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Open in new tab Download slide OBJECTIVES In endoscopic mitral valve surgery, optimal exposure is crucial. This study aims to develop a predictive model for poor mitral valve exposure in endoscopic surgery, utilizing preoperative body profiles and computed tomography images. METHODS We enrolled patients undergoing endoscopic mitral valve surgery with available operative video and preoperative computed tomography. The degree of valve exposure was graded into 0 (excellent), 1 (fair), 2 (poor) and 3 (very poor). Intrathoracic dimensions–anteroposterior width (chest anteroposterior) and left-to-right width (chest width) of the thorax, height of right hemi-thorax (chest height), angle between the left ventricular axis and the horizontal plane (left ventricle apex angle), heart width, level of diaphragm in midline, and vertical distance between the midline diaphragm level and the highest top of the right diaphragm (Δdiaphragm) were measured. RESULTS Among 263 patients, mitral valve exposure was graded as 0 in 131 (49.8%), 1 in 72 (27.4%), 2 in 46 (17.5%) and 3 in 14 (5.3%). Body mass index, chest width, left ventricle apex angle, heart width and Δdiaphragm were identified as independent predictors of grades 2 and 3 exposure by stepwise logistic regression analysis, with an area under the receiver operating characteristic curve of 0.822 (P  < 0.001). Univariate logistic regression for grade 3 exposure prediction revealed that Δdiaphragm had the largest area under the curve (0.826, P  < 0.001). CONCLUSIONS Poor mitral valve exposure occurred in approximately one-fourth of the endoscopic surgery series and might be predicted preoperatively using body mass index and computed tomography measurements to help determine the surgical approach. [ABSTRACT FROM AUTHOR]

Background The aims of this study were to assess whether sensory nerve coaptation in free flap breast reconstruction is subject to learning, and to elucidate challenges of this technique. Methods In this single-center retrospective cohort study, we reviewed consecutive free flap breast reconstructions performed between March 2015 and August 2018. Data were extracted from medical records, and missing values were imputed. We assessed learning by exploring associations between case number and probability of successful nerve coaptation using a multivariable mixed-effects model. Sensitivity analysis was performed in a subgroup of cases with evidence of attempted coaptation. Recorded reasons for failed coaptation attempts were grouped into thematic categories. Multivariable mixed-effects models were used to examine associations between case number and postoperative mechanical detection threshold. Results Nerve coaptation was completed in 250 of 564 (44%) included breast reconstructions. Success rates varied considerably between surgeons (range 21–78%). In the total sample, the adjusted odds of successful nerve coaptation increased 1.03-fold for every unit increase in case number (95% confidence interval 1.01–1.05, p < 0.05), but sensitivity analysis refuted this apparent learning effect (adjusted odds ratio 1.00, 95% confidence interval 1.00–1.01, p = 0.34). The most frequently recorded reasons for failed nerve coaptation attempts were inability to locate a donor or recipient nerve. Postoperative mechanical detection thresholds showed a negligible, positive association with case number (estimate 0.00, 95% confidence interval 0.00–0.01, p < 0.05). Conclusion This study does not provide evidence in support of a learning process for nerve coaptation in free flap breast reconstruction. Nevertheless, the identified technical challenges suggest that surgeons may benefit from training visual search skills, familiarizing with relevant anatomy, and practicing techniques for achieving tensionless coaptation. This study complements prior studies exploring therapeutic benefit of nerve coaptation by addressing technical feasibility. [ABSTRACT FROM AUTHOR]

Background and Aims The current study proposes a novel volume–outcome (V–O) meta-analytical approach to determine the optimal annual hospital case volume threshold for cardiovascular interventions in need of centralization. This novel method is applied to surgery for acute type A aortic dissection (ATAAD) as an illustrative example. Methods A systematic search was applied to three electronic databases (1 January 2012 to 29 March 2023). The primary outcome was early mortality in relation to annual hospital case volume. Data were presented by volume quartiles (Qs). Restricted cubic splines were used to demonstrate the V–O relation, and the elbow method was applied to determine the optimal case volume. For clinical interpretation, numbers needed to treat (NNTs) were calculated. Results One hundred and forty studies were included, comprising 38 276 patients. A significant non-linear V–O effect was observed (P <.001), with a notable between-quartile difference in early mortality rate [10.3% (Q4) vs. 16.2% (Q1)]. The optimal annual case volume was determined at 38 cases/year [95% confidence interval (CI) 37–40 cases/year, NNT to save a life in a centre with the optimal volume vs. 10 cases/year = 21]. More pronounced between-quartile survival differences were observed for long-term survival [10-year survival (Q4) 69% vs. (Q1) 51%, P <.01, adjusted hazard ratio 0.83, 95% CI 0.75–0.91 per quartile, NNT to save a life in a high-volume (Q4) vs. low-volume centre (Q1) = 6]. Conclusions Using this novel approach, the optimal hospital case volume threshold was statistically determined. Centralization of ATAAD care to high-volume centres may lead to improved outcomes. This method can be applied to various other cardiovascular procedures requiring centralization. [ABSTRACT FROM AUTHOR]

