Oral Anticoagulant Type and Outcomes After Transcatheter Aortic Valve Replacement

ObjectivesThe purpose of the study was to investigate the impact of oral anticoagulation (OAC) type on clinical outcomes 1 year after transcatheter aortic valve replacement (TAVR).BackgroundNon–vitamin K oral anticoagulants (NOACs) are superior to vitamin K antagonists (VKAs) in nonvalvular atrial fibrillation (AF), while their comparative performance among patients in need of OAC undergoing TAVR is underinvestigated.MethodsThe study enrolled 962 consecutive patients who underwent TAVR in 4 tertiary European centers and were discharged on either NOACs (n = 326) or VKAs (n = 636). By using propensity scores for inverse probability of treatment weighting (IPTW), the comparison of treatment groups was adjusted to correct for potential confounding.ResultsMean age and Society of Thoracic Surgeons score of the population were 81.3 ± 6.3 years and 4.5% (interquartile range: 3.0% to 7.3%); 52.5% were women and a balloon-expandable valve was used in 62.7% of cases. The primary outcome of interest, combined incidence of all-cause mortality, myocardial infarction, and any cerebrovascular event at 1-year after TAVR, was 21.2% with NOACs versus 15.0% with VKAs (hazard ratio [HR]: 1.44; 95% confidence interval [CI]: 1.00 to 2.07; p = 0.050, IPTW-adjusted). The 1-year incidence of any Bleeding Academic Research Consortium bleeds and all-cause mortality were comparable between the NOAC and VKA groups, 33.9% versus 34.1% (HR: 0.97; 95% CI: 0.74 to 1.26; p = 0.838, IPTW-adjusted) and 16.5% versus 12.2% (HR: 1.36; 95% CI: 0.90 to 2.06; p = 0.136, IPTW-adjusted), respectively.ConclusionsChronic use of both NOACs and VKAs among patients in need of OAC after TAVR are comparable regarding 1-year bleeding risk. The higher ischemic event rate observed with NOACs needs to be evaluated in large randomized trials.     

The effect of antenatal dexamethasone administration on the prevention of respiratory distress syndrome in preterm gestations with premature rupture of membranes

A prospective blinded randomized study was carried out to determine the effect of antepartum administration of dexamethasone on the incidence of respiratory distress syndrome in 250 patients with gestations between 28 and 33 weeks complicated by premature rupture of membranes. The incidence of respiratory distress syndrome was not lowered by the length of rupture of membranes in the 124 untreated patients. The overall incidence of respiratory distress syndrome was reduced from 51% to 25% by the administration of corticosteroids. Further, the dexamethasone-treated group had a statistical significant reduction in the incidence of intraventricular hemorrhage, total time of hospitalization, and average cost per patient. No statistical difference was encountered in the incidence of maternal or neonatal sepsis.     

A single-center experience of renal transplantation in elderly patients: a paired-kidney analysis

BACKGROUND: Chronic renal failure is a disease of the elderly. The elderly are the fastest growing population among dialysis patients and also on waiting lists for kidney transplantation. The objective for this study was to analyze the results of the renal transplantation in recipients elder than 60 years. To minimize the donor variability and bias, a paired kidney analysis was used. METHODS: The older renal transplantation (ORT) group included 44 patients (30 men, 14 women) aged 60 to 72 (mean 64+/-3) years. Their pairs created a younger renal transplantation (YRT) group consisting of 44 patients (30 men, 14 women) aged 14 to 59 (mean 40+/-12) years. RESULTS: Graft function estimated 1 year after transplantation applying abbreviated Modification of Diet in Renal Disease formula was significantly better in ORT (46.8+/-10.2 ml/min) versus YRT (43.7+/-16.8 ml/min). Studied groups (ORT vs. YRT) did not differ significantly with respect to 1-year patient survival (93.2% vs. 95.5%), 1-year graft survival (88.6% vs. 86.3%), 1-year death-censored graft survival (93% vs. 90.1%), and the incidences of delayed graft function and acute rejection. The most common complications noticed after ORT were cardiovascular complications, surgical complications, and infections. CONCLUSIONS: Our single-center results confirm that renal transplantation is a good option of renal replacement therapy in patients older than 60 years. Thorough recipient selection and preparation as well as customized immunosuppressive protocols are particularly important in that group of renal transplant recipients.     

Renal transplantation in dialysis patients with the history of coronary artery bypass grafting and cardiac valve replacement

