Beating heart minimally invasive mitral valve surgery in patients with previous sternotomy: the operative technique and early outcomes.

Objective: Reoperative mitral valve surgery is increasingly required and can be associated with significant morbidity and mortality. The beating heart minimally invasive mitral valve surgery has a proposed benefit in avoiding the risks of repeat sternotomy, with reducing the need for adhesiolysis and cardioplegia reperfusion injury. We describe our experience with such a technique in patients with previous sternotomy. Methods: A retrospective study was performed and all patients undergoing surgery of mitral valve through a right limited thoracotomy without application of an aortic cross-clamp (beating heart) as a redo cardiac surgery between January 2006 and January 2015 were included (n=25). Perioperative data as well as the operative technique are presented. Results: Six patients (24%) had two previous sternotomies and one (4%) had three previous sternotomies. Mitral valve repair was performed in 11 patients (44%). No patient required conversion to median sternotomy. Inotropic support beyond 4 hours after operation was required in seven patients (28%). Ventilation time was less than 12 hours in 14 patients (56%) with another six patients (24%) extubated within 24 hours after surgery. Postoperative course was complicated with cerebrovascular accident in two patients (8%). In-hospital mortality was 4% (n=1). There was no 30-day mortality after discharge. Conclusions: Reoperative mitral valve surgery can be safely performed through a limited right thoracotomy approach on a beating heart while on full cardiopulmonary bypass. The technique can be associated with potentially shorter operation, shorter cardiopulmonary bypass and a less complicated recovery.

On-X versus St Jude Medical Regent mechanical aortic valve prostheses: early haemodynamics.

OBJECTIVE: We aimed to compare the early haemodynamic data of the On-X and St Jude Medical (SJM) Regent bileaflet mechanical prostheses in the aortic position. METHODS: A retrospective study was performed using data collected prospectively for a national database. Thirty-three patients who had aortic On-X valve (On-X group) and 33 matched patients who had aortic SJM Regent valve (SJM group) were included. The intraoperative and early postoperative data were collected. The same echocardiographer reviewed all the echocardiograms and obtained the required parameters. RESULTS: The peak gradient across the prosthetic valve was comparable between the two groups except for the labelled valve size of 25 mm for which the On-X group had lower peak gradient when compared with the SJM group. Mean gradients and effective orifice area indices of the two valve types within each valve size subgroup were comparable. CONCLUSIONS: The current study confirms that in the early postoperative period, the two valve types had comparable haemodynamic outcomes.

A systematic review on the safety and efficacy of percutaneous edge-to-edge mitral valve repair with the MitraClip system for high surgical risk candidates.

BACKGROUND: MitraClip implantation has emerged as a viable option in high surgical risk patients with severe mitral regurgitation (MR). We performed the present systematic review to assess the safety and efficacy of the MitraClip system for high surgical risk candidates with severe organic and/or functional MR. METHODS: Six electronic databases were searched for original published studies from January 2000 to March 2013. Two reviewers independently appraised studies, using a standard form, and extracted data on methodology, quality criteria, and outcome measures. All data were extracted and tabulated from the relevant articles' texts, tables, and figures and checked by another reviewer. RESULTS: Overall 111 publications were identified. After applying selection criteria and removing serial publications with accumulating number of patients or increased length of follow-up, 12 publications with the most complete dataset were included for quality appraisal and data extraction. All 12 studies were prospective observational studies. Immediate procedural success ranged from 72-100%; 30 day mortality ranged from 0-7.8%. There was a significant improvement in haemodynamic profile and functional status after implantation. One year survival ranged from 75-90%. No long term outcomes have been reported for high surgical risk patients. CONCLUSIONS: MitraClip implantation is an option in managing selected high surgical risk patients with severe MR. The current evidence suggests that MitraClip can be implanted with reproducible safety and feasibility profile in this subgroup of patients. Further prospective trials with mid- to long-term follow-up are required.

A meta-analysis of MitraClip system versus surgery for treatment of severe mitral regurgitation.

