcomes achieved after implementing a treatment strategy for non-A non-B (NANB) (B 1-2 D according to the latest consensus document of the Society of Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) acute aortic dissection (AAD)). METHODS: This retrospective observational study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. All cases of NANB AAD (B 1-2 D) treated at our institution between January 2016 and December 2022 were reviewed. Morbidity, mortality, aortic-related reintervention, and remodeling were analyzed. RESULTS: Among 519 cases of acute aortic syndrome, n = 22 (4.2%) patients presented with NANB AAD (B 1-2 D) (n = 16,72.7% men, mean age 61.5 years+/14.7). Eleven cases were managed with best medical treatment (BMT) alone. Among them, one patient (9.1%) died suddenly 2 days after diagnosis for aortic rupture. Frozen elephant trunk procedure (FET) was required in the remaining 11 patients: 7 (31.8%) needed emergent operation for risks of impending aortic rupture or retrograde aortic dissection extension, and 4 (26.7%) underwent delayed surgery within a month from initial presentation. Overall, in-hospital mortality was 9.1% with both FET and BMT. At a median follow-up of 40 months (range 2 days-200 months) no other deaths occurred. A statistically significant differences in the rate of false lumen thrombosis (100% vs 55.5%, P = 0.033), and a significant positive aortic remodeling in zone 3 (P < 0.001) and 4 (P = 0.038) were reported in operated versus medically managed patients. CONCLUSIONS: The best treatment for NANB is not established. We advocate for medical stabilization with an operative approach that favors open surgery in the acute post dissection period, promotes aortic remodeling, and carries acceptable risk in centers where FET is performed routinely.

Neuromonitoring during Endovascular Thoracoabdominal Aortic Aneurysm Repair: A Systematic Review.

BACKGROUND: Spinal cord ischemia (SCI) is a potentially devastating complication of thoracic endovascular aortic repair (TEVAR) and fenestrated-branched endovascular aortic repair (F-BEVAR). The aim of this systematic review was to evaluate the efficacy of neuromonitoring modalities to mitigate the risk of SCI during TEVAR and F-BEVAR procedures. METHODS: Following the PRISMA guidelines, we conducted a detailed literature search of databases including PubMed, MEDLINE via Ovid, Embase, Scopus, and Cochrane CENTRAL, from 1998 to the present. Inclusion criteria were original research articles examining neuromonitoring during TEVAR and F-BEVAR. The primary outcome was the incidence of SCI, while the secondary outcome included early mortality. The quality of studies was assessed using the Newcastle-Ottawa Scale. RESULTS: From 1,450 identified articles, 11 met inclusion criteria, encompassing data from 1,069 patients. Neuromonitoring modalities included motor-evoked potentials (MEPs), somatosensory evoked potentials (SSEPs), and near-infrared spectroscopy. The combination of MEPs and SSEPs was most commonly used, with 93% sensitivity and 96% specificity for detecting SCI risks. SCI incidence ranged from 3.8 to 17.3%, with permanent deficits occurring in 2.7-5.8% of cases. In-hospital mortality ranged from 0.4 to 8%. Risk factors for SCI were identified, including operation duration and extent of aortic coverage. CONCLUSIONS: Neuromonitoring with MEPs and SSEPs appears to be effective in detecting perioperative SCI risk during TEVAR and F-BEVAR. However, discrepancies between neuromonitoring changes and actual SCI outcomes suggest the need for cautious interpretation. While the incidence of SCI remains variable, identified risk factors may guide clinical decisions, particularly in high-risk procedures. Future research should focus on prospective studies and randomized controlled trials to validate these findings and improve SCI prevention strategies in TEVAR and F-BEVAR.

Frozen Elephant Trunk Procedure for Acute Type a Aortic Dissection: Analysis of Distal Aortic Remodeling According to the Society for Vascular Surgery (SVS)/Society of Thoracic Surgeons (STS) Reporting Standard.

