Predictors of left atrial thrombus and spontaneous echo contrast in rheumatic valve disease before and after mitral valve replacement

In this study we aimed to analyze, with reference to mitral regurgitation (MR), the incidence and predictors of left atrial (LA) thrombus and spontaneous echo contrast in patients with rheumatic valve disease before and after mitral valve replacement. The incidence of LA thrombus is known to be less in patients with MR. The impact of mitral valve replacement on this beneficial effect has not been studied in detail. The study included 169 consecutive patients (59 men and 110 women, average age 40 +/- 13 years) with rheumatic mitral valve disease who underwent transesophageal echocardiographic examination 1 to 3 days before and within 7 days (mean 4.0 +/- 1.3) after mitral valve replacement using mechanical prostheses in a single institution. The preoperative incidence of echocardiographic LA spontaneous echo contrast (SEC) was 1.1%, 30%, and 54%, and the incidence of thrombus was 1.1%, 13%, and 17% in the groups with MR, combined mitral stenosis + MR, and isolated mitral stenosis, respectively. In the MR group, SEC and thrombus incidence increased significantly after surgery. The independent predictors for postoperative thrombus development were atrial fibrillation, postoperative SEC, and preoperative thrombus. Thrombus recurred after surgery in 64% of 14 patients who had surgical thrombectomy. The presence of postoperative MR was associated with decreased risk of postoperative SEC and thrombus development. The interaction between MR and SEC and thrombus both before and after surgery provides further support for the protective effect of MR against LA thrombus formation.

An uncommon complication of Behçet's disease: intracardiac thrombosis needing surgical treatment

Behçet's syndrome is a multisystem disorder presenting with recurrent oral and genital ulcerations as well as uveitis often leading to blindness. Although vascular lesions are a common complication of this disease, cardiac involvement is extremely rare. In this unusual case a young man had symptoms primarily related to recurrent right-atrial and right-ventricular thrombi unresponsive to medical treatment. The intracardiac lesion was successfully treated by surgical excision with the use of cardiopulmonary bypass. Surgical treatment should be considered in Behçet's disease complicated by cardiac thrombi, when a thrombus recurs despite medical treatment.

Is there a role of angiotensin-converting enzyme gene polymorphism in the failure of arteriovenous femoral shunts for hemodialysis?

In humans, thrombosis and neointimal hyperplasia are the major factors responsible for prosthetic graft occlusion. Previous studies suggest that the renin-angiotensin system is one of the key enzymes in the vascular system and has been implicated in the pathogenesis of thrombosis and neointimal hyperplasia. We conducted a case-control study to determine the frequency of the different angiotensin-converting enzyme (ACE) genotypes among the patients who had PTFE graft implantation for hemodialysis access. Between 1997 and 1999, 30 graft implantations were performed. Twelve individuals (40%) developed thrombotic complications, 8 of the 12 patients had ACE ID polymorphism, and 2 patients had DD and 2 patients had II polymorphism. The ID polymorphism was significantly more frequent in the thrombosed arteriovenous (A-V) grafts than in nonthrombosed A-V grafts (chi2 = 7.57 and p = 0.02). Overall, the frequency of the D and I alleles was 66.6 and 33.3%, respectively. In conclusion, ID polymorphism of the ACE gene plays an important role in the pathogenesis of vascular access thrombosis in subjects undergoing hemodialysis for chronic renal failure.

Leukocyte-depleted Secondary Blood Cardioplegia Attenuates Reperfusion Injury after Myocardial Ischemia

BACKGROUND

Activated neutrophils have been implicated in reperfusion injury of the myocardium; leukocyte depletion at the time of reperfusion may contribute to better myocardial protection after cardiac surgery. In the present study, we examined whether leukocyte depletion as an adjunct to terminal blood cardioplegia attenuates reperfusion injury.

