Specialty:
Cardiothoracic and Vascular Surgery
Transcatheter Valve-in-Valve and, Valve-in-Ring Interventions for Failing Bioprostheses and Annuloplasty Rings
Markus Kofler, MD, Resident, German Heart Center Berlin, Berlin, Germany, Medical University of Innsbruck, Innsbruck, Austria, Axel Unbehaun, MD, Senior Consultant, Christoph Klein, MD, Senior Consultant, Alexander Meyer, MD, Resident, Semih Buz, MD, Senior Consultant, Volkmar Falk, MD, Medical Director, Jörg Kempfert, MD, Senior Consultant, Department of Cardiothoracic, and Vascular Surgery, German Heart Center Berlin, Berlin, Germany, Department of Cardiothoracic Surgery, Charité, Universitätsmedizin Berlin, DZHK (German Center for Cardiovascular Research), partner site Berlin, Germany, Matthias Hommel, MD, Senior Consultant, German Heart Center Berlin, Berlin, Germany
34/1076
Transcatheter aortic valve implantation has dramatically changed the treatment of valvular heart disease over the past decade. At the same time, the indications for bioprosthesis implantation have been continuously extended toward younger patients, driven by excellent clinical results and improved durability. While the omission of oral anticoagulation reduces the risk of severe bleeding complications, the long-term durability of bioprostheses is still limited. In light of the growing number of elderly transcatheter aortic valve replacement (TAVR) patients, the prevalence of patients with failed bioprostheses and advanced comorbidities is expected to rise. Currently, transcatheter valve-in-valve (ViV) and valve-in-ring (ViR) interventions represent a valuable alternative treatment option for patients with a high risk for surgical reoperation. Several reports have described a high procedural success rate and low postprocedural morbidity and mortality during mid-term follow-up. We are still facing valve-specific and procedure-related challenges in all types of procedures, but especially in transcatheter ViR interventions. Considering the high technical demand of these interventions, a strong and highly specialized heart team in heart valve centers is the cornerstone of successful patient treatment. This review focuses on individualized patient selection, procedure-specific risk factors and technical aspects of transcatheter ViV/R interventions, and explores the currently available literature on postinterventional outcome.
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Transcatheter Tricuspid Valve Interventions: Current Approaches and Future Perspectives
Antonio Nenna, MD, Resident in Cardiac Surgery, Massimo Chello, MD, Full Professor of Cardiac Surgery, Consultant Cardiac Surgeon, Università Campus Bio-Medico di Roma, Rome, Italy, Sanjeet Singh Avtaar Singh, MD, Clinical Fellow in Cardiac Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom, Pierluigi Nappi, MD, Resident in Cardiology, University of Messina, Messina, Italy, Francesco Nappi, MD, Consultant Cardiac Surgeon, Centre Cardiologique du Nord, Saint-Denis, Paris, France
34/1131
Tricuspid valve regurgitation is generally functional in nature due to right-sided dysfunction in the setting of left-sided concomitant cardiac disease or pulmonary hypertension. Patients living with tricuspid regurgitation often experience numerous limitations as a result of right-sided heart failure symptoms. Patients with significant tricuspid disease, whether native, repaired, or replaced valve, often present with significant symptoms but may not be ideal candidates for operation or, eventually, reoperation. Transcatheter techniques to either repair or replace the tricuspid valve are a burgeoning frontier in structural cardiac interventions. Anatomical challenges include the large and asymmetrical annulus, paucity of calcification, adjacency of the right coronary artery system, and fragility of the valve tissue. Current approaches under investigation in feasibility and early phase clinical trials include edge-to-edge repair, coaptation enhancement, annuloplasty, heterotopic caval valve implantation, and percutaneous tricuspid valve replacement. Although there are limitations to the currently available transcatheter options for the patients, the initial data demonstrate the relative safety of using existing devices with good results and functional improvement. Hopefully, the emerging interest into interventional therapy of tricuspid valve disease will bring back the “forgotten valve” into the conscience of the cardiological and surgical community. This review intends to summarize the current strategies and evidences in transcatheter tricuspid valve intervention and enlightening new avenues for future clinical studies.
