Search

Background: Phlegmonous and gangrenous appendicitis represent independent pathophysiological entities with different clinical courses ranging from spontaneous resolution to septic disease. However, reliable predictive methods for these clinical phenotypes have not yet been established. In an attempt to provide pathophysiological insights into the matter, a genomewide gene expression analysis was undertaken in patients with acute appendicitis. Methods: Peripheral blood mononuclear cells were isolated and, after histological confirmation of PA or GA, analysed for genome-wide gene expression profiling using RNA microarray technology and subsequent pathway analysis. Results: Samples from 29 patients aged 7-17 years were included. Genomewide gene expression analysis was performed on 13 samples of phlegmonous and 16 of gangrenous appendicitis. From a total of 56 666 genes, 3594 were significantly differently expressed. Distinct interaction between T and B cells in the phlegmonous appendicitis group was suggested by overexpression of T cell receptor α and β subunits, CD2, CD3, MHC II, CD40L, and the B cell markers CD72 and CD79, indicating an antiviral mechanism. In the gangrenous appendicitis group, expression of genes delineating antibacterial mechanisms was found. Conclusion: These results provide evidence for different and independent gene expression in phlegmonous and gangrenous appendicitis in general, but also suggest distinct immunological patterns for the respective entities. In particular, the findings are compatible with previous evidence of spontaneous resolution in phlegmonous and progressive disease in gangrenous appendicitis. [ABSTRACT FROM AUTHOR]

Editorial. Comments on contradicting principles of the legality of North Atlantic Treaty Organization (NATO) intervention in Kosovo, Serbia. Noncompliance of NATO military action with United Nations Charter; Impact of NATO intervention on the Kosovo conflict; Significance of implementing international human rights law.

Retrospective studies have shown improvement in migraines after patent foramen ovale (PFO) closure. To date, no study has evaluated whether the completeness of closure affects headache status; therefore, the objective of this study was to evaluate the impact of residual right-to-left shunt (RLS) on migraine symptoms after transcatheter PFO closure in migraineurs with and without aura. This was a small-series, single-center, retrospective analysis of late follow-up data on 77 patients with presumed paradoxical embolism and migraine who underwent PFO closure for secondary stroke prevention. Power M-mode transcranial Doppler was used to assess RLS at baseline and 6 and 12 months after closure. A standardized migraine questionnaire was administered at baseline and 6, 12, and 24 months after closure. Fifty-five (71%) patients had migraine with aura. Final closure and migraine status were available for 67 patients; 23 (34%) had incomplete PFO closure, defined as 30 embolic tracks detected at final power M-mode transcranial Doppler examination (median 366 days, 95% confidence interval 332 to 474). Migraine relief (> or = 50% reduction in frequency) was independent of closure status (77% complete closure vs 83% incomplete closure, p = 0.76) at late follow-up (540 days, 95% confidence interval 537 to 711). Migraineurs with aura were 4.5 times more likely to experience migraine relief than migraineurs without aura. In conclusion, migraine relief may occur despite residual RLS after transcatheter PFO closure, which may suggest a reduction in RLS burden below a neuronal threshold that triggers migraine; however, this warrants further investigation. Migraine with aura may be an independent predictor of relief after PFO closure. [ABSTRACT FROM AUTHOR]

Background: Whether routine implantation of coronary stents is the best strategy to treat flow-limiting coronary stenoses is unclear. An alternative approach is to do balloon angioplasty and provisionally use stents only to treat suboptimum results. We did a multicentre trial to compare the outcomes of patients treated with these strategies.Methods: We randomly assigned 479 patients undergoing single-vessel coronary angioplasty routine stent implantation or initial balloon angioplasty and provisional stenting. We followed up patients for 6 months to determine the composite rate of death, myocardial infarction, cardiac surgery, and target-vessel revascularisation.Results: Stents were implanted in 227 (98.7%) of the patients assigned routine stenting. 93 (37%) patients assigned balloon angioplasty had at least one stent placed because of suboptimum angioplasty results. At 6 months the composite endpoint was significantly lower in the routine stent strategy (14 events, 6.1%) than with the strategy of balloon angioplasty with provisional stenting (37 events, 14.9%, p=0.003). The cost of the initial revascularisation procedure was higher than when a routine stent strategy was used (US$389 vs $339, p<0.001) but at 6 months, average per-patient hospital costs did not differ ($10,206 vs $10,490). Bootstrap replication of 6-month cost data showed continued economic benefit of the routine stent strategy.Interpretation: Routine stent implantation leads to better acute and long-term clinical outcomes at a cost similar to that of initial balloon angioplasty with provisional stenting. [ABSTRACT FROM AUTHOR]

