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Uskoković V. Teaching Medical Devices through Interactive Innovation: Challenges and Rewards. TEACHING AND LEARNING IN MEDICINE 2024:1-10. [PMID: 38989801 DOI: 10.1080/10401334.2024.2375223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 06/14/2024] [Indexed: 07/12/2024]
Abstract
Medical devices are manmade objects existing at the interface between numerous disciplines. They range from as simple as medical gloves to as complex as artificial limbs. This versatility of medical devices and their inherent interdisciplinary nature means that academic courses on them are attended by cohorts of students from varieties of academic backgrounds, who bring with them similarly broad spectra of interests. To satisfy the learning expectations of each and every student in such diverse classes is a daunting task for the instructor. After many years of teaching medical devices at undergraduate and graduate levels at three different universities in the states of Illinois and California, I have come up with an instructional method that solves this challenge by engaging students in the co-creation of the curriculum via selection of their own medical devices of interest and presentation to the class for collective analysis. The threefold presentations are designed so that they reflect an ascent along the hierarchy of a learning taxonomy extending from foundational concepts to critical assessment of knowledge to creative displays of it. In such a way, the students are acquainted with the ability of critical and creative thinking at the expense of rote memorization or inculcation and are prepared to enter the field of medical devices as innovation-centered individuals. The specifics of this new method of instruction are reported here, with the hope that they will be useful to fellow instructors in any interdisciplinary course that benefits from a balance between the rigorous coverage of the instructional material pertaining to engineering and medicine and the flexible selection of topics that comply with students' individual interests.
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Affiliation(s)
- Vuk Uskoković
- TardigradeNano LLC, Irvine, California, USA
- Department of Mechanical Engineering, San Diego State University, San Diego, California, USA
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Butany J, Schoen FJ. Cardiac valve replacement and related interventions. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00010-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Sun L, Liu J, Jin X, Wang Z, Li L, Bai W, Yang Y, Wu C, Chen W, Xu S, Zheng J, Zheng W. Perioperative management with biologics on severe aortic valve regurgitation caused by Behçet syndrome: the experience from a single center. Ther Adv Chronic Dis 2021; 12:20406223211026753. [PMID: 34221307 PMCID: PMC8221692 DOI: 10.1177/20406223211026753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 06/02/2021] [Indexed: 11/15/2022] Open
Abstract
Background To investigate the efficacy and safety of biologics in the perioperative management of severe aortic valve regurgitation (AR) caused by Behçet syndrome (BS). Methods We retrospectively analyzed 20 patients with severe AR caused by BS who were all treated with biologics during the perioperative period of cardiac surgeries in our center between February 2016 and October 2020. Results A total of 20 patients with severe AR were enrolled, including 19 males and 1 female, with a mean age of 39.1 ± 8.8 years and a median course of 8 [interquartile range (IQR) 5.25-10.00] years. Before biologic administration, 92.9% of the patients who underwent aortic valve replacement had failed conventional therapy and developed postoperative paravalvular leakage (PVL) at a median interval of 4 months. Biologics were administered with background glucocorticoids (GCs) and immunosuppressants during the perioperative period for 22 aortic valve surgeries, including preoperatively with a median interval of 3.5 (IQR 2.75-4.25) months in 13 cases and within 3 months postoperatively in 9 cases. After a median follow up of 21 (IQR 15-32) months, 2 out of 13 cases (15.4%) preoperatively, and 1 out of 9 cases (11.1%) postoperatively treated with biologics developed PVL, and the rest were event free. The Behçet's Disease Current Activity Form score improved significantly (7 versus 0, median, p < 0.0001). Decrease of erythrocyte sedimentation rate [25.0 (IQR 11.00-36.25) mm/h versus 6.5 (IQR 4.0-8.8) mm/h, p < 0.001], and C-reactive protein [20.77 (IQR 7.19-29.58) mg/l versus 1.53 (IQR 0.94-2.92) mg/l, p = 0.001] were achieved rapidly and effectively. The GC dosage tapered from 40 (IQR 30-60) mg/d to 10 (IQR 5-11.25) mg/d, p < 0.0001. Immunosuppressants were tapered in number and dosage in 6 (30%) and 20 patients (100%), respectively. No serious adverse event was observed. Conclusion Our study suggests that biologics were effective and well tolerated for the perioperative management of severe and refractory AR caused by BS, which significantly reduced the occurrence of postoperative PVL and had favorable GC- and immunosuppressant-sparing effect.
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Affiliation(s)
- Luxi Sun
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China
| | - Jinjing Liu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China
| | - Xiufeng Jin
- Beijing Anzhen Hospital, Beijing Institute of Heart, Lung & Vascular Diseases, Beijing Aortic Disease Center, Capital Medical University, Beijing, China
| | - Zhimian Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China
| | - Lu Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China
| | - Wei Bai
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China
| | - Yunjiao Yang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China
| | - Chanyuan Wu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China
| | - Wei Chen
- Department of Cardiology, Peking Union Medical College Hospital, Beijing, China
| | - Shangdong Xu
- Beijing Anzhen Hospital, Beijing Institute of Heart, Lung & Vascular Diseases, Beijing Aortic Disease Center, Capital Medical University, Beijing, China
| | - Jun Zheng
- Beijing Anzhen Hospital, Beijing Institute of Heart, Lung & Vascular Diseases, Beijing Aortic Disease Center, Capital Medical University, Chaoyang-qu, Beijing, China
| | - Wenjie Zheng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), State Key Laboratory of Complex Severe and Rare Diseases, No.1 Shuaifuyuan Hutong, Dongcheng-qu, Beijing 100730, China
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The New Challenge for Heart Endocarditis: From Conventional Prosthesis to New Devices and Platforms for the Treatment of Structural Heart Disease. BIOMED RESEARCH INTERNATIONAL 2021; 2021:7302165. [PMID: 34222484 PMCID: PMC8219429 DOI: 10.1155/2021/7302165] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/02/2021] [Indexed: 01/07/2023]
Abstract
Infective endocarditis is a sinister condition with considerable morbidity and mortality. Its relevance in the current era is compounded by the increased use of implanted devices such as replacement valves or cardiac implantable electronic devices. These infections are caused by multiple different bacteria with different virulence, pathogenicity, and antimicrobial resistance. Unlike in native endocarditis, the presence of foreign tissue permits sustenance by inflammatory and thrombotic processes as the artificial surfaces promote inflammatory responses and hypercoagulability. Prevention of these infections has been suggested with the use of homografts in combination with antibiotics. Others have attempted to use "low fouling coats" with little clinical success thus far. The use of antibiotic prophylaxis plays a pivotal part in reducing the incidence of prosthesis-related endocarditis. This remains especially crucial with the increasing use of transcatheter heart valve therapies. The widespread use of cardiac implantable electronic devices such as permanent pacemakers, implantable cardioverter defibrillators, and cardiac resynchronization therapy devices has also heralded a noticeable increase in cases of infectious endocarditis affecting complex equipment which can be difficult to treat. Multimodality strategies are needed with input from surgeons and cardiologists to ensure treatment is both prompt and successful, tailored to the individual needs of the patients.
