Contemporary management of aortic coarctation in adults is primarily by percutaneous intervention; however, this is not always possible. Intrapericardial ascending-to-descending aortic grafting is an alternative approach in adults with complex aortic coarctation. It can be performed off-pump and allows for a simultaneous treatment of concomitant cardiac lesions. Our aim was to examine the indications and the clinical long-term outcomes of intrapericardial ascending-to-descending aortic grafting in adults with aortic coarctation.

We retrospectively reviewed demographic, clinical, surgical, and follow-up data of patients who underwent intrapericardial ascending-to-descending aortic grafting at a single tertiary centre between September 1994 and November 2016.

Ten patients were identified. Indications were primary intervention (n = 4), re-coarctation (n = 5), and iatrogenic coarctation of aorta after stent grafting (n = 1). There were no peri-operative deaths. During a mean follow-up of 13.6 ± 9.4 years, one patient died 11 years after surgery, unrelated to intrapericardial ascending-to-descending aortic grafting. All grafts remained patent with no anastomotic pseudoaneurysms at latest follow-up.

The mean systolic blood pressure decreased from 154 ± 24 mmHg at baseline to 134 ± 20 mmHg at latest follow-up (p = 0.05), with the mean number of prescribed antihypertensive medications decreasing from 2.8 ± 1.5 preoperatively to 1.6 ± 0.5 (p = 0.11).

Intrapericardial ascending-to-descending aortic grafting is a safe and effective approach for adults with complex coarctation of aorta or re-coarctation not suitable for a percutaneous or conventional surgical approach. Improved blood pressure control and reduced anti-hypertensive use were observed long-term.

Congenitally corrected transposition of the great arteries is a rare congenital cardiac condition with varied presentations, complicating treatment decisions. This study evaluates the impact of medical management, physiologic repair, and anatomic repair on health-related quality of life.

A cross-sectional follow-up was conducted on 50 congenitally corrected transposition of the great arteries patients from a cohort of 240 at Cleveland Clinic (1995-2020). Health-related quality of life was assessed using MacNew and PROMIS-10 questionnaires. Echocardiographic data on systemic atrioventricular valvular regurgitation and systemic ventricular dysfunction were analysed. A time-varying coefficient model evaluated these factors’ impact on health-related quality of life.

Anatomic repair had significantly higher PROMIS-10 Physical T-scores compared to physiologic repair (median 50.9 vs 41.6, p = 0.04). MacNew Social scores were significantly higher for medical management compared to physiologic repair (median 6.8 vs 6.0, p = 0.02). Echocardiographic analysis revealed that systemic ventricular dysfunction had a stronger immediate impact on health-related quality of life. Systemic atrioventricular valve regurgitation showed a delayed negative effect, significant at 6-10 years after echo, although this effect gradually decreased over time. Anatomic repair patients had better systemic ventricular function (84.6% normal), and less systemic atrioventricular valve regurgitation (69.2% had none) compared to medical management and physiologic repair groups.

Anatomic repair improves health-related quality of life in congenitally corrected transposition of the great arteries patients, with physiologic repair showing some gains over time. Health-related quality of life data should provide important guidance regarding treatment decisions, especially in well-balanced congenitally corrected transposition of the great arteries patients.

Few studies have investigated stapedotomy using 1470 nm diode laser, and the present article contributes with clinical experience.

A retrospective analysis was conducted to investigate hearing performance of 22 patients undergoing 1470 nm diode laser-assisted primary stapedotomy.

In 8/22 cases, accidental breaches to the inner ear by the laser and in 14/22 cases the stapedotomy was performed as planned only by drill. Air–bone gap and loss of sensorineural hearing were low and with no significant differences for groups at follow-up. No patients with breaches by laser reported new or worse tinnitus.

Accidental breaches in the stapes footplate using this diode laser did not appear to equate with inner ear damage within this limited cohort. Hearing outcomes were not significantly affected. These findings should be interpreted with caution. Further studies evaluating this laser wavelength in stapedotomy is required.

The virtues of the scapular tip free flap for reconstruction of complex midface oncologic defects have been claimed by many. To obtain optimal functional and aesthetic results, precise positioning of the free flap used for reconstruction is paramount.