BACKGROUND: Mitral regurgitation (MR) is the second most common valvular heart disease after aortic stenosis. Without intervention, prognosis is poor in patients with severe symptomatic MR. While surgical repair is recommended for many patients with severe degenerative MR (DMR), as many as 49% of patients do not qualify as they are at high surgical risk. Furthermore, surgical correction for functional MR (FMR) is controversial with suboptimal outcomes and significant perioperative mortality. The percutaneous MitraClip implantation can be seen as a viable option in high surgical risk patients. The purpose of this meta-analysis is to compare the safety, clinical efficacy, and survival outcomes of MitraClip implantation with surgical correction of severe MR. METHODS: Six electronic databases were searched for original published studies from January 2000 to August 2013. Two reviewers independently appraised studies, using a standard form, and extracted data on methodology, quality criteria, and outcome measures. All data were extracted and tabulated from the relevant articles' texts, tables, and figures and checked by another reviewer. RESULTS: Overall 435 publications were identified. After applying selection criteria and removing serial publications with accumulating number of patients or increased length of follow-up, four publications with the most complete dataset were included for quality appraisal and data extraction. There was one randomized controlled trial (RCT) and three prospective observational studies. At baseline, patients in the MitraClip group were significantly older (P=0.01), had significantly lower LVEF (P=0.03) and significantly higher EuroSCORE (P<0.0001). The number of patients with post-procedure residual MR severity >2 was significantly higher in the MitraClip group compared to the surgical group (17.2% vs. 0.4%; P<0.0001). 30-day mortality was not statistically significant (1.7% vs. 3.5%; P=0.54), nor were neurological events (0.85% vs. 1.74%; P=0.43), reoperations for failed MV procedures (2% vs. 1%; P=0.56), NYHA Class III/IV (5.7% vs. 11.3; P=0.42) and mortality at 12 months (7.4% vs. 7.3%; P=0.66). CONCLUSIONS: Despite a higher risk profile in the MitraClip patients compared to surgical intervention, the clinical outcomes were similar although surgery was more effective in reducing MR in the early post procedure period. We conclude the non-inferiority of the MitraClip as a treatment option for severe, symptomatic MR in comparison to conventional valvular surgery.

A systematic review of transapical aortic valve implantation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) through a transapical approach (TAAVI) for severe aortic stenosis becomes the procedure of choice in cases where patients have peripheral artery disease and unfeasible access due to excessive atherosclerotic disease of the iliofemoral vessels and aorta. The present systematic review aimed to assess the safety, success rate, clinical outcomes, hemodynamic outcomes, and survival benefits of TAAVI. METHODS: Electronic searches were performed in 6 databases from January 2000 to February 2012. The primary end points included feasibility and safety. Other end points included echocardiographic findings, functional class improvement, and survival. RESULTS: After applying the inclusion and exclusion criteria, 48 out of 154 shortlisted potentially relevant articles were selected for assessment. Of these, 26 studies from 24 centers including total number of 2,807 patients were included for appraisal and data extraction. The current evidence on TAAVI for aortic stenosis is limited to observational studies. Successful TAAVI implantation occurred in >90% of patients. On average, the procedure took between 64 to 154 minutes to complete. The incidence of major adverse events included 30-day mortality (4.7-20.8%); cerebrovascular accident (0-16.3%); major tachyarrhythmia (0-48.8%); bradyarrhythmia requiring permanent pacemaker insertion (0-18.7%); cardiac tamponade (0-11%); major bleeding (1-17%); myocardial infarction (0-6%); aortic dissection/rupture (0-5%); moderate to severe paravalvular leak (0.7-24%); cardiopulmonary bypass support (0-15%); conversion to surgery (0-9.5%); and valve-in-valve implantation (0.6-8%). Mean aortic valve area improved from 0.4-0.7 cm(2) before TAAVI to 1.4-2.1 cm(2) after TAAVI. The peak pressure gradient across the aortic valve decreased from >70 mmHg to <20 mmHg after TAAVI. One-year survival ranged from 49.3% to 82% and the 3-year survival was 58% in 2 series. CONCLUSIONS: TAAVI appears to be feasible with a reasonable safety and efficacy portfolio. Randomised controlled trials are required to compare transapical vs. transfemoral TAVI when both techniques are equally feasible.

Pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension : a systematic review.

PURPOSE: Pulmonary thromboendarterectomy (PTE) is a treatment option for patients with chronic thromboembolic pulmonary hypertension (CTEPH). The present systematic review was performed to assess the safety and efficacy of PTE for CTEPH. METHODS: A systematic review was performed, and six electronic databases were searched for published studies from January 1999 to February 2010. All articles that presented morbidity and mortality data, survival data or preoperative and postoperative pulmonary hemodynamic indices were included. The primary outcome measures extracted were early morbidity and mortality, pulmonary hemodynamic and functional outcome indices prior to and after the operation, and survival data. RESULTS: Of the 654 publications retrieved, 19 relevant papers (total number of 2729 patients) representing the most recent and complete data set from each institute, were included for appraisal and data extraction. No randomized controlled trials or matched comparative studies were identified. Thirty-day mortality ranged from 1.3% to 24% (median 8%). Residual pulmonary hypertension was reported in 11%-35% of patients after PTE. Pulmonary artery pressure and pulmonary vascular resistance significantly decreased after PTE in all studies. Before PTE, 60%-100% of patients were in NYHA functional class III or IV. This percentage decreased to 0%-21% after PTE. Five-year survival ranged from 74% to 89%. CONCLUSIONS: The current literature suggests that PTE for patients with CTEPH is associated with acceptable perioperative morbidity and mortality rates and improved hemodynamic indices and survival when viewed against the prognosis associated with historical controls using medical therapy.

Intrathoracic application of a vacuum-assisted closure device in managing pleural space infection after lung resection: is it an option?

Empyema after lung resection is a challenging condition to manage and is associated with a high mortality. Intrathoracic application of a vacuum-assisted closure (VAC) device is recently introduced as an adjunct in the management of this condition. A best evidence topic was constructed to address whether this approach is effective in successful chest closure and reducing hospital stay. Twenty-three papers were found using the reported search, of which nine papers were identified that provided the best evidence to answer the question. All papers were retrospective and included a total of 69 patients treated with intrathoracic VAC. There was only one cohort study and the rest were either case series or case reports. In a cohort of 19 patients reported by Palmen et al. the average duration of an open window thoracostomy in a group of patients with VAC (n=11) was 39 ± 17 days and in those without VAC (n=8) was 933 ± 1422 days. Median length of VAC treatment was 22 days (range 6-66 days) in a series of 28 patients reported by Saadi et al. Some authors excluded patients with a bronchopleural fistula (BPF) from VAC treatment. However, Groetzner et al. have safely used VAC in patients with BPF after covering the bronchus stump with an intrathoracic muscle flap. The mediastinum and the bronchus can be covered using a polyvinyl-alcohol foam. Polyurethane foam is commonly used to fill the intrathoracic cavity up to the superficial wound. The suggested starting level of negative pressure is as low as -25 mmHg to -75 mmHg depending on the presence or absence of signs of mediastinal traction; this negative pressure can gradually be increased to -125 mmHg over time. The recommended interval between VAC changes is two to five days. Accumulated evidence in this article, although limited, suggests that VAC, as an adjunct to the standard treatment, can potentially alleviate the morbidity and decrease hospital stay in patients with empyema after lung resection. VAC can reduce inpatient length of treatment and can make the condition manageable in an outpatient setting. These results are yet to be proven by larger studies and clinical trials.

Aortic valve-sparing operations in aortic root aneurysms: remodeling or reimplantation?

