Ravitch versus Nuss procedure for pectus excavatum: systematic review and meta-analysis

BACKGROUND

Pectus excavatum is the most common congenital chest wall deformity. The two most common surgical techniques for its correction are the modified Ravitch technique and the minimally invasive Nuss technique. Despite both procedures being used widely, data comparing them are scarce.

METHODS

We conducted a systematic review and meta-analysis of comparative studies to evaluate these procedures. A systematic search of the literature was performed from six electronic databases. Pooled meta-analysis was conducted using odds ratio (OR) and weighted mean difference (WMD).

RESULTS

A total of 13 studies comprising 1,432 pediatric (79.3%) and adult (20.7%) patients were identified, including 912 patients undergoing the Nuss procedure compared to 520 patients undergoing the Ravitch procedure. There was no significant difference found between the Nuss group versus Ravitch group in pediatric patients with regard to overall complications (OR =1.16; 95% CI: 0.61-2.19; I²=56%; P=0.65), reoperations (6.1% vs. 6.4%; OR =1.00; 95% CI: 0.40-2.50; I²=0%; P=1.00), wound infections (OR =0.58; 95% CI: 0.23-1.46; I²=0%; P=0.25), hemothorax (1.6% vs. 1.3%; OR =0.74; 95% CI: 0.21-2.65; I²=12%; P=0.64), pneumothorax (3.4% vs. 1.5%; OR =1.11; 95% CI: 0.42-2.93; I²=0%; P=0.83) or pneumonia (OR =0.15; 95% CI: 0.02-1.48; I²=0%; P=0.10). Adult patients undergoing the Nuss procedure had a higher incidence of overall complications (OR =3.26; 95% CI: 1.01-10.46; I²=0%; P=0.05), though there were far fewer studies that reported data.

CONCLUSIONS

These results suggest no difference between the Nuss and Ravitch procedures for pediatric patients, while in adults the Ravitch procedure resulted in fewer complications.

Obesity and postoperative atrial fibrillation in patients undergoing cardiac surgery: Systematic review and meta-analysis

INTRODUCTION

Post-operative atrial fibrillation (POAF) is one of the most common complications following cardiac surgery. However, it is unclear whether there is a relationship between obesity and POAF. We thus assessed all available evidence investigating the association between obesity and POAF, also considering any link between POAF and other post-operative conditions such as mortality, stroke, myocardial infarctions and respiratory complications.

METHODS

Five electronic databases were searched and relevant studies were identified. Data was extracted and meta-analyzed from the identified studies.

RESULTS

We found that obese patients had significantly higher odds of POAF when compared with non-obese patients (P=0.006). There was also significant heterogeneity among the identified studies. POAF when compared with no-POAF was associated with an increased risk of stroke (P<0.0001), 30-day mortality (P=0.005) and respiratory complications (P<0.00001). However, we found no significant link between POAF and myocardial infarctions (P=0.79).

CONCLUSIONS

Our findings suggest that obesity is associated with a moderately higher risk of POAF. While POAF is also associated with an increased incidence of stroke, 30-day mortality and respiratory complications, further studies must be conducted before conclusions can be made about the long-term outcomes.

A comparison of aspirin against rivaroxaban for venous thromboembolism prophylaxis after hip or knee arthroplasty: A meta-analysis

PURPOSE

Total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients are at an elevated risk of post-operative venous thromboembolism (VTE). Newer thromboprophylactic agents such as rivaroxaban are increasingly used and effective in preventing thromboembolic events but may worsen bleeding risk. Recent studies have suggested that the more cost-effective aspirin may also be effective in preventing VTE. This systematic review and meta-analysis aimed to compare the efficacy of aspirin against rivaroxaban for the prevention of VTE following TKA and THA.

METHODS

Electronic searches were performed using five databases from their date of inception to August 2018. Relevant studies were identified, with data extracted and meta-analyzed from the studies.

RESULTS

Five studies were included, which consisted of 2257 in the aspirin group and 2337 in the rivaroxaban group. There were no differences between aspirin and rivaroxaban for either VTE (p = 0.48) or its components deep vein thrombosis (p = 0.44) and pulmonary embolism (p = 0.98). Also, there were no differences between groups for either major bleeding (p = 0.17), any bleeding (p = 0.62), readmissions (p = 0.37) or wound complications (p = 0.17).

