Single Versus Multi-Center Surgeons\u27 Risk-Adjusted Mitral Valve Repair Procedural Outcomes

The purpose of this study is to explore strategies to improve mitral valve repair (MVr) outcomes. This research explores postoperative outcomes of patients undergoing MVr surgery by single center surgeons versus patients of multicenter surgeons. Specific outcomes of interest include 30-day operative mortality, major operative complications (e.g., deep sternal wound infection, permanent stroke, renal dysfunction requiring dialysis, reoperation, and prolonged ventilation), length of stay, and 30-day readmissions. In brief, the serisk-adjusted outcome rates for surgeons that perform mitral valve repair procedures will be compared for surgeons that operate at a single center [i.e. SC surgeons] versus multiple centers [i.e. MC surgeons]. The overarching study hypothesis is: H(0) There will be no difference in the risk-adjusted outcome rates between surgeons that operate at a single center [i.e. SC surgeons] versus multiple centers [i.e. MC surgeons]. Based on prior research, however, it is anticipated that single center surgeons may have superior outcomes compared to multi-center surgeons

End-Stage Acute Thoracic Aortic Care Patients’ Interventions and Two-Year Survival: the New York State Experience

BACKGROUND: Scarce US-based regional or State-specific reports exist recording the incidence, prevalence, or post-diagnosis clinical outcomes for end-stage thoracic aortic aneurysmal (TAA) disease. This retrospective cohort study of New York State (NYS) patients with newly diagnosed ruptured or dissected thoracic aortic aneurysms (TAA-RD) documents two-year follow-up after elective and emergent procedures. METHODS: Using hospital billing codes, NYS first-time TAA-RD encounters were extracted. As the primary study endpoint, the two-year composite included all-cause death, subsequent rupture or dissection, or non-elective intervention; individual composite sub-components were secondary study endpoints. Multivariable logistic regression models estimated two-year intervention and composite outcome risks. Using multivariable regression models created for the composite endpoints, post-discharge elective TAA procedural impact was evaluated. RESULTS: Of the 5,789 NYS residents identified, 49.92% reached the two-year composite endpoint with 23.98% two-year deaths. Only 1902 (32.86%) of TAA-RD patients had an index intervention. Post-discharge elective TAA interventions dramatically reduced adverse outcome risk (odds ratio [O.R.] = 0.36; 95% confidence interval [C.I.] = 0.26 - 0.51). Multivariable regression models identified patient characteristics associated with the two-year adverse composite outcome including urgent/emergent status, increased Elixhauser comorbidity score, non-rheumatic aortic regurgitation, and carotid disease. CONCLUSIONS: Nearly 50% of NYS TAA-RD patients reached the two-year adverse endpoint. Post-2014, the TAA-RD diagnosis rates increased but emergent thoracic aortic surgery rates decreased. Surprisingly, under 50% of NYS TAA-RD patients received an index admission procedure; this rate is lower than anticipated. Beyond traditional morphologic metrics, “at risk” TAA patient-characteristics were identified. Post-discharge survivors had excellent post-procedural two-year durability rates

Morphological evaluation of experimental autologous rectus fascia sheath vascular grafts used for arterial replacement in a dog model

Although experimental autologous patch or tubular conduit vascular grafts made from the internal rectus fascia sheath (IRFS) have been reported in the literature, thorough morphological evaluation and verification of the histological arterialisation of such grafts are lacking. Four purpose-bred Beagle dogs were utilised to create eight arterial internal rectus fascia sheath (ARFS) grafts implanted between bisected ends of the external iliac arteries. Four out of the eight ARFS grafts were patent after three months. Haematoxylin-eosin and Azan staining verified that the grafts gained a vessel-like layered structure with the presence of large amounts of collagen fibres. Although the inner surface of the intact IRFS was originally covered with claudin-5-negative and pancytokeratin-positive mesothelial cells in control samples, the internal cells of the ARFS grafts became claudin-5 positive and pancytokeratin negative like in intact arteries. Spindle-shaped cells of the wall of ARFS grafts were α-smooth muscle actin (α-SMA) positive just like the smooth muscle cells of intact arteries, but α-SMA immunoreactivity was negative in the intact IRFS. According to these findings, the fibroblast cells of the ARFS graft have changed into myofibroblast cells. The study has proved that ARFS grafts may be used as an alternative in arterial replacement, since the graft becomes morphologically and functionally similar to the host vessel via arterialisation

Simultaneous thoracic aortic endovascular graft and transfemoral transcatheter aortic valve replacement in a patient with a descending aortic thrombus

© 2018 Elsevier Inc. Severe descending thoracic and abdominal aortic pathology can deter consideration of transfemoral (TF) access for transcatheter aortic valve replacement (TAVR) in adults with severe symptomatic aortic stenosis (AS) and may lead to utilization of alternative access sites. We report a case of an 88-year-old frail woman with severe symptomatic AS referred for TAVR with demonstration of a large thrombus in the descending thoracic aorta immediately distal to the left subclavian artery. Given concerns of thrombus embolization with femoral advancement of the transcatheter valve, coverage with a thoracic aortic endograft was planned immediately prior to the TAVR

Antagonism of LPS and IFN-gamma induced iNOS expression in human atrial endothelia by morphine, anandamide, and estrogen

AIM: To determine whether inducible nitric oxide synthase (iNOS) stimulation of human atrial fragments can be diminished by the naturally occurring signal molecules, such as morphine, anandamide, and estrogen. The use of iNOS as an indicator is justified since it has been associated with initiation of various types of cellular damage either directly or indirectly. METHODS: Western blots were performed on control and drug-exposed atrial tissue before and after lipopolysaccharide (LPS) and interferon-gamma (IFN-gamma) exposure. RESULTS: Preincubation of the tissue with morphine, anandamide or estrogen prior to, but not after, the addition of LPS + IFN-gamma, blocked iNOS expression. The nitric oxide donor SNAP also blocked iNOS induction while preincubation of atrial fragments with an inhibitor of NOS, L-NAME, prior to morphine or anandamide exposure, restored LPS + IFN-gamma induction of iNOS. CONCLUSION: These data suggest a direct regulatory link at the transcriptional level between constitutive (c) NOS and iNOS in human atrial tissue