BACKGROUND: To investigate impact of frozen elephant trunk (FET) on long-term distal aortic remodeling in acute A aortic dissection (AAD) according to the latest recommended standards from the Society for Vascular Surgery (SVS)/Society of Thoracic Surgeons (STS). METHODS: Clinical data and imaging of patients who underwent FET to treat acute AAD over the last 8 years were retrospectively reviewed. Patients were included if a pre and postoperative computed angio tomographies at least 30 days from surgery was available for comparison. Contrasted postprocessed imaging were analyzed with Aquarius iNtuition (TeraRecon Inc., Foster City, CA, USA) to analyze long-term positive aortic remodeling, false lumen thrombosis, and aortic expansion according to the SVS or STS recommendations. Secondary endpoints were the rate of in-hospital and long-term mortality, spinal cord ischemia (SCI), and aortic-related reinterventions. RESULTS: Out of 75 patients who underwent FET for type A AAD, n = 41 (54.6%) were included. Significant positive aortic remodeling was reported in Ishimaru zone 1-4 but not in visceral or infrarenal aorta (P < 0.001), and the overall rate of false lumen thrombosis was 95.1% (n = 39). Aortic expansion rates were as follows: 4.9% in zones 1-4, 8.3% in zones 5-6, and 15% in zone 7. The rates of in-hospital mortality and long-term mortality were 7.3% (n = 3) and 9.7% (n = 4), respectively. At a median follow-up of 11 months (range 1-141, reintervention rate was 17.1%. CONCLUSIONS: We report positive aortic remodeling of the distal thoracic aorta in patients who underwent FET for acute AAD according to the SVS or STS reporting standards. The positive effect on the distal aorta is limited to the thoracic segments but not in the visceral aorta.

Can Computerized Simulation be Used to Assess Surgical Proficiency in Laparoscopic Colorectal Surgeries? A Systematic Review.

INTRODUCTION: Computerized simulation (CS) of surgery in virtual reality (VR), augmented reality (AR) and mixed reality (MR) settings are used to teach foundational skills, but its applicability in advanced training is to be determined. This review aims to summarize the types of CS available for laparoscopic colorectal surgery (CRS) and its utility in assessment of proficiency. METHODS: A systematic review of CS in laparoscopic CRS was done on PubMed, Embase, Scopus and Cochrane Library databases. RESULTS: Eleven relevant observational studies were identified. The most common procedure simulated was laparoscopic colectomy. Assessment using performance metrics measured by the simulator such as path length moved by laparoscopic tools, procedure time and number of discrete movements had the most consistent differentiating ability between expert and non-expert cohorts. Surgeons fared similarly in proficiency scores in assessment with CS compared to assessment with traditional cadaveric or porcine models. CONCLUSION: CS of laparoscopic CRS may be used in assessment of proficiency using performance metrics measuring economy of movement. CS may be a viable assessment tool in advanced surgical training, but further studies should assess utility of incorporating it as a formal assessment tool in training programs.

Preoperative B-Type Natriuretic Peptides to Predict Postoperative Atrial Fibrillation in Cardiac Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: Post-operative atrial fibrillation (AF) is the most common complication following cardiac surgery. There has been extensive exploration of clinical variables, imaging, and biomarkers to predict its occurrence after cardiac surgery. In this study, we examine the emerging biomarkers B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) to assess their pre-operative values and correlations with the occurrence of post-operative AF in patients undergoing cardiac surgery. METHODS: A comprehensive literature search was conducted using PubMed, EMBASE, MEDLINE via Ovid, ClinicalTrials.Gov, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) to identify studies published until March 2023. The studies were included if they reported pre-operative BNP or NT-proBNP values and the development of post-operative AF in cardiac surgery patients. Subsequently, data were extracted, and a meta-analysis was performed using Review Manager 5.4 4 (The Cochrane Collaboration, 2020) and SPSS version 28 (IBM Corp, Armonk, NY, USA) to assess the difference between pre-operative BNP and NT-proBNP levels between patients with post-operative AF (AF group) and those without (No-AF group) using a random-effect model. Further analysis was performed in three subgroups: isolated coronary artery bypass grafting, isolated valve, and combined/mixed surgery group. RESULT: A total of 20 studies, including 9,079 participants were identified and included in the systematic review and meta-analysis. Pre-operative BNP levels were reported in 11 studies, and NT-proBNP levels were reported in 10 studies, of which one study reported both BNP and NT-proBNP levels. There is an overall significant difference between pre-operative levels of BNP (p=0.03, I2=95%) and NT-proBNP (p<0.001, I2=65%) when compared between AF and No-AF groups. Nonetheless, subgroup analysis showed there is no significant difference in pre-operative BNP levels, except in isolated valve surgery (p<0.001), whereas all subgroups showed significantly different pre-operative levels of NT-proBNP. CONCLUSIONS: Elevated levels of both BNP and NT-proBNP were observed in patients who developed post-operative AF after undergoing cardiac surgery. In particular, pre-operative NT-proBNP levels were elevated in all patients irrespective of the type of surgical procedure, but elevated pre-operative BNP was only seen in valve surgery patients. These findings suggest the potential usefulness of NT-proBNP as a promising biomarker for predicting the occurrence of post-operative AF following cardiac surgery.

