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European Journal of Pediatric Surgery :... Apr 2018Video-assisted thoracoscopic surgery (VATS) has gained broad acceptance among pediatric surgeons. Today, VATS can be regarded as a routine approach for various... (Review)
Review
Video-assisted thoracoscopic surgery (VATS) has gained broad acceptance among pediatric surgeons. Today, VATS can be regarded as a routine approach for various conditions in neonates and infants. However, there is a lack of information concerning the complications of thoracoscopic pulmonary surgery in neonates and infants. We aimed to review the available data. A systematic review of the literature was performed using PubMed. All publications reporting on VATS for pulmonary procedures in neonates and infants up to the age of 1 year were included. Articles were reviewed in detail for occurrence of perioperative complications and their treatment. Nine case series were eligible for analysis. Entities treated included lung sequestration, congenital pulmonary airway malformation, congenital lobar emphysema, and bronchogenic cyst. Case series reported on a total number of 135 patients. Complications occurred in 14 patients (10.4%). The major complication was an accidental transection of the middle lobar bronchus that concluded in a later resection of a prior unaffected lung lobe. Other relevant complications reported were bleeding in four patients (3.0%) and persistent air leak in four cases (3.0%). Infectious complications were reported in four patients (3.0%). Additionally, iatrogenic phrenic nerve paralysis occurred in one patient. There were no deaths related to the VATS technique. In 11 cases (8.1%), conversion to thoracotomy had been necessary. General recommendations on the treatment of complications could not be derived due to small patient numbers and lack of details of the complications reported. Reports on major complications of pulmonary VATS in neonates and infants below 1 year of age are scarce. As severe complications such as accidental bronchus transection have been described, feasibility of neonatal/infant VATS cannot be unequivocally confirmed. No literature-based recommendation can be given on the treatment of complications.
Topics: Humans; Infant; Infant, Newborn; Intraoperative Complications; Perioperative Period; Postoperative Complications; Thoracic Surgery, Video-Assisted; Treatment Outcome
PubMed: 29510429
DOI: 10.1055/s-0038-1636917 -
Heart Rhythm May 2017Early studies demonstrated relatively low success rates for pulmonary vein isolation (PVI) alone in patients with persistent atrial fibrillation (PeAF). However, the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Early studies demonstrated relatively low success rates for pulmonary vein isolation (PVI) alone in patients with persistent atrial fibrillation (PeAF). However, the advent of new technologies and the observation that additional substrate ablation does not improve outcomes have created a new focus on PVI alone for treatment of PeAF.
OBJECTIVE
The purpose of this study was to systematically review the recent medical literature to determine current medium-term outcomes when a PVI-only approach is used for PeAF.
METHODS
An electronic database search (MEDLINE, Embase, Web of Science, PubMed, Cochrane) was performed in August 2016. Only studies of PeAF patients undergoing a "PVI only" ablation strategy using contemporary radiofrequency (RF) technology or second-generation cryoballoon (CB2) were included. A random-effects model was used to assess the primary outcome of pooled single-procedure 12-month arrhythmia-free survival. Predictors of recurrence were also examined and a meta-analysis performed if ≥4 studies examined the parameter.
RESULTS
Fourteen studies of 956 patients, of whom 45.2% underwent PVI only with RF and 54.8% with CB2, were included. Pooled single-procedure 12-month arrhythmia-free survival was 66.7% (95% confidence interval [CI] 60.8%-72.2%), with the majority of patients (80.5%) off antiarrhythmic drugs. Complication rates were very low, with cardiac tamponade occurring in 5 patients (0.6%) and persistent phrenic nerve palsy in 5 CB2 patients (0.9% of CB2). Blanking period recurrence (hazard ratio 4.68, 95% CI 1.70-12.9) was the only significant predictor of recurrence.
CONCLUSION
A PVI-only strategy in PeAF patients with a low prevalence of structural heart disease using contemporary technology yields excellent outcomes comparable to those for paroxysmal AF ablation.
Topics: Atrial Fibrillation; Catheter Ablation; Humans; Pulmonary Veins
PubMed: 28434446
DOI: 10.1016/j.hrthm.2017.01.003 -
JACC. Clinical Electrophysiology Mar 2017The goal of this study was to describe short- and long-term outcomes in all patients referred for inappropriate sinus tachycardia ablation, along with the potential...
OBJECTIVES
The goal of this study was to describe short- and long-term outcomes in all patients referred for inappropriate sinus tachycardia ablation, along with the potential complications of the intervention.