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Clinical Outcomes of Patients with Severe Aortic Valve Stenosis Treated with Portico,
Transcatheter Aortic Valve System
Alberto Pozzoli MD, Maurizio Taramasso MD PhD, Mizuki Miura MD PhD, Gökhan Gülmez MD,
Shu-I Lin MD, Mara Gavazzoni MD, Francesco Maisano MD, Heart Valve Clinic, University Hospital
of Zurich, University of Zurich, Zurich, Switzerland, Phillip Haager MD, Cardiology Department,
Hans Rickli MD, Cardiology Department, Kantonsspital St. Gallen, St. Gallen, Switzerland
34/1119
The Portico™ transcatheter aortic valve implantation (TAVI) system (Abbott Vascular, Santa Clara, CA, USA) was specifically designed to reduce some of the limitations associated with first-generation TAVI devices. Most of the currently available clinical evidence was obtained from randomized studies that compared TAVI to aortic valve replacement using first-generation transcatheter heart valve devices. The aim of this review is to describe the characteristics of the repositionable and retrievable Portico™ system and the technique of implantation, as well as to provide an overview of the most recent outcomes in the literature, along with our institutional experience.
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Fibonacci’s Golden Ratio―An Innovative Approach to the Design and Management of Extra - Corporeal Circulation
Ignazio Condello, ECCP, Chief of Clinical Perfusion, Giuseppe Nasso, MD, Chief of Cardiovascular Surgery, Flavio Fiore, MD, Chief of Cardiac Surgery, Anesthesia and ICU, Seanne Azzolina, ECCP, Chief of Clinical Perfusion, Raffaele Bonifazi, MD, Cardiovascular Surgeon, Nicola Di Bari, MD, Cardiovascular Surgeon, Fabrizia Massaro, MD, Cardiac Surgery, Anesthesia and ICU, Giuseppe Speziale, MD, Head of Department of Cardiovascular Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy, Francesco Bartolomucci, MD, Cardiologist, ASL BAT, Andria, Italy
34/1104
Technological advances in the field of extracorporeal circulation (ECC) over the past decade have led to numerous methods for monitoring metabolism and coagulation during cardiopulmonary bypass (CPB), as well as materials with improved biocompatibility, which has reduced the risk associated with cardiopulmonary bypass. However, ECC is still predominantly based on a traditional design that involves the use of roller pumps. This exposes the patient to a variety of pathophysiological consequences, both intra- and postoperative, such as postoperative cognitive disorders, hemolysis and hemodilution, systemic inflammation and changes in coagulation. This article describes the advantages of an ECC circuit inspired by the Fibonacci Golden Ratio, which does not use a roller pump, in a prospective study on patients undergoing elective cardiac surgery, compared to conventional ECC. During CPB, echocardiography was used to estimate the quality of fluid dynamics in the extracorporeal circuit and the patient's arterial vessels, a DO2 management system was used to evaluate metabolism, and an electronic system was used to determine gaseous microemboli (GME) counts. Fibonacci ECC offered superior intraoperative fluid dynamics, reduced the production of and improved the elimination of GME, and improved intraoperative metabolism, particularly with regard to oxygen delivery and extraction. The improvements in fluid dynamics and metabolic variables were associated with a reduction in the incidence of pathophysiological events compared to the conventional system, particularly regarding transitory cognitive disorders, and a shorter stay in intensive care.