Seed phytic acid concentration affects rice seedling vigor irrespective of soil phosphorus bioavailability.

Rice with a black-colored pericarp (hereafter, black rice) is well-known as an antioxidant-rich food, but a high grain phytic acid (PA) concentration affects its nutritional quality. However, phytic acid helps improve seedling vigor, which is crucial for enhancing subsequent plant growth. This study investigated the effect of seed phytic acid concentration in black rice on seedling vigor compared to the effects on white rice. In the first experiment, three phytic acid concentrations in the seeds of black rice, low (LPA, 15.5 mg g-1 per seed), medium (MPA, 24.7 mg g-1 per seed), and high (HPA, 35.4 mg g-1 per seed) were tested for seedling vigor in phosphorus-deficient soils. The HPA seedlings showed substantially increased seedling vigor and shoot P uptake due to early root development and enhanced physiological processes. LPA grown seedlings showed increased ethylene production in response to P stress, which is the main physiological mechanism modulating seedling growth under P stress conditions. In the second experiment, the three phytic acid concentrations in black and white rice seeds were tested under low and high soil P conditions. Again, LPA seedlings showed significantly reduced seedling vigor in both rice varieties in P-deficient soils. Interestingly, seed phytic acid and external P application had an additive effect on seedling vigor, suggesting that the combined effect further improved seedling growth. Our results reveal that black rice seeds with a HPA concentration can be used as a seed source for planting in P-deficient ecosystems for rice plants as they can increase seedling vigor and subsequent growth, thus reducing dependence on finite P resources.

Exploring the learning curve in minimally invasive esophagectomy: a systematic review.

Minimally invasive esophagectomy (MIE) has been shown to be superior to open esophagectomy with reduced morbidity, mortality, and comparable lymph node (LN) harvest. However, MIE is technically challenging. This study aims to perform a pooled analysis on the number of cases required to surmount the learning curve (LC), i.e. NLC in MIE. PubMed, Embase, Scopus, and the Cochrane Library were systematically searched for articles from inception to June 2022. Inclusion criteria were articles that reported LC in video-assisted MIE (VAMIE) and/or robot-assisted MIE (RAMIE). Poisson means (95% confidence interval [CI]) was used to determine NLC. Negative binomial regression was used for comparative analysis. There were 41 articles with 45 data sets (n = 7755 patients). The majority of tumors were located in the lower esophagus or gastroesophageal junction (66.7%, n = 3962/5939). The majority of data sets on VAMIE (n = 16/26, 61.5%) used arbitrary analysis, while the majority of data sets (n = 14/19, 73.7%) on RAMIE used cumulative sum control chart analysis. The most common outcomes reported were overall operating time (n = 30/45) and anastomotic leak (n = 28/45). Twenty-four data sets (53.3%) reported on LN harvest. The overall NLC was 34.6 (95% CI: 30.4-39.2), 68.5 (95% CI: 64.9-72.4), 27.5 (95% CI: 24.3-30.9), and 35.9 (95% CI: 32.1-40.2) for hybrid VAMIE, total VAMIE, hybrid RAMIE, and total RAMIE, respectively. NLC was significantly lower for total RAMIE compared to total VAMIE (incidence rate ratio: 0.52, P = 0.032). Studies reporting NLC in MIE are heterogeneous. Further studies should clearly define prior surgical experiences and assess long-term oncological outcomes using non-arbitrary analysis.

Learning curve of laparoscopic and robotic total gastrectomy: A systematic review and meta-analysis.