BACKGROUND
Sinus node (SN) ablation/modification has been proposed for patients refractory to pharmacological therapy. However, available data derive from limited series.
METHODS
The electronic databases MEDLINE, Embase, CINAHL, Cochrane, and Scopus were systematically searched (January 1, 1995-December 31, 2015). Studies were screened according to predefined inclusion and exclusion criteria.
RESULTS
A total of 153 patients were included. Their mean age was 35.18 ± 10.02 years, and 139 (90.8%) were female. All patients had failed to respond to maximum tolerated doses of pharmacological therapy (3.5 ± 2.4 drugs). Mean baseline heart rates averaged 101.3 ± 16.4 beats/min according to electrocardiography and 104.5 ± 13.5 beats/min according to 24-h Holter monitoring. Two electrophysiological strategies were used, SN ablation and SN modification, with the latter being used more. Procedural acute success (using variably defined pre-determined endpoints) was 88.9%. Consistently, all groups reported high-output pacing from the ablation catheter to confirm absence of phrenic nerve stimulation before radiofrequency delivery. Need of pericardial access varied between 0% and 76.9%. Thirteen patients (8.5%) experienced severe procedural complications, and 15 patients (9.8%) required implantation of a pacemaker. At a mean follow-up interval of 28.1 ± 12.6 months, 86.4% of patients demonstrated successful outcomes. The symptomatic recurrence rate was 19.6%, and 29.8% of patients continued to receive antiarrhythmic drug therapy after procedural intervention.
CONCLUSIONS
Inappropriate sinus tachycardia ablation/modification achieves acute success in the vast majority of patients. Complications are fairly common and diverse. However, symptomatic relief decreases substantially over longer follow-up periods, with a corresponding high recurrence rate.
Topics: Adult; Anti-Arrhythmia Agents; Body Surface Potential Mapping; Catheter Ablation; Electrocardiography; Electrocardiography, Ambulatory; Electrophysiologic Techniques, Cardiac; Female; Follow-Up Studies; Humans; Male; Middle Aged; Pacemaker, Artificial; Pericardium; Phrenic Nerve; Recurrence; Sinoatrial Node; Tachycardia, Sinus; Treatment Outcome
PubMed: 29759520
DOI: 10.1016/j.jacep.2016.09.014 -
Journal of Interventional Cardiac... Apr 2017The present systematic review and meta-analysis aimed to assess and compare the safety and efficacy of radiofrequency (RF) and cryoballoon (CB) ablation for paroxysmal... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
The present systematic review and meta-analysis aimed to assess and compare the safety and efficacy of radiofrequency (RF) and cryoballoon (CB) ablation for paroxysmal atrial fibrillation (PAF). RF and CB ablation are two frequently used methods for pulmonary vein isolation in PAF, but which is a better choice for PAF remains uncertain.
METHODS
A systematic review was conducted in Medline, PubMed, Embase, and Cochrane Library. All trials comparing RF and CB ablation were screened and included if the inclusion criteria were met.
RESULTS
A total of 38 eligible studies, 9 prospective randomized or randomized controlled trials (RCTs), and 29 non- RCTs were identified, adding up to 15,496 patients. Pool analyses indicated that CB ablation was more beneficial in terms of procedural time [standard mean difference = -0.58; 95% confidence interval (CI), -0.85 to -0.30], complications without phrenic nerve injury (PNI) [odds ratio (OR) = 0.79; 95% CI, 0.67-0.93; I = 16%], and recrudescence (OR = 0.83; 95% CI, 0.70-0.97; I = 63%) for PAF; however, the total complications of CB was higher than RF. The subgroup analysis found that, compared with non-contact force radiofrequency (non-CF-RF), both first-generation cryoballoon (CB1) and second-generation cryoballoon (CB2) ablation could reduce complications with PNI, procedural time, and recrudescence. However, the safety and efficacy of CB2 was similar to those of CF-RF.
CONCLUSION
Available overall and subgroup data suggested that both CB1 and CB2 were more beneficial than RF ablation, and the main advantages were reflected in comparing them with non-CF-RF. However, CF-RF and CB2 showed similar clinical benefits.