A best evidence topic was written according to a structured protocol. The question addressed was whether the reimplantation (David) technique or the remodeling (Yacoub) technique provides the optimum event free survival in patients with an aortic root aneurysm suitable for an aortic valve-sparing operation. In total, 392 papers were found using the reported search criteria, of which 14 papers provided the best evidence to answer the clinical question. A total of 1338 patients (Yacoub technique in 606 and David technique in 732) from 13 centres were included. In most series, cardiopulmonary bypass time and aortic cross-clamp time were longer for the David technique compared to the Yacoub technique. Early mortality was comparable between the two techniques (0-6.9% for the Yacoub technique and 0-6% for the David technique). There is a tendency for a higher freedom from significant long-term aortic insufficiency in the David group than the Yacoub group, which does not necessarily result in a higher reoperation rate in the Yacoub group. In the largest series reported, freedom from a moderate-to-severe aortic insufficiency at 12 years was 82.6 ± 6.2% in the Yacoub and 91.0 ± 3.8% in the David group (P=0.035). Freedom from reoperation at the same time point was 90.4 ± 4.7% in the Yacoub group and 97.4 ± 2.2% in the David group (P=0.09). In another series, freedom from reoperation at a follow-up time of about four years was 89 ± 4% in the Yacoub group and 98 ± 2% in the David group. Although some authors merely preferred the Yacoub technique for a bicuspid aortic valve, the accumulated evidence in the current review indicates comparable results for both techniques in a bicuspid aortic valve. Current evidence is in favour of the David rather than the Yacoub technique in pathologies such as Marfan syndrome, acute type A aortic dissection, and excessive annular dilatation that may impair aortic root integrity. Careful selection of patients for each technique and successful restoration of normal cusp geometry are the keys to success in aortic valve-sparing operations.

Current treatment of Crimean-Congo hemorrhagic fever in children.

Crimean-Congo hemorrhagic fever (CCHF) is a fatal viral hemorrhagic fever and is usually transmitted to humans by tick bite, or exposure to infected blood or tissues of infected livestock or humans. Although children can be infected with the CCHF virus, infection is unusual in the younger age group. Early diagnosis and treatment of CCHF infection is critical to the survival of patients and the control of the disease. In this article, we underline current therapeutic approaches to CCHF infection in children.

Ahmed glaucoma valve and single-plate Molteno implants in treatment of refractory glaucoma: a comparative study.

PURPOSE: To report 2-year follow-up data after Ahmed valve implantation (New World Medical, Inc) and Molteno single-plate implantation surgical treatment of refractory glaucoma. DESIGN: Prospective, randomized, comparative study. METHODS: Patients with refractory glaucoma, defined as uncontrolled intraocular pressure (IOP) of more than 21 mm Hg despite maximal antiglaucoma medication, previously failed nonseton surgical treatment, or a combination thereof were included. Ninety-two patients were allocated randomly to each of the study groups and underwent implantation of either the Ahmed valve implant (model FP7; 184 mm(2) surface area) or Molteno single-plate implant (134 mm(2) surface area) and were followed up for 24 months. Main outcome measures were IOP and surgical success rate. Other outcome measures were changes in visual acuity, number of ant-glaucoma medications, mean deviation of visual field, and rate of intraoperative and postoperative complications. RESULTS: Those who successfully completed the trial (28 in the Molteno group and 29 in the Ahmed group) achieved significantly less IOP and fewer glaucoma medications, but worse visual acuity 24 months after surgery. The Molteno group, compared with the Ahmed group, achieved significantly lower IOPs after the early postoperative period until the end of the study. Both groups reasonably maintained visual field during the follow-up. The rate of surgical failure was comparable in both groups. Median survival time was 24 months for both groups. There were no devastating intraoperative or postoperative complications in either group. CONCLUSIONS: Both Ahmed and Molteno implants successfully preserved visual field, although IOP control was more pronounced in the Molteno implant group.

Antibody response to influenza immunization in coronary artery disease patients: a controlled trial.

Safety of and humoral immune response to the anti-influenza vaccine in coronary artery disease (CAD) patients were evaluated. The trivalent vaccine was administered to 137 eligible CAD patients and 67 age- and sex-matched healthy individuals. Antibody (Ab) titers were measured before and 1 month after vaccination. CAD and HC groups were not significantly different in serologic response and magnitude of change in antibody titers against each of the vaccine antigens. In multivariate analyses, regular exercise and using multivitamin supplements were independently associated with better antibody response among CAD patients. There were no major cardiac or general adverse effects. Influenza vaccine was found safe in CAD patients and antibody responses were similar to HCs.

Chronic mustard toxicity on the testis: a historical cohort study two decades after exposure.