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Choi HM, Kim HK, Park SJ, Lee HJ, Yoon YE, Park JB, Kim YJ, Cho GY, Hwang IC, Sohn DW, Oh JK. Predictors of paravalvular aortic regurgitation after surgery for Behcet's disease-related severe aortic regurgitation. Orphanet J Rare Dis 2019; 14:132. [PMID: 31182113 PMCID: PMC6558675 DOI: 10.1186/s13023-019-1083-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 04/26/2019] [Indexed: 01/12/2023] Open
Abstract
Background Behcet’s disease (BD)-related aortic regurgitation (AR) is known to be associated with paravalvular leakage (PVL) after successful aortic valve (AV) surgery. This study aimed to determine predictors of PVL after successful AV surgery in BD patients. We retrospectively collected data of 35 patients (42.1 ± 9.1 years, 27 men) who underwent surgery for severe BD-related AR at two tertiary centers. The diagnosis was established based on echocardiographic, surgical, and/or pathological findings in conjunction with the International Study Group criteria for BD. A total of 76 cases of AV surgery in 35 patients were analyzed. Results A median follow-up duration was 8.0 years (interquartile range, 5.4–14.3 years). PVL developed in 18 patients (51.4%) within 2 years after the first surgery. Six patients who met the diagnostic criteria for BD did not develop PVL, in whom 5 patients took immunosuppressive therapy (IST). However, 4 of 9 patients (44.4%) who did not meet the diagnostic criteria developed PVL, in whom four (44.4%) patients took IST. On multivariable analysis, postoperative IST and concomitant aortic root replacement (ARR) were two independent predictors for less PVL development (HR 0.38, 95% CI 0.17–0.89, p = 0.025 for postoperative IST; HR 0.17, 95% CI 0.08–0.36, p < 0.001 for concomitant ARR). Preoperative IST use did not determine PVL development (p = 0.75). Conclusions Postoperative, but not preoperative, IST and concomitant ARR were independent predictors of less development of PVL. Special attention is required for early diagnosis BD-related AR, especially in patients not satisfying the current diagnostic criteria. Electronic supplementary material The online version of this article (10.1186/s13023-019-1083-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hong-Mi Choi
- Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Gyeonggi-do, South Korea
| | - Hyung-Kwan Kim
- Division of Cardiology, Cardiovascular Center, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.
| | - Sung-Ji Park
- Division of Cardiology, Department of Medicine, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Hyun-Jung Lee
- Division of Cardiology, Cardiovascular Center, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Yeonyee E Yoon
- Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Gyeonggi-do, South Korea
| | - Jun-Bean Park
- Division of Cardiology, Cardiovascular Center, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Yong-Jin Kim
- Division of Cardiology, Cardiovascular Center, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Goo-Young Cho
- Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Gyeonggi-do, South Korea
| | - In-Chang Hwang
- Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Gyeonggi-do, South Korea
| | - Dae-Won Sohn
- Division of Cardiology, Cardiovascular Center, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Jae K Oh
- Division of Cardiology, Department of Medicine, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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Dziubek M, Pierrakos C, Chebli L, Demanet H, Sanoussi A, Wauthy P. Para-prosthetic Leaks Following Mitral Valve Replacement: Case Analysis on a 20-year Period. Curr Cardiol Rev 2018; 14:15-24. [PMID: 29141552 PMCID: PMC5872258 DOI: 10.2174/1573403x13666171110110344] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Revised: 10/19/2017] [Accepted: 11/03/2017] [Indexed: 11/22/2022] Open
Abstract
Background: Mitral para-prosthetic leaks are rare but major complications of mitral heart valve replacements. When they must be re-operated, they are burdened with high mortality rates. We proposed to review our surgical experience in terms of approach and type of operation carried out. Methods: Demographic, preoperative, intraoperative and postoperative characteristics of 34 patients benefited from a surgical treatment of mitral paravalvular leak, at the Brugmann University Hospital between 1996 and 2016, have been analysed retrospectively. We analysed the data to identify the risk factors of postoperative mortality. We then compared the data depending on the approach and the type of surgical treatment in order to compare the morbidity-mortality. Results: The postoperative mortality rate was 11.7%. The presence of endocarditis and increase in lactate dehydrogenase were predictive factors of mortality. Cardiac complications and acute kidney failure were significantly more common in the decease population. Direct mitral paravalvular leak su-turing was more frequently performed on early apparition, anterior and isolated leaks, whereas a mi-tral heart valve replacement was most often performed to cure active primary endocarditis. The inci-dence of complications and mortality rates were identical according to the approach and the type of operation performed. A mitral para-prosthetic leak recurrence was observed in 33% of the cases. Conclusion: Surgical treatment of mitral para-prosthetic leaks is accompanied by a high mortality rate. The operative strategy plays a major role and can influence the morbidity-mortality encountered in those patients.
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Affiliation(s)
- Melvin Dziubek
- Department of Cardiac Surgery, Brugmann University Hospital, Universite Libre de Bruxelles, Bruxelles, Belgium
| | - Charalampos Pierrakos
- Department of Intensive Care, Brugmann University Hospital, Universite Libre de Bruxelles, Bruxelles, Belgium
| | - Louis Chebli
- Department of Cardiac Surgery, Brugmann University Hospital, Universite Libre de Bruxelles, Bruxelles, Belgium
| | - Helene Demanet
- Department of Cardiac Surgery, Brugmann University Hospital, Universite Libre de Bruxelles, Bruxelles, Belgium
| | - Ahmed Sanoussi
- Department of Cardiac Surgery, Brugmann University Hospital, Universite Libre de Bruxelles, Bruxelles, Belgium
| | - Pierre Wauthy
- Department of Cardiac Surgery, Brugmann University Hospital, Universite Libre de Bruxelles, Bruxelles, Belgium
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Cahill TJ, Baddour LM, Habib G, Hoen B, Salaun E, Pettersson GB, Schäfers HJ, Prendergast BD. Challenges in Infective Endocarditis. J Am Coll Cardiol 2017; 69:325-344. [PMID: 28104075 DOI: 10.1016/j.jacc.2016.10.066] [Citation(s) in RCA: 377] [Impact Index Per Article: 53.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 10/26/2016] [Accepted: 10/30/2016] [Indexed: 02/06/2023]
Abstract
Infective endocarditis is defined by a focus of infection within the heart and is a feared disease across the field of cardiology. It is frequently acquired in the health care setting, and more than one-half of cases now occur in patients without known heart disease. Despite optimal care, mortality approaches 30% at 1 year. The challenges posed by infective endocarditis are significant. It is heterogeneous in etiology, clinical manifestations, and course. Staphylococcus aureus, which has become the predominant causative organism in the developed world, leads to an aggressive form of the disease, often in vulnerable or elderly patient populations. There is a lack of research infrastructure and funding, with few randomized controlled trials to guide practice. Longstanding controversies such as the timing of surgery or the role of antibiotic prophylaxis have not been resolved. The present article reviews the challenges posed by infective endocarditis and outlines current and future strategies to limit its impact.
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Affiliation(s)
- Thomas J Cahill
- Department of Cardiology, Oxford University Hospitals, Oxford, United Kingdom
| | - Larry M Baddour
- Division of Infectious Diseases, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gilbert Habib
- Aix-Marseille Universite, URMITE, Marseille, France; APHM, La Timone Hospital, Cardiology Department, Marseille, France
| | - Bruno Hoen
- Université des Antilles et de la Guyane, Faculté de Médecine Hyacinthe Bastaraud, Inserm, Service de Maladies Infectieuses et Tropicales, Dermatologie, Médecine Interne, Centre Hospitalier Universitaire de Pointe-à-Pitre/Abymes, Pointe-à-Pitre, France
| | - Erwan Salaun
- APHM, La Timone Hospital, Cardiology Department, Marseille, France
| | - Gosta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Hans Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
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Cruz-Gonzalez I, Rama-Merchan JC, Calvert PA, Rodríguez-Collado J, Barreiro-Pérez M, Martín-Moreiras J, Diego-Nieto A, Hildick-Smith D, Sánchez PL. Percutaneous Closure of Paravalvular Leaks: A Systematic Review. J Interv Cardiol 2016; 29:382-92. [PMID: 27242018 DOI: 10.1111/joic.12295] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Paravalvular leak (PVL) is an uncommon yet serious complication associated with the implantation of mechanical or bioprosthetic surgical valves and more recently recognized with transcatheter aortic valves implantation (TAVI). A significant number of patients will present with symptoms of congestive heart failure or haemolytic anaemia due to PVL and need further surgical or percutaneous treatment. Until recently, surgery has been the only available therapy for the treatment of clinically significant PVLs despite the significant morbidity and mortality associated with re-operation. Percutaneous treatment of PVLs has emerged as a safe and less invasive alternative, with low complication rates and high technical and clinical success rates. However, it is a complex procedure, which needs to be performed by an experienced team of interventional cardiologists and echocardiographers. This review discusses the current understanding of PVLs, including the utility of imaging techniques in PVL diagnosis and treatment, and the principles, outcomes and complications of transcatheter therapy of PVLs.
