Transcatheter aortic valve implantation: durability of clinical and hemodynamic outcomes beyond 3 years in a large patient cohort

BACKGROUND

Although short- and medium-term outcomes after transcatheter aortic valve implantation are encouraging, long-term data on valve function and clinical outcomes are limited.

METHODS AND RESULTS

Consecutive high-risk patients who had been declined as surgical candidates because of comorbidities but who underwent successful transcatheter aortic valve implantation with a balloon-expandable valve between January 2005 and December 2006 and survived past 30 days were assessed. Clinical, echocardiographic, and computed tomographic follow-up examinations were performed. Seventy patients who underwent successful procedures and survived longer than 30 days were evaluated at a minimum follow-up of 3 years. At a median follow-up of 3.7 years (interquartile range 3.4 to 4.3 years), survival was 57%. Survival at 1, 2, and 3 years was 81%, 74%, and 61%, respectively. Freedom from reoperation was 98.5% (1 patient with endocarditis). During this early procedural experience, 11 patients died within 30 days, and 8 procedures were unsuccessful. When these patients were included, overall survival was 51%. Transaortic pressure gradients increased from 10.0 mm Hg (interquartile range 8.0 to 12.0 mm Hg) immediately after the procedure to 12.1 mm Hg (interquartile range 8.6 to 16.0 mm Hg) after 3 years (P=0.03). Bioprosthetic valve area decreased from a mean of 1.7±0.4 cm(2) after the procedure to 1.4±0.3 cm(2) after 3 years (P<0.01). Aortic incompetence after implantation was trivial or mild in 84% of cases and remained unchanged or improved over time. There were no cases of structural valvular deterioration, stent fracture, deformation, or valve migration.

CONCLUSIONS

Transcatheter aortic valve implantation demonstrates good medium- to long-term durability and preserved hemodynamic function, with no evidence of structural failure. The procedure appears to offer an adequate and lasting resolution of aortic stenosis in selected patients.

Sonography for the investigation of a child with a limp

Hip pain is a common paediatric presentation and is potentially serious. While hip pain can be attributed to primary hip pathology, the hip area is also a common site for referred pain. This often poses a diagnostic challenge particularly in the young child who may not verbalise the point of pain and may not report an injury. Differential diagnoses for paediatric hip joint pain range from fracture, transient synovitis, septic arthritis with or without osteomyelitis, juvenile idiopathic arthritis (JIA, previously juvenile rheumatoid arthritis JRA), Legg-Calve-Perthes' disease (LCP), slipped capital femoral epiphysis (SCFE) to haemarthrosis in patient with a clotting disorder. Referred pain from abdominal pathology, for example; appendicitis, psoas abscess or haematoma should also be considered. The evaluation and management of hip pain requires a thorough history and physical examination. A radiograph is usually indicated to rule out any bony injury. Septic arthritis is a medical emergency requiring urgent surgical as well as medical treatment. Ultrasound of the hip joint plays a role in helping to differentiate which hips require early intervention and to guide a needle aspiration of joint fluid if indicated. In this article, we aim to review the anatomy of the hip, techniques in ultrasonographic examination and some common pathologies in the paediatric hip.

ASPP2 binds Par-3 and controls the polarity and proliferation of neural progenitors during CNS development

Cell polarity plays a key role in the development of the central nervous system (CNS). Interestingly, disruption of cell polarity is seen in many cancers. ASPP2 is a haplo-insufficient tumor suppressor and an activator of the p53 family. In this study, we show that ASPP2 controls the polarity and proliferation of neural progenitors in vivo, leading to the formation of neuroblastic rosettes that resemble primitive neuroepithelial tumors. Consistent with its role in cell polarity, ASPP2 influences interkinetic nuclear migration and lamination during CNS development. Mechanistically, ASPP2 maintains the integrity of tight/adherens junctions. ASPP2 binds Par-3 and controls its apical/junctional localization without affecting its expression or Par-3/aPKC lambda binding. The junctional localization of ASPP2 and Par-3 is interdependent, suggesting that they are prime targets for each other. These results identify ASPP2 as a regulator of Par-3, which plays a key role in controlling cell proliferation, polarity, and tissue organization during CNS development.

Satb2 is a postmitotic determinant for upper-layer neuron specification in the neocortex

Pyramidal neurons of the neocortex can be subdivided into two major groups: deep- (DL) and upper-layer (UL) neurons. Here we report that the expression of the AT-rich DNA-binding protein Satb2 defines two subclasses of UL neurons: UL1 (Satb2 positive) and UL2 (Satb2 negative). In the absence of Satb2, UL1 neurons lose their identity and activate DL- and UL2-specific genetic programs. UL1 neurons in Satb2 mutants fail to migrate to superficial layers and do not contribute to the corpus callosum but to the corticospinal tract, which is normally populated by DL axons. Ctip2, a gene required for the formation of the corticospinal tract, is ectopically expressed in all UL1 neurons in the absence of Satb2. Satb2 protein interacts with the Ctip2 genomic region and controls chromatin remodeling at this locus. Satb2 therefore is required for the initiation of the UL1-specific genetic program and for the inactivation of DL- and UL2-specific genes.

