Autologous microsurgical breast reconstruction and coronary artery bypass grafting: an anatomical study and clinical implications

OBJECTIVE: To identify possible avenues of sparing the internal mammary artery (IMA) for coronary artery bypass grafting (CABG) in women undergoing autologous breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps. BACKGROUND: Optimal autologous reconstruction of the breast and coronary artery bypass grafting (CABG) are often mutually exclusive as they both require utilisation of the IMA as the preferred arterial conduit. Given the prevalence of both breast cancer and coronary artery disease, this is an important issue for women's health as women with DIEP flap reconstructions and women at increased risk of developing coronary artery disease are potentially restricted from receiving this reconstructive option should the other condition arise. METHODS: The largest clinical and cadaveric anatomical study (n=315) to date was performed, investigating four solutions to this predicament by correlating the precise requirements of breast reconstruction and CABG against the anatomical features of the in situ IMAs. This information was supplemented by a thorough literature review. RESULTS: Minimum lengths of the left and right IMA needed for grafting to the left-anterior descending artery are 160.08 and 177.80 mm, respectively. Based on anatomical findings, the suitable options for anastomosis to each intercostals space are offered. In addition, 87-91% of patients have IMA perforator vessels to which DIEP flaps can be anastomosed in the first- and second-intercostal spaces. CONCLUSION: We outline five methods of preserving the IMA for future CABG: (1) lowering the level of DIEP flaps to the fourth- and fifth-intercostals spaces, (2) using the DIEP pedicle as an intermediary for CABG, (3) using IMA perforators to spare the IMA proper, (4) using and end-to-side anastomosis between the DIEP pedicle and IMA and (5) anastomosis of DIEP flaps using retrograde flow from the distal IMA. With careful patient selection, we hypothesize using the IMA for autologous breast reconstruction need not be an absolute contraindication for future CABG

Collagen-Based Hydrogels Composites from Hide Waste to Produce Smart Fertilizers

The study aims at reusing and recycling the protein hide waste from the leather industry in ecological conditions by elaborating an innovative procedure in order to obtain a collagen matrix functionalized with nitrogen, phosphorus, and potassium (NPK) nutrients to be used for preparing smart fertilizers. This is an interdisciplinary approach, as it starts from hide waste raw material as a critical industrial waste, which is then subjected to several technological steps by selection of optimal processing parameters, followed by product fabrication at the laboratory, and next scales to the industrial pilot plant to obtain novel agro-hydrogels. In this context, the technology scheme for collagen hydrolysate with encapsulated nutrients was proposed and the process parameters were optimized by functionalization of agro-hydrogels with various natural and synthetic polymers, such as polyacrylamide, poly(sodium 4-styrenesulfonate-co-glycidyl methacrylate) copolymer, starch or dolomite. Based on the laboratory experiments, a pilot plant was constructed and tested. Taking as reference the collagen hydrolysate with encapsulated nutrients, the new fertilizers were adequately characterized by chemical analysis, determination of biodegradability and the degree of release of oxidable compounds in water. Based on the biodegradation mechanism and kinetic analysis of oxidable compounds release, adequate arguments are evidenced to demonstrate that these fertilizers can be applied for amendment of poor agricultural soils

Committee Recommendations for Resuming Cardiac Surgery Activity in the SARS-CoV-2 Era: Guidance From an International Cardiac Surgery Consortium

Recommendations for the safe and optimized resumption of cardiac surgery care, research, and education during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) era were developed by a cardiovascular research consortium, based in 19 countries and representing a wide spectrum of experience with COVID-19. This guidance document provides a framework for restarting cardiac surgery in the outpatient and inpatient settings, in accordance with the current understanding of SARS-CoV-2, the risks posed by interrupted cardiovascular care, and the available recommendations from major societies

The Use of Intraoperative Transit Time Flow Measurement for Coronary Artery Bypass Surgery Systematic Review of the Evidence and Expert Opinion Statements

Transit time flow measurement (TTFM) allows quality control in coronary artery bypass grafting but remains largely underused, probably because of limited information and the lack of standardization. We performed a systematic review of the evidence on TTFM and other methods for quality control in coronary artery bypass grafting following PRISMA standards and elaborated expert recommendations by using a structured process. A panel of 19 experts took part in the consensus process using a 3-step modified Delphi method that consisted of 2 rounds of electronic voting and a final face-to-face virtual meeting. Eighty percent agreement was required for acceptance of the statements. A 2-level scale (strong, moderate) was used to grade the statements based on the perceived likelihood of a clinical benefit. The existing evidence supports an association between TTFM readings and graft patency and postoperative clinical outcomes, although there is high methodological heterogeneity among the published series. The evidence is more robust for arterial, rather than venous, grafts and for grafts to the left anterior descending artery. Although TTFM use increases the duration and the cost of surgery, there are no data to quantify this effect. Based on the systematic review, 10 expert statements for TTFM use in clinical practice were formulated. Six were approved at the first round of voting, 3 at the second round, and 1 at the virtual meeting. In conclusion, although TTFM use may increase the costs and duration of the procedure and requires a learning curve, its cost/benefit ratio seems largely favorable, in view of the potential clinical consequences of graft dysfunction. These consensus statements will help to standardize the use of TTFM in clinical practice and provide guidance in clinical decision-making