0327: Echocardiography improves the risk prediction of peri-operative outcomes in patients undergoing coronary bypass surgery? A prospective study

ObjectiveTo assess the performance of transthoracic echocardiographic (TTE) parameters to predict operative mortality and morbidity in patients undergoing coronary artery bypass grafting (CABG) and to compare their pronostic value to that obtained by the Society of Thoracic Surgeon (STS) score.Materiels and MethodsWe prospectively collected the clinical and biological data required to calculate the STS score in patients hospitalized for CABG. A preoperative TTE was performed for each patient. Primary endpoint was 30-days mortality or major morbity (i.e. stroke, renal failure, prolonged ventilation, deep sternal wound infection, reoperation) as defined by the STS. Secondary end-point was prolonged hospitalization>14 days.Results172 patients were included (mean age 66.1±10.2 years, 12.2% were women). The primary end-point occurred in 33 patients (19.2%) and 28 patients (16.3%) had a prolonged hospital stay. Independent predictive factors for the primary end-point were an increased left atrial volume (>31mL/m2) (OR=3.186, IC 95%=1.266; 8.015, p=0.014) and a decreased tricuspid annular plane systolic excursion (TAPSE<20mm) (OR=2.709, IC 95% 1.144; 6.410, p=0.023). The addition of these two parameters to the STS score improved significantly the model performance (figure) with a better risk prediction (Integrated Discrimination Improvement=7.44).ConclusionIn patients undergoing CABG, preoperative TTE is mandatory as it provides an additional prognostic value to the STS score.Abstract 0327 - Figure: Incremental prognostic value of TT

0274: Prognostic impact of pulmonary arterial pressure in patients with aortic stenosis and preserved left ventricular ejection fraction

BackgroundThe prognostic impact of pulmonary arterial pressure (PAP) remains controversial in aortic stenosis (AS) and few studies focused only on patients with preserved left ventricular ejection fraction (LVEF). We therefore aimed to investigate the impact of PAP, derived from our large catheterization database, on survival in severe AS with preserved LVEF.Methods and resultsBetween 2000 and 2010, 749 patients (74±8y, 57% of males) with preserved LVEF and severe AS without other valvular heart disease underwent cardiac catheterization, including right heart hemodynamic assessment. Pulmonary hypertension (PH) was defined as mean PAP>25mmHg.Systolic and mean PAP were 34.5±12 and 21.9±9mmHg, respectively. Overall, 29% (n=215) of patients had PH, and these patients were significantly older (p<0.0001), with lower LVEF (p<0.0001) and higher heart rate (p=0.016) than those without PH. In addition, they more frequently had, hypertension (p<0.0001), diabetes (p=0.001), coronary artery disease (CAD, p<0.0001) and chronic pulmonary disease (p=0.043). Aortic valve replacement (AVR) was performed in 91% of patients and 30-day mortality was 4.3%, significantly higher in patients with PH (7.7 vs. 3.4%, p=0.014). In logistic regression analysis, after adjustment for age, gender, LVEF, CAD and mean transaortic pressure gradient, mean PAP was an independent predictor of increased 30-day mortality (OR=1.06, 95% CI: 1.02-1.1, p=0.004). Overall long-term survival was significantly reduced in patients with PH as compared to those without PH (10-year survival: 41±8 vs. 61±3%, p<0.0001). In multivariate analysis, after adjustment for all cofactors, PH was an independent predictor of mortality (HR=1.5, 95% CI: 1.1-2.1, p=0.037).ConclusionIn patients with severe AS and preserved LVEF, PAP is an independent predictor of both 30-day and long-term mortality. In order to improve the prognosis of these patients, AVR could be considered before the occurrence of severely elevated PAP

Alterations in plasma soluble vascular endothelial growth factor receptor-1 (sFlt-1) concentrations during coronary artery bypass graft surgery: relationships with post-operative complications

