Effectiveness and safety of same day discharge after left atrial appendage closure under moderate conscious sedation

BACKGROUND

Left atrial appendage occlusion (LAAO) using Watchman device has become a world-wide, well-established therapeutic alternative to chronic systemic oral anticoagulation in patient who are at high-risk of bleeding with paroxysmal (PAF) or chronic atrial fibrillation (Afib). Currently, LAAO procedures are performed under general anesthesia (GA) and patients stay overnight post procedure in the United States. We aimed to present the effectiveness and safety of same day discharge following LAAO under moderate conscious sedation (MCS) in patients without procedural complications.

METHODS

A total of 112 patients between August 2019 and May 2020 with elevated CHA₂ DS₂ VASc (median score of 3) underwent transesophageal echocardiography (TEE)-guided LAAO with FDA approved Watchman (Boston Scientific, MN) under MCS and discharged home on the same day 6 hr following their post procedural transthoracic echocardiogram (TTE) evaluations. All patients had next day TTE and follow up at the cardiology clinic. We prospectively evaluated clinical and procedural outcomes using medical records of these patients.

RESULTS

Among all the patients, the mean age was 83.5 ± 8.5 years, 45 (40%) were women. Procedural duration, device implant time and fluoroscopic times were 45 ± 8.6, 14.5 ± 7.8 and 10.2 ± 1.2 min, respectively. The median required dosage of propofol was 105 ± 2.8 mg. No complications arose from MCS. There was no need for conversion to GA in any of the patients during the procedure. All patients were able to be discharged 6 hr following their TTE evaluation post procedure. There were no procedural complications.

CONCLUSIONS

Same day discharge following LAAO closure seems to be safe and effective in patients without procedural complications. LAAO can also be performed safely and effectively under moderate conscious sedation. Applying moderate conscious sedation may simplify the LAAO procedure, reduce procedural time, procedural costs and hospital stay while increasing overall patient satisfaction.

Feasibility of Same-Day Discharge Approach After Transcatheter Mitral Valve Repair Procedures

INTRODUCTION

Early discharge strategies are increasingly adopted after percutaneous cardiac interventions. However, there is a paucity of data on early discharge after transcatheter mitral valve repair (TMVRep) procedures. In this report, we aimed to present our data on same-day discharge after MitraClip (Abbott Structural) procedures.

METHODS

A total of 82 patients who underwent TMVRep and were discharged the same day were included in the study. Patients who underwent the procedure with moderate conscious anesthesia, and without periprocedural complications and a stable early course post procedure, were considered candidates for same-day discharge. A next-day follow-up exam at the cardiology clinic was scheduled for all patients for removal of the groin access figure-of-eight subcutaneous sutures and for echocardiographic examination.

RESULTS

Thirty-nine patients had primary mitral regurgitation (MR), while 43 patients had secondary MR. A mean of 1.4 ± 0.4 clips were implanted per patient (range, 1 to 2 clips). Postprocedural MR grade was 1+ or lower in 64 patients (63.6%) and 2+ in 38 patients (36.4%). All patients were evaluated in the office clinic the next day, and had no major complications.

CONCLUSION

Same-day discharge approach can be safely performed in selected patients after TMVRep procedures. However, further studies with larger sample sizes are needed.

Evaluation of Effectiveness and Safety of Left Atrial Appendage Closure Under Moderate Conscious Sedation

BACKGROUND

Left atrial appendage closure (LAAC) using the Watchman device has become a well-established, world-wide therapeutic alternative to oral anticoagulation in high-risk patients for bleeding with paroxysmal, persistent atrial fibrillation (Afib) or permanent Afib. Currently, in the United States, LAAC procedures are performed under general anesthesia (GA). We present the feasibility, effectiveness, and safety of LAAC under moderate conscious sedation (MCS).

METHODS

A total of 112 patients with elevated CHA2DS22VASc (median score of 3) between November 2018 and November 2019 underwent transesophageal echocardiography (TEE)-guided LAAC with the FDA-approved Watchman LAAC device (Boston Scientific) under MCS. We prospectively evaluated clinical and procedural outcomes using medical records of these patients.

