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OBJECTIVES - This study sought to assess long-term left atrial appendage (LAA) closure efficacy of the Atriclip applied via totally thoracoscopic (TT) approach with computed tomographic angiography.
BACKGROUND - LAA closure is associated with a low risk for atrial fibrillation-related embolic stroke. The Atriclip exclusion device allows epicardial LAA closure, avoiding the need for post-operative oral anticoagulation. Previous data with Atriclip during open chest procedures show a high efficacy rate of closure >95%.
METHODS - Three-dimensional volumetric 2-phase computed tomographic angiography ≥90 days post-implantation was independently assessed by chest radiology for complete LAA closure on all consented subjects identified retrospectively as having had a TT-placed Atriclip at Vanderbilt University Medical Center from June 13, 2011, to October 6, 2015.
RESULTS - Complete LAA closure (defined by complete exclusion of the LAA with no exposed trabeculations, and clip within 1 cm from the left circumflex artery) was found in 61 of 65 subjects (93.9%). Four cases had incomplete closure (6.2%). Two clips were placed too distally, leaving a large stump with exposed trabeculae. Two clips failed to address a secondary LAA lobe. No major complications were associated with TT placement of the Atriclip. Follow-up over 183 patient-years revealed 1 stroke in a patient with complete LAA closure and no thrombus (hypertensive cerebrovascular accident).
CONCLUSIONS - Angiographic LAA closure efficacy with a TT-placed Atriclip is high (93.9%). The clinical significance of a remnant stump is unknown. Confirmation of complete LAA occlusion should be made before cessation of systemic anticoagulation.
Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
OBJECTIVE - We tested the hypothesis that the ophthalmology microscalpel, compared to standard incisional instruments, causes less trauma during incisions resulting in decreased inflammation and greater tensile strength of wounds.
STUDY DESIGN - Prospective animal study.
SETTING - Animal laboratory.
SUBJECTS AND METHODS - Thirty-four Sprague-Dawley rats received dorsum skin incisions with the microscalpel, electrosurgical device, 11 blade scalpel, and 15 blade scalpel. Wounds were harvested at 1 week, 2 weeks, 3 weeks, and 6 weeks, then analyzed histologically in a blinded manner for inflammation markers and tested for tensile strength.
RESULTS - The microscalpel wounds had significantly higher tensile strength compared to the 15 blade (P = .045) and electrocautery device (P = .000) but equivocal strength to the 11 blade (P = .457). The electrocautery wounds were weaker than all 3 steel blades. No significant difference was found between the microscalpel, 11 blade, and 15 blade incisions for the 5 markers of inflammation. Electrocautery wounds had significantly worse inflammatory scores, specifically, higher angiogenesis and larger wound gap compared to the microscalpel (P = .004, P = .002), 11 blade (P = .007, P = .023), and 15 blade (P = .010, P = .003), respectively.
CONCLUSION - Microscalpel incisions result in less inflammation and increased tensile strength compared with electrocautery and higher tensile strength compared to the 15 blade in the rat model. Inflammation scores were equivocal between the microscalpel, 11 blade, and 15 blade. Our findings support the use of the microscalpel blade for facial plastic and reconstructive procedures. Prospective, randomized human studies are warranted.
© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014.
In recent work, an atlas-based statistical model for brain shift prediction, which accounts for uncertainty in the intraoperative environment, has been proposed. Previous work reported in the literature using this technique did not account for local deformation caused by surgical retraction. It is challenging to precisely localize the retractor location prior to surgery and the retractor is often moved in the course of the procedure. This paper proposes a technique that involves computing the retractor-induced brain deformation in the operating room through an active model solve and linearly superposing the solution with the precomputed deformation atlas. As a result, the new method takes advantage of the atlas-based framework's accounting for uncertainties while also incorporating the effects of retraction with minimal intraoperative computing. This new approach was tested using simulation and phantom experiments. The results showed an improvement in average shift correction from 50% (ranging from 14 to 81%) for gravity atlas alone to 80% using the active solve retraction component (ranging from 73 to 85%). This paper presents a novel yet simple way to integrate retraction into the atlas-based brain shift computation framework.
Collagenase-3 (matrix metalloproteinase 13, MMP-13) was employed as a surrogate marker to compare the characteristics of incisional wound repair after surgery with the free-electron laser at 6.1 microm and the scalpel. Using a transgenic mouse strain with the MMP-13 or the COL1A2 promoter driving luciferase expression, we observed MMP-13 and COL1A2 expression, tensile strength, macrophage infiltration, and wound histology for up to 62 d. The scalpel incisions showed higher tensile strength than free-electron laser wounds from days 10 to 22 postwounding, despite minimal collateral thermal damage. After 45 d healing was similar. Trichrome staining confirmed that the scalpel incisions had more dense collagen deposition than free-electron laser incisions up to 36 d postinjury, but at day 45 they became similar. MMP-13 expression was biphasic, with peak activities at days 15 and 37 after injury, whereas free-electron laser wounds showed greater luciferase activity than scalpel wounds. Peak COL1A2 activity preceded the MMP-13 maximum. MMP-13 expression localized predominantly to dermal fibroblasts near the epidermis at day 15, and in the region of the deep dermis, muscle, and fascia at day 37 postwounding. Migrating muscle cells, but not all skeletal muscle cells, also expressed MMP-13. Free-electron laser incisions contained more macrophages than scalpel wounds at days 2 and 7 postinjury, suggesting that free-electron laser irradiation exacerbated the inflammatory response and thereby stimulated MMP-13 expression. These results revealed that MMP-13 was involved in a series of coordinated events during wound healing, not only the long-term remodeling of wound connective tissue, but also skeletal muscle repair. MMP-13 activity in vivo may correlate with the extent of tissue damage.