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This article discusses the debate between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) as treatment options for left main coronary artery (LMCA) disease. Previous studies have shown that CABG is the standard therapy for LMCA disease, but there is limited evidence comparing PCI and CABG specifically for patients with LMCA disease and diabetes. A recent meta-analysis of four randomized clinical trials found that overall 5-year survival was similar between PCI and CABG for patients with LMCA disease, regardless of diabetic status. However, CABG was associated with improved 5-year survival in diabetic patients with high overall atherosclerotic disease burden. The study suggests that the choice between PCI and CABG should be based on individual patient characteristics and preferences. [Extracted from the article]

Background: Global photographs (GPs) have been widely used to grade the severity in female pattern hair loss (FPHL). However, existing classifications for FPHL are not useful in the evaluation of early FPHL. Although there are some variations in early FPHL, even to a mild degree, all types of early FPHL are included in just one category. Therefore, the authors have devised a grading system for early FPHL with five levels focusing on the changes revealed by the surface reflected light of flash generated on GPs. Aims: This study aims to examine the possibility of evaluating the treatment course of early FPHL using the grading system based on changes in hair surface reflection patterns. Subjects and Methods: Retrospective chart review of 114 early FPHL patients was performed. GPs of these patients were classified into five grades. Photographs of the lowest and the highest grades of each patient were selected and paired. First, the relevance between the value of FPHL-severity index (FPHL-SI) and grades of all the selected photos was analyzed. Next three volunteers graded the paired photographs and chose the milder degree, and then, the concordance rate among author's and volunteers' evaluations were analyzed. Results: The value of FPHL-SI and incidence rate of hair diameter diversity tended to rise along with increasing of GP grade. Concordance rate of grading among author and more than two volunteers was 57%. The concordance rate of course evaluation between author and two volunteers was 97%. Conclusion: The new classification can finely classify the grade of early FPHL and can be used for treatment course evaluation. [ABSTRACT FROM AUTHOR]

Background There have been few reports on the efficacy and safety of oral propranolol at 3 mg/kg/day for infantile hemangioma ( IH) in Japanese patients. Methods A multicenter, open-label phase III study was conducted to evaluate the efficacy and safety of oral propranolol solution in Japanese infants aged 35-150 days with proliferating IH. Thirty-two patients were enrolled in the study, received propranolol solution for 24 weeks at 3 mg/kg/day, and completed the study. Results The success rate (complete or nearly complete resolution) at week 24 (primary endpoint) was 78% (95% CI: 60-91%). The improvement rate since the previous visit was 100% (32/32) after week 5. Overall, the IH surface area, maximum diameter, and color intensity all decreased over time. Consistency in assessment between the centralized and the investigator on-site assessments was observed in 26 patients. Of the 32 patients, 11 needed further treatment other than the study drug. The incidence of adverse events ( AE) and drug-related AE was 97% and 31%, respectively. AE that occurred in ≥two patients were either typical of propranolol use (such as blood pressure decrease) or common events in infants. AE that resulted in dose reduction were observed in two patients, but no serious AE or AE that led to study drug discontinuation were observed. Conclusion Oral propranolol solution at 3 mg/kg/day is effective and safe in Japanese IH patients. [ABSTRACT FROM AUTHOR]

Implantation of prosthetic valve requires consideration for anticoagulation. The current guideline recommends warfarin on all mechanical valves. Dabigatran is the newgeneration anticoagulation medication which is taken orally and does not require frequent monitoring. This drug is approved for treatment for atrial fibrillation and venous thromboembolism, but the latest large trial showed that this drug increases adverse events when used for mechanical valve anticoagulation. On-X valve is the new generation mechanical valve which is considered to require less anticoagulation due to its flow dynamics. The latest study showed that lower anticoagulation level lowers the incidence of bleeding, while the risk of thromboembolism and thrombosis remained the same. Anticoagulation poses dilemma in cases such as pregnancy and major bleeding event. During pregnancy, warfarin can be continued throughout pregnancy and switched to heparin derivative during 6-12 weeks and >36 weeks of gestation. Warfarin can be safely started after 1-2 weeks of discontinuation following major bleeding episode. [ABSTRACT FROM AUTHOR]

Abstract: A trace amount of vegetable oil was picked up with solid-phase microextraction (SPME) fiber and identified using a gas chromatograph–mass spectrometer (GC–MS). Unsaponifiable constituents such as sterols could be detected by an injection of the SPME fiber, with the fiber touching the vegetable oil and then leading directly into the port of the GC–MS. After thermal desorption of unsaponifiable constituents, the remaining triacylglycerols or oil that was freshly added to the fiber were recovered with a little organic solvent, and the profiles of the fatty acids that had been constructing the acylglycerols were determined using a base-catalyzed trans-esterification method which produced fatty acid methyl esters. The simple and rapid techniques that make up this method make it possible to significantly reduce the preparation time and as well as the required sample volume. When urgent discrimination is required with high accuracy, this technique could serve as a useful and powerful tool for identification of vegetable oil. [Copyright &y& Elsevier]

Abstract: In Japan, taxed diesel fuel from non-taxed fuel oil-A is illegally produced by removing coumarin, which is added as a non-taxed marker. The coumarin is removed using concentrated sulfuric acid and this produces a high viscosity and hazardous material, called “sulfuric acid pitch”, as a by-product. This compound has a detrimental effect on the environment and is hazardous to humans. The actions have been associated with organized crime with the illegally gained taxes becoming financial bases. To discriminate legal and diesel oil from illegal product, the peak area ratio R SC, the ratio of total sulfur to carbon (>C14), was used. R SC is calculated by the total areas of sulfur and carbon (>C14) from the gas chromatogram obtained by gas chromatography-atomic emission detection (GC-AED). Sulfur in legal diesel fuels is strictly regulated by a maximum limit, which was 50ppm (and is now 10ppm), but in the preparation of illegal diesel oil, in which coumarin is eliminated, sulfur cannot be removed. Therefore, the R SC of fuel oil-A and illegal fuel oil is over 15, whereas those for legal fuel oil and diesel fuel are under 2.0. Furthermore, these ratios do not change in weathering experiments. GC-AED was applied to an actual arson case and was found to be effective for the determination of total sulfur in trace amounts of accelerants detected in fire debris at the arson scene, and hence was effective for the characterization of the ignitable liquids used. [Copyright &y& Elsevier]

