Low Rate of Invasive Coronary Angiography Following Transcatheter Aortic Valve Implantation: Real-World Prospective Cohort Findings

AimTo evaluate the real need for coronary access after transcatheter aortic valve implantation (TAVI).Methods and resultsProspective observational single-center registry, including 563 consecutive patients who underwent TAVI between April 2008 and November 2018, with both self- and balloon-expandable valves in a tertiary European center. Mean age was 82.4 ± 6.9 years, 53.3% were female, 16% had previous history of coronary artery bypass grafting, 33% of previous percutaneous coronary intervention (PCI), and 16.6% of myocardial infarction (MI). Twenty-four percent of the patients were revascularized within one year before TAVI in preparation for the procedure. Median Society of Thoracic Surgeons score was 4.82 (IQ 2.84).In a median follow-up of 24 months (IQ 21.5), 18 patients (3.2%) were identified as potentially in need for invasive coronary angiography: 9 (1.6%) in the setting of stable coronary artery disease and 9 (1.6%) for an acute coronary syndrome.A total of 11 PCIs were performed in 9 patients, with a complete success rate of 63.6%. Procedures that were unsuccessful or partially unsuccessful were due to the inability to cross the stent or the drug-eluting balloon through the valve struts or misplacement within the coronary artery due to lack of catheter support.ConclusionIn this population, a strategy of previous guideline-directed revascularization before TAVI was associated with a low rate of MI and repeated need of coronary access, with a scattered distribution over time. Assuring future access to coronary arteries in patients at increased risk may depend on the revascularization strategy rather than device selection.     

Subacute Pain as a Predictor of Long-Term Pain Following Orthopedic Surgery: An Australian Prospective 12 Month Observational Cohort Study

The aim of this study was to document the level of pain and functionality in the 12 months following orthopedic surgery and identify if high pain levels following discharge were associated with pain persisting at 12 months.An observational prospective cohort study was undertaken, following 87 patients (mean age 62.4 years [18–92]; 47.1% male) who required orthopedic surgery at the Royal Hobart Hospital, Australia. Following an initial survey, patients were telephoned at 10 days, 6 weeks, 3 months, and 12 months after discharge.Postdischarge pain levels were high with 97.4% of patients suffering pain at 10 days, 81.2% at 6 weeks and 79.5% at 3 months. Pain affected the ability to undertake activities of daily living (ADLs) for 32.7% and 20.0% of patients at 10 days and 6 weeks, respectively. Twelve months after discharge, 65.5% of patients reported pain persisting at the surgical site, with 29.9% of all patients suffering moderate–severe incidental pain; and nearly one quarter of patients reported pain affected their sleep or ADLs. Average pain levels rated as moderate–severe at 10 days (P = 0.01) and 6 weeks (P = 0.02) and pain of neuropathic origin at 3 months (30.2% vs 10.3% P = 0.03) and 12 months (30.4% vs 4.9% P = 0.01) were associated with persistent pain at 12 months.Pain in the period following discharge from hospital is significant and undermanaged. Previous studies has shown that that acute pain, particularly in the first 48 hours following surgery is a predictor for long-term pain after surgery. This study adds to the current literature by showing that pain in the subacute period, following discharge from hospital is also associated with the pain persisting at 12 months. These findings have important implications for improving quality of life as well as potentially preventing persistent pain with increased follow-up and more intensive management of post-discharge pain.     

Neutrophil Elastase Inhibitor Following Liver Resection: A Matched Cohort Study

Background:

Sivelestat is a neutrophil elastase inhibitor (NEI) with positive impact on the respiratory complications in thoracic surgery. Based on the findings of a recent study, NEI may have a good response for avoiding ischemia reperfusion injury in liver resection.

Objectives:

The current study aimed to examine the impact of NEI on the postoperative outcomes after liver resection.

Patients and Methods:

The data were collected from 374 consecutive patients scheduled to undergo liver resection. Seven perioperative variables were matched on the basis of the patients’ background. Then, the NEI (n = 61) and control (n = 61) groups were compared. NEI was administered at a dose of 0.2 mg/kg/h for three days from the postoperative day 0 (POD0). The liver function, coagulation activity, inflammatory response, respiratory complications, and overall complications were compared.