Rotational atherectomy results in platelet activation and heat generation, which may impact artery size immediately after treatment. In addition, arteries treated with balloon angioplasty may exhibit recoil within 24 hours. In this study, arteries treated with rotational atherectomy, with and without adjunctive balloon angioplasty, were analyzed by quantitative coronary angiography to determine the effect of rotational atherectomy on the dynamic behavior of the arterial wall within 24 hours after the procedure. Quantitative coronary angiography was performed at a core laboratory. Coronary angiogram acquisitions were preceded by intracoronary nitroglycerin injections and were repeated using identical angles of projection. Proximal and distal reference vessel diameters were 2.55 +/- 0.60 and 2.28 +/- 0.51 mm, respectively, and did not change from pre- to postprocedure. Both were larger the following day increasing to 2.72 +/- 0.65 and 2.52 +/- 0.52 mm, respectively, (p <0.001). Minimum luminal diameter (MLD) increased from 0.70 +/- 0.28 mm before to 1.49 +/- 0.34 mm after the procedure and to 1.72 +/- 0.37 mm at 24-hour follow-up (p <0.001). Subset analysis of patients treated with rotational atherectomy alone or rotational atherectomy with adjunctive balloon angioplasty revealed that the increase in luminal diameters occurred in both subsets. Patients treated with adjunctive angioplasty had a smaller initial MLD, a larger postprocedure MLD, and no difference in MLD at 24-hour follow-up compared with stand-alone rotational atherectomy. Subset analysis of 100 patients who had 6-month follow-up angiography revealed that both a calculated acute gain and chronic late loss, based on a 24-hour film, differed significantly from values using a film acquired immediately after the procedure. However, the slope of the linear regression between acute gain and chronic late loss did not differ. Coronary arteries treated with rotational atherectomy with or without adjunctive balloon angioplasty increase significantly in size during the first 24 hours after the procedure. This phenomenon has implications for the calculation of absolute gain and chronic late loss, but not for the linear relation between the 2 quantitative outcomes. [ABSTRACT FROM AUTHOR]

Background: The occurrence of conduction disturbances (CDs) remains the most frequent complication of transcatheter aortic valve replacement (TAVR). However, little is known about the timing of electrocardiogram (ECG) changes and CDs during the TAVR procedure., Objective: The objective of this study was to describe ECG changes throughout the TAVR procedure using the CARA monitor., Methods: This was a multicenter study including 196 prospectively enrolled patients without preexisting CDs undergoing TAVR. All patients were monitored with the CARA system, which uses a 12-lead ECG to measure PQ and QRS intervals, QRS axis, and variations with each heartbeat at every step: baseline, wire insertion, pre-dilatation, valve deployment, post-dilatation, and end of procedure., Results: PQ and QRS intervals progressively increased throughout the procedure, with a cumulative increase from 169.2 ± 20.0 ms to 186.0 ± 31.6 ms (P < .001) for the PQ interval and from 101.3 ± 10.5 ms to 126.0 ± 25.4 ms (P < .001) for the QRS interval, from baseline to the end of the procedure. A significant increase in the number of patients with left axis deviation was observed (7.7% at baseline vs 31.8% at end of procedure; P < .001). A total of 161 (82.1%) patients exhibited at least 1 CD episode (PQ >200 ms, QRS ≥120 ms, advanced heart block) during the procedure, with most episodes occurring during pre-dilatation and valve implantation maneuvers., Conclusion: The CARA system facilitated real-time ECG monitoring, detecting subtle and progressive changes during TAVR. ECG changes occurred at each step, with most patients experiencing CDs, especially during pre-dilatation and valve implantation. The potential clinical impact of monitoring ECG dynamics and timing for early detection of severe CDs should be explored in future studies., Competing Interests: Disclosures Dr Rodés-Cabau reports having received institutional research grants and speaker/consultant fees from Edwards Lifesciences and Medtronic. The rest of the authors have not reported any potential conflict of