A solid-phase microextraction (SPME) procedure involving direct contact between the SPME fibers and the solid matrix and subsequent gas chromatography/mass spectrometric analysis for the detection of accelerants in fire debris is described. The extraction performances of six fibers (100 μm polydimethylsiloxane, 65 μm polydimethylsiloxane-divinylbenzene, 85 μm polyacrylate, 85 μm carboxen-polydimethylsiloxane, 70 μm Carbowax-divinylbenzene, and 50/30 μm divinylbenzene-Carboxen-polydimethylsiloxane) were investigated by directly immersing the fibers into gasoline, kerosene, and diesel fuel. For simulated fire debris, in the direct contact extraction method, the SPME fiber was kept in contact with the fire debris matrix during extraction by penetrating plastic bags wrapping the sample. This method gave comparable results to the headspace SPME method in the extraction of gasoline and kerosene, and gave an improved recovery of low-volatile components in the extraction of diesel fuel from fire debris. The results demonstrate that this procedure is suitable as a simple and rapid screening method for detecting ignitable liquids in fire debris packed in plastic bags. [ABSTRACT FROM AUTHOR]

Gastric complications of indomethacin involve generation of reactive oxygen species, which induce gastric mucosal injury via lipid peroxidation of cell membranes. Peroxidation by reactive oxygen species alters the amounts of unsaturated fatty acids in the cell membrane and thus affects membrane fluidity. Indomethacin-induced lipid peroxidation can thus be detected by measuring cellular membrane fluidity by the fluorescence polarization (FP) method. The aim of this study was to elucidate the usefulness of the FP method for detecting indomethacin-induced gastric cellular injury in RGM-1 cells. Indomethacin-treated RGM-1 cells were investigated by conventional cytotoxicity assay, fluorometry of diphenyl-1-pyrenylphosphine (DPPP) to detect lipid peroxidation, and FP. The effects of both a radical scavenger and an initiator on membrane fluidity change (MFC) in RGM-1 cells were examined. The sensitivity of FP in detecting cellular injury was compared with those of DPPP fluorometry and conventional cytotoxicity measurements. Indomethacin caused an increase in MFC as determined by FP before cytotoxicity was detected by conventional methods. The increase in MFC was associated with increased membrane phospholipid peroxidation (MPP) but not with a prostaglandin deficiency, and the increases in both MFC and MPP were prevented by vitamin E. The FP method is potentially useful for detecting cellular injury in vitro. [ABSTRACT FROM AUTHOR]

The most recent guidelines recommend SAVR and CABG for patients who require both aortic valve replacement and revascularization.[4],[5] The guideline, however, is fluid and is subject to change as the evidence evolves. Their design compared TAVR and PCI with SAVR and CABG in patients with symptomatic aortic stenosis, stratified by the need for revascularization. Previous randomized controlled studies of high-risk patients have excluded patients who required coronary revascularization. [Extracted from the article]

One-stage degradation process was observed for a poly(methyl methacrylate) (PMMA) sample. The fractional conversion αmax at the maximum reaction rate is thus applied to determine reaction order of the thermal degradation. It is found that the PMMA degraded in the first order kinetics with weight loss. This is consistent with the fact that PMMA thermally degrades into its monomer. Activation energy was calculated. Compensation effect of the Arrhenius parameters is also found. [Copyright &y& Elsevier]

It is shown that a first-order reaction model cannot be applied to describe thermal degradation of polypropylene. The appropriate reaction order was determined to be 0.35 by using the degree of conversion at the maximum degradation rate measured under dynamic conditions. The validity of the reaction order thus determined was verified by similarity of activation energy between the single heating rate plot and the isoconversional plot. The reaction order was also supported by the consistency of the Arrhenius parameters of isothermal degradation with dynamic degradation. [Copyright &y& Elsevier]

Aortic stenosis (AS) is common, especially among the elderly. Left untreated, severe symptomatic AS is typically fatal. Surgical aortic valve replacement (SAVR) was the standard of care until transcatheter aortic valve replacement (TAVR) was shown to have lower mortality rates in patients at the highest surgical risk and was recommended for this group in the 2014 American Heart Association/American College of Cardiology (AHA/ACC) guidelines. In the 2017 AHA/ACC focused update, evidence of benefit and noninferiority extended the use of TAVR to intermediate-risk patients. More recent studies suggest potential benefit to low-risk patients, although no published guidelines yet recommend the use of TAVR for this population. An advantage of SAVR is a 30-year experience with valve durability, but SAVR may have higher rates of perioperative death and a slower return of quality of life. Although TAVR has less than 10-year experience with valve durability, it has lower or noninferior primary end points, such as mortality and stroke, and fewer periprocedural complications among anatomically permissive patients. Here, a cardiologist and a cardiothoracic surgeon debate the risks and benefits of TAVR versus SAVR for a patient with severe symptomatic AS who is at low risk for surgical death. [ABSTRACT FROM AUTHOR]

Evidence is limited regarding patient outcomes comparing redo surgical mitral valve replacement (redo SMVR) vs transcatheter mitral valve replacement (TMVR) for failed prostheses. The goal of this study was to compare the outcomes of redo SMVR vs TMVR in patients with failed prostheses, as well as evaluate the association between case volume and outcomes. Medicare beneficiaries aged ≥65 years who underwent redo SMVR or TMVR for failed mitral prostheses between 2016 and 2020 were included. The primary endpoint was mid-term (up to 3 years) major adverse cardiovascular events (MACE), including all-cause death, heart failure rehospitalization, stroke, or reintervention. Propensity score–matched analysis was used. A total of 4,293 patients were included (redo SMVR: 64%; TMVR: 36%). TMVR recipients were older, with a higher comorbidity burden. In matched cohort (n = 1,317 in each group), mid-term risk of MACE was similar (adjusted HR: 0.92; 95% CI: 0.80-1.04; P = 0.2). However, landmark analysis revealed a lower risk of MACE with TMVR in the first 6 months (adjusted HR: 0.75; 95% CI: 0.63-0.88; P < 0.001) albeit with a higher risk beyond 6 months (adjusted HR: 1.28; 95% CI: 1.04-1.58; P = 0.02). Increasing procedural volume was associated with decreased risk of mid-term MACE after redo SMVR (P = 0.001) but not after TMVR (P = 0.3). In this large cohort of Medicare beneficiaries with failed mitral prostheses, outcomes were similar between redo SMVR and TMVR at 3 years, with TMVR showing a lower initial risk but a higher risk of MACE after 6 months. These findings highlight the importance of striking a balance between surgical risk, anticipated longevity, and hospital expertise when selecting interventions. [Display omitted] [ABSTRACT FROM AUTHOR]

