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Utility of Omentoplasty in Mediastinitis Treatment following Sternotomy.

Fri, 06/16/2017 - 12:45
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Utility of Omentoplasty in Mediastinitis Treatment following Sternotomy.

Heart Surg Forum. 2016 12 01;19(6):E265-E268

Authors: Colak A, Kaya U, Ceviz M, Becit N, Sevil F, Kocak H

Abstract
BACKGROUND: Mediastinal infection is one of the most serious complications that occurs following open-heart surgery by sternotomy. In the present study, omentoplasty was initially and aggressively used to treat the infection and prevent the recurrence caused by bones in cases of mediastinitis following open-heart surgery at our clinic.
METHODS: Among the 3656 patients who underwent surgery at our department of cardiovascular surgery between January 1996 and December 2012, omentoplasty as a treatment for mediastinitis was applied to 19 (0.51%) patients (of which 13 were males) following sternotomy. The cases were revised on the 15th day following the first surgery and/or when there was a suspicion of mediastinal infection. The necrotic skin, subcutaneous tissue, and bone tissue were resected, and all the affected sternal tissues were removed until healthy hemorrhagic areas were reached.
RESULTS: The average age of the patients was between 49 and 81 years (mean: 65.7 ± 10.5 years). The mean age of the men was 66.08 ± 12.7 years (age range: 49-81 years) and that of the women was 63.2 ± 6.8 years (age range: 55-71 years). The male to female ratio was 2:1, and in both the male and female groups, the approximate age ranged from 55 and 70 years. In the intraoperative cultures received from wound cases, the most common agent of infection was methicillin-resistant coagulase-negative staphylococci. Purulent leaks from eight patients stopped in approximately 4 days. Purulent leaks from the other 11 patients continued until the 6th day, and thus, medical dressing also continued, after which the leaks stopped on the 15th day. The approximate postoperative hospital stay was 32 days (range: 13-63 days).
CONCLUSION: Omentoplasty in heart surgery can be considered an effective method when used to control infection and treat secondary poststernotomy mediastinitis.

PMID: 28054893 [PubMed - indexed for MEDLINE]

Primary Infected Left Ventricular Pseudoaneurysm and the Use of Omental Flap.

Fri, 06/16/2017 - 12:45
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Primary Infected Left Ventricular Pseudoaneurysm and the Use of Omental Flap.

Heart Surg Forum. 2016 12 01;19(6):E262-E264

Authors: Aru GM, Kim T, Aru RG, Vinson MC

Abstract
A 55-year-old man with autoimmune deficiency syndrome presented with an infected left ventricular pseudoaneurysm and sepsis. The aneurysmectomy consisted of a Dor-style pericardial patch plus debridement of the abscess cavities. The infected pseudoaneurysm recurred, much larger, within five months due to persistent infected abscess cavities. The second repair was done without a Dor-style patch and with an omental flap. No recurrence has occurred one year after the second repair, but the patient has asymptomatic, partial gastric herniation inside the pericardium. This is the first description of a primary infected left ventricular pseudoaneurysm. The omental flap contributed to the successful treatment.

PMID: 28054892 [PubMed - indexed for MEDLINE]

Extracorporeal Membrane Oxygenation in New York State: Trends, Outcomes, and Implications for Patient Selection.

Fri, 06/16/2017 - 12:45
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Extracorporeal Membrane Oxygenation in New York State: Trends, Outcomes, and Implications for Patient Selection.

Circ Heart Fail. 2016 Dec;9(12):

Authors: Batra J, Toyoda N, Goldstone AB, Itagaki S, Egorova NN, Chikwe J

Abstract
BACKGROUND: Utilization of extracorporeal membrane oxygenation (ECMO) is expanding despite limited outcome data defining appropriate use.
METHODS AND RESULTS: To quantify determinants of early and 1-year survival after ECMO in adult patients, we conducted a retrospective cohort analysis of 1286 patients aged ≥18 years who underwent ECMO in New York State from 2003 to 2014. Median follow-up time was 4.9 months (range, 0-12 months). ECMO utilization increased from 13 patients in 8 hospitals in 2003 to 330 patients in 30 hospitals in 2014. Compared with patients undergoing ECMO before 2009, later patients were older (54.4 versus 52.3 years; P=0.013) and more likely to have major comorbidity including chronic kidney disease (25.2% versus 13.2%; P=0.02) and liver disease (20.0% versus 10.7%; P=0.001). In the overall cohort, 30-day mortality was 52.2% (95% confidence interval, 49.5-54.9). Mortality at 30 days was 65.2% for patients aged ≥75 years (n=73/112) and 74.6% in patients who required cardiopulmonary resuscitation (n=91/122). Survival at 1 year was 38.4% (95% confidence interval, 35.7-41.0). The 30-day mortality and 1-year survival improved across the study period. In multivariable analysis, earlier year of ECMO, lower hospital volume, indication for ECMO after a cardiac procedure, cardiopulmonary resuscitation before ECMO placement, and age >65 years were independent predictors of worse survival.
CONCLUSIONS: Outcomes of ECMO have improved despite increasing comorbidity. Extreme mortality after ECMO in elderly patients and patients requiring cardiopulmonary resuscitation indicates that less invasive therapeutic or palliative modalities may be more appropriate in this end-of-life setting.

