Long-term outlook for transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) revolutionized the treatment of severe symptomatic aortic stenosis (AS). TAVR is increasingly offered for lower-risk patients. The role and place of TAVR in the future treatment of AS is not clear yet. In this review, we discuss the long-term outlook for TAVR, its challenges and its relationship to conventional surgical aortic valve replacement

金市場と他の金融市場との間の相互関係の実証的特徴付け

博士（経済学）神戸大

Coronary artery bypass grafting: Part 2—optimizing outcomes and future prospects

Since first introduced in the mid-1960s, coronary artery bypass grafting (CABG) has become the standard of care for patients with coronary artery disease. Surprisingly, the fundamental surgical technique itself did not change much over time. Nevertheless, outcomes after CABG have dramatically improved over the first 50 years. Randomized trials comparing percutaneous coronary intervention (PCI) to CABG have shown converging outcomes for select patient populations, providing more evidence for wider use of PCI. It is increasingly important to focus on the optimization of the short- and long-term outcomes of CABG and to reduce the level of invasiveness of this procedure. This review provides an overview on how new techniques and widespread consideration of evolving strategies have the potential to optimize outcomes after CABG. Such developments include off-pump CABG, clampless/anaortic CABG, minimally invasive CABG with or without extending to hybrid procedures, arterial revascularization, endoscopic vein harvesting, intraprocedural epiaortic scanning, graft flow assessment, and improved secondary prevention measures. In addition, this review represents a framework for future studies by summarizing the areas that need more rigorous clinical (randomized) evaluatio

Virtual reality 3D echocardiography in the assessment of tricuspid valve function after surgical closure of ventricular septal defect

Background. This study was done to investigate the potential additional role of virtual reality, using three-dimensional (3D) echocardiographic holograms, in the postoperative assessment of tricuspid valve function after surgical closure of ventricular septal defect (VSD). Methods. 12 data sets from intraoperative epicardial echocardiographic studies in 5 operations (patient age at operation 3 weeks to 4 years and bodyweight at operation 3.8 to 17.2 kg) after surgical closure of VSD were included in the study. The data sets were analysed as two-dimensional (2D) images on the screen of the ultrasound system as well as holograms in an I-space virtual reality (VR) system. The 2D images were assessed for tricuspid valve function. In the I-Space, a 6 degrees-of-freedom controller was used to create the necessary projectory positions and cutting planes in the hologram. The holograms were used for additional assessment of tricuspid valve leaflet mobility. Results. All data sets could be used for 2D as well as holographic analysis. In all data sets the area of interest could be identified. The 2D analysis showed no tricuspid valve stenosis or regurgitation. Leaflet mobility was considered normal. In the virtual reality of the I-Space, all data sets allowed to assess the tricuspid leaflet level in a single holographic representation. In 3 holograms the septal leaflet showed restricted mobility that was not appreciated in the 2D echocardiogram. In 4 data sets the posterior leaflet and the tricuspid papillary apparatus were not completely included. Conclusion. This report shows that dynamic holographic imaging of intraoperative postoperative echocardiographic data regarding tricuspid valve function after VSD closure is feasible. Holographic analysis allows for additional tricuspid valve leaflet mobility analysis. The large size of the probe, in relation to small size of the patient, may preclude a complete data set. At the moment the requirement of an I-Space VR system limits the applicability in virtual reality 3D echocardiography in clinical practice

