Transcatheter Versus Surgical Aortic Valve Replacement in Young,Low-Risk Patients With Severe Aortic Stenosis

Transcatheter aortic valve replacement (TAVR) is approved for all patient risk profiles and is an option for all patients irrespective of age. However, patients enrolled in the low- and intermediate-risk trials were in their 70s, and those in the high-risk trials were in their 80s. TAVR has never been systematically tested in young (<65 years), low-risk patients. Unanswered questions remain, including the safety and effectiveness of TAVR in patients with bicuspid aortic valves; future coronary access; durability of transcatheter heart valves; technical considerations for surgical transcatheter heart valve explantation; management of concomitant conditions such as aortopathy, mitral valve disease, and coronary artery disease; and the safety and feasibility of future TAVR-in-TAVR. The authors predict that balancing these questions with patients’ clear preference for less invasive treatment will become common. In this paper, the authors consider each of these questions and discuss risks and benefits of theoretical treatment strategies in the lifetime management of young patients with severe aortic stenosis.     

Risk of Coronary Obstruction During Redo-TAVR in Patients With Bicuspid Versus Tricuspid Aortic Valve Stenosis

ObjectivesThe aim of this study was to investigate the risk of coronary obstruction during redo–transcatheter aortic valve replacement (TAVR) within a previously implanted self-expanding valve in bicuspid aortic valve (BAV) versus tricuspid aortic valve (TAV) stenosis.BackgroundThe prevalence of BAV in TAVR patients is expected to increase as the indication expands; however, no study has investigated the risk of coronary obstruction for future redo-TAVR in these patients.MethodsComputed tomography (CT) simulation analysis was performed in 86 type 0 BAV, 70 type 1 BAV, and 132 TAV patients who underwent TAVR with 1 VenusA-Valve (Venus Medtech) between January 2014 and December 2019.ResultsCT-identified risk of coronary obstruction during redo-TAVR was observed in 36.1% of patients for the left coronary ostium (LCO) and 27.8% of patients for the right coronary ostium (RCO); however, the incidences were significantly lower in the type 0 BAV group than in the type 1 BAV or TAV group (for LCO: OR: 1.00 [reference] vs OR: 2.49; 95% CI: 1.24-5.01 vs OR: 2.60; 95% CI: 1.40-4.81; for RCO: OR: 1.00 [reference] vs OR: 2.14; 95% CI: 1.02-4.48 vs OR: 1.97; 95% CI: 1.02-3.80). The leaflet laceration technique may be unfeasible to improve coronary flow in 61.5% of the threatened LCOs and 58.8% of the threatened RCOs during redo-TAVR. The percentages were significantly or numerically lower in the type 0 BAV group than other groups (for LCO: 26.3% vs 62.1% vs 73.2%; P overall = 0.001; for RCO: 43.8% vs 65.2% vs 61.0%; P overall = 0.374).ConclusionsDifferences in anatomical features may impact the feasibility of future redo-TAVR. Type 0 BAV anatomy was associated with the lower incidence of CT-identified risk of coronary obstruction during redo-TAVR, and the leaflet laceration technique may be more feasible to ensure coronary flow in this population.     

医源性膈疝MSCT多平面重组表现

目的 分析食管癌术后继发医源性膈疝(IDH)的MSCT多平面重组(MPR)表现,探讨其诊断价值.方法 回顾性分析2010年1月至2014年3月间食管癌术后继发IDH 16例.将其CT号随机混编入其他50例食管癌术后无食管裂孔(EH)扩大患者队列,由2名不知研究目的从事腹部影像诊断的高年资医师分别就横断位和MPR图像进行判断.对不同医师、不同方法判断结果及影像表现差异采用x2检验.结果 16例IDH中3例局限性于EH,横断位2例呈假“肠套叠”征,1例呈肠扭转表现;MPR直观显示肠管挤入EH顶压胸腔胃呈“壁贴壁征”.13例超出EH范围,横断位表现为胸腔内肠管于各方向汇聚于EH处胸腔胃,其中,前外、后外及前后外侧分别为9例、5例和2例,前外侧明显多于前后外侧(x2 =6.79,P＜0.05),2例并肠系膜扭转;MPR直观显示胸腔内管肠及其系膜血管通过EH与腹腔相应结构连通.由2名医师横断位提示IGH诊断分别为3例和4例,MPR全部提示IDH诊断,均显著高于横断位(x2=21.89,19.20,P值均＜0.05).结论 食管癌术后继发IDH横断位表现隐匿,仔细观察并及时辅以MPR,对诊断具有重要意义.     

Rectal puncture complicating caudal blockade in a child with severe rectal distension

We describe a case of unrecognized rectal puncture following unsuccessful caudal blockade in a patient later found to have marked rectal distension on MRI. This may have contributed to the rectal injury.     