PMID: 27940495 [PubMed - indexed for MEDLINE]

Involvement of Macrophages in the Pathogenesis of Familial Amyloid Polyneuropathy and Efficacy of Human iPS Cell-Derived Macrophages in Its Treatment.

Fri, 06/16/2017 - 12:45
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Involvement of Macrophages in the Pathogenesis of Familial Amyloid Polyneuropathy and Efficacy of Human iPS Cell-Derived Macrophages in Its Treatment.

PLoS One. 2016;11(10):e0163944

Authors: Suenaga G, Ikeda T, Komohara Y, Takamatsu K, Kakuma T, Tasaki M, Misumi Y, Ueda M, Ito T, Senju S, Ando Y

Abstract
We hypothesized that tissue-resident macrophages in familial amyloid polyneuropathy (FAP) patients will exhibit qualitative or quantitative abnormalities, that may accelerate transthyretin (TTR)-derived amyloid deposition. To evaluate this, we examined the number and subset of tissue-resident macrophages in heart tissue from amyloid-deposited FAP and control patients. In both FAP and control patients, tissue-resident macrophages in heart tissue were all Iba+/CD163+/CD206+ macrophages. However, the number of macrophages was significantly decreased in FAP patients compared with control patients. Furthermore, the proportion of intracellular TTR in CD14+ monocytes was reduced in peripheral blood compared with healthy donors. Based on these results, we next examined degradation and endocytosis of TTR in human induced pluripotent stem (iPS) cell-derived myeloid lineage cells (MLs), which function like macrophages. iPS-MLs express CD163 and CD206, and belong to the inhibitory macrophage category. In addition, iPS-MLs degrade both native and aggregated TTR in a cell-dependent manner in vitro. Further, iPS-MLs endocytose aggregated, and especially polymerized, TTR. These results suggest that decreased tissue-localized macrophages disrupt clearance of TTR-derived amyloid deposits, leading to progression of a pathological condition in FAP patients. To improve this situation, clinical application of pluripotent stem cell-derived MLs may be useful as an approach for FAP therapy.

PMID: 27695122 [PubMed - indexed for MEDLINE]

CD4+ T lymphocytes produce adiponectin in response to transplants.

Thu, 06/15/2017 - 15:45

CD4+ T lymphocytes produce adiponectin in response to transplants.

JCI Insight. 2017 Jun 15;2(12):

Authors: Danturti S, Keslar KS, Steinhoff LR, Fan R, Dvorina N, Valujskikh A, Fairchild RL, Baldwin WM

Abstract
Adiponectin is a pleiotropic cytokine with diverse immunomodulatory effects on macrophages and lymphocytes. In the current paradigm, lymphocytes and macrophages respond to adiponectin that is produced by adipocytes and other parenchymal cells. Using a model of chronic arterial inflammation in cardiac transplants, we found that T cells derived from the recipient migrate to the heart and produce adiponectin locally. The evidence that T cells produce significant amounts of adiponectin is based on 3 experimental approaches. First, CD4+ T cells isolated from the blood and spleen after cardiac transplantation express mRNA for adiponectin. Second, reconstitution of T cell-deficient recipients with transgenic CD4+ T cells that express receptors for donor antigens results in arterial infiltrates containing T cells and increased mRNA expression for adiponectin in cardiac transplants. Third, CD4+ T cells isolated from the allograft secrete adiponectin in vitro. Taken together, these data indicate that adiponectin-competent cells originating in the recipient migrate into the transplant. Establishing T cells as a source of adiponectin provides a new dimension, to our knowledge, to the modulatory effects of adiponectin on immune responses.

PMID: 28614792 [PubMed - as supplied by publisher]

DNA Methylation and Hydroxymethylation Profile of CD34(+)-Enriched Cell Products Intended for Autologous CD34(+) Cell Transplantation.

Thu, 06/15/2017 - 15:45

DNA Methylation and Hydroxymethylation Profile of CD34(+)-Enriched Cell Products Intended for Autologous CD34(+) Cell Transplantation.