<p>Abstract</p> <p>Background</p> <p>Plasma concentrations of sFlt-1, the soluble form of the vascular endothelial growth factor receptor (VEGF), markedly increase during coronary artery bypass graft (CABG) surgery with extracorporeal circulation (ECC). We investigated if plasma sFlt-1 values might be related to the occurrence of surgical complications after CABG.</p> <p>Methods</p> <p>Plasma samples were collected from the radial artery catheter before vascular cannulation and after opening the chest, at the end of ECC just before clamp release, after cross release, after weaning from ECC, at the 6^thand 24^thpost-operative hour. Thirty one patients were investigated. The presence of cardiovascular, haematological and respiratory dysfunctions was prospectively assessed. Plasma sFlt-1 levels were measured with commercially ELISA kits.</p> <p>Results</p> <p>Among the 31 investigated patients, 15 had uneventful surgery. Patients with and without complications had similar pre-operative plasma sFlt-1 levels. Lowered plasma sFlt-1 levels were observed at the end of ECC in patients with haematological (p = 0.001, ANOVA) or cardiovascular (p = 0.006) impairments, but not with respiratory ones (p = 0.053), as compared to patients with uneventful surgery.</p> <p>Conclusion</p> <p>These results identify an association between specific post-CABG complication and the lower release of sFlt-1 during ECC. sFlt-1-induced VEGF neutralisation might, thus, be beneficial to reduce the development of post-operative adverse effects after CABG.</p

Delineation of the primary tumour Clinical Target Volumes (CTV-P) in laryngeal, hypopharyngeal, oropharyngeal and oral cavity squamous cell carcinoma : AIRO, CACA, DAHANCA, EORTC, GEORCC, GORTEC, HKNPCSG, HNCIG, IAG-KHT, LPRHHT, NCIC CTG, NCRI, NRG Oncology, PHNS, SBRT, SOMERA, SRO, SSHNO, TROG consensus guidelines

Purpose: Few studies have reported large inter-observer variations in target volume selection and delineation in patients treated with radiotherapy for head and neck squamous cell carcinoma. Consensus guidelines have been published for the neck nodes (see Gregoire et al., 2003, 2014), but such recommendations are lacking for primary tumour delineation. For the latter, two main schools of thoughts are prevailing, one based on geometric expansion of the Gross Tumour Volume (GTV) as promoted by DAHANCA, and the other one based on anatomical expansion of the GTV using compartmentalization of head and neck anatomy. Method: For each anatomic location within the larynx, hypopharynx, oropharynx and oral cavity, and for each T-stage, the DAHANCA proposal has been comprehensively reviewed and edited to include anatomic knowledge into the geometric Clinical Target Volume (CTV) delineation concept. A first proposal was put forward by the leading authors of this publication (VG and CG) and discussed with opinion leaders in head and neck radiation oncology from Europe, Asia, Australia/New Zealand, North America and South America to reach a worldwide consensus. Results: This consensus proposes two CTVs for the primary tumour, the so called CTV-P1 and CVT-P2, corresponding to a high and lower tumour burden, and which should be associated with a high and a lower dose prescription, respectively. Conclusion: Implementation of these guidelines in the daily practice of radiation oncology should contribute to reduce treatment variations from clinicians to clinicians, facilitate the conduct of multi institutional clinical trials, and contribute to improved care of patients with head and neck carcinoma. (C) 2017 Elsevier B.V. All rights reserved.Peer reviewe

Release of soluble vascular endothelial growth factor receptor-1 (sFlt-1) during coronary artery bypass surgery

<p>Abstract</p> <p>Background</p> <p>This study was conducted to follow plasma concentrations of sFlt-1 and sKDR, two soluble forms of the vascular endothelial growth factor (VEGF) receptor in patients undergoing coronary artery bypass graft (CABG) surgery with extracorporeal circulation (ECC).</p> <p>Methods</p> <p>Plasma samples were obtained before, during and after surgery in 15 patients scheduled to undergo CABG. Levels of sFlt-1 and KDR levels were investigated using specific ELISA.</p> <p>Results</p> <p>A 75-fold increase of sFlt-1 was found during cardiac surgery, sFlt-1 levels returning to pre-operative values at the 6^thpost-operative hour. In contrast sKDR levels did not change during surgery. The ECC-derived sFlt-1 was functional as judge by its inhibitory effect on the VEGF mitogenic response in human umbilical vein endothelial cells (HUVECs). Kinetic experiments revealed sFlt-1 release immediately after the beginning of ECC suggesting a proteolysis of its membrane form (mFlt-1) rather than an elevated transcription/translation process. Flow cytometry analysis highlighted no effect of ECC on the shedding of mFlt-1 on platelets and leukocytes suggesting vascular endothelial cell as a putative cell source for the ECC-derived sFlt-1.</p> <p>Conclusion</p> <p>sFlt-1 is released during CABG with ECC. It might be suggested that sFlt-1 production, by neutralizing VEGF and/or by inactivating membrane-bound Flt-1 and KDR receptors, might play a role in the occurrence of post-CABG complication.</p