Background With evolving breast cancer survival and patient preferences, it is essential that reconstructive surgeons worldwide continue searching for the best reconstruction technique for patients. Autologous fat transfer (AFT) is a relatively new technique for total breast reconstruction that has already proven to be effective and safe with all advantages of autologous tissue. However, little is known about the aesthetic results and satisfaction concerning donor sites. Objectives The aim of this study was to measure donor site satisfaction following AFT for total breast reconstruction in breast cancer patients. Methods Between May and August of 2021, participants of the BREAST− trial who were at least 24 months after their final reconstruction surgery were invited to complete an additional survey concerning donor sites. The BODY-Q was utilized for data collection. Results of AFT patients were compared with a control group of implant-based reconstruction patients who did not have a donor site. Results A total of 51 patients (20 control, 31 intervention) completed the questionnaire. Satisfaction with body did not statistically differ between the groups. The most frequent complaint was contour irregularities (31 reports, 60.8%), with the least favorable donor site being thighs (23 reports, 53.5%) in the AFT group. Conclusions Satisfaction with body did not differ between breast cancer patients receiving AFT or implant-based reconstruction, meaning that large-volume liposuction does not aesthetically affect the utilized donor sites. Nevertheless, reconstructive surgeons should be aware of possible donor site complications, especially contour irregularities at the thighs, and discuss this with their patients. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Thoracoscopic ablation for atrial fibrillation (AF) and minimally invasive direct coronary artery bypass (MIDCAB) with robot-assisted left internal mammary artery (LIMA) harvesting may represent a safe and effective alternative to more invasive surgical approaches via sternotomy. The aim of our study was to describe the feasibility, safety and efficacy of a unilateral left-sided thoracoscopic AF ablation and concomitant MIDCAB surgery. METHODS Retrospective analysis of a prospectively gathered cohort was performed of all consecutive patients with AF and at least a critical left anterior descending artery (LAD) stenosis that underwent unilateral left-sided thoracoscopic AF ablation and concomitant off-pump MIDCAB surgery in the Maastricht University Medical Centre between 2017 and 2021. RESULTS Twenty-three patients were included [age 69 years (standard deviation = 8), paroxysmal AF 61%, left atrial volume index 42 ml/m2 (standard deviation = 11)]. Unilateral left-sided thoracoscopic isolation of the left (n  = 23) and right (n  = 22) pulmonary veins and box (n  = 21) by radiofrequency ablation was succeeded by epicardial validation of exit- and entrance block (n  = 22). All patients received robot-assisted LIMA harvesting and off-pump LIMA-LAD anastomosis through a left mini-thoracotomy. The perioperative complications consisted of one bleeding of the thoracotomy wound and one aborted myocardial infarction not requiring intervention. The mean duration of hospital stay was 6 days (standard deviation = 2). After discharge, cardiac hospital readmission occurred in 4 patients (AF n  = 1; pleural- and pericardial effusion n  = 2, myocardial infarction requiring the percutaneous intervention of the LIMA-LAD n  = 1) within 1 year. After 12 months, 17/21 (81%) patients were in sinus rhythm when allowing anti-arrhythmic drugs. Finally, the left atrial ejection fraction improved postoperatively [26% (standard deviation = 11) to 38% (standard deviation = 7), P  =   0.01]. CONCLUSIONS In this initial feasibility and early safety study, unilateral left-sided thoracoscopic AF ablation and concomitant MIDCAB for LIMA-LAD grafting is a feasible, safe and efficacious for patients with AF and a critical LAD stenosis. [ABSTRACT FROM AUTHOR]

