Percutaneous coronary intervention with everolimus-eluting stents (Xience V): systematic review and direct-indirect comparison meta-analyses with paclitaxel-eluting stents (Taxus) and sirolimus-eluting stents (Cypher).

First-generation drug-eluting stents (DES) have brought major improvements in results of percutaneous coronary intervention (PCI). However, there is currently debate on the safety of these first-generation DES, given the potential for late stent thrombosis, especially after discontinuation of dual antiplatelet therapy. Second-generation DES, such as zotarolimus- (Endeavor) and everolimus-eluting stents (Xience V), have recently become available in the USA and/or Europe. Indeed, the Xience V stent holds the promise of superior anti-restenotic efficacy as well as long-term safety, yet there is uncertainty on its risk-benefit balance. Authors conducted a systematic review of basic science and clinical evidence on the Xience V, by thoroughly searching PubMed and online databases (updated September 2007). They also compared the clinical results of Xience V vs paclitaxel-eluting stents (Taxus) and sirolimus-eluting stents (Cypher) by means of direct and indirect comparison meta-analysis. A total of three clinical studies has been retrieved focusing on Xience V, however both most recent and important trials were still unpublished. The first trial compared Xience V vs bare-metal stents, whereas the other two randomized trials compared Xience V vs Taxus. Direct meta-analysis of Xience V vs Taxus showed that Xience V was significantly superior to Taxus in preventing binary angiographic restenosis and target lesion revascularization (P<0.05 for both). Indirect comparison between Xience V and Cypher, exploiting a recent 16-trial large meta-analysis, showed that Xience V was at least as effective as Cypher in preventing target lesion revascularization (P=0.12). Everolimus-eluting stents (Xience V) appear as a major breakthrough in coronary interventions, and superior efficacy has already been demonstrated in comparison to paclitaxel-eluting stents (Taxus). Data available to date also suggest that Xience V is at least as effective as sirolimus-eluting stents (Cypher). Whether long-term results and direct comparison to Cypher will also be favorable remains to be established by future clinical trials.

The Ross procedure in children and young adults: a word of caution.

BACKGROUND: Disease of the aortic valve in children and young adults is a complex entity whose management is the subject of controversy. The Ross and the Ross-Konno procedures have become the primary choices for aortic valve replacement in children because of growth potential, optimal hemodynamic performance, and lack of the need for anticoagulation. However, concern persists regarding the longevity of the pulmonary autograft, especially in patients with aortic insufficiency. METHODS: Between June 1993 and February 2000, 72 Ross and Ross-Konno procedures were performed at our institution: 81% of the patients were less than 15 years old. Preoperative, postoperative, and follow-up clinical, echocardiographic, and hemodynamic data were reviewed. Statistical analysis was performed to identify the risk factors for deteriorating autograft function. RESULTS: Aortic insufficiency was an indication for the Ross procedure in 17 patients and mixed lesions with predominant aortic insufficiency in 10. Of the 45 other patients, 32 had aortic stenosis and 13 had mixed lesions with predominant aortic stenosis. There were no deaths during a follow-up of 5 to 80 months. Autograft reoperation was necessary in the follow-up period in 7 patients for severe aortic insufficiency. Moderate insufficiency was identified in 5 additional patients. Aortic insufficiency or predominant aortic insufficiency, as a preoperative hemodynamic indication for the Ross procedure, reached statistical significance (P =.031) as a risk factor for autograft failure. CONCLUSION: The Ross and the Ross-Konno procedures have changed the prognosis of children and young adults with complex aortic valve disease. However, the Ross procedure should be performed with caution in older children in whom aortic insufficiency is a preoperative hemodynamic indication. Further follow-up to delineate the risk factors for autograft dysfunction in children and young adults is necessary to better define the indications for the Ross procedure.

Colonoscopic features of colonic anastomoses.

Colonic anastomoses are frequently encountered, but their endoscopic features have never been adequately characterized. Results of 117 consecutive colonoscopies in patients with colonic anastomoses were prospectively studied during a 12-month period. Anastomoses were photographed, videotaped, and reviewed by the authors. The age range of patients was 18 to 87 years, and interval from surgery extended to 42 years. An equal number of right and left colonic resections were encountered; 9 patients had subtotal colectomies. Ninety-two anastomoses were hand-sewn, and 25 were stapled. Ileal pouch-anal anastomoses were not included. Nine common anastomotic features were identified with the following frequency of occurrence: neovascularity, 105 (89.7%); white anastomotic edge, 64 (54.7%); disruption of haustral pattern, 64 (54.7%); radial suture tracks, 35/92 (38.0%); exposed suture, 11/92 (11.9%); exposed staples, 6/25 (24%); scar tissue adjacent to anastomotic line, 8 (6.8%); nondistensibility of anastomosis, 5 (4.3%); blind colonic pouch, 10 (8.5%). No recurrent carcinomas were noted. The site of seven anastomoses (5.5%) could not be identified. Six of these patients underwent endoscopy more than 8 years postoperatively. Of the remaining 110 patients, 94 (85.5%) had between two and four of the above features identified. In three of four patients who required dilation because of strictures, neovascularity was not seen. We conclude that colonic anastomoses have characteristic endoscopic features. These features can be used as landmarks for definitive identification of anastomotic sites at colonoscopy. The lack of neovascularity at a colonic anastomosis may be an indicator of relative ischemia, predisposing to stricture formation.