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Objective: Literature presents conflicting results on the pros and cons of pledget-reinforced sutures during surgical aortic valve replacement (SAVR). We aimed to investigate the effect of pledget-reinforced sutures versus sutures without pledgets during SAVR on different outcomes in a systematic review and meta-analysis. Methods: A literature search was performed in five different medical literature databases. Studies must include patients undergoing SAVR and must compare any pledget-reinforced with any suturing technique without pledgets. The primary outcome was paravalvular leakage (PVL), and secondary outcomes comprised thromboembolism, endocarditis, mortality, mean pressure gradient (MPG) and effective orifice area (EOA). Results were pooled using a random-effects model as risk ratios (RRs) or mean differences (MDs) for which the no pledgets group served as reference. Results: Nine observational studies met the inclusion criteria. The risk of bias was critical in seven studies, and high and moderate in two other. The pooled RR for moderate or greater PVL was 0.59 (95 % confidence interval [CI] 0.13, 2.73). The pooled RR for mortality at 30-days was 1.02 (95 % CI 0.48, 2.18) and during follow-up was 1.15 (95 % CI 0.67, 2.00). For MPG and EOA at 1-year follow-up, the pooled MDs were 0.60 mmHg (95 % CI -4.92, 6.11) and -0.03 cm2 (95 % CI -0.18, 0.12), respectively. Conclusions: Literature on the use of pledget-reinforced sutures during SAVR is at high risk of bias. Pooled results are inconclusive regarding superiority of either pledget-reinforced sutures or sutures without pledgets. Hence, there is no evidence to support or oppose the use of pledget-reinforced sutures.

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Objective: The objective of this study was to compare short- and midterm clinical and echocardiographic outcomes according to the use of pledgeted sutures during aortic valve replacement. Methods: Patients with aortic stenosis or regurgitation requiring aortic valve replacement were enrolled in a prospective cohort study to evaluate the safety of a new stented bioprosthesis. Outcomes were analyzed according to the use of pledgets (pledgeted group) or no pledgets (nonpledgeted group). The primary outcome was a composite of thromboembolism, endocarditis, and major paravalvular leak at 5 years of follow-up. Secondary outcomes included multiple clinical endpoints and hemodynamic outcomes. Propensity score matching was performed to adjust for prognostic factors, and subanalyses with small valve sizes (<23 mm) and suturing techniques were performed. Results: The pledgeted group comprised 640 patients (59%), and the nonpledgeted group 442 (41%), with baseline discrepancies in demographic characteristics, comorbidities, and stenosis severity. There were no differences between groups in any outcome. After propensity score matching, the primary outcome occurred in 41 (11.7%) patients in the pledgeted and 36 (9.8%) in the nonpledgeted group (P = .51). The effective orifice area was smaller in the pledgeted group (P = .045), whereas no difference was observed for the mean or peak pressure gradient. Separate subanalyses with small valve sizes and suturing techniques did not show relevant differences. Conclusions: In this large propensity score-matched cohort, comprehensive clinical outcomes were comparable between patients who underwent aortic valve replacement with pledgeted and nonpledgeted sutures up to 5 years of follow-up, but pledgets might lead to a slightly smaller effective orifice area in the long run.

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Introduction In the current otorhinolaryngology practice, technology has always been an essential part. Therefore, diagnostic nasal endoscopy (DNE) has become a vital examination in today's practice. In order to visualize the nasal cavity in a systematic manner without any discomfort to both patient and doctor, the nose should be well anesthetized and decongested. Objective The study is to compare and evaluate the efficacy of 4% lignocaine-oxymetazoline cotton pledget packing versus topical sprays in the preparation of nasal cavities for DNE. Methodology The prospective, randomized, double-blind study was conducted among 246 patients and was divided into two groups. In the first group, the nose was packed with cotton pledgets containing 4% lignocaine-oxymetazoline and another group with 4% lignocaine-oxymetazoline spray. Following DNE, patients and surgeons were questioned on a pre-formed questionnaire to evaluate their experience during the procedure. Results It was observed that the time taken for the pre-endoscopic preparation of the packing group was more than the spray group. A total of 91.9% of the spray group had pain during the pre-endoscopic preparation and more burning and tingling sensation than in the nasal pack (75.6%). A total of 69.9% of the patients among the spray group participants compared to 32.5% of the packing group patients experienced more throat discomfort. In addition, 12% of the packing group had mucosal bleeding during the preparation. A total of 32.5% of the spray group experienced severe pain when compared to 12.2% of the packing group during the endoscopic procedure. Most of the participants from both groups had difficulty visualizing the superior turbinate and sphenoethmoidal recess during the procedure. There was a significant difference seen between both the groups with respect to pain during the pre-endoscopic procedure (p=0.0005), burning/tingling sensation (p<0.0001), throat pain (<0.0001), mucosal bleed (p=0.0003), pain during the procedure (p=0.0001), and discomfort after the procedure (p<0.0001). Conclusion Both methods of nasal preparation have merits and demerits in terms of discomfort, pain, and visualization of structures. Still, the packing of the nasal cavity with cotton pledgets is better when compared to spraying with 4% lignocaine-oxymetazoline. However, 4% lignocaine-oxymetazoline spray can be used during an emergency situation and with sensitive patients.