PURPOSE: Minimally-invasive total gastrectomy (MITG) is associated with lower morbidity in comparison to open total gastrectomy but requires a learning curve (LC). We aimed to perform a pooled analysis of the number of cases required to surmount the LC (NLC) in MITG. METHODS: A systematic review of PubMed, Embase, Scopus and the Cochrane Library from inception until August 2022 was performed for studies reporting the LC in laparoscopic total gastrectomy (LTG) and/or robotic total gastrectomy (RTG). Poisson mean (95% confidence interval [CI]) was used to determine the NLC. Negative binomial regression was performed as a comparative analysis. RESULTS: There were 12 articles with 18 data sets: 12 data sets (n = 1202 patients) on LTG and 6 data sets (n = 318 patients) on RTG. The majority of studies were conducted in East Asia (94.4%). The majority of the data sets (n = 12/18, 66.7%) used non-arbitrary analyses. The NLC was significantly smaller in RTG in comparison to LTG [RTG 20.5 (95% CI 17.0-24.5); LTG 43.9 (95% CI 40.2-47.8); incidence rate ratio 0.47, p < 0.001]. The NLC was comparable between totally-laparoscopic total gastrectomy (TLTG) and laparoscopic-assisted total gastrectomy (LATG) [LATG 39.0 (95% CI 30.8-48.7); TLTG 36.0 (95% CI 30.4-42.4)]. CONCLUSIONS: The LC for RTG was significantly shorter for LTG. However existing studies are heterogeneous.

Surgical and endovascular treatment of late postcoarctation repair aortic aneurysms: Results from an international multicenter study.

OBJECTIVE: The formation of postaortic coarctation aneurysms (pCoAA) is well-described in the literature and carries a significant risk of rupture and death. Treatment strategies include open surgical, hybrid, and endovascular repair, depending on the clinical presentation, risk assessment, and anatomy. The aim of this study was to report the early and midterm results of open surgical and endovascular repair of pCoAA. METHODS: This is an international multicenter retrospective study including patients who underwent open surgical or endovascular repair for pCoAA between 2000 and 2021 at 14 highly specialized academic cardiovascular centers. The preoperative, intraoperative, and postoperative data were recorded and analyzed. RESULTS: A total of 74 patients (46 male; median age, 44 years; interquartile range [IQR], 35-53 years) underwent pCoAA repair. All patients had previously undergone surgical repair of aortic coarctation at a median age of 11 years for the index procedure (IQR, 7-17 years). The most common first surgical correction was synthetic patch aortoplasty in 48 patients, followed by graft interposition in 11. The median pCoAA diameter was 54 mm (IQR, 44-63 mm). The median time from the aortic coarctation repair to the pCoAA diagnosis was 33 years (IQR, 25-40 years). A total of 33 patients had symptoms at presentation, including thoracic or back pain in 8 patients. Open surgical repair was performed in 28 patients, including four frozen elephant trunk procedures and one Bentall. The remaining 46 patients underwent endovascular repair of the pCoAA. Two in-hospital deaths were observed (one frozen elephant trunk and one endovascular). After a median follow-up of 50 months (IQR, 14-127 months), there were a total of seven reinterventions. CONCLUSIONS: This international multicenter study demonstrates that patients with pCoAA can be safely treated with either open surgical or endovascular interventions. Because the median time between the coarctation repair and the aneurysm formation was more than 30 years, life-long surveillance of these patients is warranted.

Type-A acute aortic dissection complicated by parenchymal hemorrhagic stroke: Timing of surgery for a rare presentation of aortic dissection.

Acute type-A aortic dissection is a rare but life-threatening cardiac surgery emergency. Immediate operative management is important to give patients the best chance of survival. However, where an aortic dissection is complicated by a concurrent hemorrhagic stroke the risks of precipitating a catastrophic intracranial hemorrhage during surgery must be balanced against the risk of aortic rupture. The optimal timing of surgery in this rare presentation of type-A aortic dissection is unknown. In this case report we describe a 67-year-old gentleman who initially presented with neurological symptoms, and was diagnosed with an acute intracerebral hemorrhage, but was subsequently also diagnosed with an acute type-A aortic dissection. He proceeded to have a successful tissue aortic root replacement, total arch replacement with zone two frozen elephant trunk implantation 4 weeks after his initial diagnosis.

Efficacy of chest X-rays after drain removal in adult and pediatric patients undergoing cardiac and thoracic surgery: A systematic review.