CONCLUSION

Aspirin was not significantly different to rivaroxaban for prevention of VTE or adverse events after TKA or THA. However, this study was limited by the significant heterogeneity of the included studies. More large randomized studies are needed to add to this body of evidence.

Adenosine Testing After Atrial Fibrillation Ablation: Systematic Review and Meta-Analysis

BACKGROUND

Adenosine can be used to reveal dormant pulmonary vein (PV) conduction after pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF). We performed a systematic review and meta-analysis to assess the impact of adenosine administration in patients undergoing PVI for AF.

METHODS

Meta-analysis of 22 studies was performed to assess the rates of freedom from AF in 1) patients with dormant PV conduction versus patients without dormant PV conduction, and 2) patients given routine adenosine post PVI versus patients not given adenosine. Relative-risks (RR) were calculated using random effects modelling.

RESULTS

In 18 studies, 3038 patients received adenosine and freedom from AF in those patients with dormant PV reconnection was significantly lower (62.9%) compared to patients without PV reconnection (67.2%) (RR 0.87; 95% CI: 0.78-0.98). In seven studies with 3049 patients, the freedom from AF was significantly higher in patients who received adenosine (67%) versus those patients who did not receive adenosine (63%) (RR: 1.11; 95% CI: 1.01-1.22).

CONCLUSIONS

The present study showed clear benefits of adenosine testing for freedom from AF recurrence. Adenosine-guided dormant conduction is associated with higher AF recurrence despite further ablation. Future studies should investigate the optimal methodology, including dosage and waiting time between PVI and adenosine administration.

Quantitative and Morphological Corneal Endothelial Changes After Selective Laser Trabeculoplasty and Retinal Photocoagulation

PURPOSE

Selective laser trabeculoplasty (SLT) and retinal photocoagulation (RP) are two common laser procedures often performed at a wavelength of 532 nm, and may affect the corneal endothelium. This study used corneal specular microscopy to determine the impact of these procedures on the corneal endothelium.

DESIGN

Retrospective cohort study in a private practice.

METHODS

There were 249 eyes from 136 consecutive patients who underwent SLT for open-angle glaucoma and 132 eyes from 74 patients who underwent RP included. Corneal specular microscopy was performed immediately before and after each procedure and at 1-month postprocedure. Microscopy data included quantitative measures, such as cell density and central corneal thickness, and morphological measures, including percentage of hexagonal cells and coefficient of variation in cell area.

RESULTS

There was a small (just over 1%) reduction in corneal endothelial cell count from pre-SLT to post-SLT (P = 0.008), and a statistically significant recovery at 1 month (P = 0.04). Central corneal thickness also transiently increased from pre-SLT to post-SLT (P = 0.03). Although polymegathism was unchanged, changes in pleomorphism were observed (P = 0.03). The only change in the RP group was an increase in polymegathism between pre-RP and post-RP (P = 0.001).

CONCLUSIONS

SLT has measurable effects on both quantitative and morphological characteristics of the corneal endothelium, which seem to be transient. RP has fewer measurable effects, likely because, although the total laser energy is similar, it is delivered over a much longer time (3 ns versus 0.1 s). The changes observed in both procedures are minor and unlikely to be of clinical significance.

Catheter Ablation for Ventricular Tachycardia in Ischaemic Versus Non-Ischaemic Cardiomyopathy: A Systematic Review and Meta-Analysis

BACKGROUND

There are differences in substrate and ablation approaches for ventricular tachycardia (VT) in ischaemic (ICM) and non-ischaemic cardiomyopathy (NICM).

OBJECTIVE

To perform a systematic review and meta-analysis comparing clinical and procedural characteristics/outcomes of VT ablation in ICM versus NICM.

METHODS

Electronic databases were searched for comparative studies reporting outcomes of VT ablation in patients with ICM and NICM. Primary outcomes were acute procedural success, VT recurrence and long-term mortality. Meta-analyses were performed using random-effects modelling.

RESULTS

Thirty-one (31) studies (7,473 patients; 4,418 ICM and 3,055 NICM) were included. Patients with ICM were significantly older (67.0 vs 55.3 yrs), more commonly male (89% vs 79%), had lower left ventricular ejection fraction (29% vs 38%) were less likely to undergo epicardial access (11% vs 36%) and were more likely to require haemodynamic support during ablation (relative risk [RR] 1.30; 95% CI 1.01-1.69). Acute procedural success (i.e. non-inducibility of VT) was higher in the ICM cohort (RR 1.10, 95% CI 1.05-1.15). Recurrence of VT at follow-up was significantly lower in the ICM cohort (RR 0.77; 95% CI 0.70-0.84). Peri-procedural mortality, incidence of procedural complications and long-term mortality were not significantly different between the cohorts.

