New approach in treatment of acute cardiogenic shock requiring mechanical circulatory support

In 12 patients with acute cardiogenic shock who required mechanical circulatory support a short-term Abiomed BVS 5000 extracorporeal assist device was implanted using the inflow and outflow cannulas of the BerlinHeart extracorporeal assist device. In 7 patients suitable for long-term support the Abiomed pumps were later exchanged for BerlinHeart pumps. This approach avoids the risks associated with repeat sternotomy and use of cardiopulmonary bypass and decreases the total costs of patient care.     

Association of apolipoprotein E polymorphisms and dietary factors in colorectal cancer

ApoE single nucleotide polymorphisms (SNPs) Cys112Arg (Epsilon-4), and Arg158Cys (Epsilon-2) have been implicated in cardiovascular and Alzheimer''s disease, but their role in colorectal cancer (CRC) has not been extensively studied. We investigated whether ApoE polymorphisms alone or in combination with dietary factors selectively contribute to mismatch-repair (MMR) proficient (microsatellite stable/low or MSS/L) vs deficient (microsatellite unstable or MSI-H) CRCs. We carried out a case–control study with 906 CRC cases and 911 unaffected controls to examine the associations between ApoE polymorphisms and dietary factors and assessed their contribution to MSS/L and MSI-H CRCs. We used unconditional logistic regression to evaluate the associations between ApoE SNPs, tumour MSI status, and dietary factors after adjusting for age and sex. All statistical tests were two-sided. No significant differences in ApoE genotype frequencies were observed between CRC cases and unaffected controls. We observed that increased dietary intake of total fat, saturated fat, cholesterol, and red meat was significantly associated with CRC. Among non-ApoE4 carriers, 2–4 and >4 red meat servings/week were associated with developing MSS/L CRC (OR=1.51, 95% CI 1.10–2.07 and OR=1.80, 95% CI 1.30–2.48, respectively), whereas among ApoE4 allele carriers, four or more red meat servings/week were associated with MSI-H CRC (OR=4.62, 95% CI 1.20–17.77) when compared with the controls. ApoE isoforms modulate the risk of MSI-H and MSS/L CRCs among high red meat consumers.     

MSH2 118T>C and MSH6 159C>T promoter polymorphisms and the risk of colorectal cancer

The most important indicator of colorectal cancer (CRC) risk is the presence of family history of the disease. Inherited genetic changes, such as single nucleotide polymorphisms, in key candidate genes may contribute to CRC risk. We investigated whether promoter polymorphisms in DNA mismatch repair (MMR) genes MSH2 and MSH6 are associated with the risk of CRC. We genotyped 929 CRC patients and 1098 control subjects from Ontario, and 467 patients and 344 controls from Newfoundland and Labrador, for two promoter polymorphisms in the MMR genes MSH2 and MSH6 using the fluorogenic 5' nuclease assay. We used unconditional logistic regression to evaluate the association between each polymorphism and CRC after adjusting for age and sex. The associations between polymorphisms and tumor clinicopathological features were evaluated with a Pearson's chi-squared test or Fisher's exact test. All statistical tests were two sided. We observed strong associations between the MSH2 -118T>C polymorphism and family history of CRC based on the Amsterdam criteria I (P = 0.005) and Amsterdam criteria I and II (P = 0.036) among cases from Ontario. This association was especially evident among female CRC patients in Ontario (for Amsterdam criteria I, and I and II combined, P = 0.003 and P = 0.0001, respectively). The MSH2 -118T>C polymorphism was associated with strong family history of CRC in Ontario patients.     

Cannulation of the right axillary artery for surgery of acute type A aortic dissection.

OBJECTIVE: The optimal choice of the arterial inflow site during operations for type A aortic dissection is not clearly defined. The aim of the prospective study was to identify whether cannulation of the right axillary artery instead of the femoral artery may improve the results of surgery for acute type A aortic dissection. METHODS: Seventy consecutive patients were operated on because of acute type A aortic dissection from January 2000 to February 2002. The only difference in surgical strategy was the site of arterial cannulation: the right axillary artery was used in 20 patients [axillary group] and the left femoral artery in 50 patients [femoral group]. All patients had aortic surgery with open distal anastomosis during deep hypothermic arrest and retrograde cerebral perfusion. The mean age was 58.7 +/- 12 years with a range from 28 to 88 years (axillary group, 56.6 +/- 13 years; femoral group, 59.4 +/- 12 years; P = 0.435). Preoperatively evident organ malperfusion was identified in five (25%) patients of the axillary group and in seven (14%) of the femoral group. RESULTS: There was no perioperative death. The hospital mortality rate was 5.0% for the axillary group and 22% for the femoral group (all patients, 17%). Major neurological complications occurred postoperatively in 5% of patients from the axillary group (one out of 20 patients) and in 8% of patients from the femoral group (four out of 50 patients) (all patients, 7%). CONCLUSION: Cannulation of the right axillary artery improved the outcome of surgery for acute type A aortic dissection. However, postoperative complications occurred after both axillary and femoral artery cannulation.     

