Clinical features and mutation of NPHP5 in two Chinese siblings with Senior‐Løken syndrome

Senior‐Løken syndrome is a rare syndromic form of nephronophthisis that is associated with retinal dystrophy. Presently, seven genes (NPHP1‐6 and NPHP10) have been associated with Senior‐Løken syndrome. NPHP5 mutations are known to cause classical Senior‐Løken syndrome. Here, we report two sisters (II‐4, II‐5) from a Chinese Han ethnic family who presented with classical Senior‐Løken syndrome. Both affected sisters exhibited Leber's congenital amaurosis and juvenile nephronophthisis that progressed to end‐stage renal disease by the age of 16 years and 9 months in patient II‐4 and 12 years and 9 months in patient II‐5. Sequence analysis showed a homozygous truncated mutation in NPHP5, c.1090C>T (p.R364X), in the patient II‐4. This mutation is predicted to introduce a new open reading frame that results in the truncation of the C‐terminal 235 amino acids of nephrocystin‐5 and its consequent loss of function. Both parents carried a single heterozygous mutation in the same position, and no homozygous deletion of NPHP1 was found in this pedigree.     

Patient satisfaction with a rapid diagnosis of suspicious breast lesions: Association with distress and anxiety

Few studies have explored with standard measures patient satisfaction with care at the time of the diagnosis through rapid diagnostic pathways. This study aimed to assess satisfaction levels at the time of the diagnosis in a One‐Stop Breast Unit and to examine associations with psychological states. An anonymous cross‐sectional survey was conducted at a single center's One‐Stop Breast Unit, to assess patient satisfaction regarding several aspects of the Unit. Two days after the diagnosis, 113 participants completed self‐reported questionnaires evaluating satisfaction (Out‐Patsat35), anxiety (State Anxiety Inventory), and psychological distress (Distress Thermometer). Overall, patients were very satisfied (80.7±20.7) with the One‐Stop Breast Unit. The highest mean satisfaction scores concerned nurses' technical skills, interpersonal skills and availability. The lowest mean scores concerned physicians' availability, waiting time, and the provision of information. The results revealed a significant association between high state anxiety levels, lower levels of satisfaction with doctors' interpersonal skills (r =?.41, P <.001) and lower levels for information provided by nurses (r =?.38, P <.001). Moreover, greater psychological distress was associated with less satisfaction with the different aspects of care (doctors' interpersonal skills, doctors' availability and waiting‐time). The results of regression models showed that doctor‐related satisfaction scales explained 20% of the variance in anxiety (P <.01). Facing cancer diagnosis remains a stressful situation. However, our study suggested that a substantial part of this anxiety is sensitive to the quality of the patient‐doctor relationship. Consequently, further efforts should be expended on adapting patient‐doctor communication to improve patient reassurance.     

Hemodynamic Evaluation of a Biological and Mechanical Aortic Valve Prosthesis Using Patient‐Specific MRI‐Based CFD

Modeling different treatment options before a procedure is performed is a promising approach for surgical decision making and patient care in heart valve disease. This study investigated the hemodynamic impact of different prostheses through patient‐specific MRI‐based CFD simulations. Ten time‐resolved MRI data sets with and without velocity encoding were obtained to reconstruct the aorta and set hemodynamic boundary conditions for simulations. Aortic hemodynamics after virtual valve replacement with a biological and mechanical valve prosthesis were investigated. Wall shear stress (WSS), secondary flow degree (SFD), transvalvular pressure drop (TPD), turbulent kinetic energy (TKE), and normalized flow displacement (NFD) were evaluated to characterize valve‐induced hemodynamics. The biological prostheses induced significantly higher WSS (medians: 9.3 vs. 8.6 Pa, P = 0.027) and SFD (means: 0.78 vs. 0.49, P = 0.002) in the ascending aorta, TPD (medians: 11.4 vs. 2.7 mm Hg, P = 0.002), TKE (means: 400 vs. 283 cm²/s², P = 0.037), and NFD (means: 0.0994 vs. 0.0607, P = 0.020) than the mechanical prostheses. The differences between the prosthesis types showed great inter‐patient variability, however. Given this variability, a patient‐specific evaluation is warranted. In conclusion, MRI‐based CFD offers an opportunity to assess the interactions between prosthesis and patient‐specific boundary conditions, which may help in optimizing surgical decision making and providing additional guidance to clinicians.     