DNA Cell Biol. 2017 Jun 14;:

Authors: Rozman JZ, Pohar Perme M, Jez M, Malicev E, Krasna M, Vrtovec B, Rozman P

Abstract
Epigenetic dysregulation has been shown to limit functional capacity of aging hematopoietic stem cells, which may contribute to impaired outcome of hematopoietic stem cell-based therapies. The aim of our study was to gain better insight into the epigenetic profile of CD34(+)-enriched cell products intended for autologous CD34(+) cell transplantation in patients with cardiomyopathy. We found global DNA methylation content significantly higher in immunoselected CD34(+) cells compared to leukocytes in leukapheresis products (2.33 ± 1.03% vs. 1.84 ± 0.86%, p = 0.04). Global DNA hydroxymethylation content did not differ between CD34(+) cells and leukocytes (p = 0.30). By measuring methylation levels of 94 stem cell transcription factors on a ready-to-use array, we identified 15 factors in which average promoter methylation was significantly different between leukocytes and CD34(+) cells. The difference was highest for HOXC12 (58.18 ± 6.47% vs. 13.34 ± 24.18%, p = 0.0009) and NR2F2 (51.65 ± 25.89% vs. 7.66 ± 21.43%, p = 0.0045) genes. Our findings suggest that global DNA methylation and hydroxymethylation patterns as well as target methylation profile of selected genes in CD34(+)-enriched cell products do not differ significantly compared to leukapheresis products and, thus, can tell us little about the functional capacity and regenerative properties of CD34(+) cells. Future studies should examine other CD34(+) cell graft characteristics, which may serve as prognostic tools for autologous CD34(+) cell transplantation.

PMID: 28613929 [PubMed - as supplied by publisher]

Renal Function and Outcomes With Use of Left Ventricular Assist Device Implantation and Inotropes in End-Stage Heart Failure: A Retrospective Single Center Study.

Thu, 06/15/2017 - 15:45
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Renal Function and Outcomes With Use of Left Ventricular Assist Device Implantation and Inotropes in End-Stage Heart Failure: A Retrospective Single Center Study.

J Clin Med Res. 2017 Jul;9(7):596-604

Authors: Verma S, Bassily E, Leighton S, Mhaskar R, Sunjic I, Martin A, Rihana N, Jarmi T, Bassil C

Abstract
BACKGROUND: Left ventricular assist device (LVAD) and inotrope therapy serve as a bridge to transplant (BTT) or as destination therapy in patients who are not heart transplant candidates. End-stage heart failure patients often have impaired renal function, and renal outcomes after LVAD therapy versus inotrope therapy have not been evaluated.
METHODS: In this study, 169 patients with continuous flow LVAD therapy and 20 patients with continuous intravenous inotrope therapy were analyzed. The two groups were evaluated at baseline and at 3 and 6 months after LVAD or inotrope therapy was started. The incidence of acute kidney injury (AKI), need for renal replacement therapy (RRT), BTT rate, and mortality for 6 months following LVAD or inotrope therapy were studied. Results between the groups were compared using Mann-Whitney U test and Chi-square with continuity correction or Fischer's exact at the significance level of 0.05.
RESULTS: Mean glomerular filtration rate (GFR) was not statistically different between the two groups, with P = 0.471, 0.429, and 0.847 at baseline, 3 and 6 months, respectively. The incidence of AKI, RRT, and BTT was not statistically different. Mortality was less in the inotrope group (P < 0.001).
CONCLUSION: Intravenous inotrope therapy in end-stage heart failure patients is non-inferior for mortality, incidence of AKI, need for RRT, and renal function for 6-month follow-up when compared to LVAD therapy. Further studies are needed to compare the effectiveness of inotropes versus LVAD implantation on renal function and outcomes over a longer time period.

PMID: 28611860 [PubMed - in process]

Sex Differences in Mortality Based on United Network for Organ Sharing Status While Awaiting Heart Transplantation.

Thu, 06/15/2017 - 15:45
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Sex Differences in Mortality Based on United Network for Organ Sharing Status While Awaiting Heart Transplantation.