Topics: Atrial Fibrillation; Catheter Ablation; Cryosurgery; Female; Humans; Male; Middle Aged; Postoperative Complications; Prevalence; Risk Factors
PubMed: 28063111
DOI: 10.1007/s10840-016-0220-8 -
Anesthesia and Analgesia Feb 2017Supraclavicular (SC) and infraclavicular (IC) brachial plexus block (BPB) are commonly used for upper extremity surgery. Recent clinical studies have compared the effect... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Supraclavicular (SC) and infraclavicular (IC) brachial plexus block (BPB) are commonly used for upper extremity surgery. Recent clinical studies have compared the effect of SC- and IC-BPB, but there have been controversies over spread of sensory blockade in each of the 4 peripheral nerve branches of brachial plexus.
METHODS
This study included a systemic review, using the Medline and EMBASE database from their inceptions through March 2016. Randomized controlled trials (RCTs) comparing SC- and IC-BPB were included. The prespecified primary outcome was the incidences of incomplete sensory blockade in each of the 4 terminal nerve branches of brachial plexus. Secondary outcome included the incidence of successful blockade, performance time, onset of sensory block, duration of analgesia, and complication rates.
RESULTS
Ten RCTs involving 676 patients were included. Pooled analyses showed the incidence of incomplete block at 30 minutes in radial nerve territory was significantly higher in IC-BPB, favoring SC-BPB (risk ratio 0.39; 95% confidence interval [0.17-0.88], P = .02, I = 0%). However, subgroup analysis according to the number of injections of IC-BPB showed that double or triple injections IC-BPB yielded no difference in the incomplete radial block. Furthermore, the incidence of incomplete ulnar block at 30 minutes was significantly lower in IC-BPB when using double or triple injection IC-BPB. There was no difference in the secondary outcomes between SC- and IC-BPB groups, with the exception of complication rates. The incidence of paresthesia/pain on local anesthetic injection, phrenic nerve palsy, and Horner syndrome was significantly higher in the SC group, favoring IC-BPB.
CONCLUSIONS
This meta-analysis demonstrated that IC-BPB showed a significantly high incidence of incomplete radial nerve sensory block at 30 minutes, which may be avoided by double or triple injection. Furthermore, IC-BPB with multiple injection technique showed significantly lower incidence of incomplete ulnar block than SC-BPB. There were no differences in the incidence of successful blockade, block onset, and duration of analgesia between SC- and IC-BPB. Procedure-related paresthesia/pain and adjacent nerve-related complications were more frequent in SC-BPB. However, because of the small sample size, publication bias remains a concern when interpreting our results. Further studies with sufficient sample size and reporting large number of outcomes are required.
Topics: Humans; Brachial Plexus; Clavicle; Nerve Block; Randomized Controlled Trials as Topic; Treatment Failure; Ultrasonography, Interventional
PubMed: 27828793
DOI: 10.1213/ANE.0000000000001713 -
Journal of Interventional Cardiac... Jan 2017Currently, radiofrequency (RF) and cryoballoon are the most commonly used ablation technologies for atrial fibrillation (AF). We performed a meta-analysis to assess the... (Comparative Study)
Comparative Study Meta-Analysis Review
Efficacy and safety of the second-generation cryoballoons versus radiofrequency ablation for the treatment of paroxysmal atrial fibrillation: a systematic review and meta-analysis.
PURPOSE
Currently, radiofrequency (RF) and cryoballoon are the most commonly used ablation technologies for atrial fibrillation (AF). We performed a meta-analysis to assess the efficacy and safety of the second-generation cryoballoons (CB-2) compared with RF for paroxysmal atrial fibrillation (PAF) ablation.
METHODS
The PubMed, Cochrane Library, and Embase databases were searched and qualified studies were identified. The primary clinical outcome was the recurrence rate of atrial tachyarrhythmia (AT), and the secondary clinical outcomes were procedure time, fluoroscopy time, and the complications that followed.
RESULTS
Nine observational studies (2336 patients) with a mean follow-up period ranging from 8.8 to 16.8 months were included. The CB-2 group was associated with a significantly lower recurrence rate of ATs (20.8 versus 29.8 %, p = 0.01). In subgroup analysis, compared with non-contact force sensing (NCF) catheter, using CB-2 showed significantly reduced incidence of ATs (22.0 versus 38.5 %, p < 0.00001). However, the difference became negligible in contrast with contact force sensing (CF) catheter. Moreover, the CB-2 group had a tendency to decrease procedure time (weighted mean difference -39.72 min, p = 0.0003), whereas fluoroscopy time was similar between the two groups. The total complication rate showed no statistical difference (8.8 versus 4.4 %, p = 0.08). Almost all the cases of phrenic nerve palsy occurred in the CB-2 group, whereas pericardial tamponade was seldom manifested in the CB-2 group.