RESULTS

Mean patient age was 73.5 ± 4.5 years and 45 (40%) were women. Procedural duration, device implant time, and fluoroscopic times were 45 ± 8.6 minutes, 14.5 ± 2.8 minutes, and 10.2 ± 1.2 minutes, respectively. The median required dosage of propofol was 101 ± 2.8 mg. No complications were observed from MCS. There was no need for conversion to GA in any of the patients during the procedure.

CONCLUSIONS

LAAC is safe and effective when performed under MCS. Thus, applying MCS may simplify the LAAC procedure, as well as reduce procedural time and procedural costs, while increasing overall patient satisfaction.

Evaluation of Effectiveness and Safety of Transcatheter Mitral Valve Repair Under Moderate Conscious Sedation

BACKGROUND

Transcatheter mitral valve repair (TMVR) using the MitraClip system (Abbott Vascular) has become a world-wide, well-established therapeutic alternative to symptomatic patients with severe mitral regurgitation (MR) and prohibitive surgical risk. Currently, TMVRs are performed under general anesthesia. Herein, we aimed to present the effectiveness and safety of TMVR under moderate conscious sedation (MCS).

METHODS

A total of 102 patients with severe MR (49 primary MRs and 53 secondary MRs) who underwent TMVR with MCS between December 2018 and December 2019 were included. We prospectively evaluated clinical and procedural outcomes using medical records of these patients.

RESULTS

Among all the patients, the mean age was 81.6 ± 3.5 years, 60 (59%) were women, and 72.7% had coronary artery disease. The mean left ventricular ejection fraction was 47.9 ± 12.7%, while the MR grade was 3+ in 18.2% of the patients and 4+ in 81.8%. A mean of 1.2 ± 0.4 clips (range, 1-2 clips) were implanted per patient. Postprocedural MR grade was 1+ or lower in 64 patients (63.6%) and 2+ in 38 patients (36.4%). Procedural duration, clip implant time, and fluoroscopy times were 60 ± 10.5 minutes, 19.5 ± 8.0 minutes, and 10.1 ± 2.1 minutes, respectively. The median required dosage of propofol was 140 mg (interquartile range, 84-156 mg). No complications arose from MCS. There was no need for conversion to general anesthesia in any of these patients during the procedure.

CONCLUSIONS

TMVR can be performed safely and effectively under moderate conscious sedation. Applying moderate conscious sedation may simplify the TMVR procedure and reduce procedural time and costs, while increasing overall patient satisfaction.

Assessment of Vascular Patency and Inflammation with Intravascular Optical Coherence Tomography in Patients with Superficial Femoral Artery Disease Treated with Zilver PTX Stents

PURPOSE

Zilver PTX nitinol self-expanding drug-eluting stent with paclitaxel coating is effective for treatment of superficial femoral artery (SFA) disease. However, as with any stent, it induces a measure of vascular inflammatory response. The current clinical trial (NCT02734836) aimed to assess vascular patency, remodeling, and inflammatory markers with intravascular optical coherence tomography (OCT) in patients with SFA disease treated with Zilver PTX stents.

METHODS

Serial OCT examinations were performed in 13 patients at baseline and 12-month follow-up. Variables evaluated included neointimal area, luminal narrowing, thrombus area, stent expansion as well as measures of inflammation including, peri-strut low-intensity area (PLIA), macrophage arc, neovascularization, stent strut apposition and coverage.

RESULTS

Percentage of malapposed struts decreased from 10.3 ± 7.9% post-intervention to 1.1 ± 2.2% at 12-month follow-up, but one patient showed late-acquired stent malapposition (LASM). The percent of uncovered struts at follow-up was 3.0 ± 4.5%. Average expansion of stent cross-sectional area from baseline to follow-up was 35 ± 19%. The average neointimal area was 7.8 ± 3.8 mm². Maximal luminal narrowing was 61.1 ± 25.0%, and average luminal narrowing was 35.4 ± 18.2%. Average peri-strut low-intensity area (PLIA) per strut was 0.017 ± 0.018 mm². Average number of neovessels per mm of stent was 0.138 ± 0.181. Average macrophage angle per frame at follow-up was 7 ± 11°. Average thrombus area at follow-up was 0.0093 ± 0.0184 mm².