Circ Heart Fail. 2017 Jun;10(6):

Authors: Hsich EM, Blackstone EH, Thuita L, McNamara DM, Rogers JG, Ishwaran H, Schold JD

Abstract
BACKGROUND: There are sex differences in mortality while awaiting heart transplantation, and the reason remains unclear.
METHODS AND RESULTS: We included all adults in the Scientific Registry of Transplant Recipients placed on the heart transplant active waitlist from 2004 to 2015. The primary end point was all-cause mortality. Multivariable Cox proportional hazards models were performed to evaluate survival by United Network for Organ Sharing (UNOS) status at the time of listing. Random survival forest was used to identify sex interactions for the competing risk of death and transplantation. There were 33 069 patients (25% women) awaiting heart transplantation. This cohort included 7681 UNOS status 1A (26% women), 13 027 UNOS status 1B (25% women), and 12 361 UNOS status 2 (26% women). During a median follow-up of 4.3 months, 1351 women and 4052 men died. After adjusting for >20 risk factors, female sex was associated with a significant risk of death among UNOS status 1A (adjusted hazard ratio, 1.14; 95% confidence interval, 1.01-1.29) and UNOS status 1B (adjusted hazard ratio, 1.17; 95% confidence interval, 1.05-1.30). In contrast, female sex was significantly protective for time to death among UNOS status 2 (adjusted hazard ratio, 0.85; 95% confidence interval, 0.76-0.95). Sex differences in probability of transplantation were present for every UNOS status, and >20 sex interactions were identified for mortality and transplantation.
CONCLUSIONS: When stratified by initial UNOS status, women had a higher mortality than men as UNOS status 1 and a lower mortality as UNOS status 2. With >20 sex interactions for mortality and transplantation, further evaluation is warranted to form a more equitable allocation system.

PMID: 28611123 [PubMed - in process]

Whole Exome Sequencing Identifies Truncating Variants in Nuclear Envelope Genes in Patients With Cardiovascular Disease.

Thu, 06/15/2017 - 15:45
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Whole Exome Sequencing Identifies Truncating Variants in Nuclear Envelope Genes in Patients With Cardiovascular Disease.

Circ Cardiovasc Genet. 2017 Jun;10(3):

Authors: Haskell GT, Jensen BC, Samsa LA, Marchuk D, Huang W, Skrzynia C, Tilley C, Seifert BA, Rivera-Muñoz EA, Koller B, Wilhelmsen KC, Liu J, Alhosaini H, Weck KE, Evans JP, Berg JS

Abstract
BACKGROUND: The genetic variation underlying many heritable forms of cardiovascular disease is incompletely understood, even in patients with strong family history or early age at onset.
METHODS AND RESULTS: We used whole exome sequencing to detect pathogenic variants in 55 patients with suspected monogenic forms of cardiovascular disease. Diagnostic analysis of established disease genes identified pathogenic variants in 21.8% of cases and variants of uncertain significance in 34.5% of cases. Three patients harbored heterozygous nonsense or splice-site variants in the nucleoporin genes NUP37, NUP43, and NUP188, which have not been implicated previously in cardiac disease. We also identified a heterozygous splice site variant in the nuclear envelope gene SYNE1 in a child with severe dilated cardiomyopathy that underwent transplant, as well as in his affected father. To confirm a cardiovascular role for these candidate genes in vivo, we used morpholinos to reduce SYNE1, NUP37, and NUP43 gene expression in zebrafish. Morphant embryos displayed cardiac abnormalities, including pericardial edema and heart failure. Furthermore, lymphoblasts from the patient carrying a SYNE1 splice-site variant displayed changes in nuclear morphology and protein localization that are consistent with disruption of the nuclear envelope.
CONCLUSIONS: These data expand the repertoire of pathogenic variants associated with cardiovascular disease and validate the diagnostic and research use of whole exome sequencing. We identify NUP37, NUP43, and NUP188 as novel candidate genes for cardiovascular disease, and suggest that dysfunction of the nuclear envelope may be an under-recognized component of inherited cardiac disease in some cases.

PMID: 28611029 [PubMed - in process]

Congenitally corrected transposition: complex anatomic repair or Fontan pathway?

Thu, 06/15/2017 - 15:45
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Congenitally corrected transposition: complex anatomic repair or Fontan pathway?

Asian Cardiovasc Thorac Ann. 2017 Jan 01;:218492317717412

Authors: Marathe SP, Jones MI, Ayer J, Sun J, Orr Y, Verrall C, Nicholson IA, Chard RB, Sholler GF, Winlaw DS