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Affiliation(s)
| | | | - Patrick A Calvert
- Queen Elizabeth Hospital, University Hospitals Birmingham and Institute of Translational Medicine, University of Birmingham, United Kingdom
| | | | | | | | | | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom
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Schoen FJ, Gotlieb AI. Heart valve health, disease, replacement, and repair: a 25-year cardiovascular pathology perspective. Cardiovasc Pathol 2016; 25:341-352. [PMID: 27242130 DOI: 10.1016/j.carpath.2016.05.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/04/2016] [Accepted: 05/05/2016] [Indexed: 01/24/2023] Open
Abstract
The past several decades have witnessed major advances in the understanding of the structure, function, and biology of native valves and the pathobiology and clinical management of valvular heart disease. These improvements have enabled earlier and more precise diagnosis, assessment of the proper timing of surgical and interventional procedures, improved prosthetic and biologic valve replacements and repairs, recognition of postoperative complications and their management, and the introduction of minimally invasive approaches that have enabled definitive and durable treatment for patients who were previously considered inoperable. This review summarizes the current state of our understanding of the mechanisms of heart valve health and disease arrived at through innovative research on the cell and molecular biology of valves, clinical and pathological features of the most frequent intrinsic structural diseases that affect the valves, and the status and pathological considerations in the technological advances in valvular surgery and interventions. The contributions of many cardiovascular pathologists and other scientists, engineers, and clinicians are emphasized, and potentially fruitful areas for research are highlighted.
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Affiliation(s)
- Frederick J Schoen
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115; Pathology and Health Sciences and Technology (HST), Harvard Medical School, 75 Francis Street, Boston, MA 02115.
| | - Avrum I Gotlieb
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario M5S 1A8, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario M5S 1A8, Canada; Laboratory Medicine Program, University Health Network, Medical Sciences Building, 1 King's College Circle, Rm. 6275A, Toronto, Ontario M5S 1A8, Canada.
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Aboshady I, Raad I, Vela D, Hassan M, Aboshady Y, Safi HJ, Buja LM, Khalil KG. Prevention of perioperative vascular prosthetic infection with a novel triple antimicrobial-bonded arterial graft. J Vasc Surg 2015; 64:1805-1814. [PMID: 26626182 DOI: 10.1016/j.jvs.2015.09.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 09/03/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Previously, we investigated a locally developed technique of bonding arterial grafts with three antimicrobials to protect against early (within 2 weeks) perioperative bacterial contamination encountered occasionally during aortic graft prosthetic reconstruction. Vascular graft infections are classified by their appearance time (early [<4 months] vs late [>4 months] after graft implantation), degree of incorporation into the surrounding vessel wall, connectivity to the postoperative wound, and extent of graft involvement. In the current phase of testing, we evaluated the ability of our novel triple antimicrobial-bonded graft to prevent infection in the first 8 weeks after implantation. METHODS In nine Sinclair miniature pigs, we surgically implanted a 6-mm vascular Dacron patch graft in the infrarenal abdominal aorta. Five pigs received grafts chemically bonded with a 60-mg/mL solution of rifampin, minocycline, and chlorhexidine, and four pigs received unbonded grafts. Before implantation, the five bonded grafts and three of the unbonded grafts were immersed for 15 minutes in a 2-mL solution containing 1-2 × 107 colony-forming units (CFUs)/mL of Staphylococcus aureus (ATCC 29213); the fourth unbonded graft served as a control. RESULTS At week 9, all of the grafts were explanted. All S aureus-inoculated bonded grafts (n = 5) showed no bacterial growth. The unbonded, uninoculated graft (n = 1) showed low-level bacterial growth (<1.2 × 103 CFUs); S cohnii spp urealyticus, but not S aureus, was isolated, which suggested accidental direct perioperative contamination. Two pigs that received S aureus-inoculated, unbonded grafts were euthanized because of severe S aureus infection (<6.56 × 108 CFUs per graft). Results of histopathologic analysis were concordant with the microbiologic findings. Most intergroup differences were observed in the inflammatory infiltrate in the aortic wall at the site of graft implantation. In all pigs that received bonded grafts, Gram staining showed no bacteria. CONCLUSIONS Our triple-bonded aortic graft prevented perioperative aortic graft infection for at least 8 weeks in a porcine model. The synergistic antimicrobial activity of this graft was sufficient to prevent and/or eradicate infection during that period. Further studies are needed to assess the graft's ability to combat early-onset vascular graft infection for up to 4 months.
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Affiliation(s)
- Ibrahim Aboshady
- Department of Cardiovascular Pathology, Texas Heart Institute, Houston, Tex; Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center, Houston, Tex
| | - Issam Raad
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Deborah Vela
- Department of Cardiovascular Pathology, Texas Heart Institute, Houston, Tex; Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center, Houston, Tex
| | - Mohamed Hassan
- Department of Internal Medicine, The University of Texas Health Science Center, Houston, Tex
| | - Yara Aboshady
- Department of Biochemistry, Rice University, Houston, Tex
| | - Hazim J Safi
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center, Houston, Tex; Department of Cardiothoracic and Vascular Surgery, Baylor College of Medicine, Houston, Tex; Memorial Hermann Heart and Vascular Institute, Houston, Tex
| | - L Maximilian Buja
- Department of Cardiovascular Pathology, Texas Heart Institute, Houston, Tex; Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center, Houston, Tex
| | - Kamal G Khalil
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center, Houston, Tex; Department of Cardiothoracic and Vascular Surgery, Baylor College of Medicine, Houston, Tex; Memorial Hermann Heart and Vascular Institute, Houston, Tex.
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Kim GJ, Lee JT, Lee YO, Cho JY, Oh TH. Outcomes of nonpledgeted horizontal mattress suture technique for mitral valve replacement. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2014; 47:504-9. [PMID: 25551070 PMCID: PMC4279844 DOI: 10.5090/kjtcs.2014.47.6.504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 09/25/2014] [Accepted: 09/30/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Most surgeons favor the pledgeted suture technique for heart valve replacements because they believe it decreases the risk of paravalvular leak (PVL). We hypothesized that the use of nonpledgeted rather than pledgeted sutures during mitral valve replacement (MVR) may decrease the incidence of prosthetic valve endocarditis (PVE) and risk of a major PVL. METHODS We analyzed 263 patients, divided into 175 patients who underwent MVR with nonpledgeted sutures from January 2003 to December 2013 and 88 patients who underwent MVR with pledgeted sutures from January 1995 to December 2001. We compared the occurrence of PVL and PVE between these groups. RESULTS In patients who underwent MVR with or without tricuspid valve surgery and/or a Maze operation, PVL occurred in 1.1% of the pledgeted group and 2.9% of the nonpledgeted group. The incidence of PVE was 2.9% in the nonpledgeted group and 1.1% in the pledgeted group. No differences were statistically significant. CONCLUSION We suggest that a nonpledgeted suture technique can be an alternative to the traditional use of pledgeted sutures in most patients who undergo MVR, with no significant difference in the incidence of PVL.
