Short-term results of sutureless closure for primary total anomalous pulmonary venous connection: seventeen cases

Introduction: Total anomalous pulmonary venous connection (TAPVC) is a rare condition. Mortality of TAPVC has improved dramatically in the present. Sutureless closure had initially used for congenital pulmonary venous stenosis (PVS) or post-repair PVS. Recently, it had been adopted for primary TAPVC to prevent postoperative pulmonary venous obstruction, a leading cause of death. This technique had gradually applied at our institute for primary TAPVC since 2018. Methods: Prospective case series was conducted from mid-2019. Including criteria consists of patients with primary TAPVC. These are all supracardiac, infracardiac, mixed type and intracardiac TAPVC with pulmonary venous stenosis. Excluding measures are TAPVC with single ventricle, isomerism or heterotaxy. End-point outcomes were mortality and short-term PVS. Results: Seventeen TAPVC cases were enrolled in this study from 06/2019-12/2020 at Children's Hospital 1. Male/female ratio was 12/5. Median age at admission was 44 (3-1010) days old. The median operative weight was 3.9 kg (2.4-11). Of those, fourteen (82.4%) cases were supracardiac TAPVC and 3 (17.6%) cases were infracardiac TAPVC. Nine (52.9%) cases were emergency operations. Median aortic clamp time was 66 (32-138) mins. Median bypass time was 112 (86-212) mins. There were 9 (52.9%) cases with arrhythmias, 2 (11.8%) cases with chylothorax. Mean ventilation time was 3.6±0.5 days; mean CICU time was 6.5 (1-20), median LOS was 14.5 (8-39). In-hospital mortality was 5.9% (1). Mean follow-up time was 12.3±6.4 months (range 4-24), there was no PVS with median pulmonary venous score of 0 (range 0-1). Conclusions: Sutureless technique could be a safe option for primary TAPVC repair.

Apex rotation as a risk factor for total anomalous pulmonary connection repair in single ventricle

Background: The high incidence of postoperative pulmonary venous obstruction (PVO) is a major mortality-associated concern in patients with right atrial isomerism and extracardiac total anomalous pulmonary venous connection (TAPVC). We evaluated new anatomical risk factors for reducing the space behind the heart after TAPVC repair. Methods: 18 patients who underwent TAPVC repair between 2014 and 2020 were enrolled. Sutureless technique was used in 12 patients and conventional repair in six patients. The angle between the line perpendicular to the vertebral body and that from the vertebral body to the apex was defined as the “vertebral-apex angle (V-A angle).” The ratio of post- and preoperative angles, indicating the apex’s lateral rotation, was compared between patients with and without PVO. Results: The median (interquartile range) age and body weight at repair were 102 (79-176) days and 3.8 (2.6-4.8) kg, respectively. The 1-year survival rate was 83% (median follow-up, 29 [11-36] months). PVO occurred in seven patients (39%), who showed an obstruction of one or two branches in the apex side. The postoperative V-A angle (46° [45°-50°] vs. 36° [29°-38°], P = 0.001) and the ratio of post- and preoperative V-A angles (1.27 [1.24-1.42] vs. 1.03 [0.98-1.07], P = 0.001) were significantly higher in the PVO group than in the non-PVO group. The cut-off values of the postoperative V-A angle and ratio were 41° and 1.17, respectively. Conclusions: A postoperative rotation of the heart apex into the ipsilateral thorax was a risk factor for branch PVO after TAPVC repair.

Intradural extraarachnoid sutureless technique combined with laminoplasty for indirect repair of ventral dural defects in spontaneous intracranial hypotension: technical note and case series

Background There is a significant variance in surgical treatment strategies of ventral cerebrospinal fluid (CSF) leaks causing spontaneous intracranial hypotension (SIH). Posterior approaches might represent a preferable alternative to the more invasive anterior and lateral routes, as long as the spinal cord is not exposed to harmful manipulation. The aim of this technical note is to report and illustrate a new surgical technique using an intradural extraarachnoid sutureless technique via laminoplasty for indirect repair of ventral CSF leaks causing intractable SIH symptoms. Methods The surgical technique is described in a step by step fashion. Between May 2018 and May 2020, five patients with ventral spinal CSF leaks were operated on, utilizing this technique. All dural defects were located at the level of the thoracic spine. A retrospective review on demographic and radiological findings, symptoms, outcome, and follow-up was performed. Results The intra- and postoperative course was uneventful in all patients with no surgery-related complications. Three patients recovered completely at discharge, while neurological symptoms significantly improved in two patients. A postoperative MRI of the spine was obtained for all patients, demonstrating regressive signs of CSF leak. Conclusion Based on the presented case series, this intradural extraarachnoid sutureless technique combined with laminoplasty seems to be a safe and effective option for indirect repair of ventral dural defects in SIH. In our opinion, it represents a valid alternative to traditional more aggressive approaches.

Modified Flapless and Sutureless Technique of Scleral Fixation of Intraocular Lens in the Management of Dislocation of Crystalline Lens Following Closed Globe Injury

Purpose To evaluate the outcomes of management of subluxation of lens following closed globe injury with a modified technique of scleral fixation of intraocular lens (SFIOL). Methods This prospective longitudinal study evaluated eyes with subluxation of crystalline lens which underwent combined pars plana vitrectomy (PPV), lensectomy (PPL) along with a sutureless and flapless technique of SFIOL implantation. We documented clinico-demographic data of all eyes at baseline and final anatomical and visual outcomes at 6 months after the surgery. Results We evaluated 113 eyes of 113 subjects with a mean age of 51.5 +- 15.7 years. 48.7% of eyes had a partial subluxation of lens from patellar fossa, while 51.3% of eyes had complete subluxation. After 6 months, the baseline visual acuity of 1.40 +- 0.66 logMAR (Snellen equivalent = 6/180) increased to 0.23 +- 0.27 (Snellen equivalent = 6/9) (p < 0.001). Eyes having VA < 6/36 reduced from 79.6% at baseline to 4.4% at final follow-up (p < 0.001). Eyes having VA > = 6/12 increased from 8.8–85.8% (p < 0.001). The proportion of eyes having raised intraocular pressure reduced from 20.4–1.8% at final follow-up (p < 0.001). The most common cause of subnormal visual gain was macular degeneration secondary to commotio retinae. Conclusion Subluxation of lens is a common entity faced by ophthalmologists across the world. Lensectomy with PPV and SFIOL is an effective method of refractive rehabilitation for subluxation eyes following closed globe injury. Visual prognosis may still depend upon the initial insult on the retina.