Comparison of survival by allocation to medical therapy, surgery, or heart transplantation for ischemic advanced heart failure.

BACKGROUND: To ascertain survival of ischemic advanced heart failure patients by treatment allocation, we examined the outcome of transplant assessment patients allocated to medical therapy, high-risk conventional surgery, or transplantation. METHODS: Patients were identified from the Papworth transplant database and excluded if primary etiology was not ischemic. Grouping was undertaken according to treatment allocation at initial assessment, and analysis was performed by intention to treat. Survival was computed from the time of assessment and Cox regression used to stratify patients according risk with the Heart Failure Survival Score. RESULTS: From May 1993 to September 2001, a total of 755 patients were admitted for transplant assessment, with 348 (46.1%) identified as having heart failure of ischemic origin. Variables required for calculation of the Heart Failure Survival Score was available in 273 patients (78.4%), and 20 patients (7.3%) were lost to follow-up. Of the remaining 253 patients, 89 (35.2%) were allocated to medical therapy, 32 (12.6%) to surgery, and 132 (52.2%) to transplantation. The relative risk (95% confidence limit) of death compared with medical therapy was 0.62 (0.28, 1.40) for surgery and 0.38 (0.24, 0.61) for transplantation in medium- to high-risk patients. For low-risk patients, the relative risks for death compared with medical therapy were 1.87 (0.63, 5.60) for surgery and 1.97 (0.79, 4.96) for transplantation. CONCLUSIONS: Transplantation improved survival of medium- and high-risk patients compared with medical therapy. In the low-risk group, this was not evident. However, repeated assessment of risk is required because the hazard for death rises steadily after the third year in these patients.     

Expression of cyclin D1 in normal, metaplastic, hyperplastic endometrium and endometrioid carcinoma suggests a role in endometrial carcinogenesis

CONTEXT: Endometrioid carcinoma is often preceded by characteristic histopathologic lesions known as endometrial hyperplasia. Estrogen appears to be involved in the development of endometrioid carcinoma. Other mechanisms of endometrial carcinogenesis include mutations in p53 and PTEN tumor suppressor genes and overexpression of cyclin D1. However, the pattern of cyclin D1 expression is not well defined in normal, hyperplastic, neoplastic, and metaplastic endometrium. DESIGN: Cyclin D1 immunohistochemical analysis was used to evaluate 108 fixed, paraffin-embedded endometrial biopsy specimens and uterine resections obtained from 108 patients. Specimens included proliferative and secretory endometria, simple and complex hyperplastic lesions, and endometrioid adenocarcinoma. Normal and metaplastic surface epithelia were also evaluated independently of glandular morphologic features. RESULTS: Cyclin D1 was significantly overexpressed in glands with complex hyperplasia and endometrioid adenocarcinoma compared with proliferative or secretory endometrium and simple hyperplasia. Significant overexpression was also noted in papillary, syncytial, and squamous metaplasias compared with normal surface epithelium or epithelium with tubal metaplasia. CONCLUSION: Overexpression of cyclin D1 increases from normal endometrium to hyperplasia and carcinoma, suggesting that it may play a role in endometrial carcinogenesis. Overexpression of cyclin D1 in endometrial glands was independent from overexpression of cyclin D1 in surface metaplastic epithelium.     

ASC:SIL ratio following implementation of the 2001 Bethesda System

The 2001 Bethesda system (TBS 2001) eliminated the "satisfactory but limited by" category, benign cellular changes (BCC), and the designations "favor benign" (ASC-B) and "favor low grade" (ASC-L) for atypical squamous cells. We compared the unsatisfactory rate and atypical squamous cells:squamous intraepithelial lesions (ASC:SIL) ratio pre- and postimplementation of TBS 2001 to see if there was an increase in unsatisfactory specimens, ASC rate, and altered ASC:SIL ratio. Pap Tests (569,726) reviewed at the Cytopathology Laboratory of Women and Infants Hospital from 1998-2002 were included. TBS 1991 terminology was used through December 31, 2001. Conversion to TBS 2001 took place on January 1, 2002. The average ASC:SIL ratios pre- and postimplementation of TBS 2001 were 1.52:1 and 1.42:1, respectively. The rates of unsatisfactory specimens and ASC remained unchanged. Conversion to TBS 2001 did not adversely affect the ASC:SIL ratio or the detection rates of abnormalities of Pap tests.     