De Novo Donor HLA‐Specific Antibodies after Heart Transplantation Are an Independent Predictor of Poor Patient Survival

Preformed donor HLA‐specific antibodies are a known indicator for poor patient survival after cardiac transplantation. The role of de novo donor‐specific antibodies (DSA) formed after cardiac transplantation is less clear. Here we have retrospectively analyzed 243 cardiac transplant recipients, measuring HLA antibody production every year after transplantation up to 13 years post‐transplant. Production of de novo DSA was analyzed in patients who had been negative for DSA prior to their transplant. DSA including transient antibodies were associated with poor patient survival (p = 0.0018, HR = 3.198). However, de novo and persistent DSA was strongly associated with poor patient survival (p = 0.0001 HR = 4.351). Although complement fixing persistent DSA correlated with poor patient survival, this was not increased compared to noncomplement fixing persistent DSA. Multivariable analysis indicated de novo persistent DSA to be an independent predictor of poor patient survival along with HLA‐DR mismatch and donor age. Only increasing donor age was found to be an independent risk factor for earlier development of CAV. In conclusion, patients who are transplanted in the absence of pre‐existing DSA make de novo DSA after transplantation which are associated with poor survival. Early and regular monitoring of post‐transplant DSA is required to identify patients at risk of allograft failure.     

Comparison of the prognostic value of tumour‐ and patient‐related factors in patients undergoing potentially curative surgery for colon cancer

Aim To comprehensively compare the prognostic value of tumour‐ and patient‐related factors in patients undergoing curative surgery for colon cancer. Method From a database of 287 patients who underwent elective resection between 1997 and 2005, tumour factors including stage and host factors including systemic inflammatory response [modified Glasgow Prognostic Score (mGPS)] were identified. Results Median follow‐up was 65 months. Over this period, 125 patients died, 80 from cancer. On multivariate analysis of all significant patient and tumour related factors, Dukes stage (P < 0.01), vascular invasion (P < 0.01) and the mGPS (P < 0.01) were independently associated with cancer‐survival. Of the patient‐related factors, age (P < 0.01), haemoglobin (P < 0.01), white‐cell (P < 0.01), neutrophil (P < 0.01) and platelet (P < 0.01) counts, and alkaline phosphatase (P < 0.01) were most significantly associated with the mGPS. Conclusion In addition to tumour‐related factors such as Dukes stage and vascular invasion, the preoperative mGPS should be included to guide prognosis in patients undergoing curative resection for colon cancer.     

Surgical management of right aortic arch with tailored surgical approach

Abstract Background and Aim of Study: Right‐sided aortic arch is a rare congenital anomaly for which different surgical approaches have been reported. This study reviewed our experience with several techniques. Methods: We retrospectively reviewed 17 patients undergoing right‐sided arch repair at the Cleveland Clinic from 2001 to 2010. Computed tomographic angiograms of the aorta and its branches were reviewed and correlated with patient presentation and surgical approach. Results: Fourteen patients had type II right aortic arch with aberrant left subclavian artery. Fifteen patients presented with obstructive symptoms. Surgical approach included right thoracotomy (11 patients), left thoracotomy (two patients), full sternotomy (one patient), and hybrid repair (three patients). Cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest was used in 11 patients, and two patients had partial CPB. Left subclavian artery bypass was performed in seven patients. Median duration of intubation was 1.9 days. Average length of intensive care unit stay was three days and average hospital stay 11 days. Postoperative outcomes included respiratory failure (one patient), renal failure (one patient), bloodstream infection (two patients), and death (one patient). No patient had stroke or paraplegia. In‐hospital death occurred in one patient, and all survivors were alive and asymptomatic for a mean of 38 months. Conclusion: The s urgical treatment for right‐sided aortic arch can be performed with excellent perioperative outcomes when tailored to patient presentation and anatomic configuration. Patients with obstructive symptoms benefit from open or hybrid surgical treatment, with immediate relief of compression. Patients with aneurysmal dilatation without compression symptoms can be managed with open, endovascular, or hybrid surgical intervention. (J Card Surg 2012;27:511‐517)     

