Objectives
To evaluate the long‐term impact of coronary artery disease (CAD) and heart team‐guided incomplete coronary revascularization in patients undergoing transcatheter aortic valve implantation ...(TAVI).
Background
Revascularization strategy of CAD diagnosed with routine coronary angiography before TAVI is uncertain.
Methods
Five hundred and forty consecutive TAVI patients were classified as having CAD or normal coronary arteries (no‐CAD). Within the CAD group, patients were further classified as those with complete (CR) versus incomplete revascularization (IR). Revascularization strategy was guided by the Heart Team following an algorithm largely based on current guidelines. Main outcome of interest was the incidence of 5‐year cardiovascular (CV) death.
Results
Prevalence of CAD was 53.9%. CAD patients showed significantly lower left ventricular ejection fraction (LVEF: 55.8 ± 13.4% CAD vs. 61.4% ± 12.1 no‐CAD, p < .0001), lower gradients, and larger ventricular volumes in comparison with the no‐CAD group. Within the CAD group, 138 patients (47.4%) received CR and 153 (52.6%) IR. In‐hospital mortality was 3.9%, without significant difference between groups (4.0% no‐CAD vs. 3.8% CAD, p = .88; 2.9% CR vs. 4.6% IR, p = .45). Median follow‐up was 57.8 months. Five‐year survival free from CV death was 79.6% in the CAD versus 77.9% in the no‐CAD group (p = .98), and 84.3% in the CR versus 74.3% in the IR groups (p = .25). These results were confirmed excluding patients with previous revascularization. At multivariable analyses, presentation with acute coronary syndrome (ACS) was significantly associated with 5‐year CV death.
Conclusions
CAD is frequent in patients undergoing TAVI but portends an adverse prognosis only when presenting with ACS. Heart‐team directed complete or reasonably incomplete revascularization was associated with comparable outcomes.
Background-It is recognized that inflammation is an underlying cause of dry eye disease (DED), with cytokine release involved. We systematically reviewed literature with meta-analyses to ...quantitatively summarize the levels of tear cytokines in DED. Methods-The PubMed, Embase, Web of Science, Ovid, Cochrane, and Scopus databases were reviewed until September 2019, and original articles investigating tear cytokines in DED patients were included. Differences of cytokines levels of DED patients and controls were summarized by standardized mean differences (SMD) using a random effects model. Study quality was assessed by applying Newcastle-Ottawa-Scale and the GRADE quality score. Methods of analytical procedures were included as covariate. Results-Thirteen articles investigating 342 DED patients and 205 healthy controls were included in the meta-analysis. The overall methodological quality of these studies was moderate. Systematic review of the selected articles revealed that DED patients had higher tear levels of interleukin (IL)-1β, IL-6, chemokine IL-8, IL-10, interferon-γ, IFN-γ, and tumor necrosis factor-α, TNF-α as compared to controls. Evidence was less strong for IL-2 and IL-17A. Conclusions-Data show that levels of tear cytokines in DED and control display a great variability, and further studies of higher quality enrolling a higher number of subjects are needed, to define a cut-off value.
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•SSM is the most useful non-invasive test to evaluate portal hypertension, presence of GEV, probability of decompensation.•SSM is an independent risk factor for HRV, alongside LSM, ...platelet count and Child-Pugh B.•SSM cut-off (≤46 kPa) shows better specificity, with same high sensitivity as Baveno VI in ruling out patients with HRV.•A new combined Baveno VI/SSM ≤46 model can safely avoid more endoscopies than Baveno VI or SSM ≤46 alone.
Recently, Baveno VI guidelines suggested that esophagogastroduodenoscopy (EGD) can be avoided in patients with compensated advanced chronic liver disease (cACLD) who have a liver stiffness measurement (LSM) <20 kPa and platelet count >150,000/mm3. We aimed to: assess the performance of spleen stiffness measurement (SSM) in ruling out patients with high-risk varices (HRV); validate Baveno VI criteria in a large population and assess how the sequential use of Baveno VI criteria and SSM could safely avoid the need for endoscopy.
We retrospectively analyzed 498 patients with cACLD who had undergone LSM/SSM by transient elastography (TE) (FibroScan®), platelet count and EGDs from 2012 to 2016 referred to our tertiary centre. The new combined model was validated internally by a split-validation method, and externally in a prospective multicentre cohort of 115 patients.