CONCLUSION

At 12-month follow-up, OCT analysis of Zilver PTX stent shows outward remodeling and minimal neointimal growth, but evidence of inflammation including PLIA, neovessels, thrombus and macrophages.

SUMMARY

Thirteen patients with PAD had paclitaxel-coated stents implanted in their SFAs and were then imaged with OCT at baseline and 12-month follow-up. OCT proxy metrics of inflammation were quantified.

The ovarian cancers in geriatric population: the validity of inflammatory markers, malignancy risk indices 1, 2, 3, 4, and CA-125 levels in malignancy discrimination of adnexal masses

PURPOSE

To investigate the predictive value of the Risk of Malignancy Index (RMI), CA-125, and inflammatory markers in discriminating ovarian cancers (OCs).

MATERIALS AND METHODS

The postmenopausal (PM) women (n= 139) with adnexal masses who un- derwent surgery were included. The predictive value of CA-125, RMI (1, 2,3, and 4) and inflammatory markers [neutrophil lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR)] were calculated in geriatric (G) and non-geriatric women.

RESULTS

OCs had significantly increased NLR and PLR. RMI models were highly reliable in PM (Kappa: 0.642-0.715; AUC: 0.907-0.934). CA-125 measurement alone had good accuracy and moderate reliability in PM (kappa: 0.507-0.587), excellent accuracy and moderate reliability in G, NLR, and PLR predicting OCs, showed fair agreement in the PM, while PLR had a moderate agreement with G.

CONCLUSION

RMI algorithms were the best models for malignancy prediction. However, the rise of PLR and CA-125 levels in a G population may be used as refer- ring adnexal masses to gynecologic oncologists.

Specific immunotherapy improves asthma related quality of life in childhood

BACKGROUND

Asthma is the most common chronic illness in childhood and really affects the everyday life of patients who suffer from it. Since asthma is a common disease, there is a great endeavour to achieve the most appropriate treatment option. Despite inhaled corticosteroids and leukotrien receptor antagonists both being routinely used in asthma treatment, specific immunotherapy is still questioned. There are numerous aspects affecting asthma-related quality of life, such as age; seasons; disease control and severity etc, which are well studied -apart from the type of treatment. With this study we aimed to stress the influence of asthma treatment on quality of life.

METHODS

A total of 102 children, aged 6-18 years, were assigned to classic asthma therapy (n=50) and specific immunotherapy (n=52). The quality of life is assessed using the Standardized Pediatric Asthma Quality of Life Questionnaire (PAQLQ) interviewer-administered Turkish version. Pulmonary function testing was performed on the same day, after the questionnaire was completed.

RESULTS

The PAQLQ total scores were significantly higher in the specific immunotherapy group (p<0.001). Apart from emotional function domain scores; symptoms domain and activity limitation domain scores were higher in the specific immunotherapy group. Emotional function domain scores were similar in the two groups (p>0.05). There were no statistically significant differences in pulmonary function testing results between the two groups (p>0.05). There was a linear correlation between FEV1%, FVC level and total and domain scores of PAQLQ with Spearman Correlation tests.

The subclinical incidence of CTS in pregnancy: Assessment of median nerve impairment in asymptomatic pregnant women

PURPOSE

The true incidence of pregnancy related carpal tunnel syndrome (PRCTS) is unknown. Most of the diagnoses of PRCTS are made based only on clinical symptoms. Here, we report a prospective controlled clinical trial assessing the electrophysiological changes in pregnant women to provide objective measure of the median nerve function.

METHODS

Pregnant women in the third trimester (n=69) and age-matched non-pregnant women (n=40) asymptomatic for CTS were included in the study. Nerve conduction studies of the median and ulnar nerves across the carpal tunnel were bilaterally performed with the standard techniques.

