Thirty-day Outcome Following CoreValve Evolut R Transcatheter Aortic Valve Implantation: An All-comers Prospective Study

INTRODUCTION AND OBJECTIVES

There are scarce clinical outcomes data on the new generation recapturable and repositionable CoreValve Evolut R.

METHODS

Data on all-comer patients undergoing transcatheter aortic valve implantation (TAVI) with the Evolut R for severe symptomatic aortic stenosis at a single center were prospectively collected between February 2015 and April 2016. Clinical endpoints were independently adjudicated according to the Valve Academic Research Consortium-2 criteria. Primary outcomes consisted of early safety composite endpoints and 30-day device success. The incidence of new permanent pacemaker implantation was recorded.

RESULTS

Among the 83 patients undergoing TAVI during this period, 71 (85.5% of the population; median age, 83.0 [interquartile range, 80.0-87.0] years; Society of Thoracic Surgeons scores, 4.8±3.5%) were suitable for Evolut R implantation and were included in the analysis. Repositioning was performed in 26.8% of the procedures. The early safety composite endpoint was observed in 11.3% of patients at 30 days, with 2.8% all-cause mortality. Device success was documented in 90.1% of patients. Paravalvular leakage was less than grade II in 98.4% of patients. The mean transvalvular aortic gradient was reduced from 42.5±14.5mmHg at baseline to 7.7±4.0mmHg at discharge (P<.0001 vs baseline). New permanent pacemaker implantation was required in 23.9% of patients.

CONCLUSIONS

The new generation Evolut R is suitable for most patients and shows high device success and acceptable mortality in an unbiased, consecutive, all-comer population at a single center performing TAVI exclusively with Medtronic valves.

Short-Term Preoperative High-Intensity Interval Training in Patients Awaiting Lung Cancer Surgery: A Randomized Controlled Trial

INTRODUCTION

Impairment in aerobic fitness is a potential modifiable risk factor for postoperative complications. In this randomized controlled trial, we hypothesized that a high-intensity interval training (HIIT) program enhances cardiorespiratory fitness before lung cancer surgery and therefore reduces the risk of postoperative complications.

METHODS

Patients with operable lung cancer were randomly assigned to usual care (UC) (n = 77) or preoperative rehabilitation based on HIIT (Rehab) (n = 74). Maximal cardiopulmonary exercise testing and the 6-minute walk test were performed twice before surgery. The primary outcome measure was a composite of death and in-hospital postoperative complications.

RESULTS

The groups were well balanced in terms of patient characteristics. During the preoperative waiting period (median 25 days), the peak oxygen consumption and the 6-minute walking distance increased (median +15%, interquartile range, 25th to 75 percentile [IQR25%-75%, %] = +9% to +22%, p = 0.003 and +15%, IQR25%-75% = +8% to +28%, p < 0.001, respectively) in the Rehab group, whereas peak oxygen consumption declined in the UC group (median -8%, IQR25%-75% = -16% to 0%], p = 0.005). The primary end point did not differ significantly between the two groups: at least one postoperative complication developed in 27 of the 74 patients (35.5%) in the Rehab group and 39 of 77 patients (50.6%) in the UC group (p = 0.080). Notably, the incidence of pulmonary complications was lower in the Rehab compared with in the UC group (23% versus 44%, p = 0.018), owing to a significant reduction in atelectasis (12.2% versus 36.4%, p < 0.001), and this decrease was accompanied by a shorter length of stay in the postanesthesia care unit (median -7 hours, IQR25%-75% = -4 to -10).

CONCLUSIONS

In this randomized controlled trial, preoperative HIIT resulted in significant improvement in aerobic performances but failed to reduce early complications after lung cancer resection.

Management of vascular complications following transcatheter aortic valve implantation

BACKGROUND

Vascular complications (VCs) after transcatheter aortic valve implantation (TAVI) are frequent and their management is challenging.

AIM

To report the incidence, predictors and management of VCs following percutaneous transfemoral TAVI (TF-TAVI) at a single centre.

METHODS

We analyzed 102 consecutive patients who underwent percutaneous TF-TAVI between August 2008 and December 2013. All endpoints were evaluated at 30 days and 6 months according to Valve Academic Research Consortium-2 criteria. VC percutaneous treatment success was defined as residual stenosis<30%, absence of blood extravasation and absence of surgical or repeat endovascular intervention at 30 days.