SSM, LSM, platelet count and Child-Pugh-B were independent predictors of HRV. Applying the newly identified SSM cut-off (≤46 kPa) or Baveno VI criteria, 35.8% and 21.7% of patients in the internal validation cohort could have avoided EGD, with only 2% of HRVs being missed with either model. The combination of SSM with Baveno VI criteria would have avoided an additional 22.5% of EGDs, reaching a final value of 43.8% spared EGDs, with <5% missed HRVs. Results were confirmed in the prospective external validation cohort, as the combined Baveno VI/SSM ≤46 model would have safely spared (0 HRV missed) 37.4% of EGDs, compared to 16.5% when using the Baveno VI criteria alone.
A non-invasive prediction model combining SSM with Baveno VI criteria may be useful to rule out HRV and could make it possible to avoid a significantly larger number of unnecessary EGDs compared to Baveno VI criteria only.
Spleen stiffness measurement assessed by transient elastography, the most widely used elastography technique, is a non-invasive technique that can help the physician to better stratify the degree of portal hypertension and the risk of esophageal varices in patients with compensated advanced chronic liver disease. Performing spleen stiffness measurement together with liver stiffness measurement during the same examination is simple and fast and this sequential model can identify a greater number of patients that can safely avoid endoscopy, which is an invasive and expensive examination.
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•Predictive factors for early and late recurrence of HCC are different.•Early recurrence of HCC is associated with underlying primary HCC and surgical techniques and strategies.•Late ...recurrence is associated with the degree of portal hypertension assessed by spleen stiffness measurement.
Hepatocellular carcinoma (HCC) is a frequent complication of liver disease. When feasible, hepatic resection is the first-choice therapy. However, tumor recurrence complicates at least 2/3 hepatic resections at 5 years. Early recurrences are mainly tumor or treatment-related, but predictors of late recurrences are undefined. We aimed to evaluate the factors related to HCC recurrence after curative resection, with liver and spleen stiffness measurement (LSM and SSM) as markers of severity and duration of the underlying liver disease.
We enrolled patients with chronic liver disease and primary HCC suitable for hepatic resection. We followed up patients for at least 30 months or until HCC recurrence. We performed uni- and multivariate analyses to evaluate the predictive role of tumor characteristics, laboratory data, LSM and SSM for both early and late recurrence of HCC.
We prospectively enrolled 175 patients. Early HCC recurrence at multivariate analysis was associated with viral etiology, HCC grading (3 or 4), resection margins <1 cm and being beyond the Milan criteria. HCC late recurrence at univariate analysis was associated with esophageal varices (hazard ratio HR 3.321, 95% CI 1.564–7.053), spleen length (HR 3.123, 95% CI 1.377–7.081), platelet/spleen length ratio if <909 (HR 2.170, 95% CI 1.026–4.587), LSM (HR 1.036, 95% CI 1.005–1.067), SSM (HR 1.046, 95% CI 1.020–1.073). HCC late recurrence at multivariate analysis was independently associated only with SSM (HR 1.046, CI 1.020–1.073). Late HCC recurrence-free survival was significantly different according to the SSM cut-off of 70 kPa (p = 0.0002).
SSM seems to be the only predictor of late HCC recurrence, since it is directly correlated with the degree of liver disease and portal hypertension, both of which are involved in carcinogenesis.
The main result of this study is that spleen stiffness measurement, evaluated by transient elastography, seems to be the only predictor of the late recurrence of hepatocellular carcinoma, defined as recurrence after 24 months from liver resection. Indeed, spleen stiffness measurement is directly correlated with the degree of liver disease and portal hypertension, which are both involved in carcinogenesis.
Background & Aims The hepatic vein pressure gradient (HVPG) is the standard used to determine the degree of portal hypertension (PH) and an important prognostic factor for patients with cirrhosis; ...HVPG values correlate with the presence of esophageal varices (EV). However, HVPG can only be accurately determined at specialized centers; noninvasive methods are needed to predict HVPG values and the presence of EV. We compared the diagnostic performance of spleen stiffness (SS) measurement by transient elastography with that of liver stiffness (LS) and of other recently proposed noninvasive tests. Methods We measured SS and LS in 100 consecutive patients with hepatitis C virus–induced cirrhosis. Patients were also assessed by FibroScan, HVPG, esophagogastroduodenoscopy, and liver biopsy. We also analyzed LS–spleen diameter to platelet ratio score and platelet count to spleen diameter. Results SS and LS were more accurate than other noninvasive parameters in identifying patients with EV and different degrees of PH. A linear model that included SS and LS accurately predicted HVPG values ( R2 = 0.85). The results were internally validated using bootstrap analysis. Conclusions Measurement of SS can be used for noninvasive assessment and monitoring of PH and to detect EV in patients with hepatitis C virus–induced cirrhosis.