Structural valve deterioration (SVD) remains a major flaw of bioprostheses. Current recommendations advise yearly echocardiography from the fifth year after surgery with the assumption that SVD would not occur earlier. We retrospectively assessed 617 consecutive patients (aged 76.1 ±6.3 years) who underwent an aortic valve replacement with a Mitroflow bioprosthesis (12A/LX models) between 2002 and 2007 to evaluate the incidence, mode, and impact of SVD on outcome. The diagnosis of SVD was based not only on reoperation but also on echocardiography. During a follow-up of 3.8±1.4 years, we ascertained 39 cases of SVD (1.66% per patient-year), with stenosis as the main mode (n=36; 92%). The first SVD was diagnosed only 14 months after surgery. The 5-year cumulative probability of SVD was up to 8.4% (95% confidence interval, 5.3-11.3), with a higher risk in small-sized bioprostheses (19 and 21 mm). An unpredictable accelerated pattern of SVD was identified in 13 patients (33%) once the mean gradient exceeded 30 mm Hg. In this subgroup, valve-related death reached 46.2%. In multivariable analysis, SVD was the strongest correlate of overall mortality (hazard ratio, 7.7; 95% confidence interval, 4.4-13.6). To conclude, early SVD is an unexpected but frequent finding in Mitroflow bioprosthesis (12A/LX), especially for small sizes (19 and 21 mm), and reduces overall survival. In view of the large number of Mitroflow valves implanted worldwide, one can expect an epidemic of SVD and valve-related deaths. Hence, close follow-up with yearly echocardiography on surgery is advisable in patients with Mitroflow bioprostheses. An urgent reoperation should be discussed in patients with severe SVD in view of the risk of rapid progression and death. See p 2012. [ABSTRACT FROM AUTHOR]

With increasing numbers of patients undergoing transcatheter aortic valve replacement (TAVR), data on management of failed TAVR, including repeat TAVR procedure, are needed. The aim of this study was to assess the safety and efficacy of redo-TAVR in a national registry. This study included all consecutive patients in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry from Nov 9, 2011, to Dec 30, 2022 who underwent TAVR with balloon-expandable valves in failed transcatheter heart valves (redo-TAVR) or native aortic valves (native-TAVR). Procedural, echocardiographic, and clinical outcomes were compared between redo-TAVR and native-TAVR cohorts using propensity score matching. Among 350 591 patients (1320 redo-TAVR; 349 271 native-TAVR), 1320 propensity-matched pairs of patients undergoing redo-TAVR and native-TAVR were analysed (redo-TAVR cohort: mean age 78 years [SD 9]; 559 [42·3%] of 1320 female, 761 [57·7%] male; mean predicted surgical risk of 30-day mortality 8·1%). The rates of procedural complications of redo-TAVR were low (coronary compression or obstruction: four [0·3%] of 1320; intraprocedural death: eight [0·6%] of 1320; conversion to open heart surgery: six [0·5%] of 1319) and similar to native-TAVR. There was no significant difference between redo-TAVR and native-TAVR populations in death at 30 days (4·7% vs 4·0%, p=0·36) or 1 year (17·5% vs 19·0%, p=0·57), and stroke at 30 days (2·0% vs 1·9%, p=0·84) or 1 year (3·2% vs 3·5%, p=0·80). Redo-TAVR reduced aortic valve gradients at 1 year, although they were higher in the redo-TAVR group compared with the native-TAVR group (15 mm Hg vs 12 mm Hg; p<0·0001). Moderate or severe aortic regurgitation rates were similar between redo-TAVR and native-TAVR groups at 1 year (1·8% vs 3·3%, p=0·18). Death or stroke after redo-TAVR were not significantly affected by the timing of redo-TAVR (before or after 1 year of index TAVR), or by index transcatheter valve type (balloon-expandable or non-balloon-expandable). Redo-TAVR with balloon-expandable valves effectively treated dysfunction of the index TAVR procedure with low procedural complication rates, and death and stroke rates similar to those in patients with a similar clinical profile and predicted risk undergoing TAVR for native aortic valve stenosis. Redo-TAVR with balloon-expandable valves might be a reasonable treatment for failed TAVR in selected patients. Edwards Lifesciences. [ABSTRACT FROM AUTHOR]

Persistent left superior vena cava is known to be associated with cor triatriatum. The persistent left superior vena cava drains into a dilated coronary sinus and can cause left atrial outflow obstruction by impinging on the posterior wall of the left atrium. Residual obstruction can persist, even after surgical resection of the cor triatriatum membrane. We describe a novel surgical treatment in a patient with cor triatriatum and persistent left superior vena cava. [ABSTRACT FROM AUTHOR]

We present a 16-year-old girl who presented with chest pain. Given her obesity and positive family history, she was felt to have atherosclerotic heart disease. However, an echocardiogram showed an atrial myxoma, which prompted surgical excision. This case supports the routine use of echocardiography and widened differential diagnosis when presented with pediatric chest pain. [ABSTRACT FROM AUTHOR]

A response to a commentary about a study on the state of cranial asymmetry in LB1 is presented. The authors of the study concluded that posterior deformational plagiocephaly (PDP) explains the cranial asymmetries in the LB1 speciment of Homo floresiensis. They believe the criticisms against the study were either superficial or irrelevant to the diagnosis.