interest with respect to the content of this article., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Whether patent foramen ovale (PFO) closure benefits older patients with PFO and cryptogenic stroke is unknown because randomized controlled trials (RCTs) have predominantly enrolled patients younger than 60 years of age. Our objective was to estimate anticipated effects of PFO closure in older patients to predict the numbers needed to plan an RCT., Methods: Effectiveness estimates are derived from major observational studies (Risk of Paradoxical Embolism [RoPE] Study and Oxford Vascular Study, together referred to as the "RoPE-Ox" database) and all 6 major RCTs (Systematic, Collaborative, PFO Closure Evaluation [SCOPE] Consortium). To estimate stroke recurrence risk, observed outcomes were calculated for patients older than 60 years in the age-inclusive observational databases (n = 549). To estimate the reduction in the rate of recurrent stroke associated with PFO closure vs medical therapy based on the RoPE score and the presence of high-risk PFO features, a Cox proportional hazards regression model was developed on the RCT data in the SCOPE database (n = 3,740). These estimates were used to calculate sample sizes required for a future RCT., Results: Five-year risk of stroke recurrence using Kaplan-Meier estimates was 13.7 (95% CI 10.5-17.9) overall, 14.9% (95% CI 10.2-21.6) in those with high-risk PFO features. Predicted relative reduction in the event rate with PFO closure was 12.9% overall, 48.8% in those with a high-risk PFO feature. Using these estimates, enrolling all older patients with cryptogenic stroke and PFO would require much larger samples than those used for prior PFO closure trials, but selectively enrolling patients with high-risk PFO features would require totals of 630 patients for 90% power and 471 patients for 80% power, with an average of 5 years of follow-up., Discussion: Based on our projections, anticipated effect sizes in older patients with high-risk features make a trial in these subjects feasible. With lengthening life expectancy in almost all regions of the world, the utility of PFO closure in older adults is increasingly important to explore.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a sequela of a pulmonary embolus that occurs in approximately 1%-3% of patients. Pulmonary thromboendoarterectomy (PTE) can be a curative procedure, but balloon pulmonary angioplasty (BPA) has emerged as an option for poor surgical candidates. We used the National Inpatient Sample to query patients who underwent PTE or BPA between 2012 and 2019 with CTEPH. The primary outcome was a composite of in-hospital mortality, myocardial infarction, stroke, tracheostomy, and prolonged mechanical ventilation. Outcomes were compared between low- and high-volume centers, defined as 5 and 10 procedures per year for BPA and PTE, respectively. During our study period, 870 BPA and 2395 PTE were performed. There was a 328% relative increase in the number of PTE performed during the study period. Adverse events for BPA were rare. There was an increase in the primary composite outcome for low-volume centers compared to high-volume centers for PTE (24.4% vs. 12.1%, p  = 0.003). Patients with hospitalizations for PTE in low-volume centers were more likely to have prolonged mechanical ventilation (20.0%% vs. 7.2%, p  < 0.001) and tracheostomy (7.8% vs. 2.6%, p  = 0.017). In summary, PTE rates have been rising over the past 10 years, while BPA rates have remained stable. While adverse outcomes are rare for BPA, patients with hospitalizations at low-volume centers for PTE were more likely to have adverse outcomes. For patients undergoing treatment of CTEPH with BPA or PTE, referral to high-volume centers with multidisciplinary teams should be encouraged for optimal outcomes., Competing Interests: A. V.: Grant funding from the New York Academy of Medicine; A. K.: Institutional funding to Columbia University and/or Cardiovascular Research Foundation from Medtronic, Boston Scientific, Abbott Vascular, Amgen, CSI, Philips, ReCor Medical, Neurotronic, Biotronik, Chiesi, Bolt Medical, Magenta Medical, Canon, SoniVie, Shockwave Medical, and Merck. In addition to research grants, institutional funding includes fees paid to Columbia University and/or Cardiovascular Research Foundation for consulting and/or speaking engagements in which Dr. Ajay J. Kirtane controlled the content. Personal: Consulting from IMDS; Travel Expenses/Meals from Medtronic, Boston Scientific, Abbott Vascular, CSI, Siemens, Philips, ReCor Medical, Chiesi, OpSens, Zoll, and Regeneron; Z. S.: Consulting feeds from Medtronic and Abbott Vascular. The remaining authors declare no conflict of interest., (© 2024 The Authors. Pulmonary Circulation published by John Wiley & Sons Ltd on behalf of Pulmonary Vascular Research Institute.)