Could a policy of provision of hip protectors to elderly nursing home residents result in cost savings in acute hip fracture care? The case of Ontario, Canada

Hip fractures are an important problem in nursing homes. Hip protectors are external devices that decrease the risk of hip fracture in elderly nursing home residents. We estimated the overall healthcare cost savings from a hypothetical strategy of provision of hip protectors to elderly nursing home residents in Ontario, Canada. In a recent meta-analysis, we determined that a strategy of provision of hip protectors decreases the risk of hip fracture in nursing home residents.

INTRODUCTION

Our objective was to determine whether the provision of hip protectors to all Ontario nursing home residents aged > or =65 years could result in cost savings, stemming from reductions in initial hospitalizations for hip fracture.

METHODS

We conducted a cost analysis from a Ministry of Health perspective (one year cycle length). The efficacy of the intervention was estimated from a meta-analysis of randomized controlled trials.

RESULTS

A strategy of provision of hip protectors to all 60,775 elderly Ontario nursing home residents could result in an overall mean cost savings of 6.0 million Canadian dollars in one year (95% credibility interval, -26.4 million, 39.7 million), with a probability of cost savings of 0.63 (assuming no additional labor costs). In sensitivity analyses, decreasing hip protector price increased cost savings, whereas additional labor expenditures for application for hip protectors decreased cost savings.

CONCLUSION

In conclusion, if hip protectors can be provided to elderly Ontario nursing home residents without additional labor expenditures, there is a reasonable probability that such a strategy may result in healthcare cost savings.

The potential for dental plaque to protect against erosion using an in vivo-in vitro model--a pilot study

BACKGROUND

Tooth erosion is a problem for professional wine tasters (exogenous erosion from frequent exposure to wine acids) and for people with gastro oesophageal reflux disease (GORD) and bulimia who experience frequent reflux of gastric contents into the mouth (endogenous erosion from mainly HCl). The objective in this study was to determine whether plaque/pellicle could provide teeth with any protection from two common erosive acids, using an in vivo-in vitro technique.

METHODS

Tiles of human tooth enamel and root surfaces were prepared from six extracted, unerupted third molar teeth and sterilized. Mandibular stents were prepared for six volunteer subjects and the tiles bonded to the buccal flanges of these stents. They were worn initially for three days to permit a layer of pellicle and plaque to form over the tile surfaces, and for a further 10 days of experimentation. Following cleaning of the plaque/ pellicle layer from the tiles on the right side flange, all the tiles were submerged in either 0.06M HCl or white wine for an accumulated time of 600 and 1500 minutes, respectively. Depths of erosion were determined using light microscopy of sections of the enamel and root tiles. SEM of the lesion surfaces was carried out to investigate the nature of erosive damage and of plaque/pellicle remnants.

RESULTS

Retained plaque was found to significantly inhibit dental erosion on enamel, from contact with both HCl and wine, compared with that resulting following its removal. However, it was found to provide no significant protection on root surfaces. SEM analysis of the tile surfaces revealed marked etching of enamel on the cleaned surfaces, and considerable alteration to the appearance of remaining plaque and pellicle on most surfaces.

CONCLUSION

Within the limitations of numbers of specimens, dental plaque/pellicle provided a significant level of protection to tooth enamel against dental erosion from simulated gastric acids and from white wine, using an in vivo-in vitro model. It was unable to provide any significant protection to root surfaces from these erosive agents. Possible reasons for this difference are explored.

Pilot study of regional hepatic intra-arterial (HIA) paclitaxel in patients (Pts) with breast carcinoma metastatic to the liver

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Background: Approximately 50% of pts with metastatic breast carcinoma develop hepatic involvement during the course of their disease. Their median survival is 1–14 months (mo). Systemic paclitaxel has good anti-tumor activity against breast carcinoma and is safe. We sought to prospectively determine the safety and anti-tumor activity of HIA paclitaxel therapy. Methods: Ten pts with breast carcinoma and dominant liver metastases received monthly inpatient 24 hr-continuous HIA infusions of paclitaxel at 200 mg/m2 through intra-arterial catheters placed via percutaneous transfemoral approach. WHO tumor assessment guidelines were used. Results: Nine pts enrolled in this study had infiltrating ductal carcinoma and their median age at the time of treatment was 51 years. The group had received a mean of 3.8 previous treatment regimens including adjuvant regimens. Therapy was well tolerated. Fifty-six courses were delivered. Mean hospital stay was 3 days. No procedure related complications were observed. Most common treatment related toxicities included leukopenia, fatigue, nausea, and vomiting. Three pts attained partial responses (50% decrease in tumors) lasting 6, 7, and 48 months whereas in 4 others disease stabilization lasted 5 to 9 mo. One pt underwent liver resection and remained NED for 48 mo. Eight pts had received prior systemic taxane therapy alone or in combination with other cytotoxics (3 adjuvant; 5 palliative). However, no association between previous taxane exposure and clinical efficacy of this regimen was not established. Conclusions: Hepatic arterial therapy with paclitaxel at this dose and schedule is safe and well tolerated and has reasonable anti-tumor activity against breast carcinoma involving the liver. Previous taxane exposure does not hamper the potential benefit of this approach. This regimen deserves further investigation alone or in combination with targeted strategies in patients with dominant liver involvement from breast carcinoma.

No significant financial relationships to disclose.