Objective: Acute type A aortic dissection (ATAAD) is a life-threatening condition and surgical repair often includes aortic valve replacement (AVR). Aortic valve repair (AVr) is increasingly being reported with favorable outcomes from single-center experiences. This study examined national trends and outcomes of AVr in patients with ATAAD.Methods: Adults with a primary diagnosis of acute thoracic aortic dissection who underwent proximal aortic surgery from January 2016 to December 2017 were obtained from the National Inpatient Sample. Patients were stratified into an isolated aortic surgery group (no aortic valve procedure), concomitant AVR, or concomitant AVr groups. The primary outcome was in-hospital mortality and secondary outcomes included stroke, acute kidney injury, heart block, and bleeding. Propensity score matching was used to address patient and hospital-level confounders between AVR and AVr groups.Results: In total, 5115 patients underwent surgery for ATAAD and were included. Overall, 3220 (63%) underwent isolated ATAAD repair, while 1120 (22%) had concomitant AVR, and 775 (15%) had concomitant AVr. In 455 propensity-matched pairs, there was no difference in mortality or stroke between AVr and AVR groups, however, heart block (1.1% vs. 7.5%, p < .001) and bleeding (65.9% vs. 81.3%, p < .001) were significantly less common among those who underwent AVr. Patients who underwent AVr had shortest LOS (11.9 vs. 13.5 days, p < .001). There were no differences in outcomes of AVr in ATAAD based on hospital size or teaching status.Conclusion: In selected patients, AVr is being performed safely in the setting of ATAAD with mortality and composite outcomes comparable to AVR. [ABSTRACT FROM AUTHOR]

Background: Treatment of benign primary cardiac tumors involves surgical resection, but reported outcomes from multi‐institutional or national databases are scarce. This study examines contemporary national outcomes following surgical resection of benign primary atrial and ventricular tumors. Methods: The 2016–2018 Nationwide Readmissions Database was queried for all patients ≥18 years with a primary diagnosis of benign neoplasm of the heart who underwent resection of the atria, ventricles, or atrial/ventricular septum. Primary outcomes were 30‐day mortality, readmission, and composite morbidity (defined as stroke, permanent pacemaker implantation, bleeding complication, or acute kidney injury). Multivariable analysis was used to identify independent predictors of worse outcomes. Results: A weighted total of 2557 patients met inclusion criteria. Mean age was 61 years, 67.9% were female, and patients had relatively low comorbidity burdens (mean Charlson Comorbidity Index 1.39). The majority of patients underwent excision of the left atrium (71.5%), followed by the intra‐atrial septum (26.6%), right atrium (2.9%). There was no difference in 30‐day mortality (2.1% vs. 1.3%, p =.550), 30‐day readmission (7.0% vs. 9.1%, p =.222), or 30‐day composite morbidity (56.8% vs. 53.8%, p =.369) between females and males, respectively. However, on multivariable analysis, female sex was independently associated with increased risk of 30‐day mortality (adjusted odds ratio = 2.65, p =.028). Tumor location (atria, ventricles, septum) was not predictive of mortality. Conclusion: Benign atrial and ventricular tumors are uncommon, but disproportionately impact female patients, with female sex being an independent predictor of 30‐day mortality. Root‐cause analysis is necessary to determine the ultimate cause of this disparity. [ABSTRACT FROM AUTHOR]

A virtual workshop was organized by the Heart Valve Collaboratory to identify areas of expert consensus, areas of disagreement, and evidence gaps related to bioprosthetic aortic valve hemodynamics. Impaired functional performance of bioprosthetic aortic valve replacement is associated with adverse patient outcomes; however, this assessment is complicated by the lack of standardization for labelling, definitions, and measurement techniques, both after surgical and transcatheter valve replacement. Echocardiography remains the standard assessment methodology because of its ease of performance, widespread availability, ability to do serial measurements over time, and correlation with outcomes. Management of a high gradient after replacement requires integration of the patient's clinical status, physical examination, and multimodality imaging in addition to shared patient decisions regarding treatment options. Future priorities that are underway include efforts to standardize prosthesis sizing and labelling for both surgical and transcatheter valves as well as trials to characterize the consequences of adverse hemodynamics. [ABSTRACT FROM AUTHOR]

Bioprosthetic valve dysfunction (BVD) and bioprosthetic valve failure (BVF) may be caused by structural or nonstructural valve dysfunction. Both surgical and transcatheter bioprosthetic valves have limited durability because of structural valve deterioration. The main objective of this summary of experts participating in a virtual workshop was to propose standardized definitions for nonstructural and structural BVD and BVF following aortic or mitral biological valve replacement with the goal of facilitating research reporting and implementation of these terms in clinical practice. Definitions of structural BVF, based on valve reintervention or death, underestimate the true incidence of BVF. However, definitions solely based on the presence of high transprosthetic gradient at a given echocardiogram during follow-up overestimate the incidence of structural BVD and BVF. Definitions of aortic or mitral structural BVD must therefore include the confirmation by imaging of permanent structural changes to the leaflets alongside evidence of deterioration in valve hemodynamic function at echocardiography follow-up. [ABSTRACT FROM AUTHOR]

This JAMA Clinical Guidelines Synopsis summarizes the ACC/AHA guideline for the treatment of patients with valve disease, with an emphasis on mitral regurgitation. [ABSTRACT FROM AUTHOR]

Background: Aim of this study was to perform a systematic review a meta-analysis of the literature in order to identify predictors of acute kidney injury (AKI) in patients with mitral regurgitation (MR) undergoing transcatheter edge-to-edge repair (TEER) and assess its effect on in-hospital outcomes and mortality. Although iodinated contrast is not typically used in TEER, these patients are still at risk for developing AKI.Methods: Studies reporting on the effect of incident AKI on mortality following TEER for MR were included. Random-effects meta-analysis was performed, comparing clinical outcomes between the patients with or without incident AKI.Results: Six studies including a total of 2057 patients (377 AKI and 1680 No-AKI) were included and analyzed. AKI was significantly associated with 30-day mortality after TEER (Odds ratio (OR): 8.06; 95% CI: 3.20, 20.30, p < 0.01; I2 = 18.4%) and all-cause mortality over a mean follow-up time of 30 months (Hazard ratio (HR): 2.48; 95% CI: 1.89, 3.24, p < 0.01; I2 = 23.7%). AKI after TEER was associated with prolonged hospitalization (Mean difference (in days): 1.41; 95% CI: 0.52, 2.31, p < 0.01; I2 = 82.4%). Stage 4 chronic kidney disease (CKD), device failure and history of chronic obstructive pulmonary disease (COPD) were significant predictors of AKI following TEER (CKD stage 4: OR: 2.38; 95% CI: 1.18, 4.78, p = 0.02; I2 = 0.0%; Device failure: OR: 3.15; 95% CI: 1.94, 5.12, p < 0.01; I2 = 0.0%; COPD: OR: 1.92; 95% CI: 1.16, 3.17; I2 = 26.7%).Conclusions: Our findings highlight the renal vulnerability of the TEER population to renal injury and the associated deterioration in clinical outcomes and survival. [ABSTRACT FROM AUTHOR]