RESULTS

Twenty-two patients (22%) experienced VCs, including five patients (5%) with major VCs. Mortality at 30 days was significantly higher in patients with major VCs than in patients without major VCs (60% vs 3%; P=0.001). Patients with VCs had more life-threatening or major bleeding (23% vs 5%; P=0.02), but no difference in terms of need for blood transfusion was observed. Endovascular treatment was used in 13 of 22 patients with VCs (59%) and was successful in 11 of these 13 patients (85%). Primary surgical repair was necessary in only 1/22 (5%) patients, for a common femoral artery pseudoaneurysm 2 weeks after the TAVI procedure.

CONCLUSIONS

VCs following TF-TAVI are frequent. Major but not minor VCs are associated with increased mortality. Percutaneous management of VCs is feasible and safe, and surgery is rarely needed.

Impact of early haemodynamic goal-directed therapy in patients undergoing emergency surgery: an open prospective, randomised trial

Haemodynamic goal-directed therapies (GDT) may improve outcome following elective major surgery. So far, few data exist regarding haemodynamic optimization during emergency surgery. In this randomized, controlled trial, 50 surgical patients with hypovolemic or septic conditions were enrolled and we compared two algorithms of GDTs based either on conventional parameters and pressure pulse variation (control group) or on cardiac index, global end-diastolic volume index and stroke volume variation as derived from the PiCCO monitoring system (optimized group). Postoperative outcome was estimated by a composite index including major complications and by the Sequential Organ Failure Assessment (SOFA) Score within the first 3 days after surgery (POD1, POD2 and POD3). Data from 43 patients were analyzed (control group, N = 23; optimized group, N = 20). Similar amounts of fluid were given in the two groups. Intraoperatively, dobutamine was given in 45 % optimized patients but in no control patients. Major complications occurred more frequently in the optimized group [19 (95 %) versus 10 (40 %) in the control group, P < 0.001]. Likewise, SOFA scores were higher in the optimized group on POD1 (10.2 ± 2.5 versus 6.6 ± 2.2 in the control group, P = 0.001), POD2 (8.4 ± 2.6 vs 5.0 ± 2.4 in the control group, P = 0.002) and POD 3 (5.2 ± 3.6 and 2.2 ± 1.3 in the control group, P = 0.01). There was no significant difference in hospital mortality (13 % in the control group and 25 % in the optimized group). Haemodynamic optimization based on volumetric and flow PiCCO-derived parameters was associated with a less favorable postoperative outcome compared with a conventional GDT protocol during emergency surgery.

Clinical review: management of weaning from cardiopulmonary bypass after cardiac surgery

A sizable number of cardiac surgical patients are difficult to wean off cardiopulmonary bypass (CPB) as a result of structural or functional cardiac abnormalities, vasoplegic syndrome, or ventricular dysfunction. In these cases, therapeutic decisions have to be taken quickly for successful separation from CPB. Various crisis management scenarios can be anticipated which emphasizes the importance of basic knowledge in applied cardiovascular physiology, knowledge of pathophysiology of the surgical lesions as well as leadership, and communication between multiple team members in a high-stakes environment. Since the mid-90s, transoesophageal echocardiography has provided an opportunity to assess the completeness of surgery, to identify abnormal circulatory conditions, and to guide specific medical and surgical interventions. However, because of the lack of evidence-based guidelines, there is a large variability regarding the use of cardiovascular drugs and mechanical circulatory support at the time of weaning from the CPB. This review presents key features for risk stratification and risk modulation as well as a standardized physiological approach to achieve successful weaning from CPB.

Morpho-functional studies regarding the fertility prognosis of mares suffering from equine endometrosis

The aim of the present study was to characterize the morpho-functional features of endometrosis in barren and foaling mares, using both conventional histopathological and immunohistochemical methods. Endometrial biopsy samples were collected during the physiological breeding season from 159 estrous, clinically healthy mares (mean age 12 years), and the quality and degree of endometrosis was histomorphologically defined. The mares were bred and those that foaled were put in the foaling group whereas those that did not foal were placed in the barren group. Foaling mares were then compared with barren mares. Sixty-four percent (101/159) of uterine samples showed varying degrees of endometrosis and were used for this study. The sample population consisted of 51 barren and 50 foaling mares suffering from endometrosis. Expression of steroid hormone receptors (estrogen receptor, progesterone receptor) and endometrial protein secretion patterns (uteroglobin [UG], uterocalin [UC], calbindin(D9k) [CAL], uteroferrin [UF]) was evaluated by immunohistochemistry (barren mares N = 51, foaling mares N = 31). In comparison with unaffected glands, fibrotic glands generally showed a cycle-asynchronous, partially patchy protein expression pattern which is interpreted as a sign of endometrial maldifferentiation within fibrotic areas. In barren mares (N = 51) more than half of biopsy samples (27/51) showed a destructive mostly moderate (20/27) type of endometrosis. In affected glands, staining for UG (17/21) was decreased (P < 0.001). Foaling mares (N = 50) frequently showed a mild, nondestructive endometrosis (35/50). Compared with barren mares, foaling mares had statistically (P < 0.05) more often a cycle-synchronous or increased UG expression pattern within fibrotic glands. Obvious deviations of either UG or UC rarely occurred. Within fibrotic foci, UF often demonstrated a cycle-synchronous or more intense expression pattern in both foaling (28/31) and barren mares (41/51), compared with healthy glands. Mares of both groups showed a cycle-asynchronous staining for estrogen receptor and progesterone receptor in the stromal cells in areas of periglandular fibrosis and the glandular epithelia. These findings indicate that affected areas become independent of the uterine control mechanisms and exhibit specific differentiation dynamics. Immunohistochemical investigations showed that the secretory patterns differ between barren and foaling mares. The findings in this study should be considered as a useful addition to the "classical" Kenney categorization.

