Prediction of 1‐year mortality and impact of bivalirudin therapy according to level of baseline risk: A patient‐level pooled analysis from three randomized trials

Objectives : We aimed to construct a predictive model for one‐year mortality in patients undergoing invasive coronary evaluation and to examine the impact of bivalirudin on survival according to the level of baseline risk. Background : Compared to heparin plus GP IIb/IIIa inhibitors (HEP/GPI), bivalirudin decreases bleeding complications in a range of clinical presentations. The impact of preprocedural risk assessment on survival and whether this is modified by bivalirudin, has not been investigated in detail. Methods : We examined patient‐level data from the REPLACE‐2, ACUITY, and HORIZONS‐AMI trials (n = 18,819) to construct a risk‐adjusted mortality model using baseline clinical variables. Results : One‐year mortality occurred in 287 patients (3.1%) assigned to bivalirudin and 336 patients (3.6%) assigned to HEP/GPI (HR 0.85; 95% CI, 0.73–1.00; P = 0.048). Using 11 highly significant predictors of mortality, we developed an integer‐risk score to classify patients into risk tertiles. High‐risk patients had a rate of 1‐year mortality over 9‐fold greater than low‐risk patients. Consequently, the absolute mortality reduction attributed to bivalirudin was more marked in high‐risk patients: 3.1% (?0.8% to 7.0%) in the overall cohort, 4.8% (0.5% to 9.2%) in the PCI cohort (P‐interaction versus intermediate and low risk categories, 0.09 and P = 0.02, respectively). Conclusions : In patients undergoing invasive coronary evaluation, 1‐year mortality can be predicted using baseline variables. Bivalirudin treatment (versus HEP/GPI) conferred a survival benefit. © 2015 Wiley Periodicals, Inc.     

Association of susceptibility to brucellosis and interleukin-4 promoter polymorphism

A C-T substitution at position 590 in the interleukin-4 (IL-4) gene is associated with increased production of IL-4. We sought to determine the associations between this polymorphism and susceptibility to brucellosis. DNA was extracted from the whole blood of 163 control individuals and 282 patients with brucellosis. A polymorphism in the IL-4 gene at position 590 from the promoter site was determined using an allele-specific PCR method. The prevalence of the T allele of IL-4 polymorphism was significantly higher in the patients group than in controls (28.9% vs 11.4%, p<0.004). Patients with brucellosis had a higher frequency of intermediate producer genotype (CT) (53.5% vs 22.7%, p<0.001) while low producer genotype (CC) was higher in the control group (77.3% vs 44.4%). Multiple logistic regression analysis demonstrated that patients who were heterozygous (CT) for interleukin-4 promoter polymorphism had a significantly higher risk for brucellosis with an odds ratio of 4.2 (95% CI 2.7-6.6, p<0.0001). Our findings demonstrate for the first time an association between IL-4 590 promoter polymorphism and contracting brucellosis in the Iranian population.     

Echocardiography-Guided Interventions

A major advantage of echocardiography over other advanced imaging modalities (magnetic resonance imaging, computed tomographic angiography) is that echocardiography is mobile and real time. Echocardiograms can be recorded at the bedside, in the cardiac catheterization laboratory, in the cardiovascular intensive care unit, in the emergency room—indeed, any place that can accommodate a wheeled cart. This tremendous advantage allows for the performance of imaging immediately before, during, and after various procedures involving interventions. The purpose of this report is to review the use of echocardiography to guide interventions. We provide information on the selection of patients for interventions, monitoring during the performance of interventions, and assessing the effects of interventions after their completion.In this document, we address the use of echocardiography in commonly performed procedures: transatrial septal catheterization, pericardiocentesis, myocardial biopsy, percutaneous transvenous balloon valvuloplasty, catheter closure of atrial septal defects (ASDs) and patent foramen ovale (PFO), alcohol septal ablation for hypertrophic cardiomyopathy, and cardiac electrophysiology. A concluding section addresses interventions that are presently investigational but are likely to enter the realm of practice in the very near future: complex mitral valve repairs, left atrial appendage (LAA) occlusion devices, 3-dimensional (3D) echocardiographic guidance, and percutaneous aortic valve replacement.The use of echocardiography to select and guide cardiac resynchronization therapy has recently been addressed in a separate document published by the American Society of Echocardiography and is not further discussed in this document.The use of imaging techniques to guide even well-established procedures enhances the efficiency and safety of these procedures.