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The Epidemiology, Pathophysiology, and Novel Treatment of Calcific Arterial Disease
Lucyna Z. Price, MD, Surgical Fellow, Peter L. Faries, MD, Chief of Vascular Surgery, Krishnan Prakash, MD, Assistant Professor of Medicine, Jason C. Kovacic, MD, PhD, Associate Professor, Mount Sinai Hospital, New York, New York, James F. McKinsey, MD, Vice Chairman of Surgery, Mount Sinai West, Chief of Complex Aortic Intervention, Mount Sinai Health System, The Icahn School of Medicine at Mount Sinai, New York, New York, Gilbert HL Tang, MD, MBA, Associate Professor, Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, Surgical Director, Structural Heart Program, Mount Sinai Health System, New York, New York, Rami O. Tadros, MD, FACS, RPVI, Associate Program Director of Vascular Surgery, Associate Professor of Surgery and Radiology, Director, Off-site Vascular Lab, Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, New York, New York
34/1103
Endovascular treatment of arterial diseases has become first-line in most cases due to improved technology. However, until recently, excessive atherosclerotic calcification has been a major limiting factor in the endovascular management of peripheral arterial disease, as well as vascular access for endovascular aneurysm repair (EVAR) and transcatheter aortic valve replacement (TAVR). The Peripheral Intravascular Lithotripsy (IVL) System (Shockwave Medical, Inc., Fremont California) applies pulsatile mechanical energy under fluoroscopic guidance to disrupt calcified lesions. The purpose of this paper is to introduce IVL in the treatment of calcific access vessels in preparation for EVAR and TAVR, as well as peripheral arterial disease applications to enhance luminal gain. Using the IVL System, angioplasty can be performed with lower pressures, which may minimize arterial dissection. Further, the lithotripsy effect on calcium will enhance vessel compliance. We describe several cases where IVL was applied successfully and present additional cases that may have benefitted from the use of this technology.
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Percutaneous Thermal Ablation for Lung Cancer: An Update
Zachary J. Hartley-Blossom, MD, MBA, Resident, Terrance T. Healey, MD, Director of Thoracic Radiology, Department of Diagnostic Imaging, Rhode Island Hospital, Providence, RI
34/1092
Lung cancer remains the leading cause of cancer death in the United States, and accounts for more deaths than breast, colon, and prostate cancer combined. Over the past decade, percutaneous thermal ablative therapy (PTA) has become a useful adjunctive therapy in combination with longer-standing methods, or as a standalone treatment.
The physiologic basis of thermal ablation is that coagulative necrosis and cell death occur at temperatures above 60°C. During treatment, PTA of lung tumors routinely achieves temperatures above 70°C. Radiofrequency ablation has fallen out of favor in recent years as microwave ablation has been proven to be effective, with shorter treatment times.
Pulmonary PTA is a routine outpatient procedure in which conscious sedation is used in lieu of general anesthesia. The first post-procedural follow-up imaging is CT at 4 weeks, coinciding with an office visit.
In our most recent review of long-term results, which included 108 patients, all-cause survival at 1, 2, and 3 years was 83%, 59%, and 43%, respectively. When we specifically considered cancer-related survival, these numbers increased to 94%, 79%, and 57%.
Percutaneous thermal ablation has been shown to be a safe and effective treatment for patients with early-stage NSCLC who are not candidates for surgery, as well as a potential treatment for local small cell lung cancers. As the field of oncology, and specifically the treatment of lung cancer, continues to evolve, PTA will represent a useful tool in the arsenal.
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Latest Advances in Transcatheter Cardiac Valvular Treatment
Luca Weltert, MD, Cardiac Surgeon, Ruggero De Paulis, MD, PhD, Professor of Cardiac Surgery, Tiziana Salatino, MD, Cardiologist, Fabrizio Tomai, MD, PhD, Professor of Cardiology, Cardiology Division, European Hospital, Rome, Italy
33/1036
When the original monograph on valvular prostheses was published in Surgical Technology International, back in 1993, transcatheter technology had not yet been invented. These techniques have been gradually revealed in subsequent issues. When we first considered writing a paper that described both surgical and transcatheter prosthesis, we realized that such a combined paper would be impractically large. Therefore, we decided to split our survey into more than one paper. This paper seeks to address the paucity of information available regarding transcatheter aortic valve implantation (TAVI) and similar devices. This publication may serve as a reference point for critically organizing information on an evolving topic.
The following article deals with the large number of transcatheter devices related to valvular and ventricular pathologies: TAVI for the aortic and mitral valves, with a focus on indications, techniques and complications, as well as specific aortic devices, and devices to treat mitral regurgitation with non-conventional access. Every effort has been made to make the content relevant and up-to-date, which proved to be particularly challenging due to the continuous technological evolution which characterizes this field.
