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- The results of a two-stage double switch operation for congenital corrected transposition of the great arteries with a deconditioned morphologically left ventricle. [JOURNAL ARTICLE]
- Interact Cardiovasc Thorac Surg 2014 Aug 30.
The purpose of this retrospective study was to evaluate a two-stage double switch operation, morphological left ventricular (mLV) retraining followed by an atrial-arterial switch operation, in the management of patients with congenitally corrected transposition of the great arteries (CCTGA) and a deconditioned mLV.Between May 2005 and May 2011, 14 patients with CCTGA and a deconditioned mLV anomaly underwent the two-stage double switch operation. There were eight males and six females aged between 2.5 and 72 months (mean: 34.4 ± 24.0 months) old and weighing from 5 to 23 kg (mean: 12.7 ± 4.9 kg). The major associated malformations included: tricuspid regurgitation (TR, n = 13); restrictive ventricular septal defect (n = 10); atrial septal defect or patent foramen ovale (n = 7); mild pulmonary stenosis (n = 5) and patent ductus arteriosus (n = 4). These patients underwent morphological left ventricular retraining by means of pulmonary artery banding under general anaesthesia, which was then followed by a double switch operation under general anaesthesia and cardiopulmonary bypass.There were no deaths or complications during the hospital stay or follow-up for the mLV retraining. In comparison with preoperative conditions, the mLV end-diastolic diameter (mLVEDd), the posterior wall thickness of the mLV and the mLV/mRV pressure ratio were all increased; the interventricular septum had moved partially to the midline position and TR had decreased. After the atrial-arterial switch procedure, 2 patients died during the perioperative period. The causes of death included serious cardiac arrhythmia with circulatory collapse and sudden death. The others were followed up for 2-8 years: 1 patient died from serious cardiac arrhythmias with circulatory collapse in the follow-up period. With regard to the others, 8 were evaluated as New York Heart Association Functional Class I, and the other 3 as Class II. Moderate aortic valve regurgitation was noted in 3 patients and moderate mitral regurgitation in 1 patient.For CCTGA children with degraded mLV, the two-stage double switch procedure can be performed with low mortality and morbidity and may be an appealing alternative to conventional repair. mLV retraining should be performed as early as possible. The second-stage atrial-arterial switch procedure showed satisfactory early and mid-term results. More attention should be paid to the long-term function of the mLV and the aortic valve.
- Can Valeriana officinalis root extract prevent early postoperative cognitive dysfunction after CABG surgery? A randomized, double-blind, placebo-controlled trial. [JOURNAL ARTICLE]
- Psychopharmacology (Berl) 2014 Aug 31.
We hypothesized that valerian root might prevent cognitive dysfunction in coronary artery bypass graft (CABG) surgery patients through stimulating serotonin receptors and anti-inflammatory activity.The aim of this study was to evaluate the effect of Valeriana officinalis root extract on prevention of early postoperative cognitive dysfunction after on-pump CABG surgery.In a randomized, double-blind, placebo-controlled trial, 61 patients, aged between 30 and 70 years, scheduled for elective CABG surgery using cardiopulmonary bypass (CPB), were recruited into the study. Patients were randomly divided into two groups who received either one valerian capsule containing 530 mg of valerian root extract (1,060 mg/daily) or placebo capsule each 12 h for 8 weeks, respectively. For all patients, cognitive brain function was evaluated before the surgery and at 10-day and 2-month follow-up by Mini Mental State Examination (MMSE) test.Mean MMSE score decreased from 27.03 ± 2.02 in the preoperative period to 26.52 ± 1.82 at the 10th day and then increased to 27.45 ± 1.36 at the 60th day in the valerian group. Conversely, its variation was reduced significantly after 60 days in the placebo group, 27.37 ± 1.87 at the baseline to 24 ± 1.91 at the 10th day, and consequently slightly increased to 24.83 ± 1.66 at the 60th day. Valerian prophylaxis reduced odds of cognitive dysfunction compared to placebo group (OR = 0.108, 95 % CI 0.022-0.545).We concluded that, based on this study, the cognitive state of patients in the valerian group was better than that in the placebo group after CABG; therefore, it seems that the use of V. officinalis root extract may prevent early postoperative cognitive dysfunction after on-pump CABG surgery.
- Readmissions After Cardiac Surgery: Experience of the National Institutes of Health/Canadian Institutes of Health Research Cardiothoracic Surgical Trials Network. [JOURNAL ARTICLE]
- Ann Thorac Surg 2014 Aug 27.