CONCLUSIONS

NICM and ICM patients undergoing VT ablation are fundamentally different in their clinical characteristics, ablation approaches, acute procedural outcomes and likelihood of VA recurrence. VT ablation in NICM has a lower likelihood of procedural success with increased risk of VA recurrence, consistent with known challenging arrhythmia substrate.

Effectiveness and safety of simultaneous hybrid thoracoscopic endocardial catheter ablation of atrial fibrillation in obese and non-obese patients

Background

We evaluated the safety and effectiveness of the hybrid thoracoscopic endocardial epicardial ablation technique for the treatment of atrial fibrillation (AF) in obese versus non-obese patients.

Methods

Between January 2010 and January 2015, a cohort of 61 patients were retrospectively identified to undergo ablation of AF as a stand-alone procedure using a thoracoscopic, hybrid epicardial-endocardial technique. All patients underwent continuous 7-day Holter monitoring at 3, 6 months, 1 year and yearly thereafter.

Results

A total of 40% of the obese cohort had persistent or long-standing AF, compared to 54.9% of the non-obese cohort. There were no deaths or conversion to cardiopulmonary bypass required. At 3-year follow-up, 60% of the obese group were in sinus rhythm (SR) with no episode of AF, atrial flutter or atrial tachycardia lasting 30 s off anti-arrhythmic drugs. This was compared to 70.6% in the non-obese group, with no significant difference between the groups (P=0.468). For success rates on anti-arrhythmic drugs, this was 80% in the obese group compared to 86% in the non-obese group at 3-year follow-up (P=0.637). No patient died and no thromboembolic/bleeding events or procedure-related complications occurred during the follow-up.

Conclusions

In a retrospective cohort with approximately half with persistent or long-standing AF, thoracoscopic hybrid epicardial endocardial ablation proved to be equally effective and safe in obese versus non-obese patients. Current preliminary findings require further validation in multi-institutional prospective studies with larger sample sizes.

Predictors of weight loss in obese patients with obstructive sleep apnea

PURPOSE

Consistent predictors of weight loss outcomes with very low-energy diets (VLEDs) in obstructive sleep apnea (OSA) have not been identified. This study aimed to identify variables predictive of weight loss success in obese patients with OSA undertaking an intensive weight loss programme.

METHODS

We analysed biological, psychological, and behavioural variables as potential predictors of weight loss in obese patients with OSA after a 2-month VLED followed by one of two 10-month weight loss maintenance diets. Actigraphy, in-lab polysomnography, urinary catecholamines, and various psychological and behavioural variables were measured at baseline, 2, and 12 months. Spearman's correlations analysed baseline variables with 2-month weight loss, and 2-month variables with 2-12 month-weight change.

RESULTS

Forty-two patients completed the VLED and thirty-eight completed the maintenance diets. Actigraphy data revealed that late bedtime (r_s =  - 0.45, p =  < 0.01) was correlated with 2-month weight loss. The change in the time that participants got out of bed (rise-time) from baseline to two months was also correlated with 2-month weight loss (r_s = 0.36, p = 0.03). The Impact of Weight on Quality of Life-Lite questionnaire (IWQOL) Public Distress domain (r_s =  - 0.54, p =  < 0.01) and total (r_s =  - 0.38, p = 0.02) scores were correlated with weight loss maintenance from 2 to 12 months.

CONCLUSIONS

Results from this small patient sample reveal correlations between actigraphy characteristics and weight loss in obese patients with OSA. We suggest the IWQOL may also be a useful clinical tool to identify OSA patients at risk of weight regain after initial weight loss.

CLINICAL TRIAL REGISTRATION

This clinical trial was prospectively registered on 18/02/2013 with the Australia and New Zealand Clinical Trials Registry (ACTRN12613000191796).

PUBLIC REGISTRY TITLE

Sleep, Lifestyle, Energy, Eating, Exercise Program for the management of sleep apnea patients indicated for weight loss treatment: A randomised, controlled pilot study. URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363680.