Results:

The levels of serum interleukin-6 (NEI group: 113 pg/mL [26.9 - 522.0] vs. control group: 174 [28.6 - 1040.6], P < 0.01) and C-reactive protein (CRP) (2.9 IU/L [range: 0.1 - 8.6] vs. 4.11 [0.3 - 13.8], P = 0.01) on the first postoperative day (POD1) and the alveolar-arterial oxygen tension difference (32.3 Torr [-28.6 - 132.3] vs. 46.6 [-11.2 - 251.6], P = 0.04) on the third postoperative day (POD3) were significantly lower in the NEI group than the control group. The rate of pleural effusion was significantly lower in the NEI group compared to that of the control group [13 patients (21.3%) vs. 23 (37.7%), P = 0.04]. However, the coagulation activities (P = 0.68), liver function (P = 0.69), non-respiratory complications (P = 0.84), and overall complications (P = 0.71) did not differ significantly between the groups.

Conclusions:

Intravenous NEI administration had positive impact on the postoperative inflammatory response and oxygenation while it did not affect either coagulation or the liver function, as well as severe grade complications following resection.     

One-Year Results Following a Pre-Specified ABSORB Implantation Strategy in ST-Elevation Myocardial Infarction (BVS STEMI STRATEGY-IT Study)

Backgrounddata from clinical experiences with Absorb bioresorbable scaffold (BRS) in STEMI raised concerns among clinicians about the device safety because a noteworthy scaffold thrombosis (ScT) rate was reported at early and long-term follow-up. Nevertheless, pre-specified technical suggestions of how to perform an optimal BRS procedure in STEMI were lacking. In this study we sought to assess the 1-year results following a pre-specified BRS implantation strategy in ST-elevation myocardial infarction (STEMI) patients undergoing primary PCI (pPCI).MethodsThis is a prospective, multicenter study on 505 STEMI patients undergoing pPCI with Absorb following a dedicated implantation protocol. The primary end-point (a device oriented composite end-point (DOCE) of cardiac death, target-vessel myocardial infarction (TV-MI) and ischemia-driven target lesion revascularization (ID-TLR) within 30 days) was already reported. We here present DOCE, its singular components and ScT rates (secondary end-points) at 1-year.ResultsAccording to the study protocol direct Absorb implantation was feasible in 47 (9.3%) patients while post-dilatation was performed in 468 (92.7%) cases. The hierarchical DOCE rate at 1-year was 1.2% (0.4% cardiac death, 0.4% TV-MI and 0.8% ID-TLR) versus 0.6% at 30-day. Two episodes (0.4%) of ScT (one probable subacute and one late definite) were reported. At 1-year, 99.2% patients were on dual antiplatelet therapy (95% with ticagrelor or prasugrel).ConclusionsA pre-specified Absorb implantation strategy in STEMI patients was associated with persistent low DOCE and ScT rates at 1-year. Longer term follow-up is needed to assess the role of this strategy on preventing very-late events (NCT02601781).     

Quality of Life after Bariatric Surgery: A Population-based Cohort Study

Background

Bariatric surgery leads to profound weight loss, but postoperative complications and psychosocial issues may impact long-term quality of life. The primary aim of this project was to examine whether such patients have better quality of life and self-reported functional status compared with obese adults who do not have bariatric surgery.

Methods

This population-based study of patients evaluated for Roux-en-Y gastric bypass surgery involved a survey consisting of baseline and follow-up single-item overall quality-of-life items (Linear Analogue Self-Assessment Questionnaire; LASA), follow-up quality of life (Short-Form-12), and activity (Goldman's Specific Activity Scale). A total of 268 and 273 surveys were mailed, with 148 (55.2%) operative and 88 (32.2%) nonoperative survey responders assessed, respectively. Linear regression was used, adjusting for changes in co-morbidity and functional status, to assess the differences in quality of life and activity level. Individual predictors of higher or better quality-of-life scores also were assessed.

Results

There were no major differences in baseline characteristics between survey responders and nonresponders. Mean follow-up was 4.0 and 3.8 years in the operative and nonoperative groups, respectively. The change in overall LASA from baseline to follow-up between groups was 3.1 ± 0.4 (P <.001). The adjusted Short-Form-12 score was 14.4 points higher in operative patients (P <.001) at follow-up. Operative patients had symptomatic improvement as measured by Specific Activity Scale status (odds ratio 7.5, P <.001) and self-reported exercise tolerance (odds ratio 2.61, P = .01) at follow-up compared with nonoperative patients. Predictors of a high follow-up LASA (P <.05) included initial treatment for depression, percent of weight lost, and absence of dyslipidemia and cardiovascular disease. Follow-up Short-Form-12 predictors included percent of weight loss, absence of baseline diabetes, baseline depression treatment, and follow-up cardiovascular disease.

Conclusions

Profound weight loss after bariatric surgery, seeking treatment for depression, and absence of medical co-morbidities appears to predict better quality of life and self-reported functional status.     