Readmissions are a common problem in cardiac surgery. The goal of this study was to examine the frequency, timing, and associated risk factors for readmission after cardiac operations.A 10-center cohort study prospectively enrolled 5,158 adult cardiac surgical patients (5,059 included in analysis) to assess risk factors for infection after cardiac operations. Data were also collected on all-cause readmissions occurring within 65 days after the operation. Major outcomes included the readmission rate stratified by procedure type, cause of readmission, length of readmission stay, and discharge disposition after readmission. Multivariable Cox regression was used to determine risk factors for time to first readmission.The overall rate of readmission was 18.7% (number of readmissions, 945). When stratified by the most common procedure type, readmission rates were isolated coronary artery bypass grafting, 14.9% (n = 248); isolated valve, 18.3% (n = 337); and coronary artery bypass grafting plus valve, 25.0% (n = 169). The three most common causes of first readmission within 30 days were infection (17.1% [n = 115]), arrhythmia (17.1% [n = 115]), and volume overload (13.5% [n = 91]). More first readmissions occurred within 30 days (80.6% [n = 672]) than after 30 days (19.4% [n = 162]), and 50% of patients were readmitted within 22 days from the index operation. The median length of stay during the first readmission was 5 days. Discharge in 15.8% of readmitted patients (n = 128) was to a location other than home. Baseline patient characteristics associated with readmission included female gender, diabetes mellitus on medication, chronic obstructive pulmonary disease, elevated creatinine, lower hemoglobin, and longer operation time. More complex surgical procedures were associated with an increased risk of readmission compared with the coronary artery bypass grafting group.Nearly 1 of 5 patients who undergo cardiac operations require readmission, an outcome with significant health and economic implications. Management practices to avert in-hospital infections, reduce postoperative arrhythmias, and avoid volume overload offer important targets for quality improvement.
- Endovascular versus open repair of asymptomatic popliteal artery aneurysm. [JOURNAL ARTICLE]
- Cochrane Database Syst Rev 2014 Aug 31.:CD010149.
Popliteal artery aneurysm (PAA) is a focal dilatation and weakening of the popliteal artery. If left untreated, the aneurysm may thrombose, rupture or the clot within the aneurysm may embolise causing severe morbidity. PAA may be treated surgically by performing a bypass from the arterial segment proximal to the aneurysm to the arterial segment below the aneurysm, which excludes the aneurysm from the circulation. It may also be treated by a stent graft that is inserted percutaneously or through a small cut in the groin. The success of the procedure is gauged by the ability of the graft to stay patent over an extended duration. While surgical treatment is usually preferred in an emergency, the evidence on first line treatment in a non-emergency setting is unclear.To assess the effectiveness of an endovascular stent graft versus conventional open surgery for the treatment of asymptomatic popliteal artery aneurysms (PAA) on primary and assisted patency rates, hospital stay, length of the procedure and local complications.The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched their Specialised Register (last searched June 2014) and CENTRAL (2014, Issue 5). Clinical trials databases were searched for any ongoing or unpublished studies.All randomised controlled trials (RCTs) comparing endovascular stent grafting versus conventional open surgical repair in patients undergoing unilateral or bilateral prophylactic repair of asymptomatic PAAs were included.Data were collected on primary and secondary patency rates (primary endpoints) as well as operating time, the length of hospital stay, limb salvage and local wound complications (secondary endpoints).A single RCT was identified that conformed to the inclusion criteria. There was a low risk of selection bias and detection bias. However, the risks of performance bias, attrition bias and reporting bias were unclear from the study. Despite being an RCT, the level of evidence was downgraded to moderate due to the small sample size, resulting in wide confidence intervals (CIs); only 30 PAAs were randomised over a period of five years (15 PAAs each in the groups receiving endovascular stent graft and undergoing conventional open surgery). The primary patency rate at one year was 100% in the surgery group and 93.3% in the endovascular group (P = 0.49). However, the assisted patency rate at one year was similar in both groups (100% patency). There was no clear evidence of a difference between the two groups in the primary or secondary patency rates at four years (13 grafts were patent from 15 PAA treatments in each group). However, the effects were imprecise and compatible with the benefit of either endovascular stent graft or surgery or no difference. Mean hospital stay was shorter in the endovascular group (4.3 days for the endovascular group versus 7.7 days for the surgical group; mean difference (MD) -3.40 days, 95% CI -4.42 to -2.38; P < 0.001). Mean operating time was also reduced in the endovascular group (75.4 minutes in the endovascular group versus 195.3 minutes in the surgical group; MD -119.20 minutes, 95% CI -137.71 to -102.09; P < 0.001). Limb salvage was 100% in both groups. Data on local wound complications were not published in the trial report.Due to the limitations of the current evidence from one small underpowered study, we are unable to determine the effectiveness of endovascular stent graft versus conventional open surgery for the treatment of asymptomatic PAAs. A larger ongoing multicentre RCT should provide more information in the future. However, it seems reasonable to suggest that endovascular repair should be considered as a viable alternative to open repair of PAA on a case by case basis.
- Imaging of Complications of Thoracic and Cardiovascular Surgery. [REVIEW]
- Radiol Clin North Am 2014 Sep; 52(5):929-959.
