Predictors of perforation during lead extraction: Results of the Canadian Lead ExtrAction Risk (CLEAR) study.

BACKGROUND: Transvenous lead extraction can have serious adverse events, such as cardiac or vascular perforation. Risk factors have not been well characterized. OBJECTIVE: The purpose of this study was to identify factors associated with perforation and death, and to characterize lead extraction in a large contemporary population. METHODS: We performed a retrospective multicenter study examining patients undergoing lead extraction at 8 Canadian institutions from 1996 through 2016. Demographic and clinical data were used to identify variables associated with perforation and mortality using logistic regression modeling. RESULTS: A total of 2325 consecutive patients (age 61.9 ±16.5 years) underwent extraction of 4527 leads. Perforation rate was 2.7% (63/2325) and 30-day mortality was 1.6% (38/2325), with mortality of 0.4% due to perforation (10/2325). Variables associated with perforation included no previous cardiac surgery (odds ratio [OR] 3.33; 95% confidence interval [CI] 1.54-7.19; P = .002), female sex (OR 3.27; 95% CI 1.91-5.60; P <.001); left ventricular ejection fraction ≥40% (OR 2.81; 95% CI 1.28-6.14; P = .010); lead age >8 years (OR 2.64; 95% CI 1.52-4.60; P <.001); ≥2 leads extracted (OR 2.49; 95% CI 1.23-5.04; P = .011); and diabetes (OR 2.12; 95% CI 1.16-3.86; P = .014). Variables associated with death included infection as indication for extraction (OR 3.85; 95% CI 1.38-10.73; P = .010); anemia (OR 3.14; 95% CI 1.38-6.61; P = .003), and patient age (OR 1.04; 95% CI 1.01-1.07; P = .012). CONCLUSION: Risk factors associated with perforation in lead extraction include no history of cardiac surgery, female sex, preserved left ventricular ejection fraction, lead age >8 years, ≥2 leads extracted, and diabetes.

Atherosclerotic cardiovascular disease in women with endometriosis: a systematic review of risk factors and prospects for early surveillance.

Endometriosis and atherosclerotic cardiovascular disease (ASCVD) share similar pathogenic mechanisms. Hence, this systematic review evaluates the association between endometriosis and lifetime ASCVD risk including co-prevalence with dyslipidaemia, atherosclerosis and non-invasive markers of endothelial dysfunction. The electronic databases Embase, PubMed, MEDLINE, Cochrane Register of Trials and ClinicalTrials.gov were systematically searched for relevant articles. Two prospective cohort studies demonstrated an increased lifetime ASCVD risk after controlling for demographic and lifestyle confounders in women with endometriosis, as measured by higher incidence of myocardial infarction (relative risk [RR] 1.52), angiography-confirmed angina (RR 1.91), or requiring coronary artery bypass graft surgery (RR 1.35). Among 10 studies that included 407 patients with surgically proven endometriosis and 557 controls, RR of developing hypercholesterolemia and hypertension were 1.25 and 1.14, respectively, while higher serum lipoprotein a and lower paraoxonase 1 levels were found in women with endometriosis that was negatively correlated with stage of disease (r = -0.74, P < 0.0001). Hence, currently available evidence suggests that women with endometriosis are at higher lifetime risk of developing ASCVD than women without endometriosis. However, robust causal evidence is still lacking and future studies are needed to determine whether women with endometriosis represent a high-risk population for lifelong ASCVD risk.

The first transapical transcatheter aortic valve-in-valve implantation using the J-valve system into a failed biophysio aortic prosthesis in a patient with high risk of coronary obstruction.

We report the first successful valve-in-valve (ViV) implantation into a failed Edwards Biophysio surgical prosthesis (Edwards Lifesciences, Irvine, CA) and also the first use of the J-Valve system (Jie Cheng Medical Technologies, Suzhou, China) in a ViV configuration. A 77-year old male had symptomatic severe aortic stenosis secondary to failure of a 25 mm Biophysio bioprosthetic valve implanted 11 years previously, along with concomitant coronary artery bypass grafting. Transthoracic echocardiography (TTE) revealed calcified leaflets, a mean aortic gradient of 50 mm Hg, and an estimated valve area of 0.9 cm2 with no aortic insufficiency. The patient had low coronary ostial height with the right coronary artery arising only 8.5 mm from the valve annulus and the left main coronary artery arising only 9.4 mm from the valve annulus. Risk of coronary ostial obstruction was especially concerning in context of both the patient's extremely low coronary ostial height and the unique structure of the Biophysio valve. Under general anesthesia, transapical transcatheter aortic ViV implantation with a 25 mm J-Valve was performed in a hybrid operating room. The J-Valve prosthesis was deployed in the 25 mm Biophysio surgical valve without difficulty or complications. There were no intraoperative or postoperative complications. The patient was discharged home after 3 days. TTE at 1 year showed a mean aortic valve gradient of 14 mm Hg, and no aortic insufficiency. This case demonstrated that J-Valve implantation may be a new option for patients at high risk for coronary obstruction.

Safety and efficacy of prophylactic negative pressure wound therapy following open saphenous vein harvest in cardiac surgery: a feasibility study.