Intensity modulated radiotherapy (IMRT) in the treatment of children and Adolescents - a single institution's experience and a review of the literature

<p>Abstract</p> <p>Background</p> <p>While IMRT is widely used in treating complex oncological cases in adults, it is not commonly used in pediatric radiation oncology for a variety of reasons. This report evaluates our 9 year experience using stereotactic-guided, inverse planned intensity-modulated radiotherapy (IMRT) in children and adolescents in the context of the current literature.</p> <p>Methods</p> <p>Between 1999 and 2008 thirty-one children and adolescents with a mean age of 14.2 years (1.5 - 20.5) were treated with IMRT in our department. This heterogeneous group of patients consisted of 20 different tumor entities, with Ewing's sarcoma being the largest (5 patients), followed by juvenile nasopharyngeal fibroma, esthesioneuroblastoma and rhabdomyosarcoma (3 patients each). In addition a review of the available literature reporting on technology, quality, toxicity, outcome and concerns of IMRT was performed.</p> <p>Results</p> <p>With IMRT individualized dose distributions and excellent sparing of organs at risk were obtained in the most challenging cases. This was achieved at the cost of an increased volume of normal tissue receiving low radiation doses. Local control was achieved in 21 patients. 5 patients died due to progressive distant metastases. No severe acute or chronic toxicity was observed.</p> <p>Conclusion</p> <p>IMRT in the treatment of children and adolescents is feasible and was applied safely within the last 9 years at our institution. Several reports in literature show the excellent possibilities of IMRT in selective sparing of organs at risk and achieving local control. In selected cases the quality of IMRT plans increases the therapeutic ratio and outweighs the risk of potentially increased rates of secondary malignancies by the augmented low dose exposure.</p

Latest Cretaceous climatic and environmental change in the South Atlantic region

Latest Maastrichtian climate change caused by Deccan volcanism has been invoked as a cause of mass extinction at the Cretaceous-Paleogene (K-Pg) boundary (~66.0 Ma). Yet late Maastrichtian climate and ecological changes are poorly documented, in particular on the Southern Hemisphere. Here we present upper Maastrichtian-lower Danian climate and biotic records from the Bajada del Jagüel (BJ) shelf site (Neuquén Basin, Argentina), employing the TEX86 paleothermometer, marine palynology (dinoflagellate cysts), and micropaleontology (foraminifera). These records are correlated to the astronomically tuned Ocean Drilling Program Site 1262 (Walvis Ridge). Collectively, we use these records to assess climatic and ecological effects of Deccan volcanism in the Southern Atlantic region. Both the TEX86-based sea surface temperature (SST) record at BJ and the bulk carbonate δ18O-based SST record of Site 1262 show a latest Maastrichtian warming of ~2.5-4°C, at 450 to 150 kyr before the K-Pg boundary, coinciding with the a large Deccan outpouring phase. Benthic foraminiferal and dinocyst assemblage changes indicate that this warming resulted in enhanced runoff and stratification of the water column, likely resulting from more humid climate conditions in the Neuquén Basin. These climate conditions could have been caused by an expanding and strengthening thermal low over the South American continent. Biotic changes in response to late Maastrichtian environmental changes are rather limited, when compared to the major turnovers observed at many K-Pg boundary sites worldwide. This suggests that environmental perturbations during the latest Maastrichtian warming event were less severe than those following the K-Pg boundary impact