METHODS

Porcine hearts that had undergone 60 minutes of normothermic ischemia with cardioplegia and 60 minutes of reperfusion under cardiopulmonary bypass were divided into four groups according to the methods of 15 min of controlled initial reperfusion: whole blood reperfusion (n = 6), leukocyte-depleted reperfusion (n = 6), secondary blood cardioplegia (n = 6) and leukocyte-depleted secondary blood cardioplegia (n = 6). At 60 min of reperfusion, hemodynamic recovery, release of malondialdehyde (MDA) as a marker for free oxygen radicals, CK-MB-isoenzyme from the coronary sinus, recovery of adenosine triphosphate, and myocardial water content were evaluated.

RESULTS

The group with leukocyte-depleted secondary blood cardioplegia showed the best hemodynamic recovery (Emax and total dp/dt), lowest levels of MDA, CK-MB and myocardial water content, and highest adenosine triphosphate recovery.

CONCLUSIONS

These results suggest that controlled reperfusion with leukocyte-depleted secondary blood cardioplegia attenuated severe damage of the myocardium as compared to whole blood reperfusion.

DSA-based perfusion parameters versus TICI score after mechanical thrombectomy in acute ischaemic stroke patients: a congruence analysis

BACKGROUND

Several factors are frequently considered for outcome prediction rin stroke patients. We assessed the value of digital subtraction angiography (DSA)-based brain perfusion measurements after mechanical thrombectomy (MT) for outcome prediction in acute ischaemic stroke.

METHODS

From DSA image data (n = 90; 38 females; age 73.3 ± 13.1 years [mean ± standard deviation]), time-contrast agent (CA) concentration curves were acquired, and maximum slope (MS), time to peak (TTP), and maximum CA concentration (CAmax) were calculated using an arterial input function. This data was used to predict neurological deficits at 24 h and upon discharge by using multiple regression analysis; the predictive capability was compared with the predictive power of the "Thrombolysis in cerebral infarction" (TICI) score. Intraclass correlation coefficients (ICC) of the NIHSS values were analysed.

RESULTS

The comparison of means revealed a linear trend after stratification into TICI classes for CAmax (TICI 0: 0.07 ± 0.02 a.u. to TICI 3: 0.22 ± 0.07 a.u.; p < 0.001), and for MS (TICI 0: 0.04 ± 0.01 a.u./s to TICI 3: 0.12 ± 0.0  a.u./s; p < 0.001). Regression analyses demonstrated equivalent capabilities for estimating neurological deficits after 24 h and at discharge using both the TICI score and DSA-based perfusion parameters (ΔR² ~ 0.03). Compared to the actual NIHSS, the ICC ranged from 0.55 to 0.84 for DSA-based models and from 0.6 to 0.82 for TICI-based models.

CONCLUSION

Semi-quantitative evaluation of DSA-based perfusion parameters prior to and after MT is feasible and could enhance the objectivity and comparability of MT outcome prediction. This technique may offer novel approaches in acute ischaemic stroke management and data comparability.

RELEVANCE STATEMENT

DSA-based brain perfusion measurements following interventional stroke therapy could allow for an experience-independent assessment of reperfusion success. It demonstrates predictive power at least equivalent to the established methods. This could support a future automated DSA-based brain perfusion measurement method.

KEY POINTS

Currently, the evaluation of stroke therapy success is based on the treating physician's experience. The present study introduces an objective semi-quantitative evaluation method. In predicting clinical outcomes, the traditional expert-based and semi-quantitative methods are equivalent.

Atypical adverse events in a real-world study of long-term immunomodulation for multiple sclerosis and neuromyelitis optica spectrum disorder

Background

Immunotherapies are integral in managing multiple sclerosis (MS) and related demyelinating diseases, but adverse drug reactions significantly affect the tolerability of disease-modifying therapies (DMTs).

Objectives

This study aims to assess the safety profile of DMTs within a real-world cohort affected by MS and related diseases and to identify atypical adverse events (AEs) and those of exceptional severity.

Methods

A retrospective analysis was conducted on 3850 patients with MS, neuromyelitis optica spectrum disorder (NMOSD), and related conditions (2009-2022). Demographic and clinical data were analyzed for patients treated with DMTs. Parameters included prior treatments, AEs, treatment durations, and reasons for discontinuation.