Background/Aim: Peripheral access vessel dimensions in the general patient population screened for transcatheter aortic valve replacement (TAVR) can offer insight into the indications for pre‐TAVR computed tomography angiography (CTA) assessment. We seek to determine peripheral access vessel sizes in patients screened for TAVR and association with patient characteristics. Materials and Methods: All patients with severe, symptomatic aortic stenosis screened for TAVR at a high‐volume center from April 2012 to March 2019 were retrospectively reviewed. For each patient, contrast‐enhanced CTA was used to determine the minimal luminal diameters (MLDs) of the transfemoral access vessels, as measured between the inguinal ligament and the deep femoral artery for the femoral artery, and proximal to the inguinal ligament for the external and common iliac arteries, respectively. Paired and independent samples t‐tests were used to compare means and regression analyses were performed to determine factors associated with MLD. Results: A total of 1049 screened patients were included of which 826 (78.7%) underwent TAVR and 551 (52.5%) were male. The mean age was 80.6 (±9.6) years and the mean body mass index (BMI) was 26.7 (±5.9) kg/m2. About 152 (14.5%) had peripheral vascular disease and 153 (14.6%) had chronic kidney disease. The mean (±2 standard deviations) MLDs of the right and left femoral arteries were 7.73 mm (4.68–10.78) and 7.68 mm (4.63–10.72), respectively. Male sex and BMI were associated with larger average femoral MLD while hyperlipidemia, hypertension, smoking, peripheral vascular disease, and coronary artery disease were inversely associated. Conclusion: Most patients screened for TAVR have minimum peripheral access vessel sizes exceeding the recommended minimum access route diameters of modern transcatheter heart valves. As sheath sizes decrease, clinicians must carefully judge patient individual risk factors to determine whether a pre‐TAVR CTA assessing peripheral access vessel dimensions and anatomical contraindications is indicated. Larger studies and randomized controlled trials are required to compare the outcomes of TAVR with and without preoperative CTA. [ABSTRACT FROM AUTHOR]

Background: Despite the rapid growth of aortic valve replacement (AVR) for aortic stenosis (AS), limited data suggest symptomatic severe AS remains undertreated.Objectives: This study sought to investigate temporal trends in AVR utilization among patients with a clinical indication for AVR.Methods: Patients with severe AS (aortic valve area <1 cm2) on transthoracic echocardiograms from 2000 to 2017 at 2 large academic medical centers were classified based on clinical guideline indications for AVR and divided into 4 AS subgroups: high gradient with normal left ventricular ejection fraction (LVEF) (HG-NEF), high gradient with low LVEF (HG-LEF), low gradient with normal LVEF (LG-NEF), and low gradient with low LVEF (LG-LEF). Utilization of AVR was examined and predictors identified.Results: Of 10,795 patients, 6,150 (57%) had an indication or potential indication for AVR, of whom 2,977 (48%) received AVR. The frequency of AVR varied by AS subtype with LG groups less likely to receive an AVR (HG-NEF: 70%, HG-LEF: 53%, LG-NEF: 32%, LG-LEF: 38%, P < 0.001). AVR volumes grew over the 18-year study period but were paralleled by comparable growth in the number of patients with an indication for AVR. In patients with a Class I indication, younger age, coronary artery disease, smoking history, higher hematocrit, outpatient index transthoracic echocardiogram, and LVEF ≥0.5 were independently associated with an increased likelihood of receiving an AVR. AVR was associated with improved survival in each AS-subgroup.Conclusions: Over an 18-year period, the proportion of patients with an indication for AVR who did not receive AVR has remained substantial despite the rapid growth of AVR volumes. [ABSTRACT FROM AUTHOR]

Transcatheter mitral edge-to-edge repair (TEER) is an increasingly common procedure performed on patients with severe mitral regurgitation. This study assessed the impact of race/ethnicity and socioeconomic status on in-hospital complications after TEER. Cohort-based observational study using the National Inpatient Sample between October 2013 and December 2018. The population was stratified into 4 groups based on race/ethnicity and quartiles of neighborhood income levels. The primary outcome was in-hospital complications, defined as the composite of death, bleeding, cardiac and vascular complications, acute kidney injury, and ischemic stroke. 3795 hospitalizations for TEER were identified. Patients of Black and Hispanic race/ethnicity comprised 7.4% and 6.4%, respectively. We estimated that White patients received TEER with a frequency of 38.0/100,000, compared to 29.7/100,000 for Blacks and 30.5/100,000 for Hispanics. In-hospital complications occurred in 20.2% of patients and no differences were found between racial/ethnic groups (P = 0.06). After multilevel modelling, Black and Hispanic patients had similar rate of overall in-hospital complications (OR: 0.84, CI:0.67–1.05 and OR: 0.84, CI:0.66–1.07, respectively) as compared to White patients, however, higher rates of death were observed in Black patients. Individuals living in income quartile-1 had worse in-hospital outcomes as compared to quartile-4 (OR: 1.19, CI:0.99–1.42). In this study assessing racial/ethnic disparities in TEER outcomes, aged-adjusted race/ethnicity minorities were less underrepresented as compared to other structural heart interventions. Black patients experienced a higher rate of in-hospital death, but similar overall rate of post-procedural adverse events as compared to White patients. Lower income levels appear to negatively impact on in-hospital outcomes. This study appraises race/ethnic and socioeconomical disparities in access and outcomes following transcatheter mitral edge-to-edge repair. Racial minority groups were less underrepresented as compared to other structural heart interventions. While Black patients experienced a higher rate of in-hospital death, they experienced similar overall rate of post-procedural complications compared to White patients. Lower income levels also appeared to negatively impact on outcomes. [Display omitted] • This study appraises racial/ethnic and socioeconomic differences in outcomes after transcatheter mitral edge-to-edge repair. • Blacks and Hispanics underrepresented, but less so compared to other transcatheter-based structural heart interventions. • Black patients had a higher comorbidity burden and death rate, but similar total complication rate as compared to Whites. • Further work is needed to better characterize the causes and mechanisms of these racial and socioeconomic disparities. [ABSTRACT FROM AUTHOR]

