The Effect of Surgical Aortic Valve Replacement on Arterial Stiffness: Does the Valve Type Matter?

Background: Despite the increasing use of transcatheter aortic valve procedures, many patients still require surgical aortic valve replacement (SAVR). Assessing arterial properties in patients undergoing SAVR for aortic valve stenosis can be challenging, and the existing evidence is inconclusive. Our study aimed to investigate the impact of SAVR on vascular stiffness and the quality of life, as well as the different effects of valve type on arterial properties. Methods: We included 60 patients (mean age 70.25 ± 8.76 years, 65% men) with severe symptomatic aortic stenosis who underwent SAVR. Arterial stiffness (cfPWV, baPWV) and vascular parameters (AIx@75, central pressures, SEVR) were measured at baseline, pre-discharge, and 1-year post-operation. The QOL was assessed using the generic questionnaire-short-form health survey 36 (SF-36) pre-operatively and at 1 year. Results: Post-SAVR, cfPWV increased immediately (7.67 ± 1.70 m/s vs. 8.27 ± 1.92 m/s, p = 0.009) and persisted at 1 year (8.27 ± 1.92 m/s vs. 9.29 ± 2.59 m/s, p ≤ 0.001). Similarly, baPWV (n = 55) increased acutely (1633 ± 429 cm/s vs. 2014 ± 606 cm/s, p < 0.001) and remained elevated at 1 year (1633 ± 429 cm/s vs. 1867 ± 408 cm/s, p < 0.001). Acute decrease in Alx@75 (31.16 ± 10% vs. 22.48 ± 13%, p < 0.001) reversed at 1 year (31.16 ± 10% vs. 30.98 ± 9%, p = 0.71). SEVR improved (136.1 ± 30.4% vs. 149.2 ± 32.7%, p = 0.01) and persisted at 1 year (136.1 ± 30.4% vs. 147.5 ± 30.4%, p = 0.01). SV had a greater cfPWV increase at 1 year (p = 0.049). The QOL improved irrespective of arterial stiffness changes. Conclusions: After SAVR, arterial stiffness demonstrates a persistent increase at 1-year, with valve type having a slight influence on the outcomes. These findings remain consistent despite the perceived QOL.

Does minimal invasive cardiac surgery reduce the incidence of post-operative atrial fibrillation?

Atrial fibrillation (AF) is the most common post-operative complication and tends to be the most common arrhythmia after cardiac surgery. The etiology and risk factors for post-operative AF are poorly understood, but older age, large left atrium, diffuse coronary artery disease, a history of AF paroxysms and in general, pre-existing cardiac conditions that cause restricting and susceptibility towards inflammation have been consistently linked with post-operative atrial fibrillation (POAF). It has been traditionally thought that post-operative AF is transient, well-tolerated, benign to the patient and self-limiting complication of cardiac surgery that was temporary and easily treated. However, recent evidence suggests that POAF may be more "malignant" than previously thought, associated with follow-up mortality and morbidity. Several minimally invasive approaches, including the right parasternal approach, upper and lower mini-sternotomy (MS), V-shaped, Z-shaped, inverse-T, J-, reverse-C and reverse-L partial MS, transverse sternotomy and right mini-thoracotomy, have been developed for cardiac surgery operations since 1993 and have been associated with better outcomes and lower perioperative morbidity compared to full sternotomy (FS). The common goal of several minimally invasive approaches is to reduce invasiveness and surgical trauma. According to a statement from the American Heart Association (AHA), the term "minimally invasive" refers to a small chest wall incision that does not include a FS. This review is aimed to evaluate the use of minimally invasive techniques like mini-sternotomy, mini-thoracotomy and hybrid techniques versus conventional techniques which are used in cardiac surgery and to compare the frequency of post-operative AF and its effect on post-operative complications, morbidity and mortality, after cardiac surgery operations with FS versus cardiac surgery operations with the use of minimally invasive techniques.

Critical evaluation on proper antithrombotic treatment in different groups of patients undergoing vascular surgery.

Antithrombotic treatment including anticoagulants and antiplatelets has evolved during the last decades, and several recommendations have been included in the latest guidelines regarding the proper management of patients undergoing vascular surgery. However, there are significant differences compared to older recommendations, and indications vary among patients with peripheral artery disease, carotid disease, and abdominal aortic aneurysm. In this mini review, we critically evaluate all these data to produce useful conclusions for everyday clinical practice.

Proper Distal Placement of Tibial Nail Improves Rate of Malalignment for Distal Tibia Fractures.