Results

Of the cohort, 1989 patients (71.1% female) with a median follow-up of 46.3 months during DMT use were included. Monotherapy was employed in 987 patients, while 1002 received sequential DMTs, totaling 3850 treatments. Adverse reactions led to discontinuation in 24.2% of cases, while disease progression accounted for 22.9%. Among 1878 AEs, 31 (1.7%) were atypical, and 59 (3.1%) were unusually severe, which was systematically categorized based on type, timing, and remission.

Conclusion

Within the confines of this real-world study, DMT administration emerged as generally well tolerated in MS, related demyelinating diseases and NMOSD. The identification of a limited number of atypical AEs, nevertheless, broadens the spectrum of potential complications associated with DMTs. Although weaker evidence for causal associations between drug exposure and observed AEs remains a limitation in observational studies without comparable control groups, this study underscores the value of real-world investigations in offering insights into the long-term safety of DMTs, particularly for rare events.

Cerebral vasculitis as clinical manifestation of neuroborreliosis: Pattern of vascular pathology and prognostic factors of outcome

BACKGROUND

Neuroborreliosis is a tick-borne condition that affects the central and/or peripheral nervous system. Cerebral infarction associated with neuroborreliosis-related vasculitis has been reported in only a handful of cases. Therefore, specific patterns of vascular pathology and prognostic outcome factors are still incompletely understood.

AIM

To determine the pattern of vascular pathology and prognostic outcome factors in patients with neuroborreliosis-related vasculitis.

METHODS

We performed a longitudinal multicenter study between 1997 and 2022 in five academic study sites in Germany with a cumulative reference area of 1,620,000 inhabitants. All patients diagnosed with neuroborreliosis-associated cerebral vasculitis were included. The evaluation of clinical parameters, including NIH Stroke Scale (NIHSS), disability ranking (modified Rankin Scale, mRS), and neuroimaging, was performed at admission as well as after 3 and 12 months. Linear regression analysis was used to identify the independent predictors of recurrent strokes, involvement of posterior circulation, or multiple vessels.

RESULTS

Patients with neuroborreliosis-related vasculitis (n = 51) were relatively young (mean age: 62 years) and displayed a predominance of vascular events within the posterior circulation (60.8%). A history of smoking was linked to recurrent strokes/TIA (64.7% vs. 23.5%; p = 0.006), strokes in multiple territories (100% vs. 35.9%; p < 0.0001), and posterior circulation events (64.5% vs. 30.0%, p = 0.017), whereas other cardiovascular risk factors showed no significant differences. Linear regression analysis corroborated smoking's association with recurrent strokes/ transient ischemic attacks (B: 0.412; p = 0.002), multiple territory strokes/TIA (B: 0.467; p = 0.033), and posterior circulation events (B: 0.317; p = 0.033).

CONCLUSION

A thorough CSF examination for neuroborreliosis is crucial, especially in younger stroke patients, particularly those experiencing posterior circulation ischemic events. Smoking cessation should be prompted in patients with neuroborreliosis-associated cerebral vasculitis.

Real world data in mechanical thrombectomy: who are we losing to follow-up?

BACKGROUND

Missing outcome data (MOD) is a common problem in clinical trials and registries, and a potential bias when drawing conclusions from these data. Identifying factors associated with MOD may help to increase follow-up rates and assess the need for imputation strategies. We investigated MOD in a multicenter, prospective registry study of mechanical thrombectomy (MT) in large vessel occlusion ischemic stroke.

METHODS

13 082 patients enrolled in the German Stroke Registry-Endovascular Treatment from May 2015 to December 2021 were analyzed with regard to MOD (90 day modified Rankin Scale, mRS). Univariate logistic regression analyses identified factors unbalanced between patients with and without MOD. Subgroup analyses were performed to identify patients for whom increased efforts to perform clinical follow-up after hospital discharge are needed.