Four cases illustrate our approach to midface reconstruction with angular branch-based scapular tip flaps. A standard surgical navigation device was used both to plan bone cuts for the oncologic resection and to optimise the positioning of the flap.

Case 1 illustrates the usefulness of navigation for reconstruction of total palato-septectomy defects, using a horizontally positioned flap. Optimal neo-palate height, alignment of the anterior nasal spine and nasal projection were obtained. For cases 2–4, vertical inset of the flap yielded optimal midface projection and orbital floor position.

Surgical navigation systems are useful adjuncts for midface reconstruction.

Movement disorders (Parkinson’s disease, essential tremor, dystonia) are debilitating, progressive conditions that profoundly impact patients’ quality of life. Surgical therapies, such as deep brain stimulation (DBS) can provide tremendous relief to patients but remain costly and, therefore, limited in availability. It is critical to understand regional barriers to accessing this service to improve access for all patients who may benefit from it.

This is a mixed methods survey of stakeholders (patients/family members, advocacy groups, family physicians, neurologists, neurosurgeons) assessing perceived barriers to DBS for movement disorders. Closed and open-ended questions were used. Descriptive statistics were used to highlight regions of Canada where perceived access is poor and to identify barriers to access.

A total of 220 responses were recorded (12 neurosurgeons, 22 neurologists, 30 family physicians, 153 patients and caregivers and 3 advocacy group personnel). Themes included limited resources/centralization of resources, education, burdensome referral patterns and personal patient factors. Barriers included costs associated with travel, waitlists, lack of specific resources and poor understanding of movement disorders, DBS indications and referral pathways.

A number of barriers to access to DBS have been identified, related to geography and centralization of services, referrals and need for further education of indications and safety. The use of virtual care, centralized referral pathways and further research to determine the true prevalence of candidates for this therapy are required to improve access to DBS for movement disorders in Canada.

Palatine tonsil squamous cell carcinoma can be diagnosed with either tonsillectomy or tonsil biopsies. Biopsies are quicker to perform, less invasive, and provide potentially quicker results. Tonsillectomy minimises risk of missed pathology, but with greater associated morbidity. We compared whether tonsillectomy or biopsy affected surgical margin status at subsequent resection.

Our Business Intelligence Team provided a list of all patients with a primary tonsil squamous cell carcinoma who underwent surgery as their primary treatment modality in the last five years at University Hospitals Bristol. Demographic and treatment details were collected along with margin status following surgical resection.

Of the 31 patients that met inclusion criteria, 16 had biopsies and 15 had diagnostic tonsillectomies. The group who underwent tonsillectomy had a reduced risk of close or involved margins (< 5 mm) at subsequent curative-intent surgery (p < 0.001).

Our results suggest that tonsillectomy is associated with reduced likelihood of close or involved margins at subsequent curative-intent surgery. We hope this work can prompt larger multicentre comparisons between these two groups to investigate this relationship in more detail.

Sarcomas occurring during pregnancy are rare and they present significant challenges in clinical management, to optimise, investigations and treatment choices to ensure both maternal and foetal well-being.

A 32-year-old G1P0 female presented with a rapidly growing swelling in her right axilla. Ultrasound-guided core needle biopsy revealed a high-grade pleomorphic malignant tumour. The dilemmas and choices weighing the risks of staging studies, risks of contrast-enhanced scans, surgery during pregnancy and pre- and post-operative radiotherapy to both the mother and foetus are discussed in this case report

Decision of unenhanced whole-body MRI was chosen for staging studies to mitigate radiation and contrast risks to the foetus and mother. Imaging studies revealed a 10 cm tumour in the right axilla, displacing the subclavian neurovascular structures but without evidence of metastatic disease. Concerns about pre-operative radiotherapy including proton beam radiotherapy, given risk of tumour progression and surgical challenges post-radiation therapy, a consensus decision was reached to proceed with surgical resection followed by delivery of the baby and post-operative radiotherapy. Successful limb-preserving sarcoma surgery was performed at 26 weeks of gestation. She gave birth to a healthy female child at 38 weeks of gestation, and she is receiving post-operative radiotherapy.