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Affiliation(s)
- Gun Jik Kim
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Hospital
| | - Jong Tae Lee
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Hospital
| | - Young Ok Lee
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Hospital
| | - Joon Young Cho
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Hospital
| | - Tak-Hyuk Oh
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Hospital
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Myers PO, Cikirikcioglu M, Kalangos A. Biodegradable materials for surgical management of infective endocarditis: new solution or a dead end street? BMC Surg 2014; 14:48. [PMID: 25087015 PMCID: PMC4131057 DOI: 10.1186/1471-2482-14-48] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 07/24/2014] [Indexed: 01/29/2023] Open
Abstract
Background One third of patients with infective endocarditis will require operative intervention. Given the superiority of valve repair over valve replacement in many indications other than endocarditis, there has been increasing interest and an increasing number of reports of excellent results of valve repair in acute infective endocarditis. The theoretically ideal material for valve repair in this setting is non-permanent, “vanishing” material, not at risk of seeding or colonization. The goal of this contribution is to review currently available data on biodegradable materials for valve repair in infective endocarditis. Discussion Rigorous electronic and manual literature searches were conducted to identify reports of biodegradable materials for valve repair in infective endocarditis. Articles were identified in electronic database searches of Medline, Embase and the Cochrane Library, using a predetermined search strategy. 49 manuscripts were included in the review. Prosthetic materials needed for valve repair can be summarized into annuloplasty rings to remodel the mitral or tricuspid annulus, and patch materials to replace resected valvar tissue. The commercially available biodegradable annuloplasty ring has shown interesting clinical results in a single-center experience; however further data is required for validation and longer follow-up. Unmodified extra-cellular matrix patches, such as small intestinal submucosa, have had promising initial experimental and clinical results in non-infected valve repair, although in valve repair for endocarditis has been reported in only one patient, and concerns have been raised regarding their mechanical stability in an infected field. Summary These evolving biodegradable devices offer the potential for valve repair with degradable materials replaced with autologous tissue, which could further improve the results of valve repair for infective endocarditis. This is an evolving field with promising experimental or initial clinical results, however long-term outcomes are lacking and further data is necessary to validate this theoretically interesting approach to infective endocarditis.
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Affiliation(s)
- Patrick O Myers
- Cardiovascular Surgery, Geneva University Hospitals & Faculty of Medicine, 4 rue Gabrielle-Perret-Gentil, 1211 Geneva, Switzerland.
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Single-institution, 22-year follow-up of 786 CarboMedics mechanical valves used for both primary surgery and reoperation. J Thorac Cardiovasc Surg 2014; 147:1493-8. [DOI: 10.1016/j.jtcvs.2013.05.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 05/19/2013] [Accepted: 05/31/2013] [Indexed: 11/17/2022]
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Eckhardt S, Brunetto PS, Gagnon J, Priebe M, Giese B, Fromm KM. Nanobio silver: its interactions with peptides and bacteria, and its uses in medicine. Chem Rev 2013; 113:4708-54. [PMID: 23488929 DOI: 10.1021/cr300288v] [Citation(s) in RCA: 509] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Sonja Eckhardt
- Department of Chemistry, University of Fribourg, Chemin du Musée 9, 1700 Fribourg, Switzerland.
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Politano AD, Campbell KT, Rosenberger LH, Sawyer RG. Use of silver in the prevention and treatment of infections: silver review. Surg Infect (Larchmt) 2013; 14:8-20. [PMID: 23448590 DOI: 10.1089/sur.2011.097] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The use of silver for the treatment of various maladies or to prevent the transmission of infection dates back to at least 4000 b.c.e. Medical applications are documented in the literature throughout the 17th and 18th centuries. The bactericidal activity of silver is well established. Silver nitrate was used topically throughout the 1800 s for the treatment of burns, ulcerations, and infected wounds, and although its use declined after World War II and the advent of antibiotics, Fox revitalized its use in the form of silver sulfadiazine in 1968. METHOD Review of the pertinent English-language literature. RESULTS Since Fox's work, the use of topical silver to reduce bacterial burden and promote healing has been investigated in the setting of chronic wounds and ulcers, post-operative incision dressings, blood and urinary catheter designs, endotracheal tubes, orthopedic devices, vascular prostheses, and the sewing ring of prosthetic heart valves. The beneficial effects of silver in reducing or preventing infection have been seen in the topical treatment of burns and chronic wounds and in its use as a coating for many medical devices. However, silver has been unsuccessful in certain applications, such as the Silzone heart valve. In other settings, such as orthopedic hardware coatings, its benefit remains unproved. CONCLUSION Silver remains a reasonable addition to the armamentarium against infection and has relatively few side effects. However, one should weigh the benefits of silver-containing products against the known side effects and the other options available for the intended purpose when selecting the most appropriate therapy.
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Affiliation(s)
- Amani D Politano
- Department of Surgery, University of Virginia, Charlottesville, Virginia 22908, USA.
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Abstract
Medical devices have emerged as an important clinical option to treat certain serious diseases for which there are no equivalently effective surgical or pharmaceutical alternatives. Although all clinical activities impose high ethical standards of comportment to protect patients, medical device R&D and product application have a number of relatively unique aspects that distinguish them from other technologies such as pharmaceuticals. These include the following: R&D project selection; regulatory requirements, and their intended and unintended effects; when is a new product design sufficiently safe and effective for routine use in patients; and, physician-industry relationships in the innovation process in the context of real or perceived conflict of interest (COI). Each of these factors has implications for the delivery of care, health care leadership, and patient well-being.
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Hardes J, Streitburger A, Ahrens H, Nusselt T, Gebert C, Winkelmann W, Battmann A, Gosheger G. The influence of elementary silver versus titanium on osteoblasts behaviour in vitro using human osteosarcoma cell lines. Sarcoma 2011; 2007:26539. [PMID: 17680031 PMCID: PMC1920591 DOI: 10.1155/2007/26539] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2006] [Accepted: 05/18/2007] [Indexed: 01/20/2023] Open
Abstract
Purpose. The antimicrobial effect of a silver-coated tumor endoprosthesis has been proven in clinical and experimental trials. However, in the literature there are no reports concerning the effect of elementary silver on osteoblast behaviour. Therefore, the prosthetic stem was not silver-coated because of concerns regarding a possible inhibition of the osseointegration. The aim of the present study was to investigate the effect of 5–25 mg of elementary silver in comparison to Ti-6Al-4V on human osteosarcoma cell lines (HOS-58, SAOS).
Methods. Cell viability was determined by measuring the MTT proliferation rate. Cell function was studied by measuring alkaline phosphatase (AP) activity and osteocalcine production. Results. In the HOS-58 cells, the AP activity was statistically significant (P < 0.05) higher at a supplement of 5–10 mg of silver than of Ti-6 Al-4V at the same doses. For both cell lines, a supplement above 10 mg of silver resulted in a reduced AP activity in comparision to the Ti-6 Al-4V group, but a statistically significant difference (P < 0.05) was observed at a dose of 25 mg for the SAOS cells only. At doses of 20–25 mg in the HOS-58 cells and 10–25 mg in the SAOS cells, the reduction of the proliferation rate by silver was statistically significant (P < 0.05) compared to the Ti-6 Al-4V supplement. Discussion. In conclusion, elementary silver exhibits no cytotoxicity at low concentrations. In contrast, it seems to be superior to Ti-6 Al-4V concerning the stimulation of osteogenic maturation at these concentrations, whereas at higher doses it causes the known cytotoxic properties.