Abstract
Background Successful anatomic repair of congenitally corrected transposition of the great arteries achieves excellent outcomes. Several centers report excellent long-term survival with the Fontan pathway as well. We have selectively applied both approaches depending on individual patient morphology, with anatomic repair preferred but utilizing the Fontan pathway when high technical complexity or operative risk is anticipated. Methods Hospital records over an 18-year period (1998-2016) were reviewed to identify patients with congenitally corrected transposition of the great arteries who underwent surgical management. Physiological repairs and hypoplastic ventricles were excluded. Patient- and procedure-related variables were reviewed. Results We identified 19 patients. Group 1 consisted of 12 anatomic repairs, of which 10 (83.3%) required prior interim staging procedures. Mean age at anatomic repair was 2.6 ± 1.3 years, mean follow-up was 8.7 ± 5.3 years. Nine (75%) patients experienced important complications and 4 (33.3%) required reintervention during follow-up. There were no deaths; one patient required heart transplantation. Group 2 (7 patients) underwent Fontan palliation. Mean age at Fontan completion was 7.2 ± 3.8 years, mean follow-up was 6.3 ± 4 years. There was no reintervention, death, or transplant. Conclusion Patients with congenitally corrected transposition of the great arteries and two adequate-sized ventricles do well with both anatomic repair and the Fontan pathway in the medium term. Excellent outcomes with reduced early complication and reintervention rates can be achieved for this cohort of patients when a strategy of avoiding complex anatomic repair in favor of the Fontan pathway is used.

PMID: 28610439 [PubMed - as supplied by publisher]

Femoral nerve block with propofol sedation versus general anesthesia in patients with severe cardiac dysfunction undergoing autologous myoblast sheet transplantation.

Wed, 06/14/2017 - 12:45

Femoral nerve block with propofol sedation versus general anesthesia in patients with severe cardiac dysfunction undergoing autologous myoblast sheet transplantation.

J Anesth. 2017 Jun 12;:

Authors: Okitsu K, Iritakenishi T, Iura A, Kuri M, Fujino Y

Abstract
PURPOSE: Regional anesthesia is more favorable than general anesthesia in patients with severe comorbidity; however, data on the superiority of peripheral nerve blocks over general anesthesia in patients with severe cardiac dysfunction are lacking. We aimed to demonstrate that peripheral nerve blocks reduce perioperative analgesic requirements and promote faster recovery compared to general anesthesia.
METHODS: We retrospectively evaluated intraoperative blood pressure, perioperative medications, and postoperative recovery in patients who underwent skeletal muscle harvesting for autologous myoblast sheet transplantation. We compared patients who received general anesthesia (group G, n = 27) to those who received femoral nerve block with propofol sedation (group B, n = 22).
RESULTS: Left ventricular ejection fraction was 24% on average, with no significant difference between groups. Compared with group G, a lower dose of propofol was used intraoperatively (1.25 versus 2.0 µg/mL, respectively; P < 0.001) and fewer patients required opioids (13.6 versus 100%, P < 0.01) in group B. Additionally, the lowest intraoperative mean blood pressure was higher (54 versus 48 mmHg, respectively; P = 0.02) in group B. More patients received postoperative analgesic drugs (51.9 versus 13.6%, P = 0.01) and they received them more frequently (1 [0-3] versus 0 [0-1], P = 0.02) in group G. The length of heart care unit stay was shorter in group B than group G (0 [0-18.5] versus 17 [0-47] h, respectively; P < 0.0001).
CONCLUSIONS: Femoral nerve block with sedation was more beneficial than general anesthesia in patients with severe cardiac dysfunction who underwent skeletal muscle harvesting for autologous myoblast sheet transplantation.

PMID: 28608253 [PubMed - as supplied by publisher]

ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease : A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association...

Wed, 06/14/2017 - 12:45

ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease : A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons.

J Nucl Cardiol. 2017 Jun 12;:

Authors: Patel MR, Calhoon JH, Dehmer GJ, Grantham JA, Maddox TM, Maron DJ, Smith PK

Abstract
The American College of Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and American Association for Thoracic Surgery, along with key specialty and subspecialty societies, have completed a 2-part revision of the appropriate use criteria (AUC) for coronary revascularization. In prior coronary revascularization AUC documents, indications for revascularization in acute coronary syndromes and stable ischemic heart disease (SIHD) were combined into 1 document. To address the expanding clinical indications for coronary revascularization, and to align the subject matter with the most current American College of Cardiology/American Heart Association guidelines, the new AUC for coronary artery revascularization were separated into 2 documents addressing SIHD and acute coronary syndromes individually. This document presents the AUC for SIHD.Clinical scenarios were developed to mimic patient presentations encountered in everyday practice. These scenarios included information on symptom status; risk level as assessed by noninvasive testing; coronary disease burden; and, in some scenarios, fractional flow reserve testing, presence or absence of diabetes, and SYNTAX score. This update provides a reassessment of clinical scenarios that the writing group felt were affected by significant changes in the medical literature or gaps from prior criteria. The methodology used in this update is similar to the initial document but employs the recent modifications in the methods for developing AUC, most notably, alterations in the nomenclature for appropriate use categorization.A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.As seen with the prior coronary revascularization AUC, revascularization in clinical scenarios with high symptom burden, high-risk features, and high coronary disease burden, as well as in patients receiving antianginal therapy, are deemed appropriate. Additionally, scenarios assessing the appropriateness of revascularization before kidney transplantation or transcatheter valve therapy are now rated. The primary objective of the AUC is to provide a framework for the assessment of practice patterns that will hopefully improve physician decision making.