With more than a third of patients expected to endure the arrhythmia at any given time point, atrial fibrillation after cardiac surgery becomes a vexing problem in the postoperative care of cardiac surgery patients. The impact on patient care covers a spectrum fromthemore common clinically insignificant sequelae to debilitating embolic events. Despite this, postoperative atrial fibrillation generally masquerades as being insignificant, or at most as an anticipated inherent risk, merely extending one's hospital stay by a few days. As an independent risk factor for stroke, early and late mortality, and being a multibillion dollar strain on the healthcare system annually, postoperative atrial fibrillation is far more flagrant than a mere inherent risk. It is a serious medical quandary, which is not recognized as such.Though complete prevention is unrealistic, a step-wise treatment strategy that incorporatesmultiple preventative modalities can significantly reduce the impact of postoperative atrial fibrillation on patient care.The aims of this review are to present a brief overview of the arrhythmia's etiology, risk factors, and preventative strategies to reduce associatedmorbidities. Newer anticoagulants and the potential role of these drugs on future treatment paradigms are also discussed. [ABSTRACT FROM AUTHOR]

Background: The authors described their surgical technique for scaphocephaly in relatively older infants who are 5 months old or over. The technique is a kind of hybrid of distraction osteogenesis utilizing skull expanders and a traditional cranial reconstruction procedure. Surgery: The surgery usually consists of four procedures. The first is to make strip craniotomy over the superior sagittal sinus (SSS) from the major fontanelle to the minor one. The second is the occipital craniotomy for the occipital bossing. The occipital bone flap undergoes barrel stave osteotomy and is repositioned later. The third is placement of skull expander for distraction osteogenesis. Bidirectional small strip craniotomy is made along the coronal and lambdoid sutures, then transverse cutting is added to make a hinge point near the base of the parietal bone. Two to three skull expanders are placed crossing the SSS. The last procedure is radial-oriented osteotomy on the dorsal end of frontal bone to meet the elevated, expanded parietal bone. Skull expansion starts within a week with 5 mm/week base up to 20 to 30 mm. Exposed shafts of the expander are cut at the end of skull expansion. Discussion: Process of osteogenesis is followed at an outpatient clinic, and the expanders are removed 4 to 6 months later after confirming the sufficient ossification. An advantage of our procedure is that maximum skull expansion is possible with minimum regression after distraction osteogenesis in the long term. Limited craniotomy enables limited blood loss. The skin trouble caused by stretching can be avoided. No postoperative helmet is required. A disadvantage is that the procedure leaves a foreign body on the skull for several months and requires additional surgery for removal. [ABSTRACT FROM AUTHOR]

Mouse embryos lacking the Runx1 transcription factor exhibit an angiogenic defect accompanied by the absence of hematopoietic stem cells (HSCs). To ask whether Runx1 plays a direct role in angiogenesis, we established a novel endothelial progenitor cell line, designated AEL-?R1, from the aorta-gonad-mesonephros (AGM) region of Runx1-null mouse. We introduced Runx1 cDNA into AEL-?R1 cells under the doxycycline-inducible promoter. The ability of AEL-?R1 cells to form vascular networks on matrigel was highly enhanced by the restored expression of Runx1. By molecular comparison of mRNAs in AEL-?R1 cells before and after the induction of Runx1, we found that mRNA expression of insulin-like growth factor-binding protein 3 (IGFBP-3) is downregulated by Runx1. Gel retardation and reporter assays revealed that Runx1 binds to the promoter region of mouse IGFBP-3 gene and represses its transcription. When IGFBP-3 was exogenously added in the matrigel assay, the angiogenesis-enhancing activity of Runx1 was suppressed in a dose-dependent manner. These results demonstrate that Runx1 is directly involved in angiogenesis by repression of IGFBP-3 mRNA expression.Oncogene (2005) 24, 1129-1137. doi:10.1038/sj.onc.1208287 Published online 20 December 2004 [ABSTRACT FROM AUTHOR]

We present an assessment on error of the pre-exponential factor estimated from the isoconversional plot and the single heating rate plot for dynamic thermogravimetric measurement. It is found that the pre-exponential factor obtained at the correct reaction order usually has about −10% error in value. The use of a wrong reaction order can lead to a variation in the value of the pre-exponential factor by several times, sometimes even several hundred times. Curve simulation is a careful method for obtaining kinetics parameter values. Only perfect agreement of simulation curve with the experimental one can give the correct kinetic parameters. [Copyright &y& Elsevier]

