The Microbiome of Temporal Arteries

Objective: A role for microorganisms in giant cell arteritis (GCA) has long been suspected. We describe the microbiomes of temporal arteries from patients with GCA and controls. Methods: Temporal artery biopsies from patients suspected to have GCA were collected under aseptic conditions and snap-frozen. Fluorescence in situ hybridization (FISH) and long-read 16S rRNA-gene sequencing was used to examine microbiomes of temporal arteries. Taxonomic classification of bacterial sequences was performed to the genus level and relative abundances were calculated. Microbiome differential abundances were analyzed by principal coordinate analysis (PCoA) with comparative Unifrac distances and predicted functional profiling using PICRUSt. Results : Forty-seven patients, including 9 with biopsy-positive GCA, 15 with biopsy-negative GCA and 23 controls without GCA, were enrolled. FISH for bacterial DNA revealed signal in the arterial media. Beta, but not alpha, diversity differed between GCA and control temporal arteries (P = 0.042). Importantly, there were no significant differences between biopsy-positive and biopsy-negative GCA (P > 0.99). The largest differential abundances seen between GCA and non-GCA temporal arteries included Proteobacteria (P), Bifidobacterium (g), Parasutterella (g) and Granulicatella (g) [Log 2-fold change > 4]. Conclusion: Temporal arteries are not sterile, but rather are inhabited by a community of bacteria. We have demonstrated that there are microbiomic differences between GCA and non-GCA temporal arteries, but not between biopsy-positive and biopsy-negative GCA

Microbiomes of Inflammatory Thoracic Aortic Aneurysms Due to Giant Cell Arteritis and Clinically Isolated Aortitis Differ From Those of Non-Inflammatory Aneurysms

Objective: We sought to characterize microbiomes of thoracic aortas from patients with non-infectious aortitis due to giant cell arteritis (GCA) and clinically isolated aortitis (CIA) and to compare them to non-inflammatory aorta aneurysm controls. We also compared microbiomes from concurrently processed and separately reported temporal arteries (TA) and aortas. Methods: From 220 prospectively enrolled patients undergoing surgery for thoracic aorta aneurysm, 49 were selected. Inflammatory and non-inflammatory cases were selected based on ability to match for age (+/-10 years), gender, and race. Biopsies were collected under aseptic conditions and snap-frozen. Taxonomic classification of bacterial sequences was performed to the genus level and relative abundances were calculated. Microbiome differential abundances were analyzed by principal coordinates analysis. Results : Forty-nine patients with thoracic aortic aneurysms (12 CIA, 14 GCA, 23 non-inflammatory aneurysms) were enrolled. Alpha (P = 0.018) and beta (P = 0.024) diversity differed between specimens from aortitis cases and controls. There were no significant differences between CIA and GCA (P > 0.7). The largest differential abundances between non-infectious aortitis and non-inflammatory control samples includedEnterobacteriaceae, Phascolarctobacterium, Acinetobactor, Klebsiella, and Prevotella. Functional metagenomic predictions with PICRUSt revealed enrichment of oxidative phosphorylation and porphyrin metabolism pathways and downregulation of transcription factor pathways in aortitis compared to controls. Microbiomes of aortic samples differed significantly from temporal artery samples from a companion study, in both control and GCA groups (P = 0.0002). Conclusion: Thoracic aorta aneurysms, far from being sterile, contain unique microbiomes that differ from those found in temporal arteries. The aorta microbiomes are most similar between aneurysms that were associated with inflammation, GCA, and CIA, but differed from those associated with non-inflammatory etiologies. These findings are promising in that they indicate that microbes may play a role in the pathogenesis of aortitis-associated aneurysms or non-inflammatory aneurysms by promoting or protecting against inflammation. However, we cannot rule out that these changes are related to alterations in tissue substrate that favor secondary changes in microbial communities