Inferior graft survival of hepatitis B core positive grafts is not influenced by post‐transplant hepatitis B infection in liver recipients—A 35‐year single‐center experience

Nonoptimal liver grafts, and among them organs from anti‐HBc+ donors, are increasingly used for liver transplantation. In this retrospective study including 1065 adult liver transplantations performed between 1977 and 2012, we analyzed long‐term patient and graft survival and occurrence of HBV infection. A total of 52 (5.1%) patients received an anti‐HBc+ graft. The 10‐year graft and patient survival of these recipients were 50.9% and 59.0% compared to 72.0% and 76.5% (P = 0.001; P = 0.004) of patients receiving anti‐HBc‐ grafts, respectively. Cox regression model showed that high urgency allocation (P = 0.003), recipient age (P = 0.027), anti‐HCV+ recipients (P = 0.005), and anti‐HBc+ organs (P = 0.048) are associated with decreased graft survival. Thirteen of 52 (25.0%) patients receiving anti‐HBc+ grafts developed post‐transplant HBV infection within a mean of 2.8 years. In this study, antiviral prophylaxis did not have significant impact on HBV infection, but long‐term survival (P = 0.008). Development of post‐transplant HBV infection did not affect adjusted 10‐year graft survival (100% vs. 100%; P = 1). Anti‐HBc+ liver grafts can be transplanted with reasonable but inferior long‐term patient and graft survival. The inferior graft survival is not, however, related with post‐transplant HBV infection as long as early diagnosis and treatment take place.     

Symptom severity and patient perceptions in overactive bladder: how are they related?

OBJECTIVE

To assess the relationship between symptom severity and patient perceptions in patients with overactive bladder (OAB), as estimated by OAB Symptom Score (OABSS) and patient‐reported outcome measures, respectively.

PATIENTS AND METHODS

Post‐hoc analyses were conducted on the existing data from patients with OAB. In addition to the OABSS, patients completed three patient‐reported outcome measures, the OAB questionnaire (OAB‐q), Patient Perception of Bladder Condition (PPBC) and Medical Outcomes Study Short‐Form 36 (SF‐36). Relationships of the OABSS were assessed through correlations with the OAB‐q, PPBC and SF‐36; all analyses were exploratory.

RESULTS

In all, 194 participants were analysed; the OABSS correlated relatively closely with the PPBC and OAB‐q subscales of health‐related quality of life (r = 0.36–0.57). There was a particularly good correlation with the OAB‐q symptom bother (r = 0.73). However, the OABSS correlated somewhat less with the SF‐36 subscales (r = 0.16–0.27). There were fairly close correlations between the OABSS and the OAB‐q items; for daytime frequency with ‘frequency of urination during daytime hours’ (r = 0.44); night‐time frequency with ‘night‐time urination’ (r = 0.44), ‘waking up at night because you had to urinate’ (r = 0.51) and ‘awakening from sleep’ (r = 0.44); urgency with ‘a sudden urge to urinate with little or no warning’ (r = 0.65) and ‘an uncontrollable urge to urinate’ (r = 0.69), urgency incontinence with ‘accidental loss of small amounts of urine’ (r = 0.74) and ‘urine loss associated with a strong desire to urinate’ (r = 0.79). All the items except ‘awakening from sleep’ belonged to the OAB‐q symptom bother domain.

CONCLUSIONS

It is possible to roughly but sufficiently infer patient perceptions of bladder condition and symptom bother by measuring symptom severity, as estimated by the OABSS.     