Importance: There are limited data on outcomes of transcatheter aortic valve replacement (TAVR) for bicuspid aortic stenosis in patients at low surgical risk.Objective: To compare the outcomes of TAVR with a balloon-expandable valve for bicuspid vs tricuspid aortic stenosis in patients who are at low surgical risk.Design, Setting, and Participants: Registry-based cohort study of patients undergoing TAVR at 684 US centers. Participants were enrolled in the Society of Thoracic Surgeons (STS)/American College of Cardiology Transcatheter Valve Therapies Registry from June 2015 to October 2020. Among 159 661 patients (7058 bicuspid, 152 603 tricuspid), 37 660 patients (3243 bicuspid and 34 417 tricuspid) who were at low surgical risk (defined as STS risk score <3%) were included in the analysis.Exposures: TAVR for bicuspid vs tricuspid aortic stenosis.Main Outcomes and Measures: Coprimary outcomes were 30-day and 1-year mortality and stroke. Secondary outcomes included procedural complications and valve hemodynamics.Results: Among 159 661 patients (7058 bicuspid; 152 603 tricuspid), 3168 propensity-matched pairs of patients with bicuspid and tricuspid aortic stenosis at low surgical risk were analyzed (mean age, 69 years; 69.8% men; mean [SD] STS-predicted risk of mortality, 1.7% [0.6%] for bicuspid and 1.7% [0.7%] for tricuspid). There was no significant difference between the bicuspid and tricuspid groups' rates of death at 30 days (0.9% vs 0.8%; hazard ratio [HR], 1.18 [95% CI, 0.68-2.03]; P = .55) and at 1 year (4.6% vs 6.6%; HR, 0.75 [95% CI, 0.55-1.02]; P = .06) or stroke at 30 days (1.4% vs 1.2%; HR, 1.14 [95% CI, 0.73-1.78]; P = .55) and at 1 year (2.0% vs 2.1%; HR 1.03 [95% CI, 0.69-1.53]; P = .89).There were no significant differences between the bicuspid and tricuspid groups in procedural complications, valve hemodynamics (aortic valve gradient: 13.2 mm Hg vs 13.5 mm Hg; absolute risk difference [RD], 0.3 mm Hg [95% CI, -0.9 to 0.3 mm Hg]), and moderate or severe paravalvular leak (3.4% vs 2.1%; absolute RD, 1.3% [95% CI, -0.6% to 3.2%]).Conclusions and Relevance: In this preliminary, registry-based study of propensity-matched patients at low surgical risk who had undergone TAVR for aortic stenosis, patients treated for bicuspid vs tricuspid aortic stenosis had no significant difference in mortality or stroke at 30 days or 1 year. Because of the potential for selection bias and absence of a control group treated surgically for bicuspid aortic stenosis, randomized trials are needed to adequately assess the efficacy and safety of transcatheter aortic valve replacement for bicuspid aortic stenosis in patients at low surgical risk. [ABSTRACT FROM AUTHOR]

The fraction of bonds broken in thermal degradation of polyethylene was estimated. Activation energy of the degradation was then calculated from the fraction of bonds broken. It was found that the activation energy thus obtained is close to the values for β C–C bond scissions and β C–H bond scissions of hydrocarbon radicals. β C–H bond scission of radicals is proposed as part of the mechanism of thermal degradation of polyethylene, which provides an understanding of detail of hydrogen transfer in the polymer melt and provides a route for hydrogen gas formation in pyrolysis of polyethylene. [Copyright &y& Elsevier]

Background: The opioid epidemic has seen a drastic increase in the incidence of drug-associated infective endocarditis (IE). No clinical tool exists to predict operative morbidity and mortality in patients undergoing surgery.Methods: A multi-institutional database was reviewed between 2011 and 2018. Multivariate logistic regression was fitted in an automated stepwise fashion. The STratification risk analysis in OPerative management of drug-associated IE (STOP) score was constructed. Morbidity was defined as reintubation, prolonged ventilation, pneumonia, renal failure, dialysis, stroke, reoperation for bleeding, and a permanent pacemaker. Cross-validation provided an unbiased estimate of out-of-sample performance.Results: A total of 1181 patients underwent surgery for drug-associated IE (median age, 39; interquartile range [IQR], 30-54, 386 women [32.7%], 341 reoperations for prosthetic valve endocarditis [28.9%], 316 patients with multivalve disease [26.8%]). Operative morbidity and mortality were 41.1% and 5.9%, respectively. Predictors of morbidity were dialysis (95% confidence interval [CI], 1.16-2.82), emergent intervention (1.83-4.73), multivalve procedure (1.01-1.98), causative organisms other than Streptococcus (1.09-2.02), and type of valve procedure performed [aortic valve procedure (1.07-2.15), mitral valve replacement (1.03-2.05), tricuspid valve replacement (1.21-2.60)]. Predictors of mortality were dialysis (1.29-5.74), active endocarditis (1.32-83), lung disease (1.25-5.43), emergent intervention (1.69-6.60), prosthetic valve endocarditis (1.24-3.69), aortic valve procedure (1.49-5.92) and multivalve disease (1.00-2.95). Variables maximizing explanatory power were translated into a scoring system. Each point increased odds of morbidity and mortality by 22.0% and 22.4% with an accuracy of 94.0% and 94.1%, respectively.Conclusion: Drug-related IE is associated with significant morbidity and mortality. An easily-applied risk stratification score may aid in clinical decision-making. [ABSTRACT FROM AUTHOR]

Background: This study compares the postoperative outcomes, 30-day readmission rates, and incidence of sternal wound infection-related readmissions between patients receiving bilateral internal mammary arteries (BIMA) and single internal mammary artery (SIMA) grafting during coronary artery bypass graft (CABG) surgery.Methods: We utilized the weighted 2013-2014 National Readmission Database claims to identify all US adult patients who underwent CABG utilizing SIMA (n = 279,891) or BIMA (n = 11,651). Thirty-day overall and wound-related readmissions, in-hospital outcomes, costs, lengths of stay (LOS) at readmissions were compared between the two groups. Predictors of 30-day readmission were assessed using multivariable Cox proportional hazards analysis.Results: After propensity matching (n = 10,339 pairs), there were no significant differences between the two groups during the index hospitalization, except for higher total hospital costs in the BIMA group (p = .02). The incidence of wound infections was also comparable between BIMA and SIMA (1.1% vs. 1.2%; p = .50). At 30-days, the overall readmission rate was elevated in SIMA patients (9.5% vs. 8.8%; p < .01), primarily impacted by cardiovascular causes. While the proportion of 30-day readmissions due to infections was significantly higher among BIMA versus SIMA patients (20.4% vs. 15.9%; p < .01), wound infections during the index hospitalization did not predict all-cause 30-day readmission among BIMA patients (p = .24) in the risk-adjusted analysis. Among the readmitted patients, LOS (6.4 vs. 6.2 days), costs ($14,440 vs. $16,461), and in-hospital mortality (2.4% vs. 1.7%) were comparable between the two groups (all p > .05).Conclusions: BIMA grafting is not an independent predictor of all-cause 30-day readmissions. Cardiovascular causes remain the primary driver of 30-day readmissions among SIMA and BIMA patients after CABG. [ABSTRACT FROM AUTHOR]