Re-do aortic valve replacement: does a previous homograft influence the operative outcome?

BACKGROUND AND AIM OF THE STUDY: Late reoperation for failed aortic homograft is widely regarded as a high-risk procedure. A review is presented of the authors' experience of redo-aortic valve replacement (re-do AVR) examining factors which affect, and whether a previous aortic homograft replacement influences, operative outcome. METHODS: A retrospective review was conducted of consecutive re-do AVR performed at the authors' institution between 1998 and 2002. RESULTS: During the study period, 178 patients (125 males, 53 females; mean age 52.4 years; range: 16-85 years) underwent re-do AVR. The group included first-time (72%), second-time (20%), and more than third-time re-do AVR (8%). Forty-six patients (26%) received a homograft (group I), and 132 (74%) a stented biological/mechanical valve (group II). The two groups were matched for baseline clinical characteristics and operative variables. The type of explanted valve, and preoperative and operative variables, were analyzed using univariate and multivariate models. Primary outcome was defined as 30-day mortality, and secondary outcome as postoperative complications. The overall 30-day mortality was 12.3%, but was much lower (4.5%) for elective isolated and multiple re-do AVR. Univariate analysis showed significant predictors of 30-day mortality to be: age >65 years (p = 0.02); renal dysfunction (p = 0.005); preoperative unstable status (p = 0.03); preoperative NYHA class III/IV dyspnea (p = 0.02); non-elective operation (p = 0.01); preoperative arrhythmia (p = 0.005); history of chronic obstructive pulmonary disease (COPD) (p = 0.002); preoperative cardiogenic shock (p = 0.03); impaired left ventricular ejection fraction (LVEF) <50% (p = 0.04); and other valvular procedure(s) performed simultaneously (p = 0.01). In a multivariate analysis, the only significant predictors of 30-day mortality were impaired LVEF (p = 0.03) and a history of COPD (p = 0.007). Group I patients had a significantly shorter mean hospital stay (10.2+/-5.9 versus 14.1+/-12.5 days; p = 0.009), but there were no significant differences between groups in terms of postoperative complications. CONCLUSION: A previous aortic homograft replacement was not associated with an increased operative risk at the time of re-do AVR. A history was COPD was an important predictor of 30-day mortality, and this finding requires further investigation.     

A versatile technique for aortic root replacement without pre-manufactured composite graft: a 12-year experience

BACKGROUND AND AIM OF THE STUDY: Replacement of the aortic root is the treatment of choice for aneurysmal dilatation. Many modifications of the Bentall technique have been described, as have valve-sparing procedures. The study aim was to determine the outcome of a versatile modification of composite replacement that has been adopted over the past 12 years. Separate graft and prosthetic valve components were used to allow freedom of valve choice and the use of an appropriately sized graft for the distal aortic anastomosis. METHODS: Between January 1990 and March 2002, 59 patients (45 males, 14 females; mean age 56 +/- 14 years) underwent aortic root replacement using this technique. Indications for surgery were elective in 35 patients and emergent (usually type A aortic dissection) in 24. The range of valve prostheses used, their size, and the size of aortic graft used in each case was assessed. Durations of ischemia and cardiopulmonary bypass were recorded, as was postoperative blood loss and subsequent patient progress, including valve-related events, perioperative mortality and actuarial survival. RESULTS: A wide range of aortic graft sizes was combined with both mechanical and tissue valves (from 1-7 mm larger in diameter). Median postoperative blood loss was 550 ml (IQR 400-800 ml). Perioperative mortality was 5.1%. There were no valve- or technique-related deaths, and the median actuarial survival was 13.17 years. During a 12-year follow up there were no proximal aortic reoperations. CONCLUSIONS: This technique had favorable perioperative mortality, produced a secure proximal suture line, and allowed the surgeon free choice of both valve type and size of aortic graft. This minimized tension at the distal suture line, and produced good hemostasis, especially in those patients with fragile dissected tissues.