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- Spontaneous coronary artery dissection with multiple coronary artery aneurysms in a patient with diabetic ketoacidosis. [Journal Article]
- J Thorac Dis 2014 Feb; 6(2):E5-E10.
Spontaneous coronary artery dissection (SCAD) is a very rare and commonly fatal condition that typically presents with signs and symptoms of an acute myocardial infarction and cardiogenic shock. We herein present a case of a 54-year-old woman who was diagnosed with diabetic ketoacidosis (DKA) as the first manifestation of her underlying diabetes mellitus, while being hospitalized for treatment, she was found to have a non ST-elevation myocardial infarction (NSTEMI), an urgent cardiac catheterization revealed a complete dissection of the right coronary artery (RCA) with an intraluminal thrombus formation and multiple aneurismal dilatations in the left anterior descending (LAD) and left circumflex (LC) arteries. The patient underwent coronary artery bypass grafting with a favorable outcome.
- Esophageal exclusion and bypass for corrosive injury: The lessons learnt. [Journal Article]
- J Indian Assoc Pediatr Surg 2014 Jan; 19(1):46-8.
While it is always preferable to excise and replace the diseased esophagus in corrosive injuries, the surgeon may be compelled to exclude and bypass it by a substernal conduit in select situations wherein excision is technically hazardous. This case illustrates the lessons learnt from a potentially life-threatening complication of bipolar esophageal exclusion.
- Signals Controlling Un-Differentiated States in Embryonic Stem and Cancer Cells: Role of the Phosphatidylinositol 3' Kinase Pathway. [JOURNAL ARTICLE]
- J Cell Physiol 2014 Mar 7.
The capacity of embryonic stem (ES) cells to differentiate into cell lineages comprising the three germ layers makes them powerful tools for studying mammalian early embryonic development in vitro. The human body consists of approximately 210 different somatic cell types, the majority of which have limited proliferative capacity. However, both stem cells and cancer cells bypass this replicative barrier and undergo symmetric division indefinitely when cultured under defined conditions. Several signal transduction pathways play important roles in regulating stem cell development, and aberrant expression of components of these pathways is linked to cancer. Among signaling systems, the critical role of leukemia inhibitory factor (LIF) coupled to the Jak/STAT3 (signal transduction and activation of transcription-3) pathway in maintaining stem cell self-renewal has been extensively reviewed. This pathway additionally plays multiple roles in tumorigenesis. Likewise, the phosphatidylinositide 3-kinase (PI3K)/protein kinase B (PKB/Akt) pathway has been determined to play an important role in both stem cell maintenance and tumor development. This pathway is often induced in cancer with frequent mutational activation of the catalytic subunit of PI3K or loss of a primary PI3K antagonist, phosphatase and tensin homolog deleted on chromosome ten (PTEN). This review focusses on roles of the PI3K signal transduction pathway components, with emphasis on functions in stem cell maintenance and cancer. Since the PI3K pathway impinges on and collaborates with other signaling pathways in regulating stem cell development and/or cancer, aspects of the canonical Wnt, Ras/mitogen-activated protein kinase (MAPK), and TGF-β signaling pathways are also discussed. J. Cell. Physiol. © 2014 Wiley Periodicals, Inc.
- Long-term outcomes and risk analyses of coronary bypass for left main disease. [JOURNAL ARTICLE]
- Asian Cardiovasc Thorac Ann 2014 Mar 6.
We retrospectively analyzed the long-term outcomes and risk predictors of conventional coronary artery bypass grafting routinely employed for patients with left main disease.From January 2000 through December 2009, conventional coronary artery bypass grafting was routinely employed in 193 consecutive patients with left main disease. Long-term analyses were performed, looking at the primary endpoint of major adverse cardiac and cerebrovascular events which included all-cause death, stroke, myocardial infarction, and repeat revascularization. We also analyzed the effects of variables on major adverse cardiac and cerebrovascular events at 9 years after the operation.The overall 9-year rates of combined outcomes (death, stroke, myocardial infarction), repeat revascularization, and major adverse cardiac and cerebrovascular events were 20.2%, 8.9%, 27.7%, respectively. The SYNTAX score was demonstrated to be the only significant predictor of combined outcomes at 9 years (hazard ratio 1.04, p = 0.033), repeat revascularization at 9 years (hazard ratio 1.11, p = 0.0030), and major adverse cardiac and cerebrovascular events at 9 years (hazard ratio 1.07, p = 0.0003).With our routine strategy of conventional coronary artery bypass for left main disease, patients revealed excellent long-term outcomes in terms of major adverse cardiac and cerebrovascular events. These results provide a suitable benchmark against which long-term outcomes of percutaneous coronary intervention for left main disease can be compared. The SYNTAX score, which was introduced to determine treatment for complex coronary disease, is indicative of long-term outcomes after coronary artery bypass for left main disease.