RESULTS

All the median sensory nerve conduction studies (amplitude, latency and velocity) performed from the ring finger and palmar region to wrist showed significant prolongation of median nerve conduction in the pregnant women compared with the control group (*p</=0.05). Median sensory nerve latencies from palmar branches to wrist were significantly longer in the pregnant group (**p<0.01). Sensory nerve action potential amplitudes recorded in the palmar region were smaller in the pregnant women (45.1AmicroV) than in the control group (56.5AmicroV). Ulnar motor and sensory conduction studies showed no significant difference between the pregnant women and the control group. According to the mean values of median nerve conduction velocity, 8 (11%) pregnant women were electrophysiologically diagnosed as CTS and four of these cases became symptomatic later during pregnancy or after delivery.

CONCLUSIONS

Median nerve impairment occurs even in asymptomatic pregnant women. The electrophysiological characteristics of this impairment are defined and the pathophysiology of PRCTS is discussed. Electrophysiological evaluation is a tolerable and feasible technique for the early diagnosis of PRCTS.

Giant axonal neuropathy: clinical and genetic study in six cases

BACKGROUND

Giant axonal neuropathy (GAN) is a severe recessive disorder characterised by variable combination of progressive sensory motor neuropathy, central nervous system (CNS) involvement, and "frizzly" hair. The disease is caused by GAN gene mutations on chromosome 16q24.1.

AIMS

To search for GAN gene mutations in Turkish patients with GAN and characterise the phenotype associated with them.

METHODS

Linkage and mutation analyses were performed in six affected patients from three consanguineous families. These patients were also investigated by cranial magnetic resonance imaging (MRI) and electroencephalography (EEG). Electromyography (EMG) was performed in heterozygous carriers from family 1 and family 3.

RESULTS

Linkage to 16q24.1 was confirmed by haplotype analysis. GAN mutations were identified in all families. Family 1 had the R293X mutation, previously reported in another Turkish family. Families 2 and 3, originating from close geographical areas, shared a novel mutation, 1502+1G>T, at the donor splice site of exon 9. All patients displayed a common phenotype, including peripheral neuropathy, cerebellar ataxia, and frizzly hair. Cranial MRI showed diffuse white matter abnormalities in two patients from family 1 and the patient from family 3, and minimal white matter involvement in the patient from family 2. EMG of a heterozygous R293X mutation carrier showed signs of mild axonal neuropathy, whereas a 1502+1G>T mutation carrier had normal EMG. EEG abnormalities were found in three patients.

CONCLUSION

These findings highlight the association of CNS involvement, in particular white matter abnormalities, with peripheral neuropathy in GAN. The phenotypical consequences of both mutations (when homozygous) were similar.

Acute disseminated encephalomyelitis in children: outcome and prognosis

BACKGROUND

Acute disseminated encephalomyelitis (ADEM) is the most common demyelinating disorder of childhood. Its clinical features, prognosis and treatment vary in different reports.

OBJECTIVES

To examine a series of children with ADEM for clinical findings, course, recurrences, and possible variables affecting outcome.

METHODS

Multicentric data collected from 7 tertiary referral centers were registered and evaluated in a central database in 1990 - 2001 for clinical, laboratory, and MRI features. Course and prognosis were assessed in patients with at least 12 months' follow-up.

RESULTS

Forty-six patients were evaluated. Median age at onset was 8 years, M/F ratio, 1.7/1. Most common symptoms and signs pertained to the motor system and consciousness. Of 39 children with 12 months' follow-up, 71 % recovered completely. Thirteen (33 %) children had relapses. Patients who had more than one relapse (n = 4) presented with new symptoms at each attack. Treatment with high-dose methylprednisolone was associated with complete recovery, and tapering over more than 3 weeks, with a lower rate of relapses. MRI lesions could persist even in asymptomatic patients; in particular, periventricular lesions tended to disappear later than others.

CONCLUSIONS

Complete clinical recovery is common and serious complications are rare in childhood ADEM, but the rate of relapses is considerable. Clinical picture at first relapse may help to identify patients likely to experience multiple relapses. The timing and duration of steroid treatment affects outcome.

Action and imagination in the formation of images

This study examined the influence of motor enactment on the formation of mental images. Following a procedure originally used by Piaget and Inhelder in 1971, 5-yr.-old children were assigned to one of four treatments. They visually examined block configurations, imagined the construction of the configurations, imagined enacting the construction, or carried out the actual construction. When the original configurations were removed, the children were asked to reconstruct them from memory. Analysis showed that the children in the imaginary enactment and actual construction conditions were more accurate than those in the other conditions. The findings are discussed as supporting an action-based understanding of imagination.