Transesophageal Echocardiographic Guidance of Percardiac Device Closure of Intracardiac Defects in Patients Weighing Less Than 10 kg

Abstract Background: To evaluate the technology of transesophageal echocardiographic guidance of percardiac closure in patients with low weight. Methods: Forty‐two patients with intracardiac defects, aged from two months to five years (median, 18.4 months) and weighted from 4 to 10 kg (median, 8.9 kg), underwent attempted percardiac device closure under transesophageal echocardiographic guidance. Results: Thirty‐nine (93%) patients successfully underwent occlusion, whereas three patients (7.1%) were converted to conventional open‐heart surgery. There was no mortality. They were followed up from 3 months to 15 months (median, 9.4 months). First degree atrioventricular block was detected in one patient at the time of discharge. The most common electrocardiogram change was bundle‐branch block, which developed in three (7.7%) patients during follow‐up. New mild mitral valve regurgitation (MR) was detected in three patients after operation and disappeared in one but remained in two others. Pericardial perfusion and recurrent intubation developed in one patient, respectively. The incidence of late complications is 5.1% (2/39) including low cardiac output syndrome and residual shunt in one patient, and moderate pericardial perfusion in one patient, respectively. No complication such as device dislocation, thrombosis, and obstruction of left or right ventricular outflow tract was found during the follow‐up. Conclusions: This initial success indicates that transesophageal echocardiographic guidance of percardiac device closure will aid in the treatment of intracardiac defects in selected patients weighing less than 10 kg with good early outcomes. (J Card Surg 2012;27:740‐744)     

Off‐Pump Coronary Artery Bypass Grafting in Patients with End‐Stage Renal Disease on Hemodialysis

Abstract Background: Coronary artery bypass grafting (CABG) for hemodialysis patients is high risk compared with other patient groups. The aim of this study was to analyze the potential benefits of off‐pump CABG for hemodialysis patients. Methods: From April 1994 through December 2000, 26 hemodialysis patients underwent CABG. The off‐pump group consisted of 15 patients operated on without a pump and the on‐pump group consisted of 11 patients operated on with a pump. Results: There was no difference between the two groups with regard to mean age, mean number of diseased vessels and mean number of anastomoses per patient. No patient died in either group during hospitalization. The postoperative complication rate was low in both groups. The postoperative ventilation time was shorter in the off‐pump group (8.5 vs 26.1 hours, p < 0.001, respectively [off‐pump group vs on‐pump group]). The length of ICU stay was shorter in the off‐pump group (1.7 vs 3.5 days, p # 0.01, respectively [off‐pump group vs on‐pump group]). The medial cost was lower in the off‐pump group ($26,200.80 versus $44,024.10 p # 0.0001 respectively [off‐pump group vs on‐pump group]). Conclusions: Off‐pump CABG provided excellent less‐invasive cardiac surgical results for dialysis patients.     

Transplantation of solid organ recipients shedding Epstein‐Barr virus DNA pre‐transplant: A prospective study

Epstein‐Barr virus (EBV) poses a significant threat to patient and graft survival post‐transplant. We hypothesized that recipients who shed EBV at transplant had less immunologic control of the virus and hence were more likely to have active EBV infection and disease post‐transplant. To test this hypothesis, we conducted a 5‐year prospective study in primary solid organ transplant recipients. We measured EBV DNA in oral washes and blood samples by quantitative PCR before transplant and periodically thereafter for up to 4 years. Pre‐transplant samples were available from 98 subjects. EBV DNA was detected pre‐transplant in 32 of 95 (34%) and 5 of 93 subjects (5%) in oral wash and blood, respectively. Recipients with and without detectable pre‐transplant EBV DNA were not significantly different demographically and had no significant difference in patient and graft survival (P = .6 for both comparisons) or post‐transplant EBV viremia‐free survival (P = .8). There were no cases of EBV‐related disease or post‐transplant lymphoproliferative disorder (PTLD) in any of the patients with detectable EBV DNA pre‐transplant. In conclusion, detectable EBV DNA pre‐transplant was not associated with differences in patient/graft survival, post‐transplant EBV viremia, or EBV‐related diseases including PTLD.     