Objectives
To determine whether the Flemish version of the Triage Risk Screening Tool (fTRST) can be used to accurately assess frailty in an emergency setting.
Design
Prospective observational study.
...Setting
of a tertiary referral hospital.
Patients
All individuals aged 70 and older consecutively admitted to the emergency surgery unit with an urgent need for abdominal surgery between December 2015 and May 2016 who met inclusion criteria (N=110).
Measurements
Individuals were screened with the fTRST and additional metrics such as the age‐adjusted Charlson Comorbidity Index and American Society of Anesthesiology score. Thirty‐ and 90‐day postoperative complications where recorded. Regression analyses were performed to identify possible preoperative predictors of adverse outcomes.
Results
Thirty‐day major complications (Clavien‐Dindo Classification 3–5) occurred in 28.2% of participants (n=31). fTRST had the highest correlation with major complications (odds ratio (OR) = 7.42). All participants who died within 30 days of surgery has a fTRST score of 2 or greater (area under the receiver operating curve (AUC)=71.3). When risk factors for overall 90‐day mortality were analyzed, a fTRST score of 2 or greater had sensitivity of 96% (95% confidence interval CI=79.6–99.9%), specificity of 43.5% (95% CI=32.8–54.7%) (AUC=69.8%; OR=18.50, 95% CI=2.39–143.11, p = .005). The average length of hospital stay was more than twice as long in the group with a fTRST score of 2 or greater (15.2 days) than in those with a score less than 2 (6.6 days) (p = .005).
Conclusion
The fTRST is an effective tool to predict mortality, morbidity, and length of stay after emergency surgery and can therefore be used to anticipate postoperative course, determine care goals, and plan for involvement of a dedicated geriatric care team. J Am Geriatr Soc 67:309–316, 2019.
We compared the results of 2 groups of patients who underwent aortic arch replacement with the frozen elephant trunk technique. In the first group, the distal anastomosis was performed in arch zone ...2; in the second control group, the distal anastomosis was performed in arch zone 3.
Between January 2007 and April 2018, the frozen elephant trunk technique was used in 282 patients. The median age was 62 years (range 18-83 years), and 233 patients were men (82.6%). Two different frozen elephant trunk prostheses were used: the Jotec E-vita open prosthesis in 167 patients (59.2%) and the Vascutek Thoraflex hybrid prosthesis in 115 patients (40.8%). Patients were divided into 2 groups according to the distal anastomosis site: zone 2 group (69 patients) and zone 3 group (213 patients). The main indications were chronic aortic dissection (n = 164, 58.2%), degenerative aneurysm (n = 72, 25.5%) and acute aortic dissections (n = 45, 16%).
The overall in-hospital mortality rate was 17%: 20% for the zone 2 group and 16% for the zone 3 group, without significant differences, also in terms of cardiopulmonary bypass and myocardial ischaemia times. However, the visceral ischaemia time was significantly shorter for the zone 2 group, whereas the antegrade selective cerebral perfusion time was significantly longer for the same group. Recurrent laryngeal nerve injury rate was lower in the zone 2 group. The overall postoperative paraplegia rate was 3.5%, whereas the occurrence of permanent neurological dysfunction and dialysis was 9% and 19%, respectively, with no significant differences between the groups.
'Proximalization' of the distal anastomosis can be used for arch reconstruction, especially in complex cases such as reoperations or acute aortic dissections. Furthermore, with the aid of branched hybrid grafts, a reduction of the visceral ischaemia time is achieved.
There is insufficient population-based data on group B streptococcus (GBS) late-onset disease (LOD). Risk factors and routes of GBS transmission are poorly understood.
A prospective, cohort study was ...conducted to collect incidence data on LOD and evaluate GBS infections over an 8-year period (2003-2010). Starting from January 2007, maternal rectovaginal and breast milk cultures were routinely collected on confirmation of the LOD diagnosis to assess maternal GBS culture status.