Background The aim of this study was to determine associations between characteristics of arteriovenous access (AVA) flow volume (Qa; mL/min) and 4-year freedom from cardiovascular mortality (CVM) in haemodialysis (HD) patients. Methods HD patients who received a primary AVA between January 2010 and December 2017 in one centre were analysed. Initial Qa was defined as the first Qa value obtained in a well-functioning AVA by a two-needle dilution technique. Actual Qa was defined as access flow at a random point in time. Changes in actual Qa were expressed per 3-month period. CVM was assessed according to the European Renal Association–European Dialysis and Transplant Association classification. The optimal cut-off point for initial Qa was identified by a receiver operating characteristics curve. A joint modelling statistical technique determined longitudinal associations between Qa characteristics and 4-year CVM. Results A total of 5208 Qa measurements (165 patients; 103 male, age 70 ± 12 years, autologous AVA n = 146, graft n = 19) were analysed. During follow-up (December 2010–January 2018, median 36 months), 79 patients (48%) died. An initial Qa <900 mL/min was associated with an increased 4-y CVM risk {hazard ratio [HR] 4.05 [95% confidence interval (CI) 1.94–8.43], P < 0.001}. After 4 years, freedom from CVM was 34% lower in patients with a Qa <900 mL/min (53 ± 7%) versus a Qa ≥900 mL/min (87 ± 4%; P < 0.001). An association between increases in actual Qa per 3-month period and mortality was found [HR 4.48/100 mL/min (95% CI 1.44–13.97), P = 0.010], indicating that patients demonstrating increasing Qa were more likely to die. In contrast, actual Qa per se was not related to survival. Conclusions Studying novel AVA Qa characteristics may contribute to understanding excess CVM in HD patients. [ABSTRACT FROM AUTHOR]

Aims: We hypothesize that in patients with paroxysmal atrial fibrillation (AF), verapamil is associated with lower AF progression compared to beta blockers or no rate control.Methods and Results: In this pre-specified post hoc analysis of the RACE 4 randomized trial, the effect of rate control medication on AF progression in paroxysmal AF was analysed. Patients using Vaughan-Williams Class I or III antiarrhythmic drugs were excluded. The primary outcome was a composite of first electrical cardioversion (ECV), chemical cardioversion (CCV), or atrial ablation. Event rates are displayed using Kaplan-Meier curves and multivariable Cox regression analyses are used to adjust for baseline differences. Out of 666 patients with paroxysmal AF, 47 used verapamil, 383 used beta blockers, and 236 did not use rate control drugs. The verapamil group was significantly younger than the beta blocker group and contained more men than the no rate control group. Over a mean follow-up of 37 months, the primary outcome occurred in 17% in the verapamil group, 33% in the beta blocker group, and 33% in the no rate control group (P = 0.038). After adjusting for baseline characteristics, patients using verapamil have a significantly lower chance of receiving ECV, CCV, or atrial ablation compared to patients using beta blockers [hazard ratio (HR) 0.40, 95% confidence interval (CI) 0.19-0.83] and no rate control (HR 0.64, 95% CI 0.44-0.93).Conclusion: In patients with newly diagnosed paroxysmal AF, verapamil was associated with less AF progression, as compared to beta blockers and no rate control. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Although in both the US and European guidelines the 'heart team approach' is a class I recommendation, supporting evidence is still lacking. Therefore, we sought to provide comparative survival data of patients with mitral valve disease referred to the general and the dedicated heart team. METHODS In this retrospective cohort, patients evaluated for mitral valve disease by a general heart team (2009–2014) and a dedicated mitral valve heart team (2014–2018) were included. Decision-making was recorded prospectively in heart team electronic forms. The end point was overall survival from decision of the heart team. RESULTS In total, 1145 patients were included of whom 641 (56%) were discussed by dedicated heart team and 504 (44%) by general heart team. At 5 years, survival probability was 0.74 [95% confidence interval (CI) 0.68–0.79] for the dedicated heart team group compared to 0.70 (95% CI 0.66–0.74, P  = 0.040) for the general heart team. Relative risk of mortality adjusted for EuroSCORE II, treatment groups (surgical, transcatheter and non-intervention), mitral valve pathology (degenerative, functional, rheumatic and others) and 13 other baseline characteristics for patients in the dedicated heart team was 29% lower [hazard ratio (HR) 0.71, 95% CI 0.54–0.95; P  = 0.019] than for the general heart team. The adjusted relative risk of mortality was 61% lower for patients following the advice of the heart team (HR 0.39, 95% CI 0.25–0.62; P  < 0.001) and 43% lower for patients following the advice of the general heart team (HR 0.57, 95% CI 0.37–0.87; P  = 0.010) compared to those who did not follow the advice of the heart team. CONCLUSIONS In this retrospective cohort, patients treated for mitral valve disease based on a dedicated heart team decision have significantly higher survival independent of the allocated treatment, mitral valve pathology and baseline characteristics. [ABSTRACT FROM AUTHOR]