Impaired myocardial t‐PA release in patients with coronary artery disease

Aims: Myocardial ischemia remains a significant perioperative complication in coronary artery disease (CAD) patients. We hypothesized that noxious stimuli during major surgery are associated with an acute release of tissue‐type plasminogen activator (t‐PA) into the coronary circulation, and that this response is reduced by CAD. Methods and results: Two patient groups, with (n=14) and without (n=8) CAD, were studied during the initial phase of heart surgery. After retrograde great cardiac vein catheterizations during closed‐chest conditions, coronary arterial–venous concentration gradients of t‐PA and plasminogen activator inhibitor type‐1 (PAI‐1) were measured together with coronary blood flow measurements, allowing derivation of coronary net release rates. Pre‐surgery atrial pacing, performed to evaluate the influence of increases in heart rate (+40 beats/min) and coronary blood flow (+80 ml/min), did not significantly alter coronary net release of t‐PA or PAI‐1 in either patient group. Sternotomy induced a prominent increase in coronary net release of both total and active t‐PA in the non‐CAD group. This response was considerably reduced in the CAD group. Conclusions: This study provides the first analysis of coronary t‐PA release during major surgery and demonstrates a deficient local endothelial t‐PA release in patients with CAD. This suggests a reduced local fibrinolytic capacity in CAD patients, which may explain the increased risk for coronary thrombosis in this patient group.     

Vacuum‐assisted closure (VAC)‐Instill® with continuous irrigation for the treatment of Mycoplasma hominis mediastinitis

A 56‐year‐old patient who underwent ascending aorta replacement postoperatively developed mediastinitis with atypical Mycoplasma hominis. We present the first successful treatment of M. hominis mediastinitis after cardiac surgery with vacuum‐assisted closure (VAC)‐Instill^® therapy combined with dilute antiseptic irrigation for bacterial eradication.     

Adaptive compression therapy for venous leg ulcers: a clinically effective,patient‐centred approach

A prospective, randomised, 12‐week study was performed to evaluate the efficacy and tolerability of two compression methods for venous leg ulcers (VLUs); a new adaptive compression therapy (ACT) system, combining intermittent and sustained pneumatic compression (n = 38) and a conventional four‐layer bandage system (n = 52). Primary outcomes were ulcer healing and safety. Secondary outcomes were comfort, compliance, ulcer pain, patient‐perceived product performance and quality of life. Ulcer healing rate was similar (31·6% versus 42·3%, respectively, P = 0·30) between the treatments. Adverse events and patient‐rated comfort were also similar. Average daily usage for the dual system was 10·5 and 1·8 hours in the sustained and intermittent modes, respectively, representing its use during 71% of waking hours. Predicted final ulcer pain was also similar (P = 0·68). Performance was subjectively better for adaptive compression and significantly higher for exudate management (P = 0·04), skin protection (P < 0·001), removal ease (P = 0·0007), bathing (P < 0·0001) and sleep comfort (P = 0·0405). The adjusted final quality‐of‐life score was 0·1025 higher for adaptive compression (P = 0·0375). Subjects with healed ulcers attained higher final scores than unhealed subjects (P = 0·0004). This study provides evidence that ACT is comparably efficacious to successfully heal VLUs compared with four‐layer bandage management but is better accepted and achieves higher patient‐reported quality‐of‐life scores in these challenging patients.     

Long‐term clinicopathologic observation in a case of steroid‐resistant nephrotic syndrome caused by a novel Crumbs homolog 2 mutation

Recent advances in high‐throughput sequencing for clinical genetic testing have revealed novel disease‐causing genes, such as Crumbs homolog 2 (CRB2) for early‐onset steroid‐resistant nephrotic syndrome (SRNS). We report the long‐term clinicopathologic observation of a Japanese female patient with SRNS caused by a newly identified compound heterozygous mutation of CRB2 (p.Arg628Cys and p.Gly839Trp located in the 10th and 11th epidermal growth factor‐like domains, respectively). She was initially examined during a mass urinary screening for 3.5‐year‐old children in Japan. Although she developed long‐standing SRNS without any extrarenal clinical signs thereafter, her renal function was well‐preserved over the next 17 years. In total, six sequential renal biopsy specimens revealed histologic alterations ranging from minor glomerular abnormalities to advanced focal segmental glomerulosclerosis (FSGS). A genetic analysis for SRNS performed at 19 years of age revealed a newly identified compound heterozygous mutation in CRB2. Glomerular CRB2 immunoreactivity in biopsy specimens from the patient was scanty, whereas intense expression was observed in those from patients with idiopathic FSGS or in controls. To our knowledge, this is the first report regarding a long‐term outcome in a case of SRNS due to an identified CRB2 mutation. Although the phenotype of CRB2 mutation‐related syndrome is now expanding, we believe that this case might provide a novel clinicopathologic aspect of this syndrome.     