CONCLUSIONS
CB-2 tended to be more effective in comparison to NCF catheter and at least non-inferior to CF catheter, with shorter procedure time and similar safety endpoint.
Topics: Aged; Atrial Fibrillation; Catheter Ablation; Cryosurgery; Female; Humans; Male; Middle Aged; Postoperative Complications; Prevalence; Risk Factors; Treatment Outcome
PubMed: 27683062
DOI: 10.1007/s10840-016-0191-9 -
Acta Neurochirurgica Sep 2016The phrenic nerve can be transferred to the musculocutaneous nerve in patients with traumatic brachial plexus palsy in order to recover biceps strength, but the results... (Review)
Review
BACKGROUND
The phrenic nerve can be transferred to the musculocutaneous nerve in patients with traumatic brachial plexus palsy in order to recover biceps strength, but the results are controversial. There is also a concern about pulmonary function after phrenic nerve transection. In this paper, we performed a qualitative systematic review, evaluating outcomes after this procedure.
METHOD
A systematic review of published studies was undertaken in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Data were extracted from the selected papers and related to: publication, study design, outcome (biceps strength in accordance with BMRC and pulmonary function) and population. Study quality was assessed using the "strengthening the reporting of observational studies in epidemiology" (STROBE) standard or the CONSORT checklist, depending on the study design.
RESULTS
Seven studies were selected for this systematic review after applying inclusion and exclusion criteria. One hundred twenty-four patients completed follow-up, and most of them were graded M3 or M4 (70.1 %) for biceps strength at the final evaluation. Pulmonary function was analyzed in five studies. It was not possible to perform a statistical comparison between studies because the authors used different parameters for evaluation. Most of the patients exhibited a decrease in pulmonary function tests immediately after surgery, with recovery in the following months. Study quality was determined using STROBE in six articles, and the global score varied from 8 to 21.
CONCLUSIONS
Phrenic nerve transfer to the musculocutaneous nerve can recover biceps strength ≥M3 (BMRC) in most patients with traumatic brachial plexus injury. Early postoperative findings revealed that the development of pulmonary symptoms is rare, but it cannot be concluded that the procedure is safe because there is no study evaluating pulmonary function in old age.
Topics: Brachial Plexus; Brachial Plexus Neuropathies; Humans; Musculocutaneous Nerve; Nerve Transfer; Outcome Assessment, Health Care; Paralysis; Phrenic Nerve
PubMed: 27260490
DOI: 10.1007/s00701-016-2855-8 -
Child's Nervous System : ChNS :... Jun 2016Case reports, case series and case control studies have looked at the use of phrenic nerve stimulators in the setting of high spinal cord injuries and central... (Review)
Review
Evaluating the evidence: is phrenic nerve stimulation a safe and effective tool for decreasing ventilator dependence in patients with high cervical spinal cord injuries and central hypoventilation?
INTRODUCTION
Case reports, case series and case control studies have looked at the use of phrenic nerve stimulators in the setting of high spinal cord injuries and central hypoventilation syndromes dating back to the 1980s. We evaluated the evidence related to this topic by performing a systematic review of the published literature.
METHODS
Search terms "phrenic nerve stimulation," "phrenic nerve and spinal cord injury," and "phrenic nerve and central hypoventilation" were entered into standard search engines in a systematic fashion. Articles were reviewed by two study authors and graded independently for class of evidence according to published guidelines. The published evidence was reviewed, and the overall body of evidence was evaluated using the grading of recommendations, assesment, development and evaluations (GRADE) criteria Balshem et al. (J Clin Epidemiol 64:401-406, 2011).
RESULTS
Our initial search yielded 420 articles. There were no class I, II, or III studies. There were 18 relevant class IV articles. There were no discrepancies among article ratings (i.e., kappa = 1). A meta-analysis could not be performed due to the low quality of the available evidence. The overall quality of the body of evidence was evaluated using GRADE criteria and fell within the "very poor" category.
CONCLUSION
The quality of the published literature for phrenic nerve stimulation is poor. Our review of the literature suggests that phrenic nerve stimulation is a safe and effective option for decreasing ventilator dependence in high spinal cord injuries and central hypoventilation; however, we are left with critical questions that provide crucial directions for future studies.