Homes in Flux : Multiple Layers of Domesticity among Syrian Refugees in Istanbul

To date, Turkey has one of the highest refugee populations in the world. The Syrian conflict has played a major role in this as over 2,5 million Syrians have taken refuge in Turkey. Most of Syrian refugees are residing in the largest city of Turkey, Istanbul. Turkey is a signatory member of the Convention relating to the Status of Refugees, however has an exception for permanent residency granted only for European refugees. Thus, under Turkish refugee policy, Syrians are merely granted temporary protection that guarantees them a temporary residency permit. However, the policy does not cover; at the time of this research; the right to work. Syrian refugees, undocumented Syrians and Syrian Palestinians are especially vulnerable in Turkish society due to the lack of permanent residency and legal work. This research identifies how Syrian refugees create home as well as the factors that influence their home-making process in Istanbul. The factors are evaluated through the conditions under which Syrian refugees are residing in Istanbul including the right to work, housing and residency. The research also evaluates the refugees home-making in retrospective to their living conditions, feeling of home, legal position, access to a dwelling place as well as cultural identification. Although, this research focuses on the individual experience of home-making for Syrian refugees, it considers and examines Syrian refugees in a context of politicised bodies. As international refugees, Syrian refugees are highly politicized bodies, whose lives are affected by international politics as well as the domopolitics of the country in which they reside. Subsequently, their home and their home-making processes are also politicised. Beyond politics, refugeeness alters one's relationship to home and place, making home a complex concept attached with emotions and potential pain and loss. Literacy identifies that refugees displace their home through space and time. Hence, this research treats home as a socially and culturally produced metaphor that describes a person's belonging within socio-spatial narratives, but of which content is individually chosen to describe or to support a person's identity and psychological environment. The method of this research was a combination of two field trips to Istanbul, Turkey, fourteen in-depth interviews and qualitative analysis. The main reference of the research are the fourteen in-depth interviews that included ten men and four women; aged from 20 to 40 years old; Syrians residing in Istanbul. The interviewees were selected through social media online connections and face-to-face acquaintances during the field trips. The interviewees time of residence in Istanbul varied from two months to over four years. The eleven influencing factors identified in this research can be more commonly divided into two categories: the common factors and the personal factors. Common factors related to the responder's habitation environment; such as the city of Istanbul and the Turkish society. These common factors included: the city itself, the Turkish culture and society, the legislation, working life, housing, discrimination and relationships with their family and friends as well as with the Turkish people. The interviewees considered these factors as the ones that impacted everyday life and which they could not 'escape'. Personal factors that were identified are related to interviewees personality, world views and emotions. The interviewees could be divided into four main categories of personal factor denominators: their relationship to Syria, sense of belonging, definition of home and views of the future. This research concludes that displacement has an impact on how home is perceived and reflected by the interviewees. Its findings are in accordance to previous research literature on home-making among refugees, but it questions refugee policies that emphasis on repatriation as the most favourable long term solution for refugees as well as the position of housing as a most influential factor in refugees' home-making, by stating that other factors such as relationship to family and friends and earning a living, are higher in importance for those who have arrived into a new country less than two years ago.Syyrian kriisin myötä Turkissa asuu tänä päivänä maailman laajin pakolaisyhteisö: 2,5 miljoonaa. Suuri osa Syyrian pakolaisista on asettunut asumaan Turkin suurimpaan kaupunkiin, Istanbuliin. Syyrian pakolaisilla on Turkissa erikoisasema: heitä varten on säädetty erikseen pakolaisasetus, joka määrittelee syyrialaisten pakolaisten aseman Turkissa. Syyrialaiset saavat oleskella maassa niin kutsutun väliaikaisen suojeluksen nojalla, joka estää suojelusta hakevien palautukset Syyriaan, mutta tutkimuksen aikaan ei tarjonnut mahdollisuutta työskennellä laillisesti tai pysyvää oleskelulupaa. Tämä asetus laittaa syyrialaiset pakolaiset hyvin haavoittuvaan asemaan turkkilaisessa yhteiskunnassa, jossa suurin osa työskentelee laittomasti ja heillä on ongelmia muun muassa hankkia asuntoa. Tämä tutkimus perehtyy siihen, kuinka syyrialaiset pakolaiset tekevät kodin Istanbulissa ja mitkä tekijät vaikuttavat kodin tekemiseen. Näitä tekijöitä tarkastellaan niiden olosuhteiden kautta, jotka syyrialaisilla vallitsevat Istanbulissa. Huomioon otettuja seikkoja ovat muun muassa laillinen asema, asema asuntomarkkinoilla, työskentelymahdollisuudet, kulttuurinen identifioituminen sekä kodin kokeminen. Vaikka tämä tutkimus keskittyy yksilöllisiin kokemuksiin, syyrialaisten pakolaisten kodin tekemistä tarkastellaan myös pakolaiskontekstissa, jossa pakolaisten kodin tekeminen on politisoitunutta. Pakolaisina syyrialaiset ovat hyvin politisoituja henkilöitä, joiden kodin tekemiseen vaikuttaa isäntämaan domopolitiikka kuten myös kansainvälinen politiikka. Poliittisen näkökulman lisäksi tutkimus nojaa kirjallisuuteen pakolaisten kodin tekemisestä, joka huomioi pakolaisuuden muuttavan yksilön suhdetta ja käsitystä kodista. Kodin nähdään olevan merkityksellinen konsepti juuri siihen kohdistuvan menetyksen ja kivun vuoksi. Tutkimuksessa käytetyssä kirjallisuudessa pakolaisten nähdään sijoittavan kodin useisiin eri paikkoihin ja myös aikoihin. Tämä tutkimus käsittelee kotia sosiaalisesti ja kulttuurisesti tuotettuna metaforana, joka kuvaa henkilön kuulumista sosio-spatiaalisissa narratiiveissa, mutta jonka sisällön yksilö valitsee kuvatakseen tai tukeakseen omaa identiteettiään ja psykologista hyvinvointiaan. Tutkimuksen metodina on kvalitatiivinen analyysi. Sen aineisto on kerätty neljästätoista syvähaastattelusta ja kahdesta tutkimusmatkasta Istanbuliin. Haastateltavat olivat 20-40-vuotiaita syyrilaisia, jotka olivat eläneet Istanbulissa kahdesta kuukaudesta yli neljään vuoteen. Haastateltavat valittiin sosiaalisen median välityksellä luotujen suhteiden kautta. Tutkimuksessa selvisi yksitoista kodin tekemiseen vaikuttavaa tekijää, jotka on jaettu yleisiin ja yksilöllisiin tekijöihin. Yleiset tekijät ovat elinympäristöstä nousevia tekijöitä, jotka vaikuttivat kaikkiin haastateltaviin. Nämä tekijät olivat Istanbul kaupunkina, turkkilainen kulttuuri ja yhteiskunta, lainsäädäntö, työelämä, syrjiminen, ihmissuhteet perheeseen, ystäviin ja turkkilaisiin. Yksilölliset tekijät ovat haastateltavan persoonasta, maailmankatsomuksesta ja tunteista nousevia tekijöitä, jotka yleisten tekijöiden lailla vaikuttivat haastateltavien kodin kokemukseen. Yksilölliset tekijät jakautuivat neljään kategoriaan: haastateltavien suhteeseen Syyriaan, kuulumisen kokemukseen, kodin merkitykseen ja tulevaisuuden näkemyksiin. Tämän tutkimuksen tulokset tukevat aikaisempaa tutkimusta pakolaisten kodin tekemisestä ja siitä, kuinka kotimaassa sijainneen kodin menetys vaikuttaa siihen, kuinka pakolaiset käsittävät ja kokevat kodin. Tutkimus kuitenkin kyseenalaistaa pakolaisten kotouttamiseen liittyviä poliittisia ratkaisuja, kuten kotimaahan palauttamisen ensisijaisena vaihtoehtona. Tutkimuksessa kävi myös ilmi, että asumuksen sijaan kotoutumisen kannalta ensisijaisia tekijöitä olivat suhteet perheeseen ja ystäviin ja elannon ansaitseminen alle kaksi vuotta Istanbulissa asuneiden haastateltavien keskuudessa