PMID: 28608183 [PubMed - as supplied by publisher]

Quantitative Assessment of Pancreatic Texture Using a Durometer: A New Tool to Predict the Risk of Developing a Postoperative Fistula.

Wed, 06/14/2017 - 12:45

Quantitative Assessment of Pancreatic Texture Using a Durometer: A New Tool to Predict the Risk of Developing a Postoperative Fistula.

World J Surg. 2017 Jun 12;:

Authors: Marchegiani G, Ballarin R, Malleo G, Andrianello S, Allegrini V, Pulvirenti A, Paini M, Secchettin E, Boriero F, Di Benedetto F, Bassi C, Salvia R

Abstract
BACKGROUND: Pancreatic texture is one of the key predictors of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). Currently, the "gold standard" for assessment of pancreatic texture is surgeon's subjective evaluation through manual palpation.
AIM: To evaluate a new "durometer" that is able to assess quantitatively the pancreatic stiffness by measuring its elastic module (i.e., the resistance offered by the pancreatic stump when elastically deformed expressed in mPa).
METHODS: Measurements were obtained from the pancreatic remnant during 138 consecutive PDs performed at the Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust. Values were correlated to clinical features and, in particular, with the senior surgeon's evaluation of pancreatic texture (hard/soft). Sixteen beating-heart donors were used as a control group to assess the stiffness of a non-pathologic pancreas. Univariate analysis was performed for the assessment of POPF predictors.
RESULTS: Durometry allowed segregating between non-pathologic, soft and hard pancreas according to surgeon's evaluation (mean values 111 vs. 196 vs. 366 mPa, p < 0.01). There were no significant differences in stiffness with regard to histology, BMI, and neoadjuvant therapy. Larger tumors (>20 mm) and male sex were associated with greater stiffness on univariate analysis. Pancreatic texture, pancreatic duct size, BMI, prior neoadjuvant therapy, and histology were predictors of POPF. Patients who developed POPF showed a lesser stiffness (178 vs. 261 mPa, p = 0.05).
CONCLUSION: Assessment of pancreatic stiffness using a durometer correlated with the surgeon's evaluation of pancreatic texture. Measurement of pancreatic parenchymal stiffness is reliable and correlates with the development of POPF.

PMID: 28608016 [PubMed - as supplied by publisher]

Cochrane Corner: stem cell therapy for chronic ischaemic heart disease and congestive heart failure.

Wed, 06/14/2017 - 12:45

Cochrane Corner: stem cell therapy for chronic ischaemic heart disease and congestive heart failure.

Heart. 2017 Jun 12;:

Authors: Fisher SA, Doree C, Mathur A, Taggart DP, Martin-Rendon E

PMID: 28607164 [PubMed - as supplied by publisher]

2017 ACC/AHA/HFSA/ISHLT/ACP Advanced Training Statement on Advanced Heart Failure and Transplant Cardiology (Revision of the ACCF/AHA/ACP/HFSA/ISHLT 2010 Clinical Competence Statement on Management of Patients With Advanced Heart Failure and Cardiac...

Wed, 06/14/2017 - 12:45

2017 ACC/AHA/HFSA/ISHLT/ACP Advanced Training Statement on Advanced Heart Failure and Transplant Cardiology (Revision of the ACCF/AHA/ACP/HFSA/ISHLT 2010 Clinical Competence Statement on Management of Patients With Advanced Heart Failure and Cardiac Transplant): A Report of the ACC Competency Management Committee.

Circ Heart Fail. 2017 Jun;10(6):

Authors: Jessup M, Drazner MH, Book W, Cleveland JC, Dauber I, Farkas S, Ginwalla M, Katz JN, Kirkwood P, Kittleson MM, Marine JE, Mather P, Morris AA, Polk DM, Sakr A, Schlendorf KH, Vorovich EE

PMID: 28607153 [PubMed - in process]

Can immunosuppression be stopped after liver transplantation?

Wed, 06/14/2017 - 12:45

Can immunosuppression be stopped after liver transplantation?