BACKGROUND: Chest X-rays are routinely obtained after the removal of chest drains in patients undergoing cardiac and thoracic surgical procedures. However, a lack of guidelines and evidence could question the practice. Routine chest X-rays increase exposure to ionizing radiation, increase health-care costs, and lead to overutilisation of available resources. This review aims to explore the evidence in the literature regarding the routine use of chest X-rays following the removal of chest drains. MATERIALS & METHOD: A systematic literature search was conducted in PubMed, Medline via Ovid, Cochrane central register of control trials (CENTRAL), and ClinicalTrials. gov without any limit on the publication year. The references of the included studies are manually screened to identify potentially eligible studies. RESULTS: A total of 375 studies were retrieved through the search and 18 studies were included in the review. Incidence of pneumothorax remains less than 10% across adult cardiac, and pediatric cardiac and thoracic surgical populations. The incidence may be as high as 50% in adult thoracic surgical patients. However, the reintervention rate remains less than 2% across the populations. Development of respiratory and cardiovascular symptoms can adequately guide for a chest X-ray following the drain removal. As an alternative, bedside ultrasound can be used to detect pneumothorax in the thorax after the removal of a chest drain without the need for ionizing radiation. CONCLUSION: A routine chest X-ray following chest drain removal in adult and pediatric patients undergoing cardiac and thoracic surgery is not necessary. It can be omitted without compromising patient safety. Obtaining a chest X-ray should be clinically guided. Alternatively, bedside ultrasound can be used for the same purpose without the need for radiation exposure.

Cardiac amyloidosis in non-transplant cardiac surgery.

Cardiac amyloidosis is a rare infiltrative cardiomyopathy that portends a poor prognosis. There is a growing recognition of co-existent aortic valve stenosis and transthyretin cardiac amyloidosis, with some studies suggesting that dual pathology may be associated increased risk of complication and mortality during surgical intervention. This review aims to evaluate the available literature on non-transplant cardiac surgical interventions in patients with cardiac amyloidosis, with particular focus on diagnosis, high surgical risk and areas of uncertainty that require further research.

Type A aortic syndromes in COVID-19 positive patients: Case series from a UK multicentre study.

OBJECTIVE: The coronavirus disease (COVID-19) increases the respiratory complications and carries a higher mortality in the immediate postoperative period. The aim of this study was to analyze the outcomes of patients with type A acute aortic syndromes (AAS) diagnosed with COVID-19 in the perioperative period. METHODS: Retrospective analysis of prospectively collected data between March and August 2020 from 20 participating cardiac surgery centers in the United Kingdom. RESULTS: Among 122 patients who underwent emergency surgical repair for type A AAS at the participating centers, 3 patients (2.5%) tested positive for COVID-19 in the preoperative screeing, and 4 cases turned to be positive in the postoperative period having been operated on an unknown COVID-19 status. Another patient was diagnosed of COVID-19 disease based on radiological features. These eight patients had increased postoperative complications, including respiratory failure, longer ventilation times, and Intensive Therapy Unit (ITU) stay and increased mortality when compared with COVID-19 negative patients. CONCLUSION: COVID-19 disease in the perioperative period of type A AAS poses a challenge. Despite the increasing morbidity and mortality associated with the virus, the prognosis of the aortic disease is poorer and emergency surgery should not be contraindicated based on the COVID-19 diagnosis alone.

Early experience of aortic surgery during the COVID-19 pandemic in the UK: A multicentre study.

BACKGROUND: A significant restructuring of the healthcare services has taken place since the declaration of the coronavirus disease 2019 (COVID-19) pandemic, with elective surgery put on hold to concentrate intensive care resources to treat COVID-19 as well as to protect patients who are waiting for relatively low risk surgery from exposure to potentially infected hospital environment. METHODS: Multicentre study, with 19 participating centers, to define the impact of the pandemic on the provision of aortovascular services and patients' outcomes after having adapted the thresholds for intervention to guarantee access to treatment for emergency and urgent conditions. Retrospective analysis of prospectively collected data, including all patients with aortovascular conditions admitted for surgical or conservative treatment from the 1st March to the 20th May 2020. RESULTS: A total of 189 patients were analyzed, and 182 underwent surgery. Diagnosis included: aneurysm (45%), acute aortic syndrome (44%), pseudoaneurysm (4%), aortic valve endocarditis (4%), and other (3%). Timing for surgery was: emergency (40%), urgent (34%), or elective (26%). In-hospital mortality was 12%. Thirteen patients were diagnosed with COVID-19 during the peri-operative period, and this subgroup was not associated with a higher mortality. CONCLUSIONS: There was a significant change in service provision for aortovascular patients in the UK. Although the emergency and urgent surgical activity were maintained, elective treatment was minimal during early months of the pandemic. The preoperative COVID-19 screening protocol, combined with self-isolation and shielding, contributed to the low incidence of COVID-19 in our series and a mortality similar to that of pre-pandemic outcomes.