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Affiliation(s)
- Jendrik Hardes
- Department of Orthopaedics, University Clinics of Muenster, Albert-Schweitzer Street 33, 49149 Muenster, Germany
- *Jendrik Hardes:
| | - Arne Streitburger
- Department of Orthopaedics, University Clinics of Muenster, Albert-Schweitzer Street 33, 49149 Muenster, Germany
| | - Helmut Ahrens
- Department of Orthopaedics, University Clinics of Muenster, Albert-Schweitzer Street 33, 49149 Muenster, Germany
| | - Thomas Nusselt
- Institute of Pathology, University Clinic of Giessen and Marburg, Langhansstrasse 10, 35385 Giessen, Germany
| | - Carsten Gebert
- Department of Orthopaedics, University Clinics of Muenster, Albert-Schweitzer Street 33, 49149 Muenster, Germany
| | - Winfried Winkelmann
- Department of Orthopaedics, University Clinics of Muenster, Albert-Schweitzer Street 33, 49149 Muenster, Germany
| | - Achim Battmann
- Institute of Pathology, University Clinic of Giessen and Marburg, Langhansstrasse 10, 35385 Giessen, Germany
| | - Georg Gosheger
- Department of Orthopaedics, University Clinics of Muenster, Albert-Schweitzer Street 33, 49149 Muenster, Germany
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Fraser AG, Daubert JC, Van de Werf F, Estes NAM, Smith SC, Krucoff MW, Vardas PE, Komajda M, Anker S, Auricchio A, Bailey S, Bonhoeffer P, Borggrefe M, Brodin LA, Bruining N, Buser P, Butchart E, Calle Gordo J, Cleland J, Danchin N, Daubert J, Degertekin M, Demade I, Denjoy N, Derumeaux G, Di Mario C, Dickstein K, Dudek D, Estes N, Farb A, Flotats A, Fraser A, Gueret P, Israel C, James S, Kautzner J, Komajda M, Krucoff M, Lombardi M, Marwick T, Mioulet M, O'Kelly S, Perrone-Filardi P, Rosano G, Rosenhek R, Sabate M, Smith S, Swahn E, Tavazzi L, Van de Werf F, van der Velde E, van Herwerden L, Vardas P, Voigt JU, Weaver D, Wilmshurst P. Clinical evaluation of cardiovascular devices: principles, problems, and proposals for European regulatory reform: Report of a policy conference of the European Society of Cardiology. Eur Heart J 2011; 32:1673-86. [DOI: 10.1093/eurheartj/ehr171] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Nataloni M, Pergolini M, Rescigno G, Mocchegiani R. Prosthetic valve endocarditis. J Cardiovasc Med (Hagerstown) 2011; 11:869-83. [PMID: 20154632 DOI: 10.2459/jcm.0b013e328336ec9a] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Prosthetic valve endocarditis (PVE) is associated with a high mortality during the early and midterm follow-up despite diagnostic and therapeutic improvements; its incidence is increasing and reaches 20-30% of all infective endocarditis episodes. In this review, changes in epidemiology, microbiology, diagnosis and therapy that have evolved in the past few years are analyzed. Staphylococci (both Staphylococcus aureus and coagulase-negative Staphylococcus) have emerged as the most common cause of PVE and are associated with a severe prognosis. Moreover, diagnosis may often be difficult because of its complications and extracardiac manifestations; thus, a comprehensive assessment of the clinical, echocardiographic and laboratory data must be performed. Early PVE, comorbidity, severe heart failure and new prosthetic dehiscence are predictors of mortality. Therapy is not indicated by evidence-based recommendations but mostly on identification of the high-risk conditions. A PVE is a common indication for surgery, whereas medical treatment alone may be achieved in a few instances. Systematic prophylaxis should be used to prevent this severe complication of cardiac valve replacement.
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Affiliation(s)
- Maura Nataloni
- Outpatient Cardiology Service, Fabriano Hospital, Asur Marche, Italy
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Khalilpour P, Lampe K, Wagener M, Stigler B, Heiss C, Ullrich MS, Domann E, Schnettler R, Alt V. Ag/SiO(x)C(y) plasma polymer coating for antimicrobial protection of fracture fixation devices. J Biomed Mater Res B Appl Biomater 2010; 94:196-202. [PMID: 20524195 DOI: 10.1002/jbm.b.31641] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Implant-related infections are often devastating situations in orthopaedic trauma surgery particularly if multiresistant bacteria are involved. Protection of the implant surface by an antimicrobial coating exhibiting activity against multiresistant bacterial strains is of high interest. Aim of this study was to investigate the antimicrobial effects of an Ag/SiO(x)C(y) plasma polymer coating for fracture fixation devices, such as nails, plates, and external fixators, including tests against methicillin-resistant Staphylococcus aureus (MRSA) and its biocompatibility. The antimicrobial activity of the coating deposited onto 12 x 3 mm(2) stainless steel implants was tested in vitro against Staphylococcus aureus, Staphylococcus epidermidis, and MRSA using different testing methods (ASTM E-2810, JIS Z 2801, proliferation assay). Additionally, the coated devices were implanted into the paravertebral muscle of rabbits and explanted after 2, 7, 14, and 28 days to test the remaining ex vivo antimicrobial activity. For biocompatibility assessment the Ag/SiO(x)C(y) plasma polymer coating was tested in vitro according to ISO 10993-5. The Ag/SiO(x)C(y) coating exhibited excellent antimicrobial activity against all tested bacterial strains in all three in vitro tests. Ex vivo testing proved suppression of more than 99.9 % of bacterial proliferation by the coating compared to non-coated samples even after 28 days. ISO 10993-5 showed good biocompatibility of the coating without any indications of cytotoxic effects. In summary, Ag/SiO(x)C(y) plasma polymer coating showed excellent antimicrobial activity including effectiveness against MRSA and good in vitro biocompatibility. Therefore, it possesses high potential as a prophylactic agent in orthopaedic trauma surgery.
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Wijnhoven SW, Peijnenburg WJ, Herberts CA, Hagens WI, Oomen AG, Heugens EH, Roszek B, Bisschops J, Gosens I, Van De Meent D, Dekkers S, De Jong WH, van Zijverden M, Sips AJ, Geertsma RE. Nano-silver – a review of available data and knowledge gaps in human and environmental risk assessment. Nanotoxicology 2009. [DOI: 10.1080/17435390902725914] [Citation(s) in RCA: 612] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Jamieson WE, Fradet GJ, Abel JG, Janusz MT, Lichtenstein SV, MacNab JS, Stanford EA, Chan F. Seven-year results with the St Jude Medical Silzone mechanical prosthesis. J Thorac Cardiovasc Surg 2009; 137:1109-15.e2. [DOI: 10.1016/j.jtcvs.2008.07.070] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2007] [Revised: 05/06/2008] [Accepted: 07/04/2008] [Indexed: 11/16/2022]
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Johri AM, Yared K, Durst R, Cubeddu RJ, Palacios IF, Picard MH, Passeri J. Three-dimensional echocardiography-guided repair of severe paravalvular regurgitation in a bioprosthetic and mechanical mitral valve. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2009; 10:572-5. [DOI: 10.1093/ejechocard/jep019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Prophylaxis of infective endocarditis: current tendencies, continuing controversies. THE LANCET. INFECTIOUS DISEASES 2008; 8:225-32. [DOI: 10.1016/s1473-3099(08)70064-1] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Duval X. [Prophylaxis of infective endocarditis: trends and new recommendations]. Ann Cardiol Angeiol (Paris) 2008; 57:102-108. [PMID: 18402925 DOI: 10.1016/j.ancard.2008.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2008] [Accepted: 02/21/2008] [Indexed: 05/26/2023]
Abstract
The rationale having led to the profound change in the guidelines on the prevention of endocarditis is presented. The current trend to abandoning systematic antibiotic prophylaxis in patients at risk for infective endocarditis is in fact based upon a sound scientific background. Systematic antibiotic prophylaxis remains necessary, however, in the category of patients at very high risk.
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Affiliation(s)
- X Duval
- Service des maladies infectieuses et tropicales, hôpital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex 18, France.
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Baddour LM. Prophylaxis of Infective Endocarditis: Prevention of the Perfect Storm. Int J Antimicrob Agents 2007; 30 Suppl 1:S37-41. [PMID: 17884356 DOI: 10.1016/j.ijantimicag.2007.06.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2007] [Accepted: 06/01/2007] [Indexed: 11/30/2022]
Abstract
Despite the availability of endocarditis prophylaxis guidelines for more than five decades, no prospective, randomised trial has ever been conducted to evaluate the efficacy and safety of this practice. This fact, in combination with mixed results from case-control investigations and other factors, has prompted a re-evaluation of the appropriateness of the guidelines. The update provided herein highlights recent revisions in guidelines promulgated by different countries.
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Abstract
Most infective processes are straightforward and can be diagnosed from bacterial findings in a single test. IE does not always follow this tenet, so establishing the diagnosis can be difficult. The salient features of IE may present atypically or be obscured by the presence of preexisting and coexisting diseases. Flulike symptoms may mask the beginning of this devastating disease. Early diagnosis of IE is important because of its high risk of morbidity and mortality. Management of the patient who has IE is complex and requires interventions by infectious disease specialists, cardiologists, respiratory therapists, and critical care nurses to address the many multifaceted complications. Early evaluation, diagnostic validation, multidisciplinary management, prompt pharmaceutical initiation, and intense critical care nursing intervention are necessary to reduce the probability of long-standing complications and to improve patient outcomes.