Objectives: Surgical site complications following great saphenous vein (GSV) harvest presents a significant risk of morbidity. Negative pressure wound therapy (NPWT) has shown promise in the treatment and prophylaxis of open wounds and surgical incisions but has not been studied following GSV harvest. We performed a feasibility study examining the use of NPWT following GSV harvest for coronary bypass surgery. Methods: Sixty-four patients were recruited in this single-centre, single-blind, randomized controlled trial. The primary endpoint assessed feasibility by examining rates of device complication and malfunction. Secondary endpoints included rates of surgical site infection, lower leg complications, discharge date, and quality of life at discharge and 6 weeks. NPWT was delivered using the Prevena NPWT device. Results: There were no complications associated with NPWT which required intervention aside from discontinuation. NPWT was tolerated in 91% (30/33) of patients for the duration of treatment with an average of 4.8 days (±1.45 days). Device malfunction which required discontinuation was 6% (2/33) and involved a malfunctioning pressure sensor and did not affect patient care or present safety concerns. One patient had allergic contact dermatitis to the adhesive and had the device removed. NPWT patients had an earlier date of discharge (6 vs 10 days, P = 0.008), increased ability for self-care ( P = 0.0234) and quality of life ( P = 0.039) at initial assessment, and increased mobility at initial and follow-up assessment ( P = 0.0117 and 0.0123). Conclusions: The use of NPWT following GSV harvest is safe, well tolerated and improves postoperative recovery with prolonged impact on mobility at 6 weeks. Clinical trial registration: https://clinicaltrials.gov/ct2/show/NCT01698372 ; registration number: NCT01698372.

Trophic factor-induced activity 'signature' regulates the functional expression of postsynaptic excitatory acetylcholine receptors required for synaptogenesis.

Highly coordinated and coincidental patterns of activity-dependent mechanisms ("fire together wire together") are thought to serve as inductive signals during synaptogenesis, enabling neuronal pairing between specific sub-sets of excitatory partners. However, neither the nature of activity triggers, nor the "activity signature" of long-term neuronal firing in developing/regenerating neurons have yet been fully defined. Using a highly tractable model system comprising of identified cholinergic neurons from Lymnaea, we have discovered that intrinsic trophic factors present in the Lymnaea brain-conditioned medium (CM) act as a natural trigger for activity patterns in post- but not the presynaptic neuron. Using microelectrode array recordings, we demonstrate that trophic factors trigger stereotypical activity patterns that include changes in frequency, activity and variance. These parameters were reliable indicators of whether a neuron expressed functional excitatory or inhibitory nAChRs and synapse formation. Surprisingly, we found that the post- but not the presynaptic cell exhibits these changes in activity patterns, and that the functional expression of excitatory nAChRs required neuronal somata, de novo protein synthesis and voltage gated calcium channels. In summary, our data provides novel insights into trophic factor mediated actions on neuronal activity and its specific regulation of nAChR expression.

The abdomen in "thoracoabdominal" cannot be ignored: abdominal compartment syndrome complicating extracorporeal life support.

Extracorporeal life support (ECLS) is an incredible life-saving measure that is being used ever more frequently in the care of the critically ill. Management of these patients requires extreme vigilance on the part of the care providers in recognizing and addressing the complications and challenges that may arise. We present a case of overt abdominal compartment syndrome (ACS) in a previously well young male on ECLS with a history of trauma, submersion, hypothermia, and no intra-abdominal injuries. The patient developed ACS soon after ECLS was initiated which resulted in drastically compromised flow rates. Taking into account the patient's critical status, an emergent laparotomy was performed in the intensive care unit which successfully resolved the ACS and restored ECLS flow. The patient had an unremarkable course following and was weaned off ECLS but unfortunately died from his original anoxic injury. This case highlights several salient points: first, care of patients on ECLS is challenging and multiple etiologies can affect our ability to manage these patients; second, intra-abdominal pressures should be monitored liberally in the critically ill, especially in patients on ECLS; third, protocols for emergent operative treatment outside of traditional operating rooms should be established and care providers should be prepared for these situations.

A planar microelectrode array for simultaneous detection of electrically evoked dopamine release from distinct locations of a single isolated neuron.

Neurotransmission is a key process of communication between neurons. Although much is known about this process and the influence it has on the function of the body, little is understood about the dynamics of signalling from structural regions of a single neuron. In this study we have fabricated and characterised a microelectrode array (MEA) which was utilised for simultaneous multi-site recordings of dopamine release from an isolated single neuron. The MEA consisted of gold electrodes that were created in plane with the insulation layer using a chemical mechanical planarization process. The detection limit for dopamine measurements was 11 ± 3 nM and all the gold electrodes performed in a consistent fashion during amperometric recordings of 100 nM dopamine. Fouling of the gold electrode was investigated, where no significant change in the current was observed over 4 hours when monitoring 100 nM dopamine. The MEA was accessed using freshly isolated dopaminergic somas from the pond snail, Lymnaea stagnalis, where electrically evoked dopamine release was clearly observed. Measurements were conducted at four structural locations of a single isolated neuron, where electrically evoked dopamine release was observed from the cell body, axonal regions and the terminal. Over time, the release of dopamine varied over the structural regions of the neuron. Such information can provide an insight into the signalling mechanism of neurons and how they potentially form synaptic connections.