A modified “Preclosure” technique after percutaneous aortic valve replacement

Objectives: To evaluate the feasibility, safety and efficacy of suture‐mediated closure devices using a modified “preclosure” technique for access site management after percutaneous aortic valve replacement (PAVR). Background: PAVR using a retrograde transfemoral approach has recently evolved to an endovascular alternative to open surgery in high‐risk patients. However, large‐bore femoral artery access is required, commonly demanding surgical closure and general anesthesia. A truly percutaneous intervention would be desirable to reduce procedural complexity and diminish the need of vascular surgery and general anaesthesia. Methods: After direct puncture of the common femoral artery, three conventional suture‐mediated closure devices (6F Perclose) were deployed. The preloaded sutures were tied at the end of the procedure. If no immediate hemostasis was achieved, an additional device was deployed thereafter. Results: PAVR with percutaneous access site closure was attempted in 15 consecutive patients and could successfully be achieved in all patients allowing conscious sedation in all but three cases. Following complications occurred: one retroperitoneal bleeding caused by removal of the valve delivery sheath requiring surgical repair, as well as two cases of femoral and iliac artery dissection caused by delivery sheath introduction and treated by stenting and vascular surgery, respectively. Vascular surgery became only necessary due to total vessel occlusion after suture closure and remains the only closure‐related complication. However, treatment led to recovery in all patients. Conclusions: The modified “preclosure” technique is a feasible and safe method for hemostasis after PAVR improving procedural management and diminishing the need for general anesthesia. © 2008 Wiley‐Liss, Inc.     

The coronary circulation in cardioprotection: more than just one confounder

Cardioprotection, i.e. the reduction in infarct size by pre-, post-, or remote conditioning, has originally been characterized in young and healthy experimental animals. Over the last two decades many signalling steps of cardioprotection have been identified, again in young and healthy animals. Although proof-of-concept studies unequivocally demonstrated the recruitment of all forms of cardioprotection in humans, the translation of cardioprotection to clinical routine has been poor. The apparent lack of translation has been attributed to poor design of clinical trials, but also to the neglect of confounders, such as age, sex, comorbidities, and comedications, in experimental studies. The present opinionated review focuses on the coronary circulation as a major determinant of cardioprotection. Coronary occlusion and the restoration of coronary blood flow are the causes of myocardial ischaemia and reperfusion injury from which protection is sought. On the other hand, brief cycles of coronary occlusion and reperfusion are also the stimulus for protection from myocardial ischaemia/reperfusion injury. The recruitment of collateral blood flow also contributes to protection from infarction. Finally, the coronary microcirculation is also a target of both injury by myocardial ischaemia/reperfusion and protection from it. Different manifestations of coronary artery disease, such as coronary stenosis or coronary microembolization, impact on both injury and protection.     

Neoadjuvant Chemotherapy Increases the Rate of Breast Conservation in Lobular-Type Breast Cancer Patients

Introduction  

Our study aims to determine whether patients with lobular-type breast cancer have significantly improved rates of breast conservation (BCT) after neoadjuvant chemotherapy (nCT).     

Prevention of lethal murine pancreas ischemia reperfusion injury is specific for tetrahydrobiopterin

Tetrahydrobiopterin has been shown to efficiently abrogate ischemia reperfusion injury (IRI). However, it is unclear, whether its beneficial action relies on cofactor activity of one of the five known tetrahydrobiopterin-dependent reactions or on its antioxidative capacity. We therefore compared tetrahydrobiopterin with the pterin derivate tetrahydroneopterin (similar biochemical properties, but no nitric oxide synthase cofactor activity) and the antioxidants vitamin C and 5-methyltetrahydrofolate. Donor mice were pretreated with tetrahydrobiopterin, tetrahydroneopterin, vitamin C, or 5-methyltetrahydrofolate. Pancreatic grafts were subjected to 16-h cold ischemia time and implanted in syngeneic recipients. Untreated and nontransplanted animals served as controls. Following 2-h reperfusion, microcirculation was analyzed by intravital fluorescence microscopy. Graft damage was assessed by histology and nitrotyrosine immunostaining, and tetrahydrobiopterin levels were determined by HPLC. Recipient survival served as ultimate readout. Prolonged cold ischemia time resulted in microcirculatory breakdown. Only tetrahydrobiopterin pretreatment succeeded to preserve the capillary net, whereas all other compounds showed no beneficial effects. Along with increased intragraft tetrahydrobiopterin levels during recovery and implantation, only tetrahydrobiopterin pretreatment led to significant reduction of IRI-related parenchymal damage enabling recipient survival. These results show a striking superiority of tetrahydrobiopterin in preventing lethal IRI compared with related compounds and suggest nitric oxide synthases as treatment target.     

Operative treatment of scoliosis in proximal spinal muscular atrophy: results of 41 patients

Introduction

The early development of progressive scoliosis with pelvic obliquity is the most significant orthopaedic problem for non-ambulatory children with spinal muscular atrophy (SMA).

Patients

24 SMA patients were operated on for scoliosis using the ISOLA^? system and 17 patients using a telescopic rod. The average age at spinal surgery was 12.3?years (6.5?C22.7) in the ISOLA^? group and 6.7?years (4.8?C10.9) in the telescopic rod group.

Results

The Cobb angle was corrected on average from pre-operative 83°(54°?C120°) to post-operative 39°(5°?C70°) in the ISOLA^? group and, respectively, from 62°(28°?C86°) to 18°(0°?C34°) in the telescopic rod group. Mean loss of correction at mean follow-up of 6?years (3?C10) was 6°(0°?C33°) in the ISOLA^? group and at mean follow-up of 8.6?years (3?C12) 13°(0°?C49°) in the telescopic rod group excluding the patients with rod failure. The vital capacity is not worsened by these operations in comparison to the natural course. After telescopic rods were implanted, there were some unsatisfactory results due to crankshaft phenomenon and an increase of pelvic obliquity.

Conclusion

Our recommendation for non-ambulatory SMA patients is to have definitive stabilisation using multisegmental instrumentation, starting from the age of 10 to 12?years.