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Affiliation(s)
- Maria A Smith
- School of Nursing, Middle Tennessee State University, 1500 Greenland Drive, P.O. Box 81, Murfreesboro, TN 37132, USA.
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Butany J, Leask RL, Desai ND, Jegatheeswaran A, Silversides C, Scully HE, Feindel C. Pathologic Analysis of 19 Heart Valves With Silver-Coated Sewing Rings. J Card Surg 2006; 21:530-8. [PMID: 17073948 DOI: 10.1111/j.1540-8191.2006.00323.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The St. Jude Medical Silzone (Silzone) mechanical heart valve was voluntarily recalled (January 2000) due to an unusually high incidence of paravalvular leaks. We present the first series of human morphological data on the failure of these valves. METHODS Nineteen Silzone valves were evaluated from the 176 Silzone valves implanted in 147 patients at our institution between 1997 and 1999. Explanted prostheses were fixed in 10% formalin, photographed, and X-rayed. Histological sections were collected from the sewing cuff, accompanying tissues, and thrombus. For comparison, six age-matched SJM-standard valves were similarly analyzed. RESULTS Nineteen Silzone valves from 16 patients (10 male, six female, 52.0 +/- 15.2 years) were examined. Significantly more mitral (15/95) prostheses were removed than aortic (4/81) despite the nearly equal number implanted (p = 0.027). Fifteen of the Silzone valves (13/16 patients) were explanted in the early postoperative period (within six months of implantation), although collection continued for eight years after our institution stopped implanting them. The common indications for surgical explantation were paravalvular leak (8/12) and clinically suspected infective endocarditis (IE) (four patients, five valves). IE was not confirmed by histology or culture in any valve. The sewing cuffs of many Silzone valves showed large regions of pannus, granulation tissue, and purulent exudate. Polymorphonuclear leukocytes were more common in the sewing cuff of Silzone valves; however, the cellular infiltrate was superficial when compared to SJM-standard valves. CONCLUSION This is the largest morphologically analyzed series of Silzone explants. It demonstrates a consistent pattern of atypical tissue incorporation into the silver-coated sewing ring particularly in the mitral position. Clinical and morphologic features of IE (sterile) are seen in the early postimplant period. Prosthesis-related problems were almost wholly seen at the mitral site, in our group. Our current data indicate that although early failure due to dehiscence and paravalvular leak is a problem, Silzone valves that "survive" past six months will likely function as well as the SJM-standard prosthesis.
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Affiliation(s)
- Jagdish Butany
- Department of Pathology, University of Toronto, E4-322 Toronto General Hospital, 200 Elizabeth Street, Toronto, Ontario, Canada.
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Grunkemeier GL, Jin R, Starr A. Prosthetic heart valves: Objective Performance Criteria versus randomized clinical trial. Ann Thorac Surg 2006; 82:776-80. [PMID: 16928482 DOI: 10.1016/j.athoracsur.2006.06.037] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2006] [Revised: 06/12/2006] [Accepted: 06/13/2006] [Indexed: 11/21/2022]
Abstract
The current Food and Drug Administration (FDA) heart valve guidance document uses an objective performance criteria (OPC) methodology to evaluate the clinical performance of prosthetic heart valves. OPC are essentially historical controls, but they have turned out to be an adequate, and perhaps optimal, study design in this situation. Heart valves have a simple open-and-close mechanism, device effectiveness is easy to document, and the common complications (thromboembolism, thrombosis, bleeding, leak, and infection) are well known and easily detected. Thus, randomized clinical trials (RCTs) have not been deemed necessary for the regulatory approval of prosthetic heart valves. The OPC are derived from the average complication rates of all approved heart valves. Studies based on OPC have been shown to work well; many different valve models have gained FDA market approval based on this methodology. Although heart valve RCTs are not required by the FDA, they have been done to compare valves or treatment regimens after approval. Recently, the Artificial Valve Endocarditis Reduction Trial (AVERT) was designed to compare a new Silzone sewing ring, designed to reduce infection, with the Standard sewing ring on a St. Jude Medical heart valve. This was the largest heart valve RCT ever proposed (4,400 valve patients, followed for as long as 4 years), but it was stopped prematurely because of a high leak rate associated with the Silzone valve. Examining the results showed that a much smaller, OPC-based study with 800 patient-years would have been sufficient to disclose this complication of the Silzone valve.
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Abstract
PURPOSE OF REVIEW The aim of this article is to evaluate the findings of clinical trials in cardiac valve surgery and to determine the real impact in standard of care. Also, publications on randomized clinical trials were reviewed as to integrity and validity. Nineteen randomized clinical trials were identified in 11 areas of operative and clinical management. RECENT DEVELOPMENTS The Veterans Affairs and Edinburgh Heart Valve Trials confirmed the guidelines for indications for bioprostheses and mechanical prostheses. Even current prostheses have advanced technologies but the same valve-related complications determine indications. Randomized clinical trials of mechanical prostheses failed to determine prosthesis superiority. Bioprostheses of specific manufacturers contribute sub-optimal hemodynamics in small sizes. Two trials showed lack of superiority between aortic stented and stentless bioprostheses. Autografts, not allografts, are indicated for children because of structural valve deterioration of allografts. Atrial ablation surgery with concomitant mitral valve reconstruction/replacement is safe and efficacious with at least two energy sources. Minimally invasive aortic valve replacement does not provide superior results to conventional surgery. Patient-managed anticoagulation provides the most favourable thromboembolic and hemorrhagic rates with mechanical prostheses. Prosthesis sewing cuff impregnation with a bactericidal agent to reduce the incidence of prosthetic valve endocarditis was stopped because of increased incidence of major paravalvular leak requiring reoperation. SUMMARY Randomized clinical trials, although limited in number, have provided advancement of the standard of care. Randomized clinical trials are indicated in the management of mild to moderate ischemic mitral regurgitation and evaluation of new transcatheter technologies to conventional surgery.
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Affiliation(s)
- Jian Ye
- Division of Cardiovascular Surgery, Department of Surgery, University of British Columbia, Vancouver, Canada
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Monahan TS, Phaneuf MD, Contreras MA, Andersen ND, Popescu-Vladimir A, Bide MJ, Dempsey DJ, Mitchell RN, Hamdan AD, LoGerfo FW. In Vivo Testing of an Infection-Resistant Annuloplasty Ring. J Surg Res 2006; 130:140-5. [PMID: 16154148 DOI: 10.1016/j.jss.2005.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2005] [Revised: 05/23/2005] [Accepted: 06/05/2005] [Indexed: 11/21/2022]
Abstract
BACKGROUND An infection-resistant surface incorporated into a prosthetic cardiac valve has great potential clinical applications. STUDY DESIGN A sewing ring construct was created using ciprofloxacin-treated polyester. Then ciprofloxacin-treated and untreated constructs were implanted subcutaneously on the dorsum of rats and inoculated with Staphylococcus aureus. At 7, 14, and 30 days animals were sacrificed and the implants were retrieved. Each implant was assessed for frank purulence and gross tissue incorporation by a blinded observer. The implants were processed for conventional histology and examined by a blinded Pathologist. Ciprofloxacin-treated rings were also implanted in the absence of a bacterial challenge. At explantation, a maximal zone of inhibition, if present, was measured. Finally, ciprofloxacin was eluted with methanol from the explanted segments and the concentration of ciprofloxacin eluted was determined. RESULTS Ciprofloxacin-treated sewing rings had greater gross tissue incorporation than untreated rings in the presence of a bacterial challenge (P=0.005). Ciprofloxacin-treated rings also had a lower incidence of frank purulence, but this did not reach statistical significance. After 14 days of implantation, ciprofloxacin treated rings had fewer neutrophils (P=0.018) and greater histological tissue incorporation (P=0.017) than untreated rings. The explanted ciprofloxacin-treated rings maintained a zone of inhibition of 3.0+/-1.0 mm after 1 day of implantation and 1.3+/-0.6 mm after 2 days. Ciprofloxacin could be eluted in significant quantities from the explanted rings after 7 days of implantation. CONCLUSIONS Ciprofloxacin treated polyester can be incorporated into an annuloplasty ring construct that demonstrates excellent tissue incorporation and infection resistance. This study supports the use of this construct in the mitral position in a large animal model.