Clinical outcomes of ABO‐ and HLA‐incompatible kidney transplantation: a nationwide cohort study

This was a nationwide cohort study to investigate the impact of anti‐A/B and donor‐specific anti‐HLA (HLA‐DSA) antibodies on the clinical outcomes in kidney transplant recipients (KTRs). We classified a total of 1964 KTRs into four groups: transplants from ABO‐incompatible donors (ABOi, n = 248); transplants in recipients with HLA‐DSA (HLAi, n = 144); transplants from combined ABOi and HLAi donors (ABOi + HLAi, n = 31); and a control group for whom neither ABOi nor HLAi was applicable (CONT, n = 1541). We compared the incidence of biopsy‐proven acute rejection (BPAR), allograft and patient survival rates. The incidence of BPAR was higher in the HLAi and ABOi + HLAi groups relative to the CONT group; in contrast, it was not higher in the ABOi group. Death‐censored graft survival rates did not differ across the four groups. However, relative to the CONT group, patient survival rate was reduced in the ABOi and ABOi + HLAi groups, and with infection being the most common cause of death. Further, multivariable analysis revealed that desensitization therapy because of ABOi or HLAi was independent risk factors for patient mortality. HLAi was a more important risk factor for BPAR compared with ABOi. However, pretransplant desensitization therapy for either ABOi or HLAi significantly increased the risk of infection‐related mortality.     

Radial Artery Tonometry to Monitor Blood Pressure and Hemodynamics in Ambulatory Left Ventricular Assist Device Patients in Comparison With Doppler Ultrasound and Transthoracic Echocardiography: A Pilot Study

Noninvasive measurements of blood pressure (BP) and cardiac output (CO) are crucial in the follow‐up of continuous‐flow left ventricular assist device (CF‐LVAD) patients. For our pilot study, we sought to compare BP measurements between a tonometry blood pressure pulse analyzer (BPPA) (DMP‐Life, DAEYOMEDI Co., Ltd., Gyeonggi‐do, South Korea) and Doppler ultrasound in CF‐LVAD patients, as well as to compare the BPPA estimated CO to LVAD calculated blood flow and to the patient’s intrinsic CO estimated with transthoracic echocardiography (TTE). Ambulatory CF‐LVAD patients (6 HeartMate, 26 HeartMate II), were included. According to TTE findings, patients were then subdivided in two groups: patients with an opening aortic valve (OAV) [n = 21] and those with an intermittent opening aortic valve (IOAV) [n = 11]. We found a very good correlation of systolic BP (SBP) measurements between the two methods, BPPA and Doppler ultrasound (r = 0.87, P < 0.0001). Bland‐Altman plots for SBP revealed a low bias of ?4.6 mm Hg and SD of ±4.7 mm Hg. In CF‐LVAD patients with IOAV, the BPPA‐CO had a good correlation with the LVAD‐flow (r = 0.78, P < 0.0001), but in OAV patients, there was no correlation. After adding the patient’s intrinsic CO, estimated from TTE in patients with OAV to the LVAD‐flow, we found a very good correlation between the BPPA‐CO and LVAD‐flow + TTE‐CO (r = 0.81, P = 0.002). Our study demonstrated that compared with the standard clinical method, Doppler ultrasound, the BPPA measured BP noninvasively with good accuracy and precision of agreement. In addition, tonometry BPPA provided further valuable information regarding the CF‐LVAD patient’s intrinsic CO.     