The incidence rate of LOD was 0.32 per 1000 live births (1.4 and 0.24 per 1000 live births for preterm and term newborns, respectively). The registered cases of LOD (n = 100) were classified as sepsis (n = 57), meningitis (n = 36), or focal infection (n = 7). Thirty neonates were preterm (2 had recurrent infection); 68 were term. Four infants died (3 early preterm, 1 term). At the time the LOD diagnosis was confirmed, 3 (6%) of 53 mothers had GBS mastitis, and 30 (64%) of 47 carried GBS at the rectovaginal site. Early (7-30 days) LOD presentation was associated with neonatal brain lesions or death (odds ratio: 0.96 95% confidence interval: 0.93-0.99). Intrapartum antibiotic exposure was significantly associated with mild (12 of 22) rather than severe (11 of 45; P = .03) LOD.
Preterm neonates had the highest rates of LOD and mortality. Most mothers carried GBS at the time of the LOD diagnosis, whereas 6% had mastitis. Intrapartum antibiotics were associated both with delayed presentation of symptoms and milder LOD.
Incidence and long-term clinical consequences of prosthesis-patient mismatch (PPM) after transcatheter aortic valve replacement (TAVR) are still unclear.
We enrolled 710 consecutive patients who ...underwent TAVR. PPM was defined as absent if the index orifice area (iEOA) was >0.85 cm2/m2, moderate if the iEOA was between 0.65 and 0.85 cm2/m2 or severe if the iEOA was <0.65 cm2/m2.
Among the 566 patients fulfilling the study criteria, the distribution of PPM was as follows: 50.5% none (n = 286), 43% moderate PPM (n = 243) and 6.5% severe PPM (n = 37). At 5-year follow-up, patients with severe PPM had a significantly higher incidence of the combined endpoint of cardiovascular death, acute myocardial infarction and stroke (p = .025) compared with the other patients. After adjusting the results for possible confounders, severe PPM remained an independent predictor of long-term adverse outcome (HR: 2.46; 95% Confidence Interval: 1.10–5.53). The independent predictors of severe PPM were valve-in-valve procedure and body mass index. Balloon-expandable valves were not associated with higher rates of severe PPM in comparison with self-expandable valves (8% vs. 5%, respectively, p = .245).
In our study severe PPM emerged as a risk factor for long-term major adverse cardiac and cerebrovascular events.
•Prosthesis-patient mismatch (PPM) after TAVR is common, although in most of the cases it is of moderate entity.•The presence of severe PPM, but not of moderate PPM, is associated with a worse prognosis at 5 years.•The independent predictors of severe PPM in our case series were valve-in-valve TAVR and body mass index.
Real-life data on the use of pirfenidone and nintedanib to treat patients with idiopathic pulmonary fibrosis (IPF) are still scarce.
We compared the efficacy of either pirfenidone (n = 78) or ...nintedanib (n = 28) delivered over a 24-month period in patients with IPF, followed at two regional clinic centers in Italy, with a group of patients who refused the treatment (n = 36), and who were considered to be controls. All patients completed regular visits at 1- to 3-month intervals, where primary forced vital capacity (FVC) and diffusing capacity of the lungs for carbon monoxide (DLCO) and secondary outcomes (side effects, treatment compliance, and mortality) were recorded.
Over time, the decline in FVC and DLCO was significantly higher (p = 0.0053 and p = 0.037, respectively) in controls when compared with the combined treated group, with no significant difference between the two treated groups. Compared to patients with less advanced disease (GAP (Gender, Age, Physiology) stage I), those in GAP stages II and III showed a significantly higher decline in both FVC and DLCO irrespective of the drug taken. Side effects were similarly reported in patients receiving pirfenidone and nintedanib (5% and 7%, respectively), whereas mortality did not differ among the three groups.
This real-life study demonstrated that both pirfenidone and nintedanib were equally effective in reducing the decline of FVC and DLCO versus non-treated patients after 24 months of treatment; however, patients with more advanced disease were likely to show a more rapid decline in respiratory function.
•Pirfenidone and nintedanib are the mostly used anti-fibrotic drugs for idiopathic pulmonary fibrosis (IPF).•Face to face, randomized controlled and real life studies are lacking.•In real life both drugs are effective in reducing the 24-month decline of Forced Vital Capacity and Diffusing Lung Capacity.•Sicker patients in both groups were likely to show a more rapid decline in respiratory function.
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