We aimed to assess the long-term toxic effects of sulphur mustard (SM) on the testis and male fertility two decades after exposure. A historical cohort study was conducted in 2005. Sixty-four SM-exposed and 64 matched SM-unexposed casualties of the Iraq-Iran conflict were enrolled. Fecundity status, semen indices, hormonal assay results and testis histopathology were evaluated. Male factor infertility was diagnosed in 23 and 5% of married exposed and unexposed casualties, respectively (p < 0.01). All semen indices declined over the 15 years since 1990 among the exposed group. Furthermore, all indices with the exception of sperm motility were significantly lower in the exposed than in unexposed men. The follicle-stimulating hormone level was higher in the infertile than in fertile exposed men (p < 0.001). Testis histopathology of the azoospermic men showed complete absence of spermatogenesis with only Sertoli cells in the seminiferous tubules. SM can be gonadotoxic and its chronic toxicity may be permanent. Germ cells are probably the most susceptible gonadal cells to SM.

Therapeutic aspects of hepatitis C in hemodialysis patients.

BACKGROUND: Since hemodialysis (HD) patients usually suffer from multiple clinical problems and drug side effects, the treatment of hepatitis C in these patients still remains a challenging problem. METHODS: We identified eligible studies using a wide-spectrum search up to May 2007 in MEDLINE (since 1966) and EMBASE (since 1980). Two researchers (S.M.H.M. and M.R.) independently reviewed the manuscripts identified by the search strategy. To determine the most current information, only studies that had been published after 1995 were included. RESULTS: Interferon (IFN)-alpha has long been used for this purpose; however, more recently the advent of pegylated (PEG) IFN has proven to be more beneficial in these patients. Even though the usage of ribavirin is promising in the case of hepatitis C in otherwise healthy subjects, the utilization of this drug in patients with renal failure may be accompanied by catastrophic complications. CONCLUSION: Although both conventional IFN and PEG-IFN seem to be favorable options for the management of hepatitis C in HD patients, further studies on new therapeutic agents are required.

Spontaneous perforation of urinary bladder secondary to Candida cystitis: acute abdomen of urologic origin.

BACKGROUND: Spontaneous urinary bladder perforation is a rare event; presentation as an acute abdomen is rarer still. Fungal cystitis has seldom, and Candida albicans cystitis has never, to our knowledge, been reported as a cause of perforation. METHODS: Case report and literature review. RESULTS: A 70-year-old woman with diabetes mellitus presented with an acute abdomen and urinary symptoms. A diagnosis of an intraperitoneal bladder perforation was made during emergency operation; culture of the peritoneal fluid and urine yielded Candida albicans. The initial high blood urea nitrogen and serum creatinine concentrations mimicked acute renal failure but were caused by urine absorption across the peritoneum. The patient was treated successfully with emergency laparotomy, a three-week course of fluconazole, and a five-day course of bladder irrigation with amphotericin B. CONCLUSIONS: Spontaneous urinary bladder perforation secondary to Candida cystitis should be considered as a possible cause of acute abdomen, especially when the biochemical profile suggests urine absorption and yeast is reported in the urinalysis of an immunocompromised patient.

A comparison of corneal endothelial cell changes after 1-site and 2-site phacotrabeculectomy.

PURPOSE: To compare the corneal endothelial cell (CEC) changes that occurred after phacotrabeculectomy performed at 1 or 2 sites. DESIGN: A historical cohort study. METHODS: The records of patients who had 1-site (n = 61) or 2-site (n = 52) limbus-based phacotrabeculectomy over a 4-year period (2002-2005) at 1 eye surgery center (Vanak Eye Surgery Center, Tehran, Iran) by a single surgeon were reviewed, and postoperative CEC indices were measured. Preoperative CEC indices, performed for a then-ongoing trial, were compared with postoperative measurements of the last follow-ups. The main outcome measure was endothelial cell count. RESULTS: The median follow-up time was 12 months (range 9-24 months). There was no difference between the operations in improving visual acuity, lowering intraocular pressure, and decreasing the number of antiglaucoma medications required. However, 2-site surgery was associated with significantly more expansion in the CEC area (P < 0.001). On multivariate analysis, longer follow-up, 2-site surgery, and grade 4 cataract density were independently associated with more CEC loss, and longer follow-up, 2-site surgery, and steroid-induced glaucoma were associated with CEC area expansion. Postoperative complications were not markedly different between the 2 groups. CONCLUSIONS: In both groups, the longer the follow-up time was, the higher the CEC loss and the CEC area expansion were. One-site surgery seems to cause less CEC damage than the 2-site operation during the median follow-up time of 1 year.