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Cardiocutaneous fistula (CF) is a potentially serious and catastrophic complication. Infection the suture line after left ventricular aneurysm repair, presenting with the CF. We present an unusual case of CF due to staphylococcus infection 6 months after repair of a myocardial rupture secondary to dehiscence repair.

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Late Cardiocutaneous Fistula (CF) is an uncommon but potentially serious postoperative complication of cardiac surgery. We present the successful treatment of a 58-year-old female who developed a CF extending from the left ventricular apex into the left breast related to mitral valve replacement 15 years ago.

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Uterine arteriovenous malformations (AVMs) are a rare, potentially life-threatening cause of abnormal uterine bleeding that can be acquired following uterine instrumentation. We herein report a case of acquired uterine AVM following dilatation and curettage (D&C) that was successfully treated with bilateral embolization using Gelfoam (Pfizer, New York, USA) pledgets.

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PURPOSE: This study investigates if pledgeted sutures for hiatal closure could be an alternative to mesh for the surgical treatment of large hiatal hernia. METHODS: Forty-one patients who underwent laparoscopic 270° Toupet fundoplication with pledgeted sutured crura between September 2014 and April 2017 were evaluated with regard to recurrence of hiatal hernia at 3 months and 1 year after surgery. Indication for pledgets was a hiatal surface area of at least 5.60 cm2, or migration of more than 1/3 of the stomach into the thorax or preoperative hernia size > 5 cm. The integrity of repair was assessed using a barium swallow test 3 months and 1 year after surgery. RESULTS: All operations could be completed laparoscopically with no intraoperative complications. Until study end no complications related to the pledgets have occurred. Forty-four of 50 patients (88.0%) completed the follow-up radiographic examination 3 months (mean 12.7 weeks) after surgery, and 37 patients (74.0%; mean 55.1 weeks) 1 year after surgery. Postoperative recurrence was diagnosed in 3/44 patients (6.8%) at 3 months, and in 4/37 patients (10.8%) at 1 year follow-up. Only one patient was symptomatic, 1 year after surgery (2.7%). All other patients with reherniations were asymptomatic at time of the study. CONCLUSIONS: Utilization of pledgets to reinforce hiatal sutures seems safe and shows a quite low early recurrence rate compared to other methods. Long-term data will allow firm conclusions as to whether pledgeted sutures are an appropriate solution for the treatment of giant hiatal hernias.

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PURPOSE: To evaluate the relationship between gelatin sponge preparation methods and the incidence of intrauterine synechia following uterine artery embolization (UAE) for postpartum hemorrhage (PPH). MATERIALS AND METHODS: In a retrospective monocentric study, we used data from 20 consecutive UAE procedures (19 patients) for PPH, performed in 2007-2016, in which gelatin sponge had been used. The gelatin sponge was processed either into a slurry by pumping it back and forth about 10 times through two syringes connected to a three-way stopcock or into pledgets using a scalpel and small scissors to obtain pieces approximately 2 × 2 × 2 mm in size. Patient information was obtained from medical records, and the data were compared between patients treated with the slurry (n = 7) or pledgets (n = 13) forms. Due to the lack of follow-up data and hysterectomy after UAE, the sample size was 6 and 12 because 1 patient with 2 procedures was excluded. RESULTS: The rate of intrauterine synechia was significantly higher in the slurry group (5/6, 83.3%) than that in the pledgets group (0/12, 0%; P < 0.001). In contrast, there were no significant differences in population characteristics, such as the incidence of placenta accreta, non-placental diseases, and severity of shock (DIC score, shock index, or blood loss) between the groups. CONCLUSIONS: Although non-randomization and small sample size were the two main limitations, our observations suggest that UAE using gelatin sponge slurry may be associated with a high incidence of intrauterine synechia compared to UAE using pledgets.

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Surgical aortic valve replacement is the most common procedure of choice for the treatment of severe aortic stenosis. Bioprosthetic valves are traditionally sewed-in the aortic root by means of pledget-armed sutures during open-heart surgery. Recently, novel bioprostheses which include a stent-based anchoring system have been introduced to allow rapid implantation, therefore reducing the duration and invasiveness of the intervention. Different effects on the hemodynamics were clinically reported associated with the two technologies. The aim of this study was therefore to investigate whether the differences in hemodynamic performances are an effect of different anchoring systems. Two commercially available bio-prosthetic aortic valves, one sewed-in with pledget-armed sutures and one rapid-deployment, were thus tested in this study by means of a combined approach of experimental and computational tools. In vitro experiments were performed to evaluate the overall hydrodynamic performance under identical standard conditions; computational fluid dynamics analyses were set-up to explore local flow variations due to different design of the anchoring system. The results showed how the performance of cardiac valve substitutes is negatively affected by the presence of pledget-armed sutures. These are causing flow disturbances, which in turn increase the mean pressure gradient and decrease the effective orifice area. The combined approach of experiments and numerical simulations can be effectively used to quantify the detailed relationship between local fluid-dynamics and overall performances associated with different valve technologies.

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