Topics: Cervical Vertebrae; Databases, Bibliographic; Electric Stimulation Therapy; Humans; Hypoventilation; Phrenic Nerve; Spinal Cord Injuries
PubMed: 27083568
DOI: 10.1007/s00381-016-3086-2 -
Injury Mar 2016Intramuscular diaphragmatic stimulation using an abdominal laparoscopic approach has been proposed as a safer alternative to traditional phrenic nerve stimulation. It... (Review)
Review
Intramuscular diaphragmatic stimulation for patients with traumatic high cervical injuries and ventilator dependent respiratory failure: A systematic review of safety and effectiveness.
BACKGROUND
Intramuscular diaphragmatic stimulation using an abdominal laparoscopic approach has been proposed as a safer alternative to traditional phrenic nerve stimulation. It has also been suggested that early implementation of diaphragmatic pacing may prevent diaphragm atrophy and lead to earlier ventilator independence. The aim of this study was therefore to systematically review the safety and effectiveness of intramuscular diaphragmatic stimulators in the treatment of patients with traumatic high cervical injuries resulting in long-term ventilator dependence, with particular emphasis on the affect of timing of insertion of such stimulators.
METHODS
The Cochrane database and PubMed were searched between January 2000 and June 2015. Reference lists of selected papers were also reviewed. The inclusion criteria used to select from the pool of eligible studies were: (1) reported on adult patients with traumatic high cervical injury, who were ventilator-dependant, (2) patients underwent intramuscular diaphragmatic stimulation, and (3) commented on safety and/or effectiveness.
RESULTS
12 articles were included in the review. Reported safety issues post insertion of intramuscular electrodes included pneumothorax, infection, and interaction with pre-existing cardiac pacemaker. Only one procedural failure was reported. The percentage of patients reported as independent of ventilatory support post procedure ranged between 40% and 72.2%. The mean delay of insertion ranged from 40 days to 9.7 years; of note the study with the average shortest delay in insertion reported the greatest percentage of fully weaned patients.
CONCLUSIONS
Although evidence for intramuscular diaphragmatic stimulation in patients with high cervical injuries and ventilator dependent respiratory failure is currently limited, the technique appears to be safe and effective. Earlier implantation of such devices does not appear to be associated with greater surgical risk, and may be more effective. Further high quality studies are warranted to investigate the impact of delay of insertion on ventilator weaning.
Topics: Combined Modality Therapy; Diaphragm; Electric Stimulation Therapy; Humans; Phrenic Nerve; Practice Guidelines as Topic; Respiration, Artificial; Respiratory Insufficiency; Spinal Cord Injuries; Ventilator Weaning
PubMed: 26803697
DOI: 10.1016/j.injury.2015.12.020 -
Respiratory Medicine Mar 2013Inspiratory muscle fatigue (IMF) may contribute to the development of exercise limitation and respiratory failure. Identifying fatigue of the inspiratory muscles... (Review)
Review
Inspiratory muscle fatigue (IMF) may contribute to the development of exercise limitation and respiratory failure. Identifying fatigue of the inspiratory muscles requires a rigorous and integrative methodological approach. However, there is no consensus about an optimal protocol to induce and assess the fatigability of the inspiratory muscles. A systematic review was performed to identify, evaluate, and summarize the literature related to the assessment of induced IMF in healthy individuals. The aim was to identify factors that are related consistently to IMF, as well as to suggest possible assessment methods. MEDLINE and EMBASE were searched for relevant articles until February 2012. Only studies with a quantitative description of assessment and outcome were included. The search yielded 460 citations and a total of 77 studies were included. Inspiratory muscle fatigue was produced acutely by inspiratory resistive loading (IRL), whole body exercise (WBE), hyperpnea, or WBE combined with IRL, and under normocapnic, hypoxic or hypercapnic conditions. To detect IMF, most studies (64%) used phrenic nerve stimulation, 44% used a maximal voluntary inspiratory maneuver and the remainder used electromyography. The heterogeneity of the published reports precluded a quantitative analysis. Inspiratory resistive loadings at intensities of 60-80% of maximum, and cycling at 85% of maximum were found to produce IMF most consistently. Hypoxic or hypercapnic conditions, and WBE combined with IRL, exacerbated IMF. The specific outcome measures employed to detect IMF, the magnitude of their change, as well as their functional significance, are ultimately dependent upon the research question being addressed.
Topics: Diaphragm; Electric Stimulation; Exercise Test; Humans; Muscle Fatigue; Phrenic Nerve; Respiratory Muscles
PubMed: 23273596
DOI: 10.1016/j.rmed.2012.11.019