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Mid- and Long-Term Outcome of Currently Available Endografts for the Treatment of Infrarenal Abdominal Aortic Aneurysm
Leonie T. Jonker, MD, Surgical Resident, Arne de Niet, MD, PhD Candidate/Surgical Resident, Ignace F. J. Tielliu, MD, PhD, Consultant/Vascular Surgeon, Clark J. Zeebregts, MD, PhD, Consultant/Vascular Surgeon/Professor, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands, Michel M. P. J. Reijnen, MD, PhD, Consultant/Vascular Surgeon, Rijnstate Hospital, Arnhem, the Netherlands
33/1046
Currently, there is a wide range of commercially available endografts for infrarenal abdominal aortic aneurysm (AAA) repair. Results of long-term follow up after endovascular aneurysm repair (EVAR) are limited. Thereby, the durability of these endografts and the difference between manufacturers is not fully clear.
In this review, studies with mid- and long-term results, with a minimum median follow up of 36 months per endograft, were included describing results with Cook Zenith® Flex® endograft (Cook Medical Inc., Bloomington, Indiana) (n=6), Cordis Corporate INCRAFT® (Cordis Corporation, Freemont, California) (n=1), Gore® EXCLUDER® (W.L. Gore & Associates Inc., Flagstaff, Arizona) (n=3), Medtronic Endurant™ (Medtronic plc, Santa Rosa, California) (n= 6), and Vascutek Anaconda™ (Vascutek Ltd., Inchinnan, Scotland) (n=2).
The assisted technical success varied between 83% and 100%, and the perioperative mortality, early reintervention, and early conversion rates were comparable for the studied endografts. At three-year follow up, the freedom from AAA-rupture and AAA-related death varied between 98% and 100%. The results demonstrated an increasing complication and reintervention rate over time. When adhering to the instruction for use, minor differences were seen during follow up between the endografts. Latest generation endografts continue to have good postoperative results; the reintervention-rate of 10–20% over time mandates an ongoing close patient follow up. The choice of a specific design depends on native patient anatomy and the experience of the implanting surgeon.
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Extra-Thoracic Video-Assisted Thoracoscopic Surgery Rib Plating and Intra-Thoracic VATS Decortication of Retained Hemothorax
Natalie N. Merchant, BS, David Geffen School of Medicine at UCLA, Los Angeles, California, Osita Onugha, MD, MBA, Assistant Professor, John Wayne Cancer Institute, Santa Monica, California
33/1021
We report a patient who presented with multiple rib fractures after falling off a horse and was initially managed medically. Several weeks later, the patient returned to the hospital complaining of dyspnea on exertion. Physical exam revealed severe chest wall malformation and imaging revealed moderate hemothorax and complete collapse of the right lower lobe. Considering the likelihood that this patient’s multiple ribs fractures contributed to the hemothorax and trapped lung, the patient underwent surgical evacuation of the hemothorax followed by rib fixation of ribs three through six. The procedures were performed using both intra-thoracic and extra-thoracic video-assisted thoracoscopic surgery (VATS) and did not require the use of thoracotomy incision or open exposure of the thoracic cavity. This case report suggests that this operative technique is a viable option for delayed presentation of multiple rib fractures and complex sequela associated with this pathology.
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Latest Advances in Cardiac Valvular Replacement
Ruggero De Paulis, MD, PhD, Professor of Surgery, Salvatore D’Aleo, MD, Cardiac Surgeon, Ilaria Chirichilli, MD, Cardiac Surgeon, Luca Paolo Weltert, MD, Cardiac Surgeon, Heart Surgery Division, European Hospital, Rome, Italy
32/918
The original monograph on valvular prostheses in Surgical Technology International was published in 1993. It represents a milestone and a reference point for critically organizing information on a complex and rapidly evolving topic. The last update was published in 2010.
Since then, there have been significant developments regarding both “traditional” surgical prosthesis and valves for transcatheter implantation.