The association, if any, between the effective regurgitant orifice area (EROA) to left ventricular end-diastolic volume (LVEDV) ratio and 1-year mortality is controversial in patients who undergo mitral transcatheter edge-to-edge repair (m-TEER) with the MitraClip system (Abbott Vascular, Santa Clara, CA). This study's objective was to determine the association between EROA/LVEDV and 1-year mortality in patients who undergo m-TEER with MitraClip. In patients with severe secondary (functional) mitral regurgitation (MR), we analyzed registry data from 11 centers using generalized linear models with the generalized estimating equations approach. We studied 525 patients with secondary MR who underwent m-TEER. Most patients were male (63%) and were New York Heart Association class III (61%) or IV (21%). Mitral regurgitation was caused by ischemic cardiomyopathy in 51% of patients. EROA/LVEDV values varied widely, with median = 0.19 mm 2 /ml, interquartile range [0.12,0.28] mm 2 /ml, and 187 patients (36%) had values <0.15 mm 2 /ml. Postprocedural mitral regurgitation severity was substantially alleviated, being 1+ or less in 74%, 2+ in 20%, 3+ in 4%, and 4+ in 2%; 1-year mortality was 22%. After adjustment for confounders, the logarithmic transformation (Ln) of EROA/LVEDV was associated with 1-year mortality (odds ratio 0.600, 95% confidence interval 0.386 to 0.933, p = 0.023). A higher Society of Thoracic Surgeons risk score was also associated with increased mortality. In conclusion, lower values of Ln(EROA/LVEDV) were associated with increased 1-year mortality in this multicenter registry. The slope of the association is steep at low values but gradually flattens as Ln(EROA/LVEDV) increases., Competing Interests: Declaration of competing interest Dr. Lim reports a relation with Abbott that includes funding grants; a relation with Boston Scientific Corp. that includes funding grants; a relation with Corvia Medical that includes funding grants; a relation with Edwards Lifesciences Corporation that includes funding grants; a relation with Medtronic Inc. that includes funding grants; a relation with Trisol that includes funding grants; a relation with Philips that includes consulting or advisory; a relation with Valgen that includes consulting or advisory; and a relation with Venus that includes consulting or advisory. Dr. Rodriguez reports a relation with Abbott that includes consulting or advisory, funding grants, and speaking and lecture fees. Dr. Zahr reports a relation with Medtronic Inc. that includes board membership, consulting or advisory, and funding grants; a relation with Edwards Lifesciences Corporation that includes funding grants; and a relation with SIEMENS that includes: funding grants. Dr. Ailawadi reports a relation with Medtronic Inc. that includes consulting or advisory; a relation with Abbott that includes consulting or advisory; a relation with Edwards Lifesciences Corporation that includes consulting or advisory; a relation with Gore that includes consulting or advisory; a relation with Anteris that includes consulting or advisory; a relation with AtriCure Inc. that includes consulting or advisory; a relation with CryoLife that includes consulting or advisory; a relation with Philips that includes consulting or advisory; and a relation with Johnson & Johnson that includes consulting or advisory. Dr. Rogers reports a relation with Abbott that includes consulting or advisory and funding grants; a relation with Boston Scientific Corp that includes consulting or advisory and funding grants; and a relation with Baylis Medical Company, Inc. that includes consulting or advisory. Dr. Chen reports a relation with Philips that includes consulting or advisory; a relation with Abbott that includes consulting or advisory; and a relation with Akura Medical that includes consulting or advisory. Dr. Vannan reports a relation with Abbott that includes funding grants and speaking and lecture fees. Dr. Duggal reports a relation with Medtronic Inc. that includes consulting or advisory. Dr. Sodhi reports a relation with Medtronic Inc that includes consulting or advisory; and a relation with Boston Scientific Corp that includes consulting or advisory. Dr. Sorajja reports a relation with 4C Medical Technologies Inc. that includes consulting or advisory; a relation with Anteris that includes consulting or advisory; a relation with Abbott that includes consulting or advisory; a relation with Boston Scientific Corp that includes consulting or advisory; a relation with Edwards Lifesciences Corporation that includes consulting or advisory; a relation with Evolution Medical that includes consulting or advisory; a relation with Foldax that includes consulting or advisory; a relation with GLG that includes consulting or advisory; a relation with Medtronic Inc. that includes consulting or advisory; a relation with Philips that includes consulting or advisory; a relation with SIEMENS that includes consulting or advisory; a relation with Shifamed that includes consulting or advisory; a relation with WL Gore that includes consulting or advisory; a relation with vDyne that includes consulting or advisory; and a relation with xDot