Death with a functioning kidney is the most frequent cause of graft failure. Cardiovascular disease is the most frequent cause of death after renal transplantation. Therefore, prior to grafting, it is mandatory to diagnose and treat coronary artery disease and heart valve impairment. Transplantation is the best option for renal replacement therapy as far as the quality of life and life expectancy are concerned, although patients with such comorbidities may experience a higher short-term mortality risk. The objective for this study was to analyze both short- and long-term results of patients after coronary artery bypass grafting (CABG) or cardiac valve replacement (CVR). The cardiac surgery recipient group (CSR) included 16 patients (15 men, 1 woman) aged from 44 to 73 (mean 54.9 +/- 7.8) years. CABG was performed in 13/16 patients, and CVR in 3/16. The rest of our patients were treated as a comparative noncardiac surgery recipient (non-CSR) group. It consisted of 422 patients (264 men, 158 women) aged from 14 to 68 years (mean 43.2 +/- 12.9). The comparison revealed that graft function estimated at 1 year after transplantation was not different: serum creatinine concentrations of 1.7 +/- 0.2 and 1.6 +/- 0.5 mg/dL in CSR and non-CSR, respectively. One-year patient survival in the CVR group of 93.8% was slightly worse than that in the non-CSR group (97.9%), but death-censored 1-year graft survivals were comparable in both groups (93.8% vs 92%). Urinary tract and cytomegalovirus infections were the most common complications in the CSR group. One patient lost his graft in month 3(rd) due to many serious infectious complications. One patient died at the end of 12 months as a result of a cardiovascular event (1/16). Our single-center results confirm that transplantation in patients after CABG or CVR is a safe procedure; therefore, such patients should be referred into the waiting list.     

Electrocardiographic ST-T wave patterns, extent of coronary artery disease, and left ventricular performance following non-Q-wave myocardial infarction

Subendocardial, nontransmural, or non-Q-wave myocardial infarction (NQM) carries a serious prognosis. Many previous studies of NQMI include only patients without new Q waves at the time of infarction. Since the site of transmural MI (by Q waves) has implications concerning extent of coronary disease (CAD) and left ventricular (LV) dysfunction, we wondered what the extent of CAD and LV dysfunction is among acute MI patients who have neither new nor old Q waves. Furthermore, we sought to determine whether ST-T wave patterns or resting LV ejection fraction (EF), alone or combined, could separate NQMI patients with significant CAD from those with normal or nearly normal coronaries. Therefore, we retrospectively examined angiographic and electrocardiographic data in 55 symptomatic patients with NQMI. ST-T wave patterns on admission were classified as either ischemic (transient ST elevation, persistent horizontal ST depression, or persistent deep T wave inversion) or nonspecific. Eleven patients (20%) had normal or nearly normal coronaries (N); ten patients (18%) had one, seven patients (13%) had two, and 19 patients (34%) had three vessel CAD; eight patients (15%) had left main (LM) disease. Six of the 11 N patients had ergonovine tests and all six were negative. Segmental LV wall motion abnormalities (WMA) were commonly observed; however, diffuse LVWMA were present only among patients with three vessel and LM disease. EF was below 0.50 in 48% of patients with three vessel or LM disease. Although ischemic ST-T wave patterns were more common (P less than 0.05) among patients with significant CAD than among N patients, neither the ST-T wave pattern nor EF, alone or in combination, allowed confident separation of N patients from significant CAD patients. We conclude 1) A large proportion of NQMI patients have LM disease, three vessel disease, or normal or nearly normal coronaries. 2) Despite the absence of Q waves, LV dysfunction is common and the degree of LV impairment is worse among patients with more extensive CAD. 3) NQMI patients who may have normal or nearly normal coronaries cannot be reliably separated from NQMI patients with significant CAD on the basis of ST-T wave patterns or resting LVEF. 4) Coronary angiography appears warranted to assess the extent of CAD in symptomatic NQMI patients.     

Polymorphisms of the DNA Mismatch Repair Gene <Emphasis Type="BoldItalic">HMSH2</Emphasis> in Breast Cancer Occurence and Progression

Summary The response of the cell to DNA damage and its ability to maintain genomic stability by DNA repair are crucial in preventing cancer initiation and progression. Therefore, polymorphism of DNA repair genes may affect the process of carcinogenesis. The importance of genetic variability of the components of mismatch repair (MMR) genes is well documented in colorectal cancer, but little is known about its role in breast cancer. hMSH2 is one of the crucial proteins of MMR. We performed a case-control study to test the association between two polymorphisms in the hMSH2 gene: an A → G transition at 127 position producing an Asn → Ser substitution at codon 127 (the Asn127Ser polymorphism) and a G → A transition at 1032 position resulting in a Gly → Asp change at codon 322 (the Gly322Asp polymorphism) and breast cancer risk and cancer progression. Genotypes were determined in DNA from peripheral blood lymphocytes of 150 breast cancer patients and 150 age-matched women (controls) by restriction fragment length polymorphism and allele-specific PCR. We did not observe any correlation between studied polymorphisms and breast cancer progression evaluated by node-metastasis, tumor size and Bloom-Richardson grading. A strong association between breast cancer occurrence and the Gly/Gly phenotype of the Gly322Asp polymorphism (odds ratio 8.39; 95% confidence interval 1.44–48.8) was found. Therefore, MMR may play a role in the breast carcinogenesis and the Gly322Asp polymorphism of the hMSH2 gene may be considered as a potential marker in breast cancer.     

Genetic risk for alcoholic chronic pancreatitis

In recent years many studies have examined the genetic predisposition to pancreatic diseases. Pancreatic disease of an alcoholic etiology was determined to be a multi-factorial disease, where environmental factors interact with the genetic profile of the individual. In this review we discuss the main results from studies examining the frequency of genetic mutations in alcoholic chronic pancreatitis.