Both bioprostheses and mechanical prostheses continue to evolve with respect to both their design and materials to further optimize hemodynamics and prevent a patient-prosthesis mismatch.
Each type of prosthesis has its own Achilles’s heel: limited durability leading to structural failure for bioprostheses, and the need for anticoagulation for mechanical prostheses. After a long period of only marginal improvements, new techniques for tissue preservation and manufacturing seem to have placed surgeons on the verge of a minor revolution regarding bioprostheses. In addition, in the realm of mechanical prostheses, the many promises of silicon-free pyrolitic carbon still need to be confirmed, while an extremely cautious approach with new anticoagulants has left patients out of the non-dose-adjusted revolution, which has radically improved the quality of life of other patients, such as those suffering from atrial fibrillation.
On the other hand, transcatheter therapies are maturing, and the next few years will probably see an even stronger shift in the treatment of patients away from surgical theaters to cath labs, or perhaps to a new mixed theater (which could lead to a new mixed surgeon/catheter expert professional).
This paper provides device descriptions and images of the technologies that are considered to be predominant, at least for the moment, to help orient surgeons and to serve as a reference for students. This report would not have been possible without the prior work of Profs. Denton Cooley and Eric Jamieson.
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Transcatheter Technologies for Valvular Replacement: an Update
Antonio Nenna, MD, Resident, Department of Cardiovascular Surgery, University Campus Bio-Medico of Rome, Rome, Italy, Massimo Chello, MD, Full Professor of Cardiac Surgery, Sanjeet Singh Avtaar Singh, MD, Research Fellow, Department of Cardiac Surgery, Golden Jubilee National Hospital, Glasgow, UK, Simone Morganti, PhD, Professor, Department of Electrical, Computer, and Biomedical Engineering, University of Pavia, Pavia, Italy, Laura Mazzocchi, MSc, Researcher, Ferdinando Auricchio, PhD, Professor, Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy, Francesco Nappi, MD, Consultant, Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
32/999
This report provides a brief overview of the basic principles, recent advances, and recommendations for the treatment of severe aortic stenosis with transcatheter aortic valve replacement (TAVR) in adults. Approaches that avoid neurological, cardiac and peripheral vascular complications have been developed. In addition, TAVR can be performed in intermediate- and low-risk patients. However, these procedures require specialized training and may not allow for complete resolution of the underlying issue. Even if cardiologists learn to perform the procedure and despite advancements in device technology, TAVR is still susceptible to structural valve degeneration, thrombosis and late cerebral embolization. To date, TAVR has shown no consistent advantage over surgical aortic valve replacement (SAVR) in intermediate- and low-risk patients.
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Percutaneous Edge-to-Edge Transcatheter Mitral Valve Repair: Current Indications and Future Perspectives
Martino Pepe, MD, PhD, Interventional Cardiologist, Annagrazia Cecere, MD, Resident in Cardiology, Pasquale D’Alessandro, MD, Resident in Cardiology, Marco Matteo Ciccone, MD, FESC, Associate Professor of Cardiology, Department of Emergency and Organ Transplantation (DETO), University of Bari, Bari, Italy, Emanuela De Cillis, MD, PhD, Interventional Cardiologist, Institute of Cardiac Surgery, University of Bari, Bari, Italy, Tommaso Acquaviva, MD, Cardiologist, Institute of Cardiac Surgery, University of Bari, Bari, Italy, Arturo Giordano, MD, PhD, Interventional Cardiologist, Invasive Cardiology Unit, “Pineta Grande” Hospital, Castel Volturno, Caserta, Italy, and Department of Invasive Cardiology, Casa di Salute “Santa Lucia”, San Giuseppe Vesuviano, Napoli, Italy, Alessandro Santo Bortone, MD, PhD, Associate Professor of Cardiology, Interventional Cardiologist, Institute of Cardiac Surgery, University of Bari, Bari, Italy
32/1014
Mitral regurgitation (MR) is the most prevalent valvular heart disease (VHD) and represents an important cause of heart failure. Medical therapy has a limited role in improving symptoms and does not hinder the progression of valvular disease. Surgery is the treatment of choice for severe symptomatic MR; valve repair is currently the preferred surgical approach because it reduces peri-operative mortality and ensures a good medium- to long-term survival outcome. Nevertheless, a non-negligible proportion of patients with indications for surgical correction are considered to be at prohibitive perioperative risk, mainly because of old age and multiple comorbidities. The introduction of percutaneous interventions to clinical practice has changed the natural history of this population. Percutaneous edge-to-edge transcatheter mitral valve repair (Mitraclip®, Abbott Vascular, Menlo Park, CA) is a state-of-the-art therapy for approaching MR in patients with a high surgical risk. Despite having been only recently introduced, this transvenous transfemoral percutaneous intervention has already been performed in more than 40,000 subjects worldwide, with reassuring post-operative results in terms of safety, feasibility, mortality and morbidity. Since Mitraclip® is considered to be minimally invasive, it is currently indicated in “frail” patients with severe comorbidities. We provide a critical review of the literature to clarify current indications, procedural details, patient selection criteria, and future perspectives for this innovative technique.