II. Introduction

Traditionally, percutaneous cardiovascular interventions have predominantly used angiographic and fluoroscopic guidance, which is limited when interventions involve the myocardium, pericardium, and cardiac valves.The purposes of this report are to (1) delineate the role of echocardiography in guiding a wide variety of interventional and electrophysiological procedures, (2) discuss the critical echocardiographic aspects of these procedures, and (3) delineate the intraprocedural differences between echocardiographic modalities, comparing transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and intracardiac echocardiography (ICE) wherever appropriate data are available. We have particularly emphasized the use of ICE where appropriate, because it is the newest of the echocardiographic modalities, and readers may be unaware of some potential applications. Table 1 provides a summary of literature data concerning the use of the different echocardiographic modalities for each of the specific procedures. This report is not intended to provide detailed instructions on “how to” perform these procedures; more specific procedural details are available for review in the referenced documents. Instead, we intend to highlight and illustrate the ways in which echocardiography has had an important impact in the procedures being performed and their outcomes. Summary recommendations are listed in boldface type at the end of each section.Table 1. Interventional procedures: use of echocardiography for guidance

Interventional Procedure	TTE	TEE	ICE
Transseptal catheterization	+	++	++ (radial or phased array)
PMBV	++	+++	++
Transcatheter closure of ASD, ventricular septal defect, and PFO	+	++	++ (phased array)
Alcohol septal ablation in HOCM	++	++	?
Percutaneous mitral valve repair	+	+++	+
Percutaneous left ventricular assist device placement	?	++	++
Percutaneous stented aortic valve prosthetic placement	?	+	+
Balloon or blade atrial septostomy	++	++	++
Placement of LAA occlusion devices	?	++	++
Myocardial and intravascular biopsy	++	++	++ (phased array)
Congenital heart disease applications (completion of Fontan procedure, coarctation repair)	+	+	+
Placement of aortic endograft	?	?	+ (radial or phased array)

?, No documented role or benefit in the literature; +, anecdotal reports of use and benefit exist, but further study is needed to delineate; ++, advantages favor use when available; +++, clearly documented benefit or role.     

Effect of White Mineral Trioxide Aggregate Mixed With Disodium Hydrogen Phosphate on Inflammatory Cells

IntroductionThe aim of this study was subjective evaluation of inflammatory cells subsequent to subcutaneous implantation of white mineral trioxide aggregate (WMTA) mixed with disodium hydrogen phosphate (Na₂HPO₄) in rats.MethodsForty Wistar rats were used in this study. Polyethylene tubes filled with WMTA mixed with Na₂HPO₄ and WMTA alone and also empty tubes serving as control were implanted into subcutaneous tissue and harvested after 7, 15, 30, and 90 days. Histologic sections were stained with hematoxylin-eosin and observed under a light microscope. Inflammatory reactions were categorized as 0 or none (without inflammatory cells), 1 or mild (inflammatory cells < 25), 2 or moderate (25–125 inflammatory cells), and 3 or severe (more than 125 inflammatory cells). Statistical analyses were performed with the Kruskal-Wallis and Mann-Whitney tests.ResultsWMTA alone provoked a moderate inflammatory reaction after 7 and 15 days, which significantly differed from WMTA mixed with Na₂HPO₄ and the control group, which provoked a mild inflammatory reaction (P < .05). However, there were no significant differences at any period beyond 30 days.ConclusionsThis study indicates that adding Na₂HPO₄ to WMTA creates a more biocompatible material than WMTA alone.     

VEGF and MVD expression in sinus augmentation with autologous bone and several graft materials

Objective:  The aim of this study was to assess vascular endothelial growth factor (VEGF) expression and microvessel density (MVD) in maxillary sinus augmentation with autogenous bone and different graft materials for evaluating their angiogenic potential.
Methods:  Biopsies were harvested 10 months after sinus augmentation with a combination of autogenous bone and different graft materials: hydroxyapatite (HA, n  =   6 patients), demineralized freeze-dried bone allograft (DFDBA, n  =   5 patients), calcium phosphate (CP, n  =   5 patients), Ricinus communis polymer ( n  =   5 patients) and control group – autogenous bone only ( n  =   13 patients).
Results:  In all the samples, higher intensities of VEGF expression were prevalent in the newly formed bone, while lower intensities of VEGF expression were predominant in the areas of mature bone. The highest intensity of VEGF expression in the newly formed bone was expressed by HA ( P  < 0.001) and CP in relation to control ( P  < 0.01) groups. The lowest intensities of VEGF expression in newly formed bone were shown by DFDBA and polymer groups ( P  <   0.05). When comparing the different grafting materials, higher MVD were found in the newly formed bone around control, HA and CP ( P  <   0.001).
Conclusion:  Various graft materials could be successfully used for sinus floor augmentation; however, the interactions between bone formation and angiogenesis remain to be fully characterized.