Background Nurse-led integrated care is expected to improve outcome of patients with atrial fibrillation compared with usual-care provided by a medical specialist. Methods and results We randomized 1375 patients with atrial fibrillation (64 ± 10 years, 44% women, 57% had CHA2DS2-VASc ≥ 2) to receive nurse-led care or usual-care. Nurse-led care was provided by specialized nurses using a decision-support tool, in consultation with the cardiologist. The primary endpoint was a composite of cardiovascular death and cardiovascular hospital admissions. Of 671 nurse-led care patients, 543 (81%) received anticoagulation in full accordance with the guidelines against 559 of 683 (82%) usual-care patients. The cumulative adherence to guidelines-based recommendations was 61% under nurse-led care and 26% under usual-care. Over 37 months of follow-up, the primary endpoint occurred in 164 of 671 patients (9.7% per year) under nurse-led care and in 192 of 683 patients (11.6% per year) under usual-care [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.69 to 1.04, P  = 0.12]. There were 124 vs. 161 hospitalizations for arrhythmia events (7.0% and 9.4% per year), and 14 vs. 22 for heart failure (0.7% and 1.1% per year), respectively. Results were not consistent in a pre-specified subgroup analysis by centre experience, with a HR of 0.52 (95% CI 0.37–to 0.71) in four experienced centres and of 1.24 (95% CI 0.94–1.63) in four less experienced centres (P for interaction <0.001). Conclusion Our trial failed to show that nurse-led care was superior to usual-care. The data suggest that nurse-led care by an experienced team could be clinically beneficial (ClinicalTrials.gov NCT01740037). Trial Registration number ClinicalTrials.gov (NCT01740037). Open in new tab Download slide Open in new tab Download slide [ABSTRACT FROM AUTHOR]

Background Tacrolimus, a drug for prevention of rejection after kidney transplantation, has a narrow therapeutic window and is metabolized by the cytochrome P540 3A (CYP3A) system. Tacrolimus exposure increases after steroid tapering in many patients. The pregnane X receptor (PXR)—a mediator for CYP3A —has a steroid receptor and might regulate CYP3A5 activity depending on single nucleotide polymorphisms (SNPs) of CYP3A5 or PXR. This may contribute to differences in tacrolimus exposure after steroid tapering. Methods In a cohort of renal transplant recipients, the influence of CYP3A5 and PXR SNPs (A7635G, C8055T and C25385T) on the dose-normalized Tacrolimus trough concentration (DnC0) and their potential interaction with each other after steroid taper were analysed by linear regression. Eligible were all 83 outpatient renal transplant patients on tacrolimus and steroids in a pharmacokinetic steady state at least 6 weeks after transplantation and whose blood was available for genetic analysis. Results Compared with the CYP3A5*1/*3 genotype, the CYP3A5*3/*3 SNP showed a significantly stronger increase in DnC0 after steroid taper (+0.29 µg/L/mg; P = 0.002). Of the tested PXR SNPs, PXR G7635G individuals had a significantly stronger increase in DnC0 (compared with A7635A, +0.31 µg/L/mg; P = 0.02), with a weaker increase in A7635G heterozygotes (+0.17 µg/L/mg; P = 0.124). There was neither interaction nor association between CYP3A5 and PXR SNPs. Conclusions The magnitude of the DnC0 increase due to steroid taper after renal transplantation is related to CYP3A5 SNPs. Independently, the PXR G7635G SNP is related to this increase, proving the role of PXR in tacrolimus metabolism. [ABSTRACT FROM AUTHOR]

The line "If all three measurements differed by >15%, an average of all three was used" has been corrected to "If all three measurements differed by >=15%, an average of all three was used". The legend should read as: [black line] Survived during follow-up [red line] Died during follow-up Graph: Figure 2: class="chapter-para">Qa over time of individual patients (A) and (B) entire study cohort (n = 165). [Extracted from the article]

Objective: To develop a model to identify women at very low risk of recurrent early-onset preeclampsia. Methods: We enrolled 407 women who had experienced early-onset preeclampsia in their first pregnancy, resulting in a delivery before 34 weeks' gestation. Preeclampsia was defined as hypertension (systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg) after 20 weeks' gestation with de novo proteinuria (≥300 mg urinary protein excretion/day). Based on the previous published evidence and expert opinion, 5 predictors (gestational age at previous birth, prior small-for-gestational-age newborn, fasting blood glucose, body mass index, and hypertension) were entered in a logistic regression model. Discrimination and calibration were evaluated after adjusting for overfitting by bootstrapping techniques. Results: Early-onset disease recurred in 28 (6.9%) of 407 women. The area under the receiver operating characteristic (ROC) curve of the model was 0.65 (95% CI: 0.56-0.74). Calibration was good, indicated by a nonsignificant Hosmer-Lemeshow test (P = .11). Using a predicted absolute risk threshold of, for example, 4.6% (ie, women identified with an estimated risk either above or below 4.6%), the sensitivity was 100%, with a specificity of 26%. In such a strategy, no women who developed preeclampsia were missed, while 98 of the 407 women would be regarded as low risk of recurrent early-onset preeclampsia, not necessarily requiring intensified antenatal care. Conclusion: Our model may be helpful in the identification of women at very low risk of recurrent early-onset preeclampsia. Before widespread application, our model should be validated in other populations. [ABSTRACT FROM PUBLISHER]