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Affiliation(s)
- Thomas S Monahan
- Department of Surgery, Division of Vascular Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02115, USA.
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Pate GE, Al Zubaidi A, Chandavimol M, Thompson CR, Munt BI, Webb JG. Percutaneous closure of prosthetic paravalvular leaks: Case series and review. Catheter Cardiovasc Interv 2006; 68:528-33. [PMID: 16969856 DOI: 10.1002/ccd.20795] [Citation(s) in RCA: 150] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Paravalvular leaks (PVLs) are a well-recognized complication of prosthetic valve replacement. Most are asymptomatic and benign, but some may cause symptoms due to a large regurgitant volume or hemolysis. Medical therapy is palliative, while reoperation carries significant morbidity and mortality. Percutaneous transcatheter closure techniques, now routinely applied in the management of pathological cardiac and vascular communications, may be adaptable to PVL closure, potentially offer symptomatic relief. METHODS We reviewed our experience with attempted percutaneous closure of PVLs, using data from medical and procedural records. RESULTS Between 2001 and 2004, 14 procedures were performed in 10 patients, all under general anesthesia, with transesophageal and radiographic guidance. Mitral (9) and aortic (1) valve replacements were involved, both mechanical and bioprosthetic. A variety of devices were used, including atrial septal occluders, patent ductus arteriosus occluders, and coils (all of label use). Six had a single procedure, which was technically successful in four: in two, the PVL could not be crossed. Four underwent a second procedure, which was technically successful in three; in one the previously deployed device was dislodged necessitating urgent, but ultimately uneventful, surgical removal and leak repair. One patient had transient severe hemolysis, which resolved after 1 week. At 1-year follow-up (9/10 pts) three had died, five had sustained symptomatic improvement while 1 patient with a residual leak still required regular blood transfusions. CONCLUSIONS Percutaneous closure of PVLs is time-consuming but feasible in selected patients, with a reasonable degree of technical and clinical success. A second procedure may be necessary and a variety of complications can occur.
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Affiliation(s)
- Gordon E Pate
- Division of Cardiology, St. Paul's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada
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Mahesh B, Angelini G, Caputo M, Jin XY, Bryan A. Prosthetic valve endocarditis. Ann Thorac Surg 2005; 80:1151-8. [PMID: 16122521 DOI: 10.1016/j.athoracsur.2004.11.001] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2004] [Revised: 10/28/2004] [Accepted: 11/02/2004] [Indexed: 01/21/2023]
Abstract
Prosthetic valve endocarditis is a catastrophic complication of cardiac valve replacement, associated with high mortality rates. Medical treatment is effective in a few instances of endocarditis involving the leaflets alone in bioprostheses. However, accurate diagnosis, better myocardial protection, and improved surgical strategies have led to better survival in patients undergoing surgery after failed conservative therapy. This comprehensive review addresses various issues involved in the management of this complication.
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Emery RW, Krogh CC, Arom KV, Emery AM, Benyo-Albrecht K, Joyce LD, Nicoloff DM. The St. Jude Medical Cardiac Valve Prosthesis: A 25-Year Experience With Single Valve Replacement. Ann Thorac Surg 2005; 79:776-82; discussion 782-3. [PMID: 15734375 DOI: 10.1016/j.athoracsur.2004.08.047] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2004] [Indexed: 11/16/2022]
Abstract
BACKGROUND From October 1977 to October 2002, 4,480 patients (age range, 17 to 94 years; average, 64 +/- 13 years) underwent single valve replacement with the St. Jude Medical heart valve. Of 2,982 aortic (AVR) and 1,498 mitral valve replacements (MVR), concomitant coronary artery bypass grafting was performed on 42% and 33%, respectively. METHODS Cardiac Surgical Associates has maintained an independent database of patients having valve replacement with the St. Jude Medical prosthesis since the world's first implant. Patients were contacted by questionnaire or phone from November 2002 through June 2003. Hospital course and valve-related events were verified by patient chart review or physician contact. RESULTS Follow-up was 95% complete. Operative mortality was 4% with AVR and 9% with MVR. Total follow-up was 32,190 patient-years (range, 1 month to 24.8 years; average, 7 +/- 5 years). During the study period, patient freedom from late mortality was 61% (AVR, 61%; MVR, 63%), and from valve-related mortality 92% (AVR, 93%; MVR, 91%). Freedom from thromboembolic events was 85% (86% AVR, 81% MVR), from bleeding events, 81% (81% AVR, 81% MVR), from reoperation, 98% (99% AVR, 97% MVR), from endocarditis, 98% (99% AVR, 98% MVR), and from valve thrombosis, 99% (99% AVR, 98% MVR). There was one MVR structural failure (0.06%). CONCLUSIONS The St. Jude Medical valve has proven to be an effective and durable valve prosthesis with a low event rate during the long term.
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Affiliation(s)
- Robert W Emery
- Cardiac Surgical Associates, PA, St. Paul, Minnesota 55114, USA.
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Alt V, Bechert T, Steinrücke P, Wagener M, Seidel P, Dingeldein E, Scheddin D, Domann E, Schnettler R. [Nanoparticulate silver. A new antimicrobial substance for bone cement]. DER ORTHOPADE 2004; 33:885-92. [PMID: 15241590 DOI: 10.1007/s00132-004-0690-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Multiresistant bacteria have become an important problem in prosthetic joint infections. Their frequent resistance against gentamicin, which is commonly used in antibiotic-loaded bone cements, makes a new prophylaxis necessary. METHODS PMMA-cement was loaded with 1% nanoparticulate silver and its antibacterial activity tested in vitro against gentamicin-resistant MRSE and MRSA strains as well as being compared to the activity of plain and gentamicin-loaded bone cements. A quantitative elution testing was also done to study the potentially cytotoxic effects of NanoSilver cement. RESULTS Unloaded and PMMA-cement loaded with 2% gentamicin did not exhibit any antibacterial activity against MRSE and MRSA. At 1%, NanoSilver cement completely inhibited the proliferation of MRSA and MRSE. NanoSilver bone cement did not show any significant differences compared to the non-toxic control group. CONCLUSIONS If these promising in vitro results can be confirmed in vivo, NanoSilver bone cement may be of considerable value in total joint arthroplasty.
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Affiliation(s)
- V Alt
- Klinik und Poliklinik für Unfallchirurgie der Justus-Liebig-Universität Giessen.
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Alt V, Bechert T, Steinrücke P, Wagener M, Seidel P, Dingeldein E, Domann E, Schnettler R. An in vitro assessment of the antibacterial properties and cytotoxicity of nanoparticulate silver bone cement. Biomaterials 2004; 25:4383-91. [PMID: 15046929 DOI: 10.1016/j.biomaterials.2003.10.078] [Citation(s) in RCA: 541] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2003] [Accepted: 10/22/2003] [Indexed: 12/13/2022]
Abstract
Infections with multiresistant bacteria have become a serious problem in joint arthroplasty. This study reports about in vitro antibacterial activity against multiresistant bacteria and in vitro cytotoxicity of polymethylmetacrylate bone cement loaded with metallic silver particles with a size of 5-50 nm called NanoSilver. In vitro antibacterial activity against S. epidermidis, methicillin-resistant S. epidermidis (MRSE), and methicillin-resistant S. aureus (MRSA) was studied by microplate proliferation tests. Quantitative elution testing and qualitative ongrowth of human osteoblasts was done to study in vitro cytotoxicity. Only NanoSilver cement showed high-antibacterial activity against all strains, including MRSE and MRSA. Gentamicin cement was not effective against MRSA and MRSE due to the high-level gentamicin resistance of the tested strains. Plain cement did not inhibit proliferation of any strains. There was no significant difference regarding in vitro cytotoxicity between NanoSilver and the non-toxic control. Cytotoxicity of cement loaded with silver salts made this kind of silver unsuitable for all day clinical use in the past. This new form of silver called NanoSilver was free of in vitro cytotoxicity and showed high effectiveness against multiresistant bacteria. If the results can be confirmed in vivo NanoSilver may have a high interest in joint arthroplasty.
