Prospective Evaluation of Transseptal TMVR for Failed Surgical Bioprostheses: MITRAL Trial Valve-in-Valve Arm 1-Year Outcomes

ObjectivesThe aim of this study was to assess 1-year clinical outcomes among high-risk patients with failed surgical mitral bioprostheses who underwent transseptal mitral valve-in-valve (MViV) with the SAPIEN 3 aortic transcatheter heart valve (THV) in the MITRAL (Mitral Implantation of Transcatheter Valves) trial.BackgroundThe MITRAL trial is the first prospective study evaluating transseptal MViV with the SAPIEN 3 aortic THV in high-risk patients with failed surgical mitral bioprostheses.MethodsHigh-risk patients with symptomatic moderate to severe or severe mitral regurgitation (MR) or severe mitral stenosis due to failed surgical mitral bioprostheses were prospectively enrolled. The primary safety endpoint was technical success. The primary THV performance endpoint was absence of MR grade ≥2+ or mean mitral valve gradient ≥10 mm Hg (30 days and 1 year). Secondary endpoints included procedural success and all-cause mortality (30 days and 1 year).ResultsThirty patients were enrolled between July 2016 and October 2017 (median age 77.5 years [interquartile range (IQR): 70.3 to 82.8 years], 63.3% women, median Society of Thoracic Surgeons score 9.4% [IQR: 5.8% to 12.0%], 80% in New York Heart Association functional class III or IV). The technical success rate was 100%. The primary performance endpoint in survivors was achieved in 96.6% (28 of 29) at 30 days and 82.8% (24 of 29) at 1 year. Thirty-day all-cause mortality was 3.3% and was unchanged at 1 year. The only death was due to airway obstruction after swallowing several pills simultaneously 29 days post-MViV. At 1-year follow-up, 89.3% of patients were in New York Heart Association functional class I or II, the median mean mitral valve gradient was 6.6 mm Hg (interquartile range: 5.5 to 8.9 mm Hg), and all patients had MR grade ≤1+.ConclusionsTransseptal MViV in high-risk patients was associated with 100% technical success, low procedural complication rates, and very low mortality at 1 year. The vast majority of patients experienced significant symptom alleviation, and THV performance remained stable at 1 year.     

Modified subintimal transcatheter withdrawal: A novel technique for hematoma decompression to facilitate distal reentry during coronary chronic total occlusion recanalization

A controlled antegrade dissection and reentry technique is the most commonly employed crossing strategy for long coronary chronic total occlusions. The development of compressive hematoma is a recognized complication and results in the impairment of distal vessel visualization and hinders successful reentry attempts. We describe a novel technique utilizing a widely available microcatheter to decompress the subintimal hematoma to restore distal visualization and allow successful reentry.     

The immune system and hypertension

Immunologic Research - A powerful interaction between the autonomic and the immune systems plays a prominent role in the initiation and maintenance of hypertension and significantly contributes to...     

Prevalence of chronic obstructive pulmonary disease and chronic bronchitis in eight countries: a systematic review and meta-analysis

ObjectiveTo estimate the prevalence of chronic obstructive pulmonary disease (COPD) and chronic bronchitis in eight countries in South Asia through a systematic review and meta-analysis.MethodsWe searched MEDLINE® Complete, Web of Science, Embase®, Scopus, CINAHL and reference lists of screened studies for research on the prevalence of COPD and chronic bronchitis in South Asian countries published between January 1990 and February 2021. We used standardized diagnostic criteria for definitions of COPD and chronic bronchitis. Two reviewers undertook study screening, full-text review, quality appraisal and data extraction.FindingsOf 1529 studies retrieved, 43 met the inclusion criteria: 32 provided data from India; four from Bangladesh; three from Nepal; two from Pakistan; and two from both India and Sri Lanka. Twenty-six studies used standardized diagnostic definitions and 19 were included in the meta-analysis. The estimated pooled prevalence of COPD was 11.1% (95% confidence interval, CI: 7.4–14.8%), using the Global Initiative for Chronic Obstructive Lung Disease fixed criteria and 8.0% (95% CI: 5.6–10.4%) using the lower limit of normal criteria. The prevalence of COPD was highest in north India (19.4%) and Bangladesh (13.5%) and in men. The estimated pooled prevalence of chronic bronchitis was 5.0% (95% CI: 4.1–6.0%) in India and 3.6% (95% CI: 3.1–4.0%) in Pakistan.ConclusionIncluded countries have a high prevalence of COPD although it varied by geographical area and study characteristics. Future research in South Asia should use standardized diagnostic criteria to examine the contribution of setting-specific risk factors to inform prevention and control strategies.     

A Retrospective Review of Histopathologic Features Associated with Increased Risk of Recurrence of Non-melanoma Skin Cancer After Mohs Micrographic Surgery

ObjectiveMohs micrographic surgery (MMS) is the gold standard treatment for non-melanoma skin cancer (NMSC). However, NMSC recurrence may occur in a small proportion of patients. The aim of this study was to identify histopathologic features seen on the final stage of previous MMS, which may increase the risk of NMSC recurrence.MethodsThis was a single-institution retrospective study of 39 recurrent basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs), which were treated with MMS. Slides from the final stage of previous MMS were reviewed by two board-certified dermatopathologists for the following histopathologic features: perineural inflammation, dense inflammation, mucin, ruptured follicle, actinic keratosis, and missing tissue.ResultsTwenty recurrent BCCs and 19 recurrent SCCs were included. Histopathologic features identified on the final stage of previous MMS included missing tissue from the epidermis, dermis, and/or subcutis (69%), actinic keratosis (51%), perineural inflammation (10%), and dense inflammation (8%). Ruptured follicle was present in one BCC case, and mucin was not identified in any cases.LimitationsLimitations include retrospective study design, small number of recurrent cases, single institution, and lack of a control group consisting of NMSC cases which did not recur after MMS.ConclusionMohs surgeons should carefully evaluate NMSC frozen sections for the presence of missing tissue, actinic keratosis, perineural inflammation, and dense inflammation as these histopathologic features may be associated with tumor recurrence. It is of paramount importance to acquire high quality frozen sections for thorough margin evaluation.     

Late spontaneous epigastric arterial bleeding associated with abciximab: successful percutaneous treatment with coil gel-foam embolization

We describe a case of spontaneous hemorrhage from a branch of the right inferior epigastric artery, unrelated to the access site. This complication occurred in association with the administration of abciximab. Prompt identification of this unusual complication resulted in successful bleeding control using coil and gel-foam embolization. Our purpose is to draw attention to yet another potentially catastrophic adverse side effect of abciximab infusion. To our knowledge, spontaneous rupture of an inferior epigastric artery during abciximab therapy has not been previously reported. In addition, the treatment of such an artery with coil and gel-foam has not been previously described. As with the other described complications, due diligence is required so that spontaneous arterial bleeding can be identified and swift intervention be taken.