Clinical Presentation and Outcome of Right Isomerism

Background: Right isomerism is one of the most complex forms of congenital heart disease. Recent advances in medicaltreatment and surgical procedures have allowed addressing the management of these patients. Nevertheless, the prognosisremains uncertain or unsatisfactory.Objective: The aim of this study was to report the clinical characteristics, management and outcomes of right isomerism inour hospital population.Methods: This was a retrospective cohort design study conducted at Hospital Nacional de Pediatría “Prof. Dr. Juan P. Garrahan”.Between 1997 and 2011, 72 patients with median follow-up of 5.1 years (1 and 26 years) were identified.Results: In 91.7% of cases, patients were in the neonatal period, 66 patients with cyanosis and 6 patients with heart failure.The most frequent anatomic lesions were: common AV valve (n=56), pulmonary obstruction (n=67), ventriculoarterialdiscordance (n=44) and double outlet right ventricle (n=27), commom atrium (n=25), bilateral superior vena cava withoutinnominate vein (n=30), total anomalous pulmonary venous return (APVR) (n=43) and asplenia (n=53).Extracardiac lesions were detected in 11 patients. Objetivo:Reportar las características clínicas,conductas y resultados del dextroisomerismo en nuestra población hospitalaria. Material y métodos:Entre1997-2011se identificaron 72pacientes(p)con una mediana de seguimiento de 5.1años(rango 1-26 años) Resultados:En el 91,7%la presentación fue neonatal,66p con cianosis y6p con insuficiencia cardíaca. Las características anatómicas más frecuentes fueron:válvula AV común(N=56),obstrucción pulmonar(N=67),conexión ventrículoarterial discordante(N=44)y tipo doble salida(N=27), aurícula única(N=25),vena cava superior bilateral sin innominada(N=30),anomalía total del retorno venoso pulmonar(ARVP)(N=43),asplenia (N= 53). Se detectaron anomalías extracardíacas en11p. Al 76,38%se les indicó tratamiento quirúrgico,el estadio máximo alcanzado fue la cirugía paliativa14p,Glenn17p,bypass de ventrículo subpulmonar (BPVP)23p,1p cirugía ventrículo uno y medio. La mortalidad global fue39,45%(N=28);para los diferentes procedimientos paliativos(29%),para el estadio Glenn(29%)yBTVP(21,76%). En el análisis univariado la mortalidad asociada a ARVP infradiafragmática fue significativa p0,02.Para el estadio Glenn la mortalidad se relacionó al Glenn bilateral p0.04,mientras que para el BTVP no se identificó una causa determinada. En los estadios de la cirugía univentricular desarrollaron estenosis de venas pulmonares(3p),colaterales aortopulmonares(4p)y progresión a insuficiencia AV severa(2p). Conclusiones: En la mayoría la  edad de presentación fue neonatal y con clínica de cianosis.En el dextrosiomerismo la fisiología univentricular es predominante.Se detectaron 15%de anomalías extracardíacas.La mortalidad de los pacientes no quirúrgicos y con cirugía paliativa estuvo asociada a ARVP infradiafragmática.En el estadio de Glenn la mortalidad se relacionó con el tipo bilateral.Solamente un tercio de los pacientes pudo alcanzar el estadio de BTVP.Los eventos en el seguimiento a mediano plazo en los pacientes en estadio Glenn y BTVP son frecuentes.