- [Symetis Acurate Transapical Aortic Valve: the initial experience with a second generation of transcatheter aortic valve replacement device]. [English Abstract, Journal Article]
- Kardiol Pol 2014; 72(2):187-93.
Transcatheter aortic valve replacement (TAVR) has proven to be a valuable alternative to conventional surgical aortic valve replacement in high risk and surgically in operable patients who suffer from severe symptomatic aortic stenosis. However, a significant number of complications, associated with both the learning curve and device specificity, have required attention and subsequent improvement. The Symetis transapical TAVR system is a self-positioning bioprosthesis composed of a non-coronary leaflet of surgical quality porcine tissue valve sewn into a self-expanding nitinol stent that iscovered with a PET-skirt.From June to September 2013 six patients have been operated on severe aortic stenosis using the new TAVR device. All patients have undergone critical assessment of a local Heart Team and have been disqualified from conventional AVR. Five were woman. Mean age was 82.3 ± 2.0 (mean LogEuroScore 23.9 ± 14.3). Four patients suffered from coronary artery disease - two had history of previous percutaneous coronary intervention with intracoronary stents, while the next two had history of coronary artery bypass grafting. Diabetes was frequent (n = 3) as well as chronic obstructive pulmonary disease (n = 4). Carotid artery disease was encountered in three patients similarly to atrial fibrillation. Mean left ventricular ejection fraction (LVEF) was 51.5 ± 11.8%, but one patient had suffered from low-flow-low-gradient aortic stenosis with LVEF of 29%.The procedure was carried out successfully in all six cases. Two patients have received the valve sized L, three - M and one - S. Mean procedure time was 180 ± 19 min, mean cine 7.2 ± 1.2 min. Mean X-ray dose 930 ± 439 mGy, while mean volume of contrast given was 135 ± 61 mL. In all patients but one perivalvular leak (PVL) was not present. One patient had trace of PVL. Also, good LVEF was noted in all patients. Similar findings were obtained 30 days post procedure. No strokes, transient ischaemic attack or other cerebrovascular incidents were observed.This brief clinical communication reports the first Polish experience with the second generation of TAVR device - the Symetis Acurate Transapical Aortic Valve. While it lacks large patient population and longer follow-up, it reveals that TAVR procedure can be performed safely, with minimal X-ray exposure time and contrast given and successfully - with almost nonexistent PVL and no cerebrovascular incidents or heart rhythm disturbances. Heart Team approach is vital, and transapical access should not be treated inferiorly, but rather as an equally appealing TAVR option.
- Mild Cognitive Impairment with Associated Inflammatory and Cortisol Alterations as Independent Risk Factor for Postoperative Delirium. [JOURNAL ARTICLE]
- Dement Geriatr Cogn Disord 2014 Mar 1; 38(1-2):65-78.
Aims: The present study aimed to determine the impact of mild cognitive impairment (MCI) on the development of postoperative delirium and, secondly, to assess the association between MCI and raised perioperative cortisol, cytokine, cobalamin and homocysteine levels. Methods: The study recruited 113 consecutive adult patients scheduled for cardiac surgery with cardiopulmonary bypass. The patients were examined preoperatively with the Montreal Cognitive Assessment and Trail Making Test. A diagnosis of MCI was established based upon the criteria of the National Institute on Aging and Alzheimer's Association. Patients were screened for delirium within the first 5 days postoperatively. Results: MCI was diagnosed in 24.8% of the patients, whereas the frequency of delirium was 36%. A multivariate analysis demonstrated that individuals with MCI were at a significantly higher risk of postoperative delirium (OR = 6.33, p = 0.002). Preoperative cortisol, postoperative cortisol and IL-2 plasma levels were higher in the MCI group as compared to non-MCI subjects. Conclusion: MCI is associated with a higher risk of postoperative delirium. Perioperative cortisol and inflammatory alterations observed in MCI may provide a physiological explanation for this increased risk. © 2014 S. Karger AG, Basel.