The rationale for heart team decision-making for patients with stable, complex coronary artery disease

Stable complex coronary artery disease can be treated with coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or medical therapy. Multidisciplinary decision-making has gained more emphasis over the recent years to select the most optimal treatment strategy for individual patients with stable complex coronary artery disease. However, the so-called 'Heart Team' concept has not been widely implemented. Yet, decision-making has shown to remain suboptimal; there is large variability in PCI-to-CABG ratios, which may predominantly be the consequence of physician-related factors that have raised concerns regarding overuse, underuse, and inappropriate selection of revascularization. In this review, we summarize these and additional data to support the statement that a multidisciplinary Heart Team consisting of at least a clinical/non-invasive cardiologist, interventional cardiologist, and cardiac surgeon, can together better analyse and interpret the available diagnostic evidence, put into context the clinical condition of the patient as well as consider individual preference and local expertise, and through shared decision-making with the patient can arrive at a most optimal joint treatment strategy recommendation for patients with stable co

Causes of Death Following PCI Versus CABG in Complex CAD 5-Year Follow-Up of SYNTAX

AbstractBackgroundThere are no data available on specific causes of death from randomized trials that have compared coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI).ObjectivesThe purpose of this study was to investigate specific causes of death, and its predictors, after revascularization for complex coronary disease in patients.MethodsAn independent Clinical Events Committee consisting of expert physicians who were blinded to the study treatment subclassified causes of death as cardiovascular (cardiac and vascular), noncardiovascular, or undetermined according to the trial protocol. Cardiac deaths were classified as sudden cardiac, related to myocardial infarction (MI), and other cardiac deaths.ResultsIn the randomized cohort, there were 97 deaths after CABG and 123 deaths after PCI during a 5-year follow-up. After CABG, 49.4% of deaths were cardiovascular, with the greatest cause being heart failure, arrhythmia, or other causes (24.6%), whereas after PCI, the majority of deaths were cardiovascular (67.5%) and as a result of MI (29.3%). The cumulative incidence rates of all-cause death were not significantly different between CABG and PCI (11.4% vs. 13.9%, respectively; p = 0.10), whereas there were significant differences in terms of cardiovascular (5.8% vs. 9.6%, respectively; p = 0.008) and cardiac death (5.3% vs. 9.0%, respectively; p = 0.003), which were caused primarily by a reduction in MI-related death with CABG compared with PCI (0.4% vs. 4.1%, respectively; p <0.0001). Treatment with PCI versus CABG was an independent predictor of cardiac death (hazard ratio: 1.55; 95% confidence interval: 1.09 to 2.33; p = 0.045). The difference in MI-related death was seen largely in patients with diabetes, 3-vessel disease, or high SYNTAX (TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries) trial scores.ConclusionsDuring a 5-year follow-up, CABG in comparison with PCI was associated with a significantly reduced rate of MI-related death, which was the leading cause of death after PCI. Treatments following PCI should target reducing post-revascularization spontaneous MI. Furthermore, secondary preventive medication remains essential in reducing events post-revascularization. (TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX]; NCT00114972