Megalencephaly and leukodystrophy with mild clinical course: a report on 12 new cases

Twelve patients with early infancy onset megalencephaly and leukodystrophy with a mild clinical course are reported. The neuroradiological, clinical, and genetic aspects of this recently recognized familial leukodystrophy syndrome were reviewed. Five were affected siblings, and all patients had consanguineous parents. Macrocephaly, a slowly progressive delay in motor development and mild mental deterioration constitute the clinical triad of the disease, showing characteristic age-related onset. The clinical findings outlined remarkably slight functional deterioration despite severe lesions on magnetic resonance imaging (MRI), especially in the initial period. Characteristically, mental function is preserved for years after onset of the motor deficit. The MRI lesions do not reflect the progress of disease. The disease probably has an autosomal recessive mode of inheritance even though no metabolic defect has been detected to date. In a more severe variant of the mentioned disease, there is more progressive and severe neurological dysfunction, including ataxia and spastic quadriparesis, leading to an inability to walk independently after 10 years of age. In mild variants, however, disease severity varies from macrocephaly with near-normal pyschomotor development to mild motor and/or mental dysfunction. Seizures were observed in both types but response to drugs was good. The 12 patients reported here confirm the specific and distinguishing clinical and radiological features of the previously reported 51 cases with this new syndrome, while adding some information regarding identification of the disease.

Bilateral cavernous carotid artery aneurysms in a 4-year-old child: endovascular treatment with mechanically detachable coils

We present a 4-year-old child who suffered bilateral third nerve palsies secondary to bilateral giant saccular cavernous carotid artery aneurysms. Endovascular treatment was performed by means of direct endosaccular aneurysm occlusion on the right side and parent vessel occlusion on the left, using mechanically detachable coils. No complication occurred during or after the procedure. The bilateral third nerve palsies resolved over 3 months. Follow-up angiography at 1 year is presented.

The relationship between anxiety and problem-solving skills in children with and without learning disabilities

This study compared the effects of low, medium, and high pretest anxiety levels on the social and nonsocial problem-solving performance of 45 boys with learning disabilities (LD) and 45 boys with no learning disabilities (NLD). Participants ranged from 9 to 11 years of age. Boys with LD reported significantly higher pretest trait and state anxiety on the State-Trait Anxiety Inventory for Children than did NLD boys, and their perceived state anxiety escalated over the course of the problem-solving session. There were no pervasive effects of LD status on problem solving by itself, boys with LD being as effective in problem solving as NLD boys. However, means for task solution suggest a tendency for an interaction between group and anxiety level, which should be examined using a larger, well-defined sample and an unstructured task.

Body-image distortion and mental imagery

This study explored whether body-image distortion is a function of difficulties with imagery or problems with judgment. 49 subjects were given the Modified Video Camera Technique to measure body-image distortion. Mental imagery was measured by a modified version of the Vividness of Visual Imagery Questionnaire and the Spatial Relations subtest of the Woodcock-Johnson Psycho-educational Battery. Visual recall was assessed on the Meier Art Judgment Test. Judgment bias was assessed by the Stunkard Silhouette Method and the shape and weight subscales of the Eating Disorder Examination. Subjects who distorted body-image scored significantly more poorly on mental imagery than those who did not distort. No differences were found between groups on visual memory recall or in judgment bias.

Effects of discrimination training on reading improvement among adults

This study examined the effects of discrimination training on improving reading skills for young adults. 90 college students (M age = 26.2 yr.), who were identified as low achievers with below average reading skills, were randomly assigned to one of three training conditions: the General Discrimination Group, the Reading Discrimination Group, and the Study Skills Group. Following 10 days of training, the subjects were tested on a standard reading achievement test, a problem-solving test, and a measure of cognitive style. Minimal differences between the pre- and posttraining scores for all three training conditions were noted. These findings contrast with developmental research that has indicated the importance of discrimination ability and suggest distinctive problems of adults with poor reading skills.