OBJECTIVES: We hypothesize that the anatomic center of the distal tibia is just lateral and anterior to the center of the distal tibia articular surface in the coronal and sagittal planes, respectively, and that placement of the nail along this axis results in improved rates of malalignment when treating distal tibia fractures. DESIGN: Retrospective study. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. SETTING: One Level I and one Level II trauma center. PATIENTS/PARTICIPANTS: Two hundred three distal tibia fractures treated with intramedullary nailing (IMN) (primary cohort) whose main fracture line extended within 5 cm of the plafond to evaluate the rate of malalignment with distal nail placement. Additionally, we retrospectively reviewed a secondary cohort of 15 patients with proximal tibia fractures treated with intramedullary nailing for evaluation of passive anatomic distal nail position. MAIN OUTCOME MEASURES: Primary malalignment ≤5 degrees on the anteroposterior (AP), mortise, and lateral planes were evaluated in distal tibia fractures on perioperative radiographs. RESULTS: Primary Cohort: 85 patients met inclusion criteria for evaluation in the coronal plane. Overall malalignment in the coronal plane was 17.6%. There was a 2.9% (1/34) fracture malalignment rate when the nail was placed lateral to the center of the joint versus 27.5% (14/51) when placed medial to the center of the joint, with all occurring in valgus. This achieved statistical significance (P = 0.04). Correlation was highest when measuring the trajectory on mortise view using the talus as reference point. When evaluating the sagittal plane, there were 64 patients that met inclusion criteria with a 48% malalignment rate. Malalignment was greatest when the nail was placed in the anterior quadrant 100% (4/4), versus 50% (22/44) in the anterior middle, and 31.3% (5/16) in the posterior middle quadrant. This achieved statistical significance (P = 0.05). No nails were placed in the most posterior quadrant. Secondary Cohort: 15 patients met inclusion criteria for distal nail placement. The position of the nail in the coronal plane was measured on both the anteroposterior and mortise ankle radiographs using both the plafond and talus as a reference, whereas sagittal nail placement was measured on the lateral ankle radiographs. In the coronal plane, the mean passive distal position of the nail when referenced from the lateral cortex was 45.2% of the tibia plafond and 45.5% the width of the talus, or just lateral to the center of each. In the sagittal plane, passive nail placement was 40% the sagittal width of the joint measured from the anterior cortex, or just anterior to the center of the joint. CONCLUSIONS: This is the first patient series that defines optimal tibial nail placement in the treatment of distal tibia fractures. Distal placement of the nail just lateral to the center of the talus and plafond, or along mechanical axis of the tibia, results in significantly reduced rates of malalignment on the coronal plane when compared to nail placement medial to the center of the talus or plafond. Fluoroscopic judgment of distal nail trajectory was improved on the mortise view using the talus as a reference when compared to using the anteroposterior view. On the sagittal plane, anatomic passive nail placement is just anterior to the center of the plafond. However, nonanatomic nail placement just posterior to the center of the plafond had a lower incidence of malalignment compared with nails placed anterior to the center of the plafond. Further study of appropriate nail positioning on the sagittal plane is needed.

Stage-II thymoma and emergency coronary artery bypass. To irradiate or not to irradiate to avoid radiation induced vascular injury? Case report and literature review.

PURPOSE: The purpose of this study was to present the controversial role of adjuvant radiotherapy to a 72-year-old male patient with Masaoka stage II thymoma and coronary artery bypass and to review the relevant literature. METHODS: The data were collected by relevant studies on PubMed and EMBASE. Articles up to March 2017 were included. RESULTS: Although the radiation-induced vascular injury to the internal thoracic artery and its suitability for grafting in a patient who is candidate for coronary artery bypass is documented, the possible catastrophic effect of adjuvant radiotherapy to existing grafts in a patient with prior bypass surgery has not been fully investigated. CONCLUSION: The application of radiotherapy in a patient with R0 stage II thymoma is currently considered of 2B level of evidence but its potential occlusive effect to an underlying coronary graft may dramatically affect the survival of the patient and accordingly drop the level of evidence of its use.

Urine NGAL as a biomarker of kidney damage after on- and off-pump coronary artery bypass graft surgery: a prospective pilot study.

INTRODUCTION: Acute kidney injury (AKI) is a relatively frequent complication after coronary artery bypass graft surgery (CABG). We compared the off- and on-pump CABG procedures with respect to changes in renal function as reflected by levels of urine neutrophil gelatinase-associated lipocalin (UrNGAL). METHODS: In a prospective design, we studied patients who underwent CABG, off- or on-pump, with respect to changes in glomerular filtration rate (GFR) and UrNGAL pre- and postoperatively. UrNGAL was measured using a chemiluminescent microparticle immunoassay. We recorded patients' demographics, past medical history, cardiac function and laboratory findings. Patients were grouped according to the CABG type. RESULTS: Of 72 patients, 31 underwent off-pump and 41 on-pump CABG. The mean age was 65.7 ± 8.1 years and 81.9% were males. Groups were similar with respect to the prevalence of hypertension, diabetes, dyslipidaemia, body mass index, and smoking at entry. No patient experienced acute renal failure and there were no deaths. At both time points, the UrNGAL levels were similar in the two groups. Patients in the on-pump group showed a significant improvement in renal function 48 hours postoperatively compared to baseline (p<0.001). UrNGAL levels decreased significantly 3 hours after surgery in the on-pump group (p=0.001), while they tended to decrease in the off-pump group (p=0.057). The overall change in UrNGAL did not differ significantly between groups. CONCLUSIONS: According to the UrNGAL measurements, neither of the two CABG techniques was superior in terms of their effect on postoperative renal function. Renal function significantly improved in the on-pump group while UrNGAL levels decreased after surgery in the same group.