Sarcomas diagnosed during pregnancy are rare and delicate balance is required for optimising oncologic outcomes and minimising risks to the mother and the foetus. Decision-making involving multiple specialties and multidisciplinary teams, a treatment plan was formulated that prioritised the safety of the patient and her baby.

Extubation failure after neonatal cardiac surgery is associated with increased intensive care unit length of stay, morbidity, and mortality. We performed a quality improvement project to create and implement a peri-extubation bundle, including extubation readiness testing, spontaneous breathing trial, and high-risk criteria identification, using best practices at high-performing centers to decrease neonatal and infant extubation failure by 20% from a baseline of 15.7% to 12.6% over a 2-year period.

Utilising the transparency of the Pediatric Cardiac Critical Care Consortium database, five centres were identified as high performers, having better-than-expected neonatal extubation success rates with the balancing metric of as-expected or better-than-expected mechanical ventilation duration. Structured interviews were conducted with cardiac intensive care unit physician leadership at the identified centers to determine centre-specific extubation practices. Data from those interviews underwent qualitative content analysis which was used to develop a peri-extubation bundle. The bundle was implemented at a single-centre 17-bed cardiac intensive care unit. Extubation failure, defined as reintubation within 48 hours of extubation for anything other than a procedure, ventilator days and bundle compliance was tracked.

There was a 41.4% decrease in extubation failure following bundle implementation (12 failures of 76 extubations pre-implantation; 6 failures of 65 extubations post-implementation). Bundle compliance was 95.4%. There was no difference in ventilator days (p = 0.079) between groups.

Implementation of a peri-extubation bundle created from best practices at high-performing centres reduced extubation failure by 41.4% in neonates and infants undergoing congenital heart surgery.

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) improves motor outcomes in Parkinson’s disease (PD) but may have adverse long-term effects on specific cognitive domains. The aim of this study was to investigate the association between total electrical energy (TEED) delivered by DBS and postoperative changes in verbal fluency.

Seventeen PD patients undergoing bilateral STN-DBS were assessed with the Alternate Verbal Fluency Battery (AVFB), which includes phonemic (PVF), semantic (SVF), and alternate verbal fluency (AVF) tests, before surgery (T0) and after 6 (T1) and 12 months (T2). Bilateral TEED and average TEEDM were recorded at T1 and T2. For each AVFB measurement, changes from T0 to T1 (Δ-01) and from T0 to T2 (Δ-02) were calculated.

At T1, PVF (p = 0.007) and SVF scores (p = 0.003) decreased significantly. TEED measures at T1 and T2 were unrelated to Δ-01 and Δ-02 scores, respectively. However, an inverse, marginally significant association was detected between the TEEDM and Δ-01 scores for the AVF (p = 0.041, against an αadjusted = 0.025).

In conclusion, the present reports provide preliminary evidence that TEED may not be responsible or only slightly responsible for the decline in VF performance after STN-DBS in PD.

Preoperative pneumonia in children with CHD may lead to longer stays in the ICU after surgery. However, research on the associated risk factors is limited. This study aims to evaluate the pre-, intra-, and postoperative risk factors contributing to extended ICU stays in these children.

This retrospective cohort study collected data from 496 children with CHD complicated by preoperative pneumonia who underwent cardiac surgery following medical treatment at a single centre from 2017 to 2022. We compared the clinical outcomes of patients with varying ICU stays and utilised multivariate logistic regression analysis and multiple linear regression analyses to evaluate the risk factors for prolonged ICU stays.

The median ICU stay for the 496 children was 7 days. Bacterial infection, severe pneumonia, and Risk Adjustment for Congenital Heart Surgery-1 were independent risk factors for prolonged ICU stays following cardiac surgery (P < 0.05).

CHD complicated by pneumonia presents a significant treatment challenge. Better identification of the risk factors associated with long-term postoperative ICU stays in these children, along with timely diagnosis and treatment of respiratory infections in high-risk populations, can effectively reduce ICU stays and improve resource utilisation.