Lancet Gastroenterol Hepatol. 2017 Jul;2(7):531-537

Authors: Clavien PA, Muller X, de Oliveira ML, Dutkowski P, Sanchez-Fueyo A

Abstract
Liver transplantation has improved dramatically over the past three decades, mainly as a result of advances in surgical techniques and management of post-transplant complications. The focus has now turned towards rescuing additional organs in the face of scarce organ supply, or prevention of long-term toxicity associated with immunosuppression. The liver appears to be privileged in terms of immune tolerance, with a low incidence of antibody-mediated rejection, which is in sharp contrast to other solid organ transplants, such as kidney, lung, and heart transplants. However, tolerogenic processes remain poorly understood, and strategies for complete drug withdrawal should be selected carefully to avoid graft rejection. In this Review, we summarise the current understanding of liver-specific immune responses and provide an outlook on future approaches.

PMID: 28606879 [PubMed - in process]

Impact of a modified anti-thrombotic guideline on stroke in children supported with a pediatric ventricular assist device.

Wed, 06/14/2017 - 12:45

Impact of a modified anti-thrombotic guideline on stroke in children supported with a pediatric ventricular assist device.

J Heart Lung Transplant. 2017 May 20;:

Authors: Rosenthal DN, Lancaster CA, McElhinney DB, Chen S, Stein M, Lin A, Doan L, Murray JM, Gowan MA, Maeda K, Reinhartz O, Almond CS

Abstract
BACKGROUND: Stroke is the most feared complication associated with the Berlin Heart EXCOR pediatric ventricular assist device (VAD), the most commonly used VAD in children, and affects 1 in 3 children. We sought to determine whether a modified anti-thrombotic guideline, involving more intense platelet inhibition and less reliance on platelet function testing, is associated with a lower incidence of stroke.
METHODS: All children supported with the EXCOR at Stanford from 2009 to 2014 were divided into 2 cohorts based on the primary anti-thrombotic guideline used to prevent pump thrombosis: (1) the Edmonton Anti-thrombotic Guideline (EG) cohort, which included children implanted before September 2012 when dual anti-platelet therapy was used with doses titrated to Thromboelastrography/PlateletMapping (TEG/PM); and (2) the Stanford Modified Anti-thrombotic Guideline (SG) cohort, which included children implanted on or after September 2012 when triple anti-platelet therapy was used routinely and where doses were uptitrated to high, weight-based dosing targets, with low-dose steroids administered as needed for inflammation.
RESULTS: At baseline, the EG (N = 16) and SG (N = 11) cohorts were similar. The incidence rate of stroke in the SG cohort was 84% lower than in the EG cohort (0.8 vs 4.9 events per 1,000 days of support, p = 0.031), and 86% lower than in the previous Investigational Device Exemption trial (p = 0.006). The bleeding rate was also lower in the SG cohort (p = 0.015). Target doses of aspirin, clopidogrel and dipyridamole were higher (all p < 0.003), with less dosing variability in the SG cohort than in the EG cohort. There was no difference in adenosine diphosphate inhibition by TEG/PM, but arachidonic acid inhibition was higher in the SG cohort (median 75% vs 39%, p = 0.008).
CONCLUSIONS: Stroke was significantly less common in pediatric patients supported with the Berlin Heart EXCOR VAD using a triple anti-platelet regimen uptitrated to high, weight-based dosing targets as compared with the dual anti-platelet regimen titrated to PM, and without a higher risk of bleeding. Larger studies are needed to confirm these findings.

PMID: 28606584 [PubMed - as supplied by publisher]

Biological and mechanical evaluation of a Bio-Hybrid scaffold for autologous valve tissue engineering.

Wed, 06/14/2017 - 12:45
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Biological and mechanical evaluation of a Bio-Hybrid scaffold for autologous valve tissue engineering.

Mater Sci Eng C Mater Biol Appl. 2017 Apr 01;73:59-71

Authors: Jahnavi S, Saravanan U, Arthi N, Bhuvaneshwar GS, Kumary TV, Rajan S, Verma RS

Abstract
Major challenge in heart valve tissue engineering for paediatric patients is the development of an autologous valve with regenerative capacity. Hybrid tissue engineering approach is recently gaining popularity to design scaffolds with desired biological and mechanical properties that can remodel post implantation. In this study, we fabricated aligned nanofibrous Bio-Hybrid scaffold made of decellularized bovine pericardium: polycaprolactone-chitosan with optimized polymer thickness to yield the desired biological and mechanical properties. CD44(+), αSMA(+), Vimentin(+) and CD105(-) human valve interstitial cells were isolated and seeded on these Bio-Hybrid scaffolds. Subsequent biological evaluation revealed interstitial cell proliferation with dense extra cellular matrix deposition that indicated the viability for growth and proliferation of seeded cells on the scaffolds. Uniaxial mechanical tests along axial direction showed that the Bio-Hybrid scaffolds has at least 20 times the strength of the native valves and its stiffness is nearly 3 times more than that of native valves. Biaxial and uniaxial mechanical studies on valve interstitial cells cultured Bio-Hybrid scaffolds revealed that the response along the axial and circumferential direction was different, similar to native valves. Overall, our findings suggest that Bio-Hybrid scaffold is a promising material for future development of regenerative heart valve constructs in children.