First,Do No Harm: Adverse Effects and the Need for Practice Standards in Neurofeedback

Adverse and iatrogenic effects associated with psychotherapy have been substantiated in research for more than 40 years. Controlled research also exists in the field of neurofeedback (electroencephalographic biofeedback) that documents that negative effects can occur from inappropriate training. This article presents accumulating evidence, taken directly from acknowledgments by neurofeedback practitioners of the existence of both transient side effects and of more serious adverse reactions that have occurred. Unlicensed and unqualified practitioners pose a risk to the public and to the integrity and future of the profession. It is vitally important that both professionals and professional societies emphasize standards of practice and that the public be protected from individuals seeking to use neurofeedback to work with medical, psychiatric, and psychological conditions for which they are not qualified and licensed to work. Some in the field propose pursuing biofeedback or psychophysiology licensure as a means to establish standards of practice and address ethical concerns. This is a reasonable option to consider, although it may take many years to implement in various states. In the meantime it is vitally important that individuals offering neurofeedback services for clinical diagnostic conditions be licensed to lawfully provide services for such conditions.     

Jejunal and Bladder Perforation: Complication of Intravesical Nd-YAG Laser Irradiation of Bladder Tumour

Nd-YAG laser coagulation is a therapeutic method for the treatment of refractory superficial bladder cancer. Complications resulting from its use are uncommon. We report a case of jejunal and bladder perforation 24 h after Nd-YAG bladder irradiation of a recurrent bladder tumour.     

Care and monitoring of the anaesthetized patient

Anaesthesia and surgery produce significant physiological changes in the human body. These significant changes mandate the need to monitor the continuously changing physiological parameters for patient safety and optimization. It is not uncommon to encounter iatrogenic harm to the patient during anaesthetic and surgical intervention. This article covers the importance of monitoring and interventions to reduce harm to the patients and promote safety.     

输尿管镜下电凝构建兔尿道狭窄模型

目的 采用输尿管镜下电凝建立兔尿道狭窄模型.方法 新西兰雄性兔18只,采用随机数字表法分为手术组(10只)、对照组(8只).采用自制电凝装置,在可视操作下,对手术组兔尿道球部进行环状多点位电凝,对照组仅实施尿道镜检查.术后第30天行逆行尿道造影和尿道镜检查,同时取手术组损伤段尿道组织及对照组相应部位尿道组织进行病理组织学观察.结果 成功建立兔尿道狭窄模型,实验过程中无实验动物死亡.术后30 d,手术组10只动物尿道球部均显示典型狭窄征象[狭窄段内径(1.69 ±0.28) mm,狭窄长度(16.93 ±2.82)mm];组织学观察显示狭窄段尿道上皮剥脱、缺失,黏膜下组织发生明显纤维化增生伴成纤维细胞浸润,Masson染色呈监色.对照组HE染色观察显示结构正常,Masson染色观察显示无纤维组织增生.结论 采用输尿管镜下电凝装置成功建立兔尿道狭窄模型,该方法具有操作简单、精确、成功率高等优点,可以为尿道狭窄研究提供良好的动物模型.     

医源性胆管损伤行胆管空肠吻合术后近远期疗效分析

目的探讨医源性胆管损伤行胆管空肠吻合术近远期疗效及影响疗效的主要危险因素。方法回顾性分析2004年1月至2018年12月安徽医科大学第一附属医院接诊胆囊切除术医源性胆管损伤行胆管空肠Rouxen-Y吻合术(HJ)36例病人临床资料。术后近期并发症采用Clavien-Dindo评分系统进行分级评价,远期疗效按Terblanche分级进行分级评价。单因素及多因素分析TerblancheⅣ级病人的高危因素。结果36例病人,8例(22.2%)病人出现Clavien-DindoⅢ级以上的近期并发症。中位随访时间为117个月(IQR 49~156个月)。远期随访疗效Terblanche分级显示:Ⅰ、Ⅱ级21例(58.3%);Ⅲ级6例(16.7%)间断性胆管炎发作保守治疗;Ⅳ级9例(25.0%)吻合口狭窄或结石形成伴胆管炎均接受再次手术治疗。吻合口狭窄或结石形成伴胆管炎的中位时间为24个月(IQR 12~60个月)。单因素分析显示,术前存在脓毒症、转诊前修复、围手术期Clavien-DindoⅢ级以上并发症和术后住院时间≥15 d与术后胆管狭窄或胆管结石形成伴胆管炎显著相关。多因素分析显示,术前存在脓毒症、转诊前修复和高位损伤(Stresberger分型E3-E5)是术后发生胆管狭窄或胆管结石形成伴胆管炎的独立危险因素。结论医源性胆管损伤可行HJ进行修复,损伤后由经验丰富的肝胆外科专科医师手术修复及术前感染控制是保证病人近期和远期疗效的重要条件。