Degenerative disease of the cervical spine and its relationship to athletes.

Each sport presents with unique risk factors and different mechanisms of injury, and therefore extrapolation of the data from one sport to another makes comparison difficult. The current evidence exploring the relationship of athletes and degenerative changes of the cervical spine leaves much to be debated, and future prospective longitudinal studies will be needed to clarify our understanding further. Such research will help structure clinical recommendations and improve sports safety and the care of athletes of all ages. Currently, there is evidence to suggest that participation in collision sports is implicated in premature degeneration of the cervical spine. There is some evidence to suggest that the same is true with noncollision sports and activities that result in direct and indirect repetitive loads to the cervical spine over time. The risk factors have yet to be clearly identified. The natural history and sequelae of premature degeneration have yet to be elucidated. Cervical spondylosis also appears to increase the severity, but not the frequency, of irreversible neurologic injury during collision sport participation. Prudence dictates that we not ignore the present evidence suggesting a link between neuropraxia and cervical stenosis. Proper screening for cervical stenosis in patients with transient neuropraxia with subsequent cessation of participation in collision sports if severe stenosis is present is suggested. There is no consensus for RTP guidelines in the setting of transient neurologic injuries in the athlete when severe degeneration is present, and each case must be considered individually with regard to the sport involved.

Microalbuminuria: a strong predictor of 3-year adverse prognosis in nondiabetic patients with acute myocardial infarction.

BACKGROUND: The aim of this study is to evaluate the significance of microalbuminuria (MA) as a 3-year prognostic index in nondiabetic patients with acute myocardial infarction (AMI). METHODS: One hundred seventy-five patients with AMI were followed prospectively for 3 years. The study end point was cardiac death or rehospitalization for an acute coronary event. RESULTS: Forty-two patients (24%) developed a new cardiac event during the follow-up. Microalbuminuria (P < .001), pulmonary edema during initial hospitalization (P < .001) and postinfarction angina (P = .0364), advanced age (P = .001), severe atherosclerosis (high Gensini score) (P = .036), ejection fraction <50% (P = .0013), history of bypass surgery (P = .0265), and early conservative management (P = .0214) were all associated with adverse prognosis. Cox proportional hazards regression analysis showed that MA was an independent predictor of 3-year adverse prognosis in all the models tested, with an adjusted relative risk for the development of a cardiac event ranging from 2.1 to 4.3. CONCLUSIONS: In nondiabetic patients with AMI, MA is a strong and independent predictor of an adverse cardiac event within the next 3 years.

A prospective, double-blind study on the efficacy of the bioline surface-heparinized extracorporeal perfusion circuit.

BACKGROUND: We evaluated the newly introduced Bioline heparin coating and tested the hypothesis that surface heparinization limited to the oxygenator and the arterial filter will ameliorate systemic inflammation and preserve platelets during cardiopulmonary bypass (CPB). METHODS: In a prospective double-blind study, 159 patients underwent coronary revascularization using closed-system CPB with systemic heparinization, mild hypothermia (33 degrees C), a hollow-fiber oxygenator, and an arterial filter. The patients were randomly divided in three groups. In group A (controls, n = 51), surface heparinization was not used. In group B (n = 52), the extracorporeal circuits were totally surface-heparinized with Bioline coating. In group C (n = 56), surface heparinization was limited to oxygenator and arterial filter. RESULTS: No significant difference was noted in patient characteristics and operative data between groups. Operative (30-day) mortality was zero. Platelet counts dropped by 12.3% of pre-CPB value among controls at 15 minutes of CPB, but were preserved in groups B and C throughout perfusion (p = 0.0127). Platelet factor 4, plasmin-antiplasmin levels, and tumor necrosis factor-alpha increased more in controls during CPB than in groups B or C (p = 0.0443, p = 0.0238 and p = 0.0154 respectively). Beta-thromboglobulin, fibrinopeptide-A, prothrombin fragments 1 + 2, factor XIIa levels, bleeding times, blood loss, and transfusion requirements were similar between groups. Intensive care unit stay was shorter in groups B and C than in controls (p = 0.037). CONCLUSIONS: Surface heparinization with Bioline coating preserves platelets, ameliorates the inflammatory response and is associated with a reduced fibrinolytic activity during CPB. Surface heparinization limited to the oxygenator and the arterial filter had similar results as totally surface-heparinized circuits.