Transventricular edge-to-edge repair of the mitral valve during surgical ventricular restoration: review of the literature

Abstract Background: Mitral valve surgery for functional ischemic mitral regurgitation (MR) in high‐risk patients, including those requiring multiple concomitant cardiac operations, carries a significant risk of morbidity and mortality. In patients undergoing surgical ventricular restoration, transventricular edge‐to‐edge repair provides an effective alternative to conventional mitral valve surgery. We report such a case. Methods: A 67‐year‐old male with ischemic cardiomyopathy and severe left ventricular dysfunction presented to our institution with a 3‐month history of dyspnea on exertion, angina, and leg edema. He was found to have triple‐vessel coronary artery disease, a severely dilated left ventricle with an apical aneurysm, and moderate‐to‐severe MR (3+). In addition to coronary artery bypass graft surgery, an edge‐to‐edge mitral valve repair was undertaken via a longitudinal ventriculotomy performed for concomitant surgical ventricular restoration. Results: Total cardiopulmonary bypass and aortic cross‐clamp times were 101 minutes and 86 minutes, respectively. Postoperative transesophageal echocardiography revealed no MR, and the patient was discharged home on postoperative day 9. A follow‐up transthoracic echocardiogram revealed trace MR on postoperative day 15. At 11 months postoperative, the patient remains in New York Heart Association functional class I. Conclusion: Transventricular edge‐to‐edge repair of the mitral valve in patients with ischemic cardiomyopathy and functional MR undergoing SVR is a safe and effective alternative to conventional valve surgery, and should be considered in this high‐risk population. (J Card Surg 2012;27:52–55)     

De novo donor‐specific anti‐HLA antibodies mediated rejection in liver‐transplant patients

The incidence and consequences of de novo donor‐specific anti‐HLA antibodies (DSAs) after liver transplantation (LT) are not well known. We investigated the incidence, risk factors, and complications associated with de novo DSAs in this setting. A total of 152 de novo liver‐transplant patients, without preformed anti‐HLA DSAs, were tested for anti‐HLA antibodies, with single‐antigen bead technology, before, at transplantation, at 1, 3, 6 and 12 months after transplantation, and thereafter annually and at each time they presented with increased liver‐enzyme levels until the last follow‐up, that is, 34 (1.5–77) months. Twenty‐one patients (14%) developed de novo DSAs. Of these, five patients had C1q‐binding DSAs (24%). Younger age, low exposure to calcineurin inhibitors, and noncompliance were predictive factors for de novo DSA formation. Nine of the 21 patients (43%) with de novo DSAs experienced an acute antibody‐mediated rejection (AMR). Positive C4d staining was more frequently observed in liver biopsies of patients with AMR (9/9 vs. 1/12, P < 0.0001). Eight patients received a B‐cell targeting therapy, and one patient received polyclonal antibodies. Only one patient required retransplantation. Patient‐ and graft‐survival rates did not differ between patients with and without DSAs. In conclusion, liver‐transplant patients with liver abnormalities should be screened for DSAs and AMR.     

Quality of life before reconstructive breast surgery: FA preoperative comparison of patients with immediate,delayed, and major revision reconstruction

Background: Women undergo breast reconstruction at different time‐points in their cancer care; knowing patients' preoperative quality of life (QoL) is critical in the overall care of the patient with breast cancer. Our objective was to describe presurgical QoL among women undergoing immediate, delayed, or major revision breast reconstructive surgery at our institution. Methods: From March 2008 to February 2009, we administered preoperative BREAST‐Q questionnaires to women who presented to our institution for breast reconstruction. Univariate and multivariate analyses were performed to compare patient cohorts across multiple QoL domains including body image, physical well‐being, psychosocial well‐being, and sexual well‐being. Results: Of the 231 patients who presented for preoperative consultation, 176 returned the questionnaire (response rate 76%; 117 from the immediate, 21 from the delayed, and 32 from the major revision reconstruction groups, plus 6 mixed or unknown). The three groups differed significantly (P < 0.05) across four of the six domains: body image (satisfaction with breasts), psychosocial well‐being, sexual well‐being, and physical well‐being of the chest and upper body. The immediate reconstruction group had higher (better) scores than the delayed reconstruction group, which had higher (better) scores than the major revision group. Conclusion: These data suggest that women presenting for breast reconstruction at different stages of reconstruction have different baseline QoL. Such data may help us better understand patient selection, education, and expectations, and may lead to improved patient–surgeon communication. © 2013 Wiley Periodicals, Inc. Microsurgery, 2013.