that includes consulting or advisory. Dr. Yadav reports a relation with Edwards Lifesciences Corporation that includes consulting or advisory and speaking and lecture fees; a relation with Abbott that includes consulting or advisory and speaking and lecture fees; a relation with Boston Scientific Corp. that includes consulting or advisory and speaking and lecture fees; and a relation with Dasi Simulations that includes board membership. Dr. Chadderdon reports a relation with Medtronic Inc that includes consulting or advisory; a relation with Edwards Lifesciences Corporation that includes consulting or advisory; and a relation with GE Healthcare that includes funding grants. Dr. Chetcuti reports a relation with Medtronic Inc. that includes consulting or advisory and funding grants; a relation with Boston Scientific Corp. that includes consulting or advisory and funding grants; a relation with Jena that includes funding grants; a relation with Abbott that includes funding grants; a relation with Edwards Lifesciences Corporation that includes funding grants; and a relation with Gore that includes funding grants. The remaining authors have no competing interests to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Left ventricular (LV) volume reshaping reduces myocardial wall stress and may induce reverse remodeling in patients with heart failure with reduced ejection fraction. The AccuCinch Transcatheter Left Ventricular Restoration system consists of a series of anchors connected by a cable implanted along the LV base that is cinched to the basal free wall radius. We evaluated the echocardiographic and clinical outcomes following transcatheter left ventricular restoration., Methods and Results: We analyzed 51 heart failure patients with a left ventricular ejection fraction between 20% and 40%, with no more than 2+ mitral regurgitation treated with optimal medical therapy, who subsequently underwent transcatheter left ventricular restoration. Serial echocardiograms, Kansas City Cardiomyopathy Questionnaire scores, and 6-minute walk test distances were measured at baseline through 12 months. Primary analysis end point was change in end-diastolic volume at 12 months compared with baseline. Patients (n = 51) were predominantly male (86%) with a mean age of 56.3 ± 13.1 years. Fluoroscopy showed LV free wall radius decreased by a median of 9.2 mm amounting to a 29.6% decrease in the free wall arc length. At 12 months, the LV end-diastolic volume decreased by 33.6 ± 34.8 mL (P < .01), with comparable decreases in the LV end-systolic volume. These decreases were associated with significant improvements in the overall Kansas City Cardiomyopathy Questionnaire score (16.4 ± 18.7 points; P < .01) and 6-minute hall walk test distance (45.9 ± 83.9 m; P < .01). There were no periprocedural deaths; through the 1-year follow-up, 1 patient died (day 280) and 1 patient received a left ventricular assist device (day 13)., Conclusions: In patients with heart failure with reduced ejection fraction without significant mitral regurgitation receiving optimal medical therapy, the AccuCinch System resulted in decreases of LV volume, as well as improved quality of life and exercise endurance. A randomized trial is ongoing (NCT04331769)., Competing Interests: Conflicts of Interest Nadira Hamid reports Institutional grant support. Ulrich Jorde reports travel support from Ancora Heart. Mark Reisman reports travel support from Ancora Heart. Azeem Latib has nothing to declare. D. Scott Lim has nothing to declare. Susan Joseph has nothing to declare. Alena Kurlianskaya has nothing to declare. Oleg Polonetsky, MD, reports consultancy fees from Ancora Heart, and consultancy or proctoring fees from Edwards Lifesciences and Medtronic. Petr Neuzil has nothing to declare. Vivek Reddy has nothing to declare. Jason Foerst has nothing to declare. Hemal Gada has nothing to declare. Kendra J. Grubb reports advisory board and consulting fees for Medtronic, Boston Scientific, Abbott, Ancora, 4C Medical, and honorarium for Edwards Lifesciences. Guilherme Silva has nothing to declare. Dean Kereiakes has nothing to declare. Satya Shreenivas has nothing to declare. Sean Pinney reports consulting fees from Abbott, CareDx, Medtronic, Procyrion, and Transmedics. Giedrius Davidavicius is a consultant to Ancora Heart. Paul Sorajja has nothing to declare. John Boehmer has nothing to declare. Franz X. Kleber is a consultant to Ancora Heart. Patrick Perier has nothing to declare. Nicolas M. Van Mieghem reports research grant support from Abbott, Boston Scientific, Edwards Lifesciences, Medtronic, PulseCath BV, Abiomed, Siemens, and Daiichi Sankyo. Nicolas Dumonteil reports consultancy fees from Ancora Heart, is the co-PI of the CorCinch European study; and reports consultancy and proctoring fees from Abbott Vascular, Boston Scientific, Edwards Lifesciences, and Medtronic. Martin B. Leon reports institutional clinical research grants from Abbott, Abiomed, Ancora, Boston Scientific, Edwards, and Medtronic. Daniel Burkhoff reports institutional grant support from Ancora Heart to the Cardiovascular Research Foundation., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)