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The Transradial Approach for Lower Extremity Vascular Intervention
Rami O. Tadros MD, Associate Professor of Surgery, Vivek S. Prakash, MD, Vascular Surgery Resident, Melissa J. Baldwin, MD, Vascular Surgery Resident, Adam Korayem, MD, Vascular Surgery Resident, Icahn School of Medicine at Mount Sinai, New York, New York, Peter L. Faries, MD, Chief of Vascular Surgery, Vascular Surgery Department, Michael L. Marin, MD, Chair of Surgery, Surgical Department, Icahn School of Medicine at Mount Sinai, New York, New York
32/1018
Simultaneous technological advancements in both imaging as well as devices have resulted in an expansion of endovascular options for vascular access. In particular, radial access has traditionally been more favored for coronary interventions; its use in the aortoiliac and lower extremity vasculature has been constrained by the length of devices and the size of sheaths required. However, with increasing catheter shaft lengths, in addition to new thin-walled sheaths allowing for downsizing, the ability to perform transradial interventions on infrainguinal and infrageniculate vessels has been more readily facilitated. In this review, we analyze the potential for transradial therapies in the treatment of peripheral arterial disease (PAD).
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Use of a NobleStitch™ EL Device for PFO Closure
Emanuela de Cillis, MD, PhD, Interventional Cardiologist, Tommaso Acquaviva, MD, Chief of Echo Laboratory, Pasquale D’Alessandro, MD, Fellow of Interventional Laboratory, Alessandro Santo Bortone MD, PhD, FESC, FAHA, FACC, Assistant Professor, Department of Emergency and Organs Transplantation, University of Bari, Bari, Italy
32/997
Cryptogenic stroke is the final diagnosis in almost 40% of ischemic acute cerebrovascular events. There is currently no definitive clinical evidence that percutaneous closure of patent foramen ovale (PFO) can prevent the recurrence of stroke or transient ischemic attack (TIA). Identification of the causes of neurologic ischemic syndromes is essential for any strategy intended to prevent the catastrophic consequences of cerebral infarction.
Since the initial reports of an unexpectedly high prevalence of PFO in younger patients with cryptogenic stroke in 1988, there has been growing interest and experience in diagnosing and treating these patients, both medically and/or with percutaneous closure, in particular for the potential to eliminate paradoxical embolism via PFO, which is a likely mechanism for stroke in these patients. Selection of the appropriate occluder device is of paramount importance for the success of the procedure. While devices like the Amplatzer™ PFO Occluder (St. Jude Medical), which, based on the extended follow-up of the RESPECT Trial, was approved by the U.S. Food and Drug Administration last year for recurrent stroke prevention, have become generally accepted as being better than medical therapy for patients needing treatment, concerns remain regarding device- and procedure-related complications. NobleStitch™ EL is a novel device that offers a simple non-prosthetic implant method of PFO closure without the inherent risks seen with septal occluders: no risk of device embolization, device thrombosis or late erosion, and probably no risk of arrhythmia. Futhermore, there is no material that would hinder future access to the left atrium and no requirement for anti-coagulation.