- EuroSCORE II with SYNTAX score to assess risks of coronary artery bypass grafting outcomes. [JOURNAL ARTICLE]
- Eur J Cardiothorac Surg 2014 Mar 5.
We evaluated the usefulness of the combination of European System for Cardiac Operative Risk Evaluation score (EuroSCORE II) and SYNergy between percutaneous intervention with TAXus drug-eluting stents and cardiac surgery (SYNTAX) score in predicting risks associated with early and late outcomes after coronary artery bypass grafting (CABG).Between January 2010 and April 2012, 412 patients underwent isolated CABG at our institution. EuroSCORE II and SYNTAX score were calculated retrospectively, and their ability to predict early and long-term outcomes was evaluated. Patients were divided into four groups according to median EuroSCORE II and SYNTAX score: Group 1, low EuroSCORE II, low SYNTAX (n = 103); Group 2, low EuroSCORE II, high SYNTAX (n = 103); Group 3, high EuroSCORE II, low SYNTAX (n = 99); and Group 4, high EuroSCORE II, high SYNTAX (n = 107).Operative death was not different among the groups; however, Group 4 had the highest major complication rate of the four groups (0 in Group 1, 2.9% in Group 2, 3.0% in Group 3 and 8.4% in Group 4; P = 0.011). Multivariate analyses revealed that both high EuroSCORE II (odds ratio [OR]: 4.154; P = 0.030) and high SYNTAX score (OR: 3.988; P = 0.035) were independent predictors of postoperative major complications and that high EuroSCORE II was an independent predictor of late mortality (OR: 4.673; P = 0.016) but high SYNTAX score was not (OR: 0.808; P = 0.662). Actuarial survival rate at 3 years was the lowest in Group 4 (99.0 ± 1.0% in Group 1, 97.7 ± 1.6% in Group 2, 91.9 ± 2.7% in Group 3 and 90.5 ± 4.7% in Group 4; P = 0.045).The combination of EuroSCORE II and SYNTAX score was useful in predicting early major complications after CABG. In the long term, EuroSCORE II continued to be associated with late mortality, but SYNTAX score did not.
- Contrast-induced acute kidney injury after primary percutaneous coronary intervention: results from the HORIZONS-AMI substudy. [JOURNAL ARTICLE]
- Eur Heart J 2014 Mar 6.
We sought to examine the short- and long-term outcomes of patients who developed contrast-induced acute kidney injury (CI-AKI; defined as an increase in serum creatinine of ≥0.5 mg/dL or a 25% relative rise within 48 h after contrast exposure) from the large-scale HORIZONS-AMI trial.Multivariable analyses were used to identify predictors of CI-AKI, as well predictors of the primary and secondary endpoints. The incidence of CI-AKI in this cohort of ST-segment elevation myocardial infarction (STEMI) patients was 16.1% (479/2968). Predictors of CI-AKI were contrast volume, white blood cell count, left anterior descending infarct-related artery, age, anaemia, creatinine clearance <60 mL/min, and history of congestive heart failure. Patients with CI-AKI had higher rates of net adverse clinical events [NACE; a combination of major bleeding or composite major adverse cardiac events (MACE; consisting of death, reinfarction, target vessel revascularization for ischaemia, or stroke)] at 30 days (22.0 vs. 9.3%; P < 0.0001) and 3 years (40.3 vs. 24.6%; P < 0.0001). They also had higher rates of mortality at 30 days (8.0 vs. 0.9%; P < 0.0001) and 3 years (16.2 vs. 4.5%; P < 0.0001). Multivariable analysis confirmed CI-AKI as an independent predictor of NACE [hazard ratio ([HR), 1.53; 95% confidence interval (CI), 1.23-1.90; P = 0.0001], MACE (HR, 1.56; 95% CI, 1.23-1.98; P = 0.0002), non-coronary artery bypass grafting major bleeding (HR, 2.07; 95% CI, 1.57-2.73; P < 0.0001), and mortality (HR, 1.80; 95% CI, 1.19-2.73; P = 0.005) at 3-year follow-up.Contrast-induced acute kidney injury is associated with poor short- and long-term outcomes after primary percutaneous coronary intervention in STEMI.