Turn down of acute aortic syndrome cases during COVID-19: Results from UK multicentre studies.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has restructured the healthcare systems, prioritizing resources to treat COVID-19 patients. The aim of this study was to establish if patients affected by acute aortic syndrome (AAS) had unrestricted access to emergency treatment and evaluate outcome of these patients during the peak of the pandemic. METHODS: This is a retrospective analysis of prospectively collected data between March and June 2020 from 19 participating cardiac surgery centers in the United Kingdom. RESULTS: Among 95 patients who presented with an AAS in the participating centers; 85 (89%) underwent surgery, 7 (7%) were turned down for surgery because of their profile of comorbidities, and 3 (3%) died on transfer. Among the patients treated conservatively, three of them (43%) were alive at 30 days. We observed no significant restriction in access to treatment for AAS during the early months of the pandemic. CONCLUSION: Services for life-threatening aortic surgery patients were maintained during the COVID-19 period through patient selection and timing of surgery. The rate of surgical turn-down was comparable to published figures despite the challenges faced during the COVID-19 pandemic.

Application of optical coherence tomography to study the structural features of oral mucosa in biopsy tissues of oral dysplasia and carcinomas.

OBJECTIVE: This study aims to examine the ability of optical coherence tomography (OCT) to differentiate ex vivo epithelial structure of benign disorders, dysplastic, and oral squamous cell carcinoma (OSCC) in comparison with the structure of normal marginal mucosa of oral biopsies. As a secondary objective, we examined the inter- and intra-observer variations of OCT measurements of two calibrated assessors. MATERIALS AND METHODS: Oral biopsies (n = 44) were scanned using the swept source OCT (SSOCT) and grouped by pathology diagnosis to benign, dysplasia or carcinoma. Two trained and calibrated assessors scored on the five OCT variables: thickness of keratin layer (KL), epithelial layer (EL), homogeneity of lamina propria (LP), basement membrane integrity (BMI), and the degree of reflection of the epithelial layer (Ep Re). Chi-square tests and Fischer's exact method were used to compare the data. RESULTS: The OCT images showed breached BM status in all the OSCC samples (100%). Epithelial reflection was noted to be hyper-reflective in all the OSCC and oral dysplasia samples (100%). An increase in KL in 66.67% of the OSCC and 100% of the oral dysplasia samples was found. EL was increased in all the OSCC samples (100%) and 85.72% of the oral dysplasias. Kappa values showed that there was very good agreement (over 0.7) when scoring individual parameters between the two assessors. CONCLUSION: The study showed that the BM status was a key parameter in the detection of SCC and for differentiating SCC from oral dysplasia or benign disorders. CLINICAL RELEVANCE: OCT is a non-invasive and non-radioactive adjunct diagnostic tool that can provide immediate results on the structure of oral mucosa. The BM status measured ex vivo was a key parameter in the detection of SCC and for differentiating SCC from oral dysplasia or benign disorders.

A systematic review and meta-analysis of endovascular versus open surgical repair for the traumatic ruptured thoracic aorta.