RESULTS

We identified 19.7% (2580/13 082) of patients with MOD at the 90 day follow-up. MOD was more common with higher pre-stroke disability (mRS 3-5, 32.2% vs mRS 0-2, 13.7%; P<0.001), absence of bridging intravenous thrombolysis, longer time to treatment, and in patients with high post-stroke disability at discharge (mRS 3-5 vs 0-2: OR 1.234 (95% CI 1.107 to 1.375); P<0.001). In contrast, MOD was less common with futile recanalization (thrombolysis in cerebral infarction (TICI) score of 0-2a, 12.4% vs TICI 2b-3, 15.0%; P=0.001). In patients discharged alive with well documented baseline characteristics, shorter hospital stay (OR 0.992 (95% CI 0.985 to 0.998); P=0.010) and discharge to institutional care or hospital (OR 1.754 (95% CI 1.558 to 1.976); P<0.001) were associated with MOD.

CONCLUSION

MOD in routine care MT registry data was not random. Increased efforts to perform clinical follow-up are needed, especially in the case of higher pre-stroke and post-stroke disability and discharge to hospital or institutional care.

TRIAL REGISTRATION

NCT03356392.

Current management of acute leg ischaemia: results of an audit by the Vascular Surgical Society of Great Britain and Ireland

Experimental study of the effect of intraperitoneal heparin on tumour implantation following laparoscopy

P. Ziprin, M. Puttick, A. Darzi, Minimal Access Surgical Unit, Imperial College School of Medicine, St Mary's Hospital, London W2 INY, UK

Effect of training on the incidence of nerve damage in thyroid surgery

S. Sinha, Department of General Surgery, Arrowe Park Hospital, Wirral L49 5PE, UK

Current management of acute leg ischaemia: results of an audit by the Vascular Surgical Society of Great Britain and Ireland

S. Akgun, A. Civelek, S. İsbir, Department of Cardiovascular Surgery, Marmara University Hospital, Istanbul, Turkey

Author's reply

W. B. Campbell, Department of Surgery, Royal Devon and Exeter Hospital, Exeter EX2 5DW, UK

Leucocyte count and C-reactive protein in the diagnosis of acute appendicitis

J. V. Taylor, Department of Surgery, School of Medicine, University of Louisville, Kentucky 40292, USA

Author's reply

J. Grönroos, Department of Surgery, University of Turku, PB 52, FIN-20521 Turku, Finland

Interstitial laser coagulation for hepatic tumours

L. R. Jiao, Department of Surgery, Maidstone Hospital, Maidstone ME16 9QQ, UK and N. A. Habib, Liver Surgery Section, Hammersmith Hospital, Imperial College School of Medicine, London W12 0HS, UK

Author's reply

J. Heisterkamp, R. van Hillegersberg, J. N. M. Ijzermans, Department of Surgery, Erasmus University Rotterdam, University Hospital Rotterdam ‘Dijkzigt’, Rotterdam, The Netherlands.

Risk scoring in surgical patients

P. P. Tekkis, L. M. South, G. A. Trotter, Department of Surgery, Maidstone General Hospital, Maidstone ME16 9QQ and A. J. E. Bentley, R. M. Kocher, Queen Mary's Hospital, Sidcup DA14 6LT

Author's reply

H. J. S. Jones, L. de Cossart, Department of Surgery, Countess of Chester Hospital, Chester CH2 1UL, UK

Intraoperative lymphatic mapping and the sentinel node concept in colorectal carcinoma

M. R. S. Keshtgar, A. Amin, I. Taylor, Department of Surgery, Royal Free and University College Medical School, Charles Bell House, 67–73 Riding House Street, London W1P 7LD, UK

Author's reply

L. J. A. Strobbe, on behalf of the authors, Department of Surgery, C22, Canisius Wilhelmina Hospital, PO Box 9015, 6500 GS Nijmegen, The Netherlands

Randomized clinical trial of laparoscopic versus open inguinal hernia repair

D. S. Bhandarkar, Department of Surgery, Sir Hurkisondas Hospital, Prarthana Samaj, Mumbai 400 004, India

Letter 2

A. E. Kark, M. Kurzer, P. Belsham, British Hernia Centre, 87 Watford Way, Hendon, London NW4 4RS, UK

Author's reply

P. Juul, Department of Surgery, Nyborg Hospital, 5800 Nyborg, Denmark.