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Is There a Role for VATS Sleeve , Lobectomy in Lung Cancer?
Natalie N. Merchant, BS, Medical Student, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California , Robert McKenna Jr, MD, Medical Director, Thoracic Surgery Department, John Wayne Cancer Institute, Santa Monica, California, Osita Onugha, MD, MBA, Assistant Professor, Thoracic Surgery Department, John Wayne Cancer Institute, Santa Monica, California
32/996
Lung cancer is the second most commonly diagnosed cancer and continues to be the leading cause of death for both men and women, with non-small cell lung cancer (NSCLC) accounting for 85% of all lung cancer cases. Once a lung mass is visualized on imaging, accurate staging is required for determination of treatment options and, when possible, surgical resection is recommended as it has been proven to have the best survival rates versus non-surgical treatment. If a patient has advanced or metastatic disease, therapeutic options include chemotherapy and radiation, while immunotherapy and specific agents that target tumor mutations are only recommended for appropriate candidates. Additionally, surgical options differ based on whether the tumor is peripherally or centrally located in the lung parenchyma. This article will review relevant literature concerning current surgical techniques for resection of centrally located NSCLC using thoracotomy and will emphasize the benefits and challenges of a video-assisted thoracic surgery (VATS) approach.
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Correlation of Values for Indocyanine Green Angiography in the Arterographically Normal Lower Extremity
Paul J. Kim, DPM, MS, Associate Professor, Christopher E. Attinger, MD, Professor, Cameron M. Akbari, MD, Associate Professor, Caitlin Ward, BA, Research Associate, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
Introduction: Indocyanine green angiography (ICGA) is an assessment tool used to detect the degree of perfusion of tissue. This technology is being utilized in a variety of applications, including in the lower extremity. Principally, ICGA has been reported as a tool to determine pre-, intra-, or post-operative perfusion. The aim of this study is to determine objective values for ICGA in patients with arterographically normal lower extremities.
Materials and Methods: Prospectively, 20 patients were identified with no history of peripheral vascular disease who were scheduled to undergo distal subtraction angiography of the lower extremity. Based on the angiogram, 18 patients were deemed anatomically normal—a patent posterior tibial, anterior tibial, and peroneal artery with blood flow past the ankle into the foot. These patients then underwent ICGA on the dorsal and plantar aspects of the foot. The time to blush (seconds) and ingress and egress rates (units/second) were calculated. Results: The mean time to blush for the dorsal aspect is 26.7s (standard deviation [SD]=22.16) and the median is 14s (range=4–81s) and for the plantar aspect is 9.33s (SD=18.64), and the median is 3.5s (range=1–68s). The region of interest (ROI) ingress rates for the dorsal foot is: mean 3.29 (SD=5.18) and median is 1.60 (range=0.2–21.7). The ROI egress rates for the dorsal foot is: mean 0.55 (SD=0.43) and median is 0.35 (range=0.3–1.40). The ROI ingress rates for the plantar foot is: mean 10.02 (SD=11.91) and median 2.60 (range=0.30–34.20). The ROI egress rates for the plantar foot is: mean 1.57 (SD=1.65) and median is 1.00 (range=0.10–5.70).
Conclusions: This is the first study attempting to establish objective values for ICGA in the vascularly patent lower extremity.
31/917
22-09-2017
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Short-Term Results of Eluvia™ Paclitaxel-Eluting Stent in External Iliac and Femoropopliteal Lesions
Maxime Elens, MD, Medical Doctor, Robert Verhelst, PhD, Professor, Julien Possoz, MD, Medical Doctor, Stefano Mastrobuoni, MD, Medical Doctor, Valerie Lacroix, PhD, Professor, Parla Astarci, PhD, Professor, Cardiovascular and Thoracic Surgery Department, St Luc Hospital, Catholic University of Louvain, Brussels, Belgium
.
31/894
14-08-2017
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