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Affiliation(s)
- Volker Alt
- Department of Trauma Surgery, Justus-Liebig-University Giessen, Rudolf-Buchheim-Str. 7, 35385 Giessen, Germany.
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Dávila-Román VG, Waggoner AD, Kennard ED, Holubkov R, Jamieson W, Englberger L, Carrel TP, Schaff HV. Prevalence and severity of paravalvular regurgitation in the Artificial Valve Endocarditis Reduction Trial (AVERT) echocardiography study. J Am Coll Cardiol 2004; 44:1467-72. [DOI: 10.1016/j.jacc.2003.12.060] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2003] [Revised: 11/17/2003] [Accepted: 12/09/2003] [Indexed: 11/26/2022]
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Peterson ED, Hirshfeld JW, Ferguson TB, Kramer JM, Califf RM, Kessler LG. Part II: Sealing holes in the safety net. Am Heart J 2004; 147:985-90. [PMID: 15199344 DOI: 10.1016/j.ahj.2004.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Eric D Peterson
- Centers for Education and Research on Therapeutics (CERTs) Coordinating Center, Duke Clinical Research Institute, Durham, NC 27705, USA.
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Affiliation(s)
- J Conor O'Shea
- Duke Center for Education and Research on Therapeutics (CERTs) Research Center, Duke Clinical Research Institute, Durham, NC 27705, USA
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Abstract
The explosive growth in the use of cardiac devices and the continued large number of thoracic operations produce a significant number of costly infectious complications. These infections represent a leading cause of death and disability after device implantation or surgery. Unfortunately, few objective data are available to validate the clinical epidemiology of surgical and device-related infections, and although the number of randomized trials is increasing, too few have tested strategies for prophylaxis or treatment, particularly in the cardiac arena. Because of the expected increase in invasive vascular procedures and device implantations, it is timely to consider innovative approaches to clinical research that will hasten the translation of effective therapeutic strategies and technologies into clinical practice. Because of the multidisciplinary nature of the care of patients undergoing thoracic surgery or device implantation, bringing together existing networks and several arms of the Federal government could rapidly advance this field to provide a definitive base of evidence to guide clinical practice and improve clinical outcomes. The remainder of the articles in this supplement discuss specific issues on the diagnosis and treatment of device-related or surgical infection. The purpose of this manuscript is to discuss issues about the design of studies and their organization.
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Affiliation(s)
- Robert M Califf
- Division of Cardiology, Duke University Medical Center and the Duke Clinical Research Institute, Durham, NC 27715, USA.
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Abstract
Despite improvements in health care, the incidence of infective endocarditis has not decreased over the past decades. This apparent paradox is explained by a progressive evolution in risk factors; while classic predisposing conditions such as rheumatic heart disease have been all but eradicated, new risk factors for infective endocarditis have emerged. These include intravenous drug use, sclerotic valve disease in elderly patients, use of prosthetic valves, and nosocomial disease. Newly identified pathogens, which are difficult to cultivate--eg, Bartonella spp and Tropheryma whipplei--are present in selected individuals, and resistant organisms are challenging conventional antimicrobial therapy. Keeping up with these changes depends on a comprehensive approach, allying understanding of the pathogenesis of disease with the development of new drugs for infective endocarditis. Infection by staphylococci and streptococci is being dissected at the molecular level. New ideas for antimicrobial agents are being developed. These novel insights should help redefine preventive and therapeutic strategies against infective endocarditis.
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Affiliation(s)
- Philippe Moreillon
- Institute of Fundamental Microbiology, Centre Hospitalier Universitaire, University of Lausanne, Switzerland.
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Butany J, Ahluwalia MS, Munroe C, Fayet C, Ahn C, Blit P, Kepron C, Cusimano RJ, Leask RL. Mechanical heart valve prostheses:. Cardiovasc Pathol 2003; 12:322-44. [PMID: 14630298 DOI: 10.1016/s1054-8807(03)00105-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Mechanical heart value prostheses have been in use since the 1950s. Many prostheses have been used for a while and then discontinued. Today, there are a large number and variety of prostheses in use and an even larger variety that are in place in patients. These may be explanted at any time for a number of reasons. It is essential for the practicing pathologist to be able to identify the prosthesis and be aware of some of its reported complications and modes of failure. This article, and a second one on bioprosthetic heart valves, is designed as a ready reference guide to heart valve prostheses, their important identifying features, their common complications, and modes of failure. It should help in the accurate identification of explanted prosthetic valves and more definitive reports. This accuracy of identification as well as tracking of abnormalities noted will, we hope, permit the identification of new failure modes and the recording of causes of failure of new (or even modified) prosthetic heart valves.
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Affiliation(s)
- Jagdish Butany
- Department of Pathology E4-322, Toronto General Hospital, Toronto, ON, Canada M5G 2C4.
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Ionescu A, Payne N, Fraser AG, Giddings J, Grunkemeier GL, Butchart EG. Incidence of embolism and paravalvar leak after St Jude Silzone valve implantation: experience from the Cardiff Embolic Risk Factor Study. Heart 2003; 89:1055-61. [PMID: 12923026 PMCID: PMC1767860 DOI: 10.1136/heart.89.9.1055] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Silver coating of the sewing ring (Silzone) was introduced as a modification of the St Jude Medical standard valve to provide antibacterial protection, but the valve has recently been withdrawn. OBJECTIVE To study patients with these prostheses to assess possible adverse effects, and to guide their follow up. DESIGN Prospective observational study of risk factors for stroke after valve replacement. SETTING Cardiology and cardiac surgery departments in a tertiary centre. PATIENTS There were 51 patients with Silzone and 116 with St Jude Medical standard valves. Patients undergoing aortic valve replacement were well matched for stroke risk factors. Silzone patients with mitral valve replacement were younger (mean (SD) age 61 (10) v 66 (7) years), more likely to be female (95% v 65%), and had more pulmonary arterial hypertension (100% v 78%), but fewer coronary artery bypass grafts (5% v 33%) than patients with standard mitral valve replacements (all p < 0.05). RESULTS Follow up was 100% in the Silzone group (mean duration 3.0 (0.9) years) and 97.4% in the standard group (4.7 (1.4) years). Survival, morbidity, and anticoagulant control were documented over 682 follow up years (153 for Silzone and 529 for standard). There were six embolic strokes and one peripheral embolism in the Silzone group, all within three months after operation, and five embolic strokes and one peripheral embolism in the standard group. Freedom from major thromboembolism at three months was 65% in the Silzone mitral valve replacement group and 100% in the standard mitral valve replacement group (difference 35%, 95% confidence interval 8% to 62%). There was one reoperation for paravalvar leak in the standard group, but none in the Silzone group (NS). Anticoagulant control in the two groups was similar. CONCLUSIONS Patients with Silzone mitral valves had a high rate of early postoperative embolism but no excess paravalvar leak.
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Affiliation(s)
- A Ionescu
- Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, UK
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Abstract
Bioprosthetic heart valves have evolved over the years into remarkably useful and predictable devices. During this process, a number of specific designs have come and gone, and a few have remained. Many design changes were successful, and many were not. This article will describe the successes and failures of the various bioprosthetic valve designs and will detail the specific reasons why a particular design change succeeded or failed to improve bioprosthetic valve performance.
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Affiliation(s)
- I Vesely
- Department of Biomedical Engineering/ND20, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Butany J, Ahluwalia MS, Munroe C, Fayet C, Ahn C, Blit P, Kepron C, Cusimano RJ, Leask RL. Mechanical heart valve prostheses: identification and evaluation. Cardiovasc Pathol 2003; 12:1-22. [PMID: 12598013 DOI: 10.1016/s1054-8807(02)00128-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jagdish Butany
- Department of Pathology E4-322, Toronto General Hospital, M5G 2C4, Toronto, ON, Canada.
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