- Setting up and utilizing a service for measuring perioperative transcranial motor evoked potentials during thoracoabdominal aortic surgery and thoracic endovascular repair. [JOURNAL ARTICLE]
- Interact Cardiovasc Thorac Surg 2014 Mar 6.
Paraplegia is a complication that may occur following surgery or endovascular stenting of thoracic and thoracoabdominal aortic pathology. Measuring transcranial motor evoked potentials (tcMEPs) has been shown to provide a reliable measure of spinal cord function during such procedures allowing interventions to protect cord function. In the spirit of sharing experience and eliminating the learning curve for others, this manuscript describes our experience of setting up a service for tcMEP monitoring as well as the documents and algorithms for measuring, recording and acting on the patient data, the so-called 'MEP Pathway'.Recording and interpretation of tcMEP during thoracoabdominal aortic intervention requires training of staff and close team working in the operating theatre and postoperative intensive care unit. Providing consistent, reliable, specific and sensitive information on spinal cord function and its safe and effective use to alter patient outcomes requires a protocol. The MEP pathway was developed by medical and paramedical staff at our institution based on clinical experience and literature reviews over a 1-year period (2012-2013).The tcMEP pathway comprises six documents that guide staff in: (a) assessing suitability of patients, (b) setting up hardware, (c) preparing algorithms for management, (d) documenting intervention (left heart bypass, cardiopulmonary bypass or endovascular stenting) as well as (e) documenting postoperative intensive care processes.The tcMEP pathway acts as a guide for safe introduction and use of tcMEPs in thoracoabdominal aortic interventions. tcMEP-led guidance of intraoperative and postoperative management in thoracic aortic surgery is an important adjunct in caring for this patient group.
- Effects of Roux-en-Y gastric bypass and ileal transposition surgeries on glucose and lipid metabolism in skeletal muscle and liver. [JOURNAL ARTICLE]
- Surg Obes Relat Dis 2013 Oct 15.
Roux-en Y gastric bypass (RYGB) and ileal transposition (IT) surgeries produce weight loss and improve diabetic control; however, the mechanisms of glycemic improvements are largely unknown. Because skeletal muscle and liver play a key role in glucose homeostasis, we compared the effects of RYGB and IT surgeries on key molecules of glucose and lipid metabolism in muscle and liver.Sprague-Dawley rats were subjected to RYGB, IT, or sham surgeries; sham-animals were ad-lib fed or pair-fed to RYGB rats (n = 7-9/group). At 8 weeks postoperatively, blood samples were collected for glucagon-like peptide-1 (GLP-1) and insulin analyses by ELISA. Leg muscle and liver tissues were analyzed for mRNA (RT-qPCR) and/or protein abundance (immuno blotting) of important molecules of glucose and lipid metabolism [glucose transporter-4 (GLUT-4), hexokinase, phosphofructokinase (PFK), adenosine monophosphate activated protein kinase-α (AMPKα), cytochrome C oxidase-IV (COX-IV), citrate synthase, carnitine palmitoyl transferase-1 (CPT-1), medium-chain acyl-CoA dehydrogenase (MCAD), peroxisome proliferator-activated receptor gamma co-activator 1 α (PGC-1 α), PGC-1-related coactivator (PRC), uncoupling protein-3 (UCP-3)].Plasma GLP-1 concentrations were increased comparably with RYGB and IT. RYGB and IT increased muscle GLUT-4 protein content, muscle hexokinase mRNA, and liver PFK mRNA. IT increased muscle AMPKα and COX-IV protein content and liver citrate synthase activity. IT increased muscle CPT-1, MCAD and PRC mRNA, whereas RYGB increased UCP-3 mRNA in muscle and liver, and PGC-1 α mRNA in liver.The data suggest that RYGB and IT surgeries lead to enhanced GLP-1 secretion and produce similar stimulatory effects on important molecules of glucose metabolism but differential effects on key molecules of lipid oxidation in muscle and liver.