PMID: 28183649 [PubMed - indexed for MEDLINE]

Single-Center Experience With the Senning Procedure in the Current Era.

Wed, 06/14/2017 - 12:45
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Single-Center Experience With the Senning Procedure in the Current Era.

Semin Thorac Cardiovasc Surg. 2016 Summer;28(2):514-520

Authors: Ferro G, Murthy R, Sebastian VA, Guleserian KJ, Forbess JM

Abstract
The Senning procedure is an operative technique for atrial inversion in congenital heart anomalies. We sought to evaluate our contemporary outcomes employing this technique. A retrospective analysis of all patients who underwent the Senning procedure at our institution was performed. Hospital records were reviewed, and follow-up data were obtained to evaluate outcomes. Overall, a total of 19 patients underwent a Senning procedure between August 2005 and July 2014. Median age at repair was 594 days (range: 5 days to 15 years). Of those, 7 patients underwent a combined Senning-Rastelli operation and 10 patients underwent a double switch operation (arterial switch or atrial switch). Primary diagnosis was congenitally corrected transposition of the great arteries (cc-TGA) in 17 patients. Associated lesions included ventricular septal defect (n = 10), pulmonary stenosis or atresia (n = 7), and Ebstein׳s anomaly of the tricuspid valve (n = 4). There was an operative death (5%). In all, 2 patients required superior vena cava baffle revision in the operating room. No new pulmonary venous or systemic venous baffle obstruction was observed during follow-up. A total of 5 (26%) patients developed heart block requiring pacemaker implantation. Actuarial survival was 81% at 5 years with a median follow-up of 38 months. The 2 patients in the cc-TGA group were subsequently transplanted. Surviving patients (n = 15) are all well at the last clinical follow-up, most with normal biventricular function. In conclusion, the Senning procedure offers excellent outcomes with regard to systemic and pulmonary venous baffle patency. Results in patients with cc-TGA, however, are affected by significant early mortality after Senning-Rastelli and incidence of left ventricular dysfunction after double switch; which should be considered during patient selection and surgical planning.

PMID: 28043470 [PubMed - indexed for MEDLINE]

Cardiosphere-Derived Cells Facilitate Heart Repair by Modulating M1/M2 Macrophage Polarization and Neutrophil Recruitment.

Wed, 06/14/2017 - 12:45
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Cardiosphere-Derived Cells Facilitate Heart Repair by Modulating M1/M2 Macrophage Polarization and Neutrophil Recruitment.

PLoS One. 2016;11(10):e0165255

Authors: Hasan AS, Luo L, Yan C, Zhang TX, Urata Y, Goto S, Mangoura SA, Abdel-Raheem MH, Zhang S, Li TS

Abstract
Cardiosphere-derived cells (CDCs), one of the promising stem cell sources for myocardial repair, have been tested in clinical trials and resulted in beneficial effects; however, the relevant mechanisms are not fully understood. In this study, we examined the hypothesis that CDCs favor heart repair by switching the macrophages from a pro-inflammatory phenotype (M1) into a regulatory anti-inflammatory phenotype (M2). Macrophages from mice were cultured with CDCs-conditioned medium or with fibroblasts-conditioned medium as a control. Immunostaining showed that CDCs-conditioned medium significantly enhanced the expression of CD206 (a marker for M2 macrophages), but decreased the expression of CD86 (a marker for M1 macrophages) 3 days after culture. For animal studies, we used an acute myocardial infarction model of mice. We injected CDCs, fibroblasts, or saline only into the border zone of infarction. Then we collected the heart tissues for histological analysis 5 and 14 days after treatment. Compared with control animals, CDCs treatment significantly decreased M1 macrophages and neutrophils but increased M2 macrophages in the infarcted heart. Furthermore, CDCs-treated mice had reduced infarct size and fewer apoptotic cells compared to the controls. Our data suggest that CDCs facilitate heart repair by modulating M1/M2 macrophage polarization and neutrophil recruitment, which may provide a new insight into the mechanisms of stem cell-based myocardial repair.

PMID: 27764217 [PubMed - indexed for MEDLINE]

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