Does Concomitant CABG Influence the Outcomes of Post-Myocardial Infarction Ventricular Septal Defect Repair?

Introduction: Ventricular septal defect (VSD) following myocardial infarction (MI) is a relatively infrequent complication with high mortality. Over time, understanding of the pathology and its management has resulted in improved outcomes; however, controversies remain. Objective: We sought to investigate the effect of concomitant coronary artery bypass graft (CABG) on outcomes following post-MI VSD repair. Methods: Electronic search was performed to identify all relevant studies published from 2000 to 2018. After assessment for inclusion and exclusion criteria, 66 studies were selected for the analysis. Data were extracted and pooled for systematic review and meta-analysis. Results: Average age was 68.7 years (95% CI 67.3-70.1) with 57% (95% CI 54-60) males. Coronary angiogram was available preoperatively in 94% (95% CI 92-96) of patients. Single-vessel disease was most common (47%, 95% CI 42-52) with left anterior descending coronary artery the most commonly involved vessel (55%, 95% CI 46-63). Concomitant CABG was performed in 52% (95% CI 46-57) of patients. Of these, infarcted territory was revascularized in 54% (95% CI 23-82). No significant survival difference was observed between those who had concomitant CABG versus those without CABG at 30 days (65%, 95% CI 58-72) vs (60%, 95% CI 47-72), 1 year (59%, 95% CI 50-68) vs (51%, 95% CI 41-61), and 5 years (46%, 95% CI 38-54) vs (39%, 95% CI 27-52) respectively. Discussion: Overall, concomitant CABG did not have a significant effect on survival following VSD repair, therefore, decision on revascularization should be weighed against the risks associated with prolonged cardiopulmonary bypass

Active Learning in Medical Education: Application to the Training of Surgeons

Our article defines active learning in the context of surgical education and reviews the growing body of research on new approaches to teaching. We then discuss future perspectives and the challenges faced by the trainee and surgeon in applying active learning to surgical training. As modern surgical education faces numerous challenges, we hope our article will help surgical educators in the evaluation of curriculum development, methods of instruction, and assessment

Transcatheter, sutureless and conventional aortic-valve replacement: A network meta-analysis of 16,432 patients

Background: Minimally invasive surgical techniques pose alternatives to conventional surgery for the treatment of aortic stenosis (AS). We present a Bayesian network analysis comparing Valve Academic Research Consortium-2 clinical outcomes between transcatheter aortic valve implantation (TAVI), sutureless (SL-AVR) and conventional aortic valve replacement (CAVR). Methods: Electronic searches of databases were conducted and seven two-arm randomized-controlled trials and 25 propensity-score-matched studies comparing clinical outcomes of TAVI, SL-AVR and CAVR for treatment of AS were identified. Bayesian Markov chain Monte Carlo modelling was used to analyze clinical outcomes. Results: The analysis included 16,432 patients who underwent TAVI [7,056], SL-AVR [1,238] or CAVR [8,138]. Compared to CAVR, TAVI and SL-AVR were associated with reduced postoperative major bleeding of 59% (OR 0.41, 95% CI: 0.28–0.59) and 44% (OR 0.56, 95% CI: 0.30–0.99) respectively. TAVI had a 41% reduction in postoperative myocardial infarction (OR 0.59, 95% CI: 0.40–0.86) and SL-AVR had a 40% reduction in postoperative acute kidney injury (AKI) (OR 0.62, 95% CI: 0.42–0.86). Compared to TAVI, CAVR and SL-AVR had a reduction in moderate/severe paravalvular regurgitation of 89% (OR 0.11, 95% CI: 0.07–0.16) and 92% (OR 0.08, 95% CI: 0.03–0.17). CAVR had a 67% decreased postoperative permanent pacemaker (PPM) implantation compared to TAVI (OR 0.33, 95% CI: 0.24–0.45) and a 63% reduction compared to SL-AVR (OR 0.37, 95% CI: 0.22–0.61). There were no differences in 30-day mortality or postoperative stroke between the groups. Conclusions: In selected patients, minimally invasive surgical interventions including TAVI and SL-AVR for severe AS are viable alternatives to conventional surgery. However, TAVI is associated with increased paravalvular regurgitation, whereas TAVI and SL-AVR are associated with increased conduction disturbances compared to CAVR