Arterial Switch Operation: Long-term Outcome

Background: Arterial switch is the surgical procedure of choice for transposition of the great arteries. However, its outcome is not free from adverse events. Objective: The aim of this study was to evaluate the mid- and long-term outcome of this surgery at our hospital. Methods: The study analyzed 224 patients who underwent the Jatene operation at our institution with mean follow-up of 7.6 years (±5.4 years). Results: The survival rate at 15 years was 98%, with all survivors currently in functional class I-II and with adequate ventricular function. Thirty-nine patients (17.4%) evolved with significant pulmonary stenosis, mainly located at the supravalvular level (94.8%). Twelve percent of patients developed aortic root dilation and 10.3% significant aortic regurgitation. The latter was associated with aortic root dilation (p=0.0000), prior left ventricular preparation (p=0.001) and aortic regurgitation in the immediate postoperative period (p=0.01). Coronary artery lesions were detected in 5 patients (2.2%) and arrhythmias in 4 (1.8%). Freedom from reintervention at 5, 10 and 15 years was 94%, 86% y 58%, respectively, with pulmonary stenosis as the leading cause for reintervention. Mortality was 0.9% (2 patients) during follow-up, and it was associated with coronary artery involvement (p=0.0000) and development of arrhythmias (p=0.0000). Conclusions: – The arterial switch operation has excellent long-term survival. – The most frequent adverse event during follow-up was pulmonary stenosis.Introducción: La corrección anatómica de la transposición de los grandes vasos descripta por Jatene en 1975 continúa siendo la cirugía de elección para  este grupo de pacientes. Sin embargo, no está exenta de complicaciones en su evolución alejada. Objetivo: Analizar los resultados a mediano y largo plazo de la cirugía de switch arterial en nuestro hospital. Material y método: Se analizaron 224 pacientes operados con cirugía de Jatene en nuestra institución durante el período 1992-2013 y que asistieron a control evolutivo con una media de seguimiento de 7,6 años(DS+-5.4 años). Las variantes anatómicas identificadas fueron: transposición simple de los grandes vasos(122p=54,4%),  transposición compleja(77p=34.3%)  y anomalía de Taussig Bing (25p=11%). El 77.2% tuvo patrón coronario habitual. Resultados: La sobrevida a 15 años fue del  98% encontrándose todos en CF I-II y con buena  función ventricular. Evolucionaron con estenosis pulmonar significativa  39pacientes (17.4%) localizada principalmente a nivel  supravalvular(94.8%). El 12% desarrolló dilatación de raíz aórtica y el 10,3% insuficiencia aórtica significativa. Esta última se asoció a dilatación de raíz aórtica(p 0.0000), preparación previa de ventrículo izquierdo(p 0.001), mayor edad quirúrgica(0.045), presencia de insuficiencia aórtica en el postquirúrgico inmediato(p 0.01) y mayor tiempo de seguimiento (p0.02). Se evidenció obstrucción aórtica en 9 pacientes(4%), lesión coronaria en 5(2,2%) y arritmias en 4(1.8%). Permanecieron libres de reintervenciones a 5,10 y 15 años el 94%, 86% y 58%, respectivamente siendo la estenosis pulmonar la indicación más frecuente. La mortalidad en el seguimiento fue de 0.9%(2p) y se asoció a compromiso coronario(p 0.0000) y al desarrollo de arritmias(p 0.0000). Conclusiones: - La cirugía de switch arterial tiene excelente sobrevida alejada. - En la evolución, la estenosis pulmonar fue la complicación más frecuente - La insuficiencia aórtica significativa se asoció a dilatación de neoraíz, preparación previa de ventrículo izquierdo e insuficiencia aórtica en el postquirúrgico inmediato. - El 22% de los pacientes requirió reintervenciones en el seguimiento. - La obstrucción coronaria y las arritmias tuvieron baja incidencia pero se asociaron a mortalidad.

Role of Non-Invasive Multimodality Imaging in Autoimmune Pericarditis

Systemic autoimmune diseases are an important cause of pericardial involvement and contribute to up to ∼22% cases of pericarditis with a known aetiology. The underlying mechanism for pericardial involvement varies with each systemic disease and leads to a poor understanding of its management. Multimodality imaging establishes the diagnosis and determines the type and extent of pericardial involvement. In this review, we elaborate upon various pericardial syndromes associated with different systemic autoimmune and autoinflammatory diseases and the multitude of imaging modalities that can be used to further characterize autoimmune pericardial involvement. Lastly, these forms of pericarditis have a greater likelihood of recurrence, and clinicians need to understand their unique treatment approaches to improve patient outcomes

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)