Background: Given the recent growth in the number of MitraClip procedures in patients with functional mitral regurgitation (MR), there is interest in an echocardiographic index to predict technical success before intervention. We investigated the utility of a novel leaflet coaptation index (LCI) to predict outcomes after MitraClip in functional MR patients. Methods: Forty consecutive patients with functional MR who underwent MitraClip were included. The LCI was defined as the coapted leaflet length divided by the anteroposterior diameter of the mitral annulus. The coapted leaflet length was calculated by separately tracing the total length of the mitral valve leaflets at early and end systole on transesophageal echocardiography. The primary endpoint was defined as residual MR ≥ moderate after MitraClip. Results: The LCI was significantly associated with residual MR ≥ moderate (odds ratio, 0.827; 95% confidence interval, 0.696–0.982; p =.030) with the cut‐off LCI value of 0.14 (sensitivity 70.4%, specificity 69.2%, c‐statistic 0.815; p =.001). Conclusion: This novel index may be a useful adjunct that can be incorporated into the armamentarium of contemporary clinical performance risk prediction tools for MitraClip success. [ABSTRACT FROM AUTHOR]

Background: Preoperative dental screening before cardiac valve surgery is widely accepted but its required scope remains unclear. This study evaluates two preoperative dental screening (PDS) approaches, a focused approach (FocA) and a comprehensive approach (CompA), to compare postsurgical 90-day mortality.Methods: Retrospective cohort analysis was performed on all patients who underwent valve surgery at Brigham and Women's Hospital with FocA and Massachusetts General Hospital with CompA of PDS approach from January 2009 to December 2016. Patients with intravenous drug abuse and systemic infections were excluded. Univariate, multivariable, and subgroup analysis was performed.Results: A total of 1835 patients were included in the study. With FocA 96% of patients (1097/1143) received dental clearance in a single encounter with 3.3% receiving radiographs and undergoing dental extractions. With CompA 35.5% of patients (245/692) received dental clearance in a single encounter, 94.2% received radiographs, and 21.8% underwent dental extractions. There was no significant difference in 90-day mortality when comparing both PDS approach (10% vs 8.4%, P = .257). This remained unchanged in a multivariable model after adjusting for risk factors (odds ratio:1.32 [95%CI:0.91-1.93] [P = .14]). Reoperation due to infection was less in FocA (0.5%) vs CompA (2.6) (P < .001) and postoperative septicemia was increased in the FocA (1.7%) cohort when compared to the CompA (0.7%) (P < .001) patients.Conclusions: There was no difference in post valve surgery 90-day mortality between patients who underwent a FocA vs CompA of PDS. [ABSTRACT FROM AUTHOR]

Background: Currently, there is a paucity of information on surgical explantation after transcatheter aortic valve replacement (TAVR).Objectives: The purpose of this study was to examine the incidence, patient characteristics, predictors, and outcomes of surgical explantation after TAVR using a population-based, nationally representative database.Methods: We analyzed the Medicare Provider profile to include all U.S. patients undergoing TAVR from 2012 to 2017. Time to surgical explant was calculated from the index TAVR discharge to surgical explantation. Post-operative survival was assessed using time-dependent Cox proportional hazard regression analysis and landmark analysis.Results: The incidence of surgical explantation was 0.2% (227 of 132,633 patients), and was 0.28% and 0.14% in the early and newer TAVR era, respectively. The median time to surgical explant was 212 days, whereas 8.8% and 70.9% underwent surgical explantation within 30 days and 1 year, respectively. The primary indication for reintervention was bioprosthetic failure (79.3%). Compared with the no-explant cohort, the explant cohort was significantly younger (mean age 73.7 years vs. 81.7 years), with a lower prevalence of heart failure (55.9% vs. 65.8%) but more likely a lower-risk profile cohort (15% vs. 2.4%; all p < 0.05). The 30-day and 1-year mortality rates were 13.2% and 22.9%, respectively, and did not vary by either time to surgical explant or TAVR era, or between patients with versus without endocarditis (all p > 0.05). The time-dependent Cox regression analysis demonstrated a higher mortality in those with surgical explantation (hazard ratio: 4.03 vs. no-explant group; 95% confidence interval: 1.81 to 8.98). Indication, time-to-surgical-explant, and year of surgical explantation were not associated with worse post-explantation survival (all p > 0.05).Conclusions: The present study provides updated evidence on the incidence, timing, and outcomes of surgical explantation of a TAVR prosthesis. Although the overall incidence was low, short-term mortality was high. These findings stress the importance of future mechanistic studies on TAVR explantation and may have implications on lifetime management of aortic stenosis, particularly in younger patients. [ABSTRACT FROM AUTHOR]

Background and Aim: The opioid epidemic has become a major public health crisis in recent years. Discharge opioid prescription following cardiac surgery has been associated with opioid use disorder; however, ideal practices remain unclear. Our aim was to examine current practices in discharge opioid prescription among cardiac surgeons and trainees. Methods: A survey instrument with open‐ and closed‐ended questions, developed through a 3‐round Delphi method, was circulated to cardiac surgeons and trainees via the Canadian Society of Cardiac Surgeons. Survey questions focused on routine prescription practices including type, dosage and duration. Respondents were also asked about their perceptions of current education and guidelines surrounding opioid medication. Results: Eighty‐one percent of respondents reported prescribing opioids at discharge following routine sternotomy‐based procedures, however, there remained significant variability in the type and dose of medication prescribed. The median (interquartile range) number of pills prescribed was 30 (20‐30) with a median total dose of 135 (113‐200) Morphine Milligram Equivalents. Informal teaching was the most commonly reported primary influence on prescribing habits and a lack of formal education regarding opioid prescription was associated with a higher number of pills prescribed. A majority of respondents (91%) felt that there would be value in establishing practice guidelines for opioid prescription following cardiac surgery. Conclusions: Significant variability exists with respect to routine opioid prescription at discharge following cardiac surgery. Education has come predominantly from informal sources and there is a desire for guidelines. Standardization in this area may have a role in combatting the opioid epidemic. [ABSTRACT FROM AUTHOR]