[Magnetic resonance imaging and ultrasonography in dogs and cats with ocular and orbital diseases. Part 1: Ocular diseases]

OBJECTIVE

This two-part study describes the clinical usefulness and value of ultrasound and magnetic resonance imaging (MRI) in dogs and cats with ocular (n=30) and orbital diseases (n=31). MRI and ultrasonography characteristics are described in single cases with ocular and orbital disease.

MATERIAL AND METHODS

Ultrasonography and MRI were performed in 15 dogs and 15 cats with intraocular neoplasia or intraocular inflammatory disease.

RESULTS

In all patients with intraocular neoplasia, sonography revealed masses with increased echogenicity and fairly uniform echotexture, thus allowing the tentative diagnosis of an intraocular tumour. In these cases, MRI often proved to be a valuable diagnostic tool in showing the complete extent of intraocular lesion. An additional benefit of MRI was seen in the tissue characterization of tumours based on MRI signal characteristics and pattern of contrast enhancement. Discreet intraocular inflammatory alterations, in particular to the anterior and posterior segment of the eyeball, were more clearly shown by ultrasound than by MRI. Neoplasia could be excluded and inflammatory disease was successfully diagnosed using MRI due to the different image sequences with or without contrast medium administration. Traumatic ruptures of the lens capsule and the globe after trauma were depicted more clearly with MRI.

CONCLUSIONS AND CLINICAL RELEVANCE

When opacity of the anterior eye segment is present, various intraocular changes can be quickly diagnosed by ultrasound with high accuracy, without requiring anaesthesia of the patient. MRI of the globe allows differentiation of diverse pathologies, gives detailed information of infiltration in orbital structures and the exact degree of ocular lesions after trauma. This additional evidence often makes it easier to predict the correct prognosis and choose the best therapy.

[Two cases of disseminated toxoplasmosis]

Two cases of disseminated fatal toxoplasmosis of a pet mouse and a red panda are described. The pet mouse had a private owner; the red panda lived in a zoological garden in Saxony. At necropsy, both animals suffered from a systemic toxoplasmosis. A severe necrotizing hepatitis was the main histological feature in both animals. Parasitic cysts could be abundantly found in the liver, moderately in the brain and in a low number in other organs. With the PAS-reaction, cysts showed a weak staining in the mouse and a strong staining in the red panda. Diagnosis was confirmed by PCR and immunohistochemistry.

Immunohistochemical study of angiogenesis and angiogenic factors in equine granulosa cell tumours

The first part of our study (Müller et al., 2009) characterized angiogenesis in the equine cycling ovary through histomorphological and immunohistochemical examinations (vascular endothelial growth factors A and B [VEGF A, VEGF B], vascular endothelial growth factor receptors 1 and 2 [VEGF-R1, VEGF-R2], vascular angiopoietins 1 and 2 [Ang1, Ang2], angiopoietin receptor [Tie2], and von Willebrand Factor). Since angiogenesis plays an important role in development and growth of numerous tumours, the second part of our study involved a similar examination of 70 equine granulosa cell tumours (GCTt). The results of the second study were compared with those of the normal equine ovary. Certain similarities in the expression pattern could be detected between normal, cyclical ovaries (Müller et al., 2009) and GCTt. The immunoreactivity of granulosa cells and Leydig-like cells in GCTt resembles granulosa cells and luteinized thecal cells in periovulatory cycling ovaries. The neoplastic cells support circulation, supply and growth of GCTt by contributing to angiogenesis.