Iatrogenic complications of thoracic and cardiovascular surgery are relatively uncommon, but contribute to potentially significant patient morbidity and mortality. The incidence of iatrogenic disease reflects the complexity of surgical procedures, including lung resection, esophagectomy, coronary artery bypass grafting, thoracic aorta repair, and cardiac valve replacement. Some iatrogenic complications are minor and common to all procedures, whereas others can be potentially devastating and are associated with precise technical components of specific surgeries. Multimodality imaging plays an important role in the diagnosis and management of operative thoracic and cardiovascular iatrogenic disease.
- Migration of a retained temporary epicardial pacing wire into an abdominal aortic aneurysm. [JOURNAL ARTICLE]
- Eur J Cardiothorac Surg 2014 Aug 30.
A 69-year old male was referred to our hospital for the treatment of coronary artery disease. Preoperative computed tomography (CT) revealed an abdominal aortic aneurysm (AAA) and a giant tumour of the left kidney. He underwent off-pump coronary artery bypass grafting (OPCAB) prior to aneurysmectomy and nephrectomy. Temporary epicardial pacing wires (TEPWs) were placed on the right atrium and right ventricle. The bipolar ventricular wire was removed and the unipolar atrial wire was cut flush with the skin surface on postoperative day 5. CT 7 days after the OPCAB procedure revealed a retained TEPW sutured to the right atrial wall. One month later, the patient underwent a repair of the AAA and left nephrectomy. We found that a TEPW had migrated inside the AAA intraoperatively. The retained TEPW was thus no longer observed on postoperative CT. Migration of the atrial pacing wire through the aortic lumen was suspected, although the detailed mechanism is unknown. This is the first reported case of a migrated temporary pacing wire into the aorta under noninfectious conditions.
- 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). [JOURNAL ARTICLE]
- Eur J Cardiothorac Surg 2014 Aug 29.
- Diagnostic accuracy of multidetector computed tomography coronary angiography in 325 consecutive patients referred for transcatheter aortic valve replacement. [JOURNAL ARTICLE]
- Am Heart J 2014 Sep; 168(3):332-339.
Multidetector computed tomography (MDCT) provides detailed assessment of valve annulus and iliofemoral vessels in transcatheter aortic valve replacement (TAVR) patients. However, data on diagnostic performance of MDCT coronary angiography (MDCT-CA) are scarce. The aim of the study is to assess diagnostic performance of MDCT for coronary artery evaluation before TAVR.A total of 325 consecutive patients (234 without previous myocardial revascularization, 49 with previous coronary stenting, and 42 with previous coronary artery bypass graft [CABG]) underwent invasive coronary angiography and MDCT before TAVR. MDCT-CA was performed using the same data set dedicated to standard MDCT aortic annulus evaluation. Multidetector computed tomography-CA evaluability and diagnostic accuracy in comparison with invasive coronary angiography as criterion standard were assessed.The MDCT-CA evaluability of native coronaries was 95.6%. The leading cause of unevaluability was beam-hardening artifact due to coronary calcifications. In a segment-based analysis, MDCT-CA showed sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for detecting ≥50% stenosis of 91%, 99.2%, 83.4%, 99.6% and 98.8%, respectively. The MDCT-CA evaluability of coronary stents was 82.1%. In a segment-based analysis, MDCT-CA showed sensitivity, specificity, PPV, NPV, and accuracy for detecting ≥50% in-stent restenosis of 94.1%, 86.7%, 66.7%, 98.1%, and 88.3%, respectively. All CABGs were correctly assessed by MDCT-CA. In a patient-based analysis, MDCT-CA showed sensitivity, specificity, PPV, NPV, and accuracy of 89.7%, 90.8%, 80.6%, 95.4%, and 90.5%, respectively.Multidetector computed tomography-CA allows to correctly rule out the presence of significant native coronary artery stenosis, significant in-stent restenosis, and CABG disease in patients referred for TAVR.
- 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). [JOURNAL ARTICLE]
- Eur Heart J 2014 Aug 29.
- Structure of cohesin subcomplex pinpoints direct shugoshin-Wapl antagonism in centromeric cohesion. [JOURNAL ARTICLE]
- Nat Struct Mol Biol 2014 Aug 31.
Orderly termination of sister-chromatid cohesion during mitosis is critical for accurate chromosome segregation. During prophase, mitotic kinases phosphorylate cohesin and its protector sororin, triggering Wapl-dependent cohesin release from chromosome arms. The shugoshin (Sgo1)-PP2A complex protects centromeric cohesin until its cleavage by separase at anaphase onset. Here, we report the crystal structure of a human cohesin subcomplex comprising SA2 and Scc1. Multiple HEAT repeats of SA2 form a dragon-shaped structure. Scc1 makes extensive contacts with SA2, with one binding hotspot. Sgo1 and Wapl compete for binding to a conserved site on SA2-Scc1. At this site, mutations of SA2 residues that disrupt Wapl binding bypass the Sgo1 requirement in cohesion protection. Thus, in addition to recruiting PP2A to dephosphorylate cohesin and sororin, Sgo1 physically shields cohesin from Wapl. This unexpected, direct antagonism between Sgo1 and Wapl augments centromeric cohesion protection.