Accuracy and coverage of reproductive health information on the Internet accessed in English and Persian from Iran.

BACKGROUND AND METHODOLOGY: The Internet is a useful resource for obtaining information. We evaluated the accuracy and coverage of reproductive health information on the Internet in English- and Persian-language sites accessed from Iran. An expert committee decided on five reproductive health topics to be evaluated and specified a checklist of content for these (36 items in total). We employed selected keywords in search engines between February and March 2006. About one of every four screened websites (n = 200) addressed at least one target topic and were subjected to in-depth assessment. Three medical doctors independently rated each of the selected websites. Accuracy and coverage percentages were calculated for each website. RESULTS: A total of 168 English- and 32 Persian-language websites were found that addressed the specified topics. The mean accuracy and coverage percentages of the 200 websites assessed were 98.8% (95%CI 98.1-99.6) and 45.2% (95%CI 41.0-49.3), respectively. Thirty-four (17%) websites, all in English, achieved a coverage percentage of 80% or more. Academic referencing was not present in 152 (76%) websites. 'Sexually transmitted diseases' and 'family planning' were the topics with highest coverage in both the English- and Persian-language websites studied. 'Reproductive system and puberty' had the least coverage in the Persian websites. The top 20 websites found for the general population on reproductive health are reported. DISCUSSION AND CONCLUSIONS: Websites providing comprehensive reproductive health information are not easy to locate from Iran; in particular, Persian-language websites and those targeting young people are scarce. However, for the websites identified the accuracy of information provided was acceptable. There is a need to identify high-quality, easily accessible websites for use by both professionals and the general public and to develop new ones.

Corneal endothelial cell injury induced by mitomycin-C in photorefractive keratectomy: nonrandomized controlled trial.

PURPOSE: To evaluate the effect of intraoperative use of mitomycin-C (MMC) on the corneal endothelium during excimer laser photorefractive keratectomy (PRK). SETTING: Vanak Eye Surgery Center, Tehran, Iran. METHODS: This nonrandomized trial comprised 81 patients (162 eyes) with bilateral low to moderate myopia and adequate corneal thickness to allow PRK (estimated postoperative residual stromal thickness >350 microm without considering epithelial thickness). The indication for intraoperative application of MMC 0.02% (0.2 mg/mL) was an ablation depth of 75 microm or more. Patients were divided into 3 groups: bilateral (both eyes treated with MMC), unilateral (only 1 eye treated with MMC), and untreated (no eye treated with MMC). Visual acuity, refraction, endothelial cell density (ECD), and corneal thickness were measured preoperatively as well as 1 week and 1, 3, and 6 months postoperatively. RESULTS: Overall, 76 eyes were treated with MMC. Eyes treated with MMC and untreated eyes were comparable in postoperative visual acuity and refraction. Preoperative to postoperative changes in ECD were statistically significantly greater in the treated eyes (-14.8%) than in untreated eyes (-5.1%) 6 months after PRK (P<.001). Longer MMC contact time (P<.001) and male sex (P= .04) were the only factors independently associated with greater endothelial cell loss. CONCLUSIONS: The prophylactic use of diluted intraoperative MMC 0.02% solution caused corneal endothelial cell loss. The rate of cell loss was correlated with the duration of MMC exposure.

Clinical and epidemiologic features of Crimean-Congo hemorrhagic fever among children and adolescents from southeastern Iran.

This study aimed to investigate the clinical and epidemiologic features of Crimean-Congo hemorrhagic fever among 34 children and adolescents (mean age, 13.3 +/- 4.6 years) from a highly endemic region. Clinical manifestations were similar to those in adults. The case-fatality ratio was 26.5% (9 of 34). Compared with adult patients, children and adolescents may be more vulnerable to severe and fatal Crimean-Congo hemorrhagic fever.