The significance of postprocedural aortic regurgitation after transcatheter aortic valve implantation on postprocedural prognosis

Transcatheter aortic valve implantation (TAVI) is becoming a more and more important treatment for aortic valve stenosis in high-risk surgical patients. Furthermore, there currently is a discussion for the expansion of TAVI to intermediate-risk patients. In the past, surgical aortic valve replacement was the standard treatment, with excellent results in hemodynamic, as well as echocardiographic parameters and survival rates. However, the results of the Partner A and Partner B trials, as well as the ADVANCE study demonstrate the promise of establishing TAVI as a real alternative treatment option for aortic valve stenosis. One of the risks of a TAVI procedure is the occurrence of aortic regurgitation (AR) post-TAVI. Mild AR is a common finding after TAVI and seems not to be a clinical problem; however, occurrence of significant postprocedural AR after TAVI is still a problem. There is a clear association between significant postprocedural AR and clinical outcomes. Therefore, this review focuses on the occurrence, reasons, diagnostics, clinical impact and treatment options of AR post-TAVI.     

Sirolimus-Eluting Versus Bare-Metal Stents for the Reduction of Coronary Restenosis

PURPOSE: The GERSHWIN study (German Stent Health Outcome and Economics Within Normal Practice) was designed to evaluate long-term effects of treatment of coronary artery disease (CAD) with sirolimus-eluting stents (SES), as compared to bare-metal stents (BMS). PATIENTS AND METHODS: Within a multicenter, prospective intervention study in 35 hospitals throughout Germany, CAD patients with coronary stenosis and elective percutaneous coronary intervention (PCI) indication were treated either with SES or BMS (sequential control design with a case-to-control ratio of 2 : 1). Standardized questionnaires were completed by patients and their physicians at baseline, 3, 6, 12, and 18 months following PCI to document re-PCI for restenosis, myocardial infarction (MI), coronary bypass surgery (CABG), and death. Angiographic PCI documentation was evaluated by an independent expert. RESULTS: From April 2003 until June 2005, 658 patients were treated with SES (mean age 63 +/- 9 years, 87% male) and 294 patients with BMS (mean age 64 +/- 10 years, 79% male). Significant baseline differences were found by age, gender, household status, three vessel disease, and number of implanted stents. After 18 months, 8% of the SES versus 17% of the BMS group had undergone target vessel revascularization (p adjusted < 0.0001). There were no significant differences between BMS and SES regarding MI, CABG, or death. Re-PCI of target and new non-target vessel lesions was performed at a significantly lower degree of stenosis in SES than in BMS. CONCLUSION: Compared to patients with BMS, patients with implantation of SES experienced considerably fewer target vessel revascularizations. The threshold to perform re-PCI appeared lower in SES than in BMS. An extended evaluation of the effects of SES will be available from the 3-year follow-up of the GERSHWIN study.     

Impact of a Dedicated Cancer Center Surveillance Program on Guideline Adherence for Patients With Stage II and III Colorectal Cancer

BackgroundOur aims were to evaluate adherence to guidelines on colorectal cancer surveillance and outcomes for patients enrolled in an innovative follow-up program at our cancer center.Patients and MethodsA retrospective chart review was conducted at the Cross Cancer Institute in Edmonton, Canada. Patients with stage II/III colorectal cancer who completed treatment and who entered into the program from December 1, 2007, to December 31, 2009, were identified. The minimum standard of care follow-up was defined as (1) carcinoembryonic antigen (CEA) testing every 120 days for 3 years; (2) computed tomography of chest, abdomen, and pelvis at 10 to 14 months and 22 to 26 months after surgery; and (3) colonoscopy within 14 months of surgery.ResultsA total of 408 patients met inclusion criteria. Two hundred (49.0%) patients were adherent to all 3 components of surveillance. Among all patients, 57 (14.0%) were nonadherent to computed tomography imaging, 135 (33.1%) were nonadherent to colonoscopy, and 96 (23.5%) were nonadherent to CEA testing. Determinants of nonadherence are described. In total, 192 (47.2%) patients had an abnormal surveillance investigation that led to 307 follow-up events. After a median of 1.6 years, 69 (16.9%) patients had documented tumor recurrence. Sixty-one (88.4%) of these 69 patients had recurrence diagnosed via surveillance, and 31 (44.9%) patients were considered potentially resectable.ConclusionsOur study demonstrated an improvement in CEA testing since the program began; however, adherence rates for all components are not yet optimal. Alterations to surveillance program management are outlined. Further investigation will determine whether intense follow-up improves patient survival locally.     

Tissue ACE inhibition improves microcirculation in remote myocardium after coronary stenosis: MR imaging study in rats

ACE inhibition has been shown to improve left ventricular (LV) and myocardial blood flow. Previous data regarding changes in capillary density and angiogenesis during ACE inhibition are controversial. The aim of the following study was to determine myocardial microcirculation and heart function in the rat after coronary stenosis using non invasive MR imaging techniques.MR spin labeling and cine techniques have been performed in female Wistar rats 2 weeks after coronary artery stenosis. In one group, animals were treated with quinapril in a dose of 6 mg/kg/day. Perfusion, relative blood volume (RBV), LV mass and function were determined non-invasively 2 weeks after treatment. Finally, fibrosis and capillary density were analyzed histologically. Additionally, hemodynamic measurements were realized in a further group in order to calculate systemic vascular resistance (SVR).Quinapril resulted in a significant increase in perfusion at rest in the remote and the poststenotic myocardium with improved systolic function and a decrease in SVR compared to the non treated control group. Additionally, maximum perfusion and RBV were slightly elevated whereas capillary density was unchanged among the groups.MRI allows for non-invasive quantification of functional microcirculation and heart function. In addition to the well known effect of ACE inhibition on systolic function, treatment with the tissue specific ACE inhibitor quinapril revealed an important microvascular improvement, especially at arteriolar level. These findings may support the use of tissue ACE inhibitors to improve cardiac microcirculation after ischemia.