The importance of communication in secondary fragility fracture treatment and prevention

Introduction We report on a Canadian longitudinal qualitative case study of midlife women with fragility fractures, their treating orthopaedic surgeons and family physicians. Methods Women and their treating physicians were followed for an average of one year post fracture to investigate the health outcomes and what, if any, follow-up occurred aimed at secondary fracture prevention. The final dataset includes 223 interviews gathered from women aged 40 to 65 with fragility fractures, orthopaedic surgeons and family physicians. Results The circle of care for those with fragility fractures is disrupted at vital communication junctures: (1) the inconsistent flow of information between acute care institutions and family physicians; (2) unidirectional and inconsistent communication from orthopaedic surgeons to family physicians; and (3) competing demands of the cast clinic environment and patient expectations. It is not the lack of will that is undermining the consistent and detailed communication among patients, physicians and institutions. It is the episodic nature of fracture care that makes communication among involved parties difficult, if not impossible. Conclusions Communication about events, acuity and clear expectations around roles and follow-up is urgently needed to improve communication throughout the circle of care to support secondary fracture prevention. Fractures from a standing height or similar trauma in women aged 40 to 65 should be treated as suspicious fractures and followed-up to investigate the underlying bone condition. This article reports on challenges and barriers to clear communication among women, their orthopaedic surgeons and family physicians that is necessary for follow-up and prevention of future fractures.     

Intraoperative Hochfrequenzstromablation zur Therapie von Vorhofflimmern Die Berlin-Modifikation

Hintergrund: Die Cox-Maze-Operation in Kombination mit Operationen zur Behandlung organischer Herzerkrankungen ist sehr erfolgreich in der Beseitigung von chronischem Vorhofflimmern. Jedoch führt sie zu einer signifikanten Verlängerung der Aortenklemmzeit und Operationsdauer. In dieser Studie wurde eine vereinfachte linksatriale Maze-Operation, ein verkürztes Verfahren mittels Hochfrequenzablation unter Verwendung einer chirurgischen Sonde, zusätzlich zu elektiven offenen Herzoperationen bei Patienten mit Vorhofflimmern durchgeführt. Patienten und Methode: 95 Patienten mit Vorhofflimmern (Dauer: 6 Monate bis 33 Jahre) unterzogen sich einer elektiven offenen Herzoperation (isolierte Herzklappen- oder Bypassoperationen, n = 51 Patienten; kombinierte Eingriffe, n = 44 Patienten) kombiniert mit einer intraoperativen Hochfrequenzstromablation des linken Atriums. Die Dauer der postoperativen Nachbeobachtungszeit betrug zwischen 1 und 24 Monate (im Mittel 8 Monate). Die möglichen Prädiktoren für persistierendes Vorhofflimmern wurden aus 40 Variablen durch univariate und multivariate Analysen ermittelt. Ergebnisse: Die intraoperative Hochfrequenzstromablation führte zu einer Verlängerung der Aortenklemmzeit von 6-14 Minuten (im Mittel 11 Minuten). Intraoperativ waren alle Patienten frei von Vorhofflimmern, 30% nach 1 Woche postoperativ und 84% nach 6 und 12 Monaten. Der einzige Prädiktor für postoperativ persistierendes Vorhofflimmern war eine bestehende koronare Herzkrankheit (Odds-Ratio 7,5; 80%-Konfidenzintervall 2,24-25,13). Schlussfolgerungen: Die intraoperative Hochfrequenzstromablation des linken Vorhofs in Verbindung mit Herzoperationen bei organischen Herzerkrankungen führt zur effektiven Beseitigung des Vorhofflimmerns ohne signifikante Verlängerung der Aortenklemmzeit oder Operationsdauer. Das Vorliegen einer koronaren Herzkrankheit verringert die Erfolgsrate während der ersten 6 Monate postoperativ. Background: The Cox-maze procedure combined with an operation for organic heart disease is highly succesful in the elimination of chronic atrial fibrillation. However, it prolongs significantly the aortic cross-clamp and operating time. In this study, a simplified left atrial maze procedure, a short procedure performed using a surgical radiofrequency ablation probe, is added to elective open-heart procedures in patients with atrial fibrillation. Patients and Methods: 95 adults with atrial fibrillation (duration, 6 months to 33 years) underwent elective open heart operations (isolated valve procedures or coronary artery bypass grafting, n = 51 patients; combined procedures, n = 44 patients) combined with intraoperative radiofrequency ablation of the left atrium. The postoperative follow-up period ranged from 1 to 24 months (mean, 8 months). Possible predictors for persistent postoperative atrial fibrillation were determined among 40 variables by univariate and multivariate analyses. Results: Intraoperative radiofrequency ablation prolonged the aortic cross-clamp time for 6-14 minutes (mean, 11 minutes). Freedom from atrial fibrillation was 100% intraoperatively, 30% at 1 week after operation, and 84% and 84% at 6 and 12 months postoperatively. The only predictor of postoperative atrial fibrillation was the presence of coronary artery disease (odds ratio, 7.5; 80% confidence interval, 2.24-25.13). Conclusions: Intraoperative radiofrequency ablation of the left atrium combined with an operation for organic heart disease effectively eliminates atrial fibrillation without significant prolongation of the aortic cross-clamp and operative time. The presence of coronary artery disease decreases the success rate during the first 6 postoperative months.     

TAVI for pure aortic valve insufficiency in a patient with a left ventricular assist device

We report transcatheter aortic valve implantation (TAVI) for pure aortic valve insufficiency in a patient with an otherwise normal aortic valve and a long-term left ventricular assist device (LVAD). An oversized 29-mm Edwards SAPIEN valve (Edwards Lifesciences, Irvine, CA) was implanted in the 21-mm native aortic valve annulus. Despite the complete absence of aortic calcifications, the prosthesis remained stably anchored inside the annulus. The reported experience demonstrates that TAVI is feasible even in patients with pure aortic valve regurgitation and can be a reasonable option in patients with aortic regurgitation after LVAD implantation.