OBJECTIVE: The purpose of this study was to compare clinical outcomes between open repair and thoracic endovascular aortic repair (TEVAR) in traumatic ruptured thoracic aorta. METHODS: A comprehensive search was undertaken of the four major databases (PubMed, Embase, Scopus, and Ovid) to identify all published data comparing open vs endovascular repair. Databases were evaluated to July 2018. Odds ratios (ORs), weighted mean differences, or standardized mean differences and their 95% confidence intervals (CIs) were analyzed. The primary outcomes were stroke, paraplegia, and 30-day mortality rates; secondary outcomes were requirement for reintervention and 1-year and five-year mortality rates. RESULTS: A total of 1968 patients were analyzed in 21 articles. TEVAR was performed in 29% (n = 578) and open repair in 71% (n = 1390). TEVAR and open repair did not differ in the mean age of patients (42.1 ± 14 years vs 44.1 ± 14 years; P = .48). There was no difference in duration of intensive care and total hospital stay between TEVAR and open repair groups (12.7 ± 11.1 days vs 12.6 ± 8 days [P = .35] and 27.5 ± 14.6 days vs 25.9 ± 11 days [P = .80], respectively). Similarly, no statistically significant difference in postoperative paraplegia or stroke rate was noted between TEVAR and open repair (1.4% vs 2.3% [OR, 1.27; 95% CI, 0.59-2.70; P = .54] and 1% vs 0.5% [OR, 0.63; 95% CI, 0.18-2.18; P = .46]). Lower 30-day and 1-year mortality was noted in TEVAR (7.9% vs 20% [OR, 2.94; 95% CI, 1.92-4.49; P < .00001] and 8.7% vs 17% [OR, 2.11; 95% CI, 0.99-4.52; P = .05]). There was no difference in 5-year mortality (23% vs 17%; OR, 0.07; 95% CI, -0.07 to 0.20; P = .33). However, there was a higher rate of reintervention at 1 year in the endovascular group (0% vs 6%; OR, 0.17; 95% CI, 0.03-0.96; P = .04). CONCLUSIONS: TEVAR carries lower in-hospital mortality and provides satisfactory perioperative outcomes compared with open repair in traumatic ruptured thoracic aorta. It also provides a favorable 1-year survival at the expense of higher reintervention rates.

Hour-specific nomogram for transcutaneous Bilirubin in newborns in Myanmar.

BACKGROUND: Neonatal hyperbilirubinemia is a significant health problem in Myanmar, and the rate of kernicterus is also higher than in developed countries. Non-invasive methods for early detection and treatment of hyperbilirubinemia are urgently needed. In this study, we used transcutaneous bilirubin (TcB) measurements to develop an hour-specific TcB nomogram for the effective management of hyperbilirubinemia in Myanmar newborns. METHODS: The bilirubin levels of neonates born in Central Women Hospital in Yangon, Myanmar were measured three times a day within 72 h after birth using a transcutaneous bilirubinometer. An hour-specific TcB nomogram was created based on the data. RESULTS: Participants were 512 infants (287 boys, 225 girls) born in Central Women's Hospital in Yangon. The mean (±SD) gestational age was 38.4 ± 1.2 weeks; birthweight was 3078 ± 412 g. A total of 3,039 plots were obtained, and the TcB nomogram was created with smoothed percentile curves (97.5th, 50th, and 2.5th percentiles) for 0-72 h after birth. CONCLUSIONS: An hour-specific TcB nomogram was successfully created to manage hyperbilirubinemia in Myanmar newborns.

Prosthetic aortic valve endocarditis complicated by COVID-19 and hemorrhage.

The novel coronavirus, now termed SARS-CoV-2, has caused a significant global impact in the space of 4 months. Almost all elective cardiac surgical operations have been postponed with only urgent and emergency operations being considered in order to maximise resource utilisation. We present a case of a 69-year old lady with an infected prosthetic aortic valve for consideration of urgent inpatient surgery. Despite being asymptomatic and testing negative initially for COVID-19 RT-PCR swab, further investigations with CT revealed suspicious findings. She subsequently tested positive on a repeat swab and unfortunately deteriorated rapidly with complications including gastro-intestinal and intracerebral haemorrhage.

Cardiac surgery in patients with confirmed COVID-19 infection: Early experience.

The novel coronavirus, now termed SARS-CoV-2, has caused a significant global impact in the space of 4 months. Almost all elective cardiac surgical operations have been postponed in order to reduce transmission and to allocate resources adequately. Urgent and emergency cardiac surgery is still taking place during the pandemic. The decision to operate in urgent patients with active/recent COVID-19 infection is difficult to make, particularly as it is still an unknown disease entity in the setting of emergent cardiac surgery. We present a case series of three patients who underwent urgent cardiac surgery and who have had recent or active COVID-19 infection.