Combined Transapical Valve-in-Valve/Valve-in-Ring Transcatheter Mitral Valve Implantation and Paravalvular Leak Closure for Failed Mitral Valve Surgery

Recurrent mitral regurgitation (MR) after mitral valve repair or replacement is associated with adverse outcomes. MR may be transvalvular, paravalvular/para-ring, or both, and careful evaluation with transesophageal echocardiography is required. Often patients have high risk of morbidity or mortality, and transcatheter therapies are emerging as an alternative to reoperation. We present 2 cases of complex recurrent MR treated by a transapical transcatheter approach and discuss important clinical and technical considerations.     

Digital Ischemia Associated With Cancer: Results from a Cohort Study

Digital ischemia associated with cancer (DIAC) is increasing in frequency and recent reports have suggested the concept of paraneoplastic manifestation. The aims of this study were to characterize the clinical presentation of DIAC and identify clinical features that could lead physicians to diagnose underlying cancer.From January 2004 to December 2011, 100 patients were hospitalized in the Department of Internal Medicine at Rouen University Hospital, France for a first episode of DI. Fifteen (15%) exhibited symptomatic or asymptomatic cancer during the year preceding or following vascular episode and constituted the DIAC group. Other patients without cancer made up the digital ischemia (DI) group.Median time between diagnosis of cancer and episode of digital necrosis was 2 months [0.25–9]. Diagnosis of DI and concomitant cancer was made in 7 of the 15 patients, while DI preceded the malignant disorder in 2 cases and followed it in 6 cases. Histological types were adenocarcinoma for 7 (46.7%), squamous cell carcinoma for 4 (26.7%), and lymphoid neoplasia for 3 patients (20%). Six patients (40%) had extensive cancer. Three patients were lost to follow-up and 5 patients died <1 year after diagnosis of cancer. Cancer treatment improved vascular symptoms in 6 patients (40%). Patients with DIAC, compared to patients with DI, were significantly older (56 years [33–79] vs 46 [17–83] P =0.005), and had significantly lower hemoglobin and hematocrit levels (12.7 g/dl vs 13.9 g/dl; P =0.003 and 38% vs 42%; P =0.003, respectively). Patients with DIAC had a higher platelet rate (420 vs 300 G/L P =0.01), and 6 patients with DIAC (40%) had thrombocytosis. There was no difference between groups either in C-reactive protein level (12 mg/L vs 5 mg/L; P =0.08) or regarding cardiovascular risk factors, presence of autoimmunity, or monoclonal protein.This retrospective study suggests that DIAC may be more prevalent than previously reported. Outcomes of the 2 diseases were not strictly chronologically parallel. However, in the majority of cases, treatment of the tumor resolved vascular involvement. Our findings suggest that age >50 years and thrombocytosis should alert physicians to consider a possible occult malignancy when digital necrosis occurs.     

Quality of Life,Dyspnea, and Functional Exercise Capacity Following a First Episode of Pulmonary Embolism: Results of the ELOPE Cohort Study

Background

We aimed to evaluate health-related quality of life (QOL), dyspnea, and functional exercise capacity during the year following the diagnosis of a first episode of pulmonary embolism.

Risk of Restless Legs Syndrome Following Tension-Type Headache: A Nationwide Population-Based Cohort Study

Migraine and restless legs syndrome (RLS) appear to be associated, but the relationship between tension-type headache (TTH) and RLS is unknown. This nationwide, population-based, retrospective cohort study explored the potential association between TTH and RLS.We identified 15,504 patients with newly diagnosed TTH from 2000 to 2007 and 62,016 individuals without TTH who were selected by frequency matched based on sex, age, and the index year. The study participants were followed until diagnosed with RLS, withdrawal from the NHI program, or the end of 2011. Cox proportional hazard models were used to identify risk factors for RLS in TTH patients.After adjusting for sex, age, comorbidity, and medications, TTH was significantly associated with an increased risk of RLS (hazard ratio [HR] = 1.57, 95% confidence interval [CI] = 1.22–2.02). The risk was most prominent in patients aged 20 to 39 years in the TTH group, which exhibited a 2.60-fold higher risk (95% confidence interval = 1.53–4.42) of RLS compared with the non-TTH group. The TTH group had a higher risk of RLS than that of the non-TTH group regardless of sex.Tension-type headache appears to be associated with an increased risk of developing RLS. This similarity to migraines may indicate that headache and RLS have a coincident pathophysiological mechanism, a possibility requiring further study. Clinicians should be more attentive to RLS as a possible comorbidity in patients with TTH.