Porcine Bioprosthetic Aortic Valve Endocarditis with Ring Abscess and Aortic Stenosis

Porcine bioprosthetic valve endocarditis is an infrequent but serious complication of valve replacement surgery. Ring (or annular) abscess is a frequent finding in mechanical valve endocarditis. In contrast, porcine valve endocarditis most often involves the cusps, and annular infection is uncommon. Porcine valvular dysfunction secondary to endocarditis usually takes the form of incompetence, whereas stenosis is less frequent. We report a case of a 76-year-old female who developed endocarditis wilh Staphylococcus epidermidis nine months after placement of a Carpenter-Edwards porcine aortic valve. Her initial presentation included complete heart block and moderate aortic stenosis. Transesophageal echocardiography aided the diagnosis by demonstrating large vegetations, while transthoracic echocardiography showed only slight thickening of the valve leaflets. At operation, there was a circumferential abscess around the sewing ring causing valve dehiscence and virtual discontinuity of the aorta from the left ventricle. Valve degeneration and organisms within the cusps were observed on microscopy. This case illustrates two infrequent complications of porcine aortic valve endocarditis, namely massive annular abscess with invasion of the conducting system and aortic stenosis. It also demonstrates the utility and limitations of transesophageal echocardiography in the diagnosis of this disorder

Association of Operator and Hospital Experience With Procedural Success Rates and Outcomes in Patients Undergoing Percutaneous Coronary Interventions for Chronic Total Occlusions: Insights From the Blue Cross Blue Shield of Michigan Cardiovascular Consortium

BACKGROUND: An inverse relationship has been described between procedural success and outcomes of all major cardiovascular procedures. However, this relationship has not been studied for percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). METHODS: We analyzed the data on patients enrolled in Blue Cross Blue Shield of Michigan Cardiovascular Consortium registry in Michigan (January 1, 2010 to March 31, 2018) to evaluate the association of operator and hospital experience with procedural success and outcomes of patients undergoing CTO-PCI. CTO-PCI was defined as intervention of a 100% occluded coronary artery presumed to be ≥3 months old. RESULTS: Among 210 172 patients enrolled in the registry, 7389 (3.5%) CTO-PCIs were attempted with a success rate of 53%. CTO-PCI success increased with operator experience (45% and 65% in the lowest and highest experience tertiles) and was the highest for highly experienced operators at higher experience centers and the lowest for inexperienced operators at low experience hospitals. Multivariable logistic regression models (with spline transformed prior operator and institutional experience) demonstrated a positive relationship between prior operator and site experience and procedural success rates (likelihood ratio test=141.12, df=15, P\u3c0.001) but no relationship between operator and site experience and major adverse cardiac event (likelihood ratio test=19.12, df=15, P=0.208). CONCLUSIONS: Operator and hospital CTO-PCI experiences were directly related to procedural success but were not related to major adverse cardiac event among patients undergoing CTO-PCIs. Inexperienced operators at high experience centers had significantly higher success but not major adverse cardiac event rates compared with inexperienced operators at low experience centers. These data suggested that CTO-PCI safety and success could potentially be improved by selective referral of these procedures to experienced operators working at highly experienced centers

Design and recruitment in the United States of a multicenter quantitative angiographic trial of pravastatin to limit atherosclerosis in the coronary arteries (PLAC I)

The present study was designed to test the effect of pravastatin, a new, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor, on the progression of coronary artery disease in patients with moderate hypercholesterolemia. Angiographic entry criteria included the presence of >=1 stenosis >=50% in a major epicardial coronary artery, and certification of film quality through the core angiography laboratory. Patients qualified for randomization if after diet stabilization their low density lipoprotein cholesterol concentrations were >=130 and < 190 mg/dl, and triglycerides were <= 350 mg/dl. Pravastatin (40 mg) or placebo is administered once daily at bedtime. Arteriography will be repeated at the end of 3 years of treatment. The primary end point of the study is the change in absolute mean coronary artery diameter. During a 30-month recruitment period, 44,145 patients were screened, and 408 were randomized. The most frequent reason for excluding patients during the screening and dietary lead-in periods was a low serum cholesterol level. A large proportion of patients with documented coronary artery disease have cholesterol concentrations that are considered to be normal or only modestly increased. Adherence to strict standards of quality control for digital analysis of angiograms ensures that baseline angiograms can be interpreted at the end of 3-year follow-up.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/30692/1/0000337.pd

Efficacy and safety of pravastatin in the long-term treatment of elderly patients with hypercholesterolemia

Elevated cholesterol levels are a major risk factor for coronary heart disease, which remains a significant problem in patients beyond age 65 years. Because drug therapy for the control of hypercholesterolemia in elderly patients is frequently considered to be indicated, we investigated the efficacy and safety of pravastatin in the treatment of elderly subjects with primary hypercholesterolemia. In this 96-week, multicenter, double-blind, placebo-controlled study, 142 subjects (95 women, 47 men) 64 to 90 years of age with elevated cholesterol levels despite dietary intervention were randomized to receive pravastatin 20 mg at bedtime or matching placebo (2:1). Dosage could be doubled after 8 weeks, a bile acid-binding resin could be added after 16 weeks, and nicotinic acid or probucol could be added after 32 weeks, as needed, to adequately lower the low-density lipoprotein cholesterol (LDL-C) levels. Significant reductions in the levels of LDL-C (-30.9%), total cholesterol (Total-C; -21.9%), and triglycerides (TG; -16.7%) and significant increases in the levels of high-density lipoprotein cholesterol (HDL-C; 11.3%) were noted in the group receiving pravastatin treatment at 16 weeks (P In this study, pravastatin was well tolerated and effective in lowering LDL-C, Total-C, and TG and in raising HDL-C during long-term treatment of elderly patients with primary hypercholesterolemia.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/31935/1/0000888.pd

Incidence of post myocardial infarction left ventricular thrombus formation in the era of primary percutaneous intervention and glycoprotein IIb/IIIa inhibitors. A prospective observational study

BACKGROUND: Before the widespread use of primary percutaneous coronary intervention (PCI) and glycoprotein IIb/IIIa inhibitors (GP IIb/IIIa) left ventricular (LV) thrombus formation had been reported to complicate up to 20% of acute myocardial infarctions (AMI). The incidence of LV thrombus formation with these treatment modalities is not well known. METHODS: 92 consecutive patients with ST-elevation AMI treated with PCI and GP IIb/IIIa inhibitors underwent 2-D echocardiograms, with and without echo contrast agent, within 24–72 hours. RESULTS: Only 4/92 (4.3%) had an LV thrombus, representing a significantly lower incidence than that reported in the pre-PCI era. Use of contrast agents did not improve detection of LV thrombi in our study. CONCLUSION: The incidence of LV thrombus formation after acute MI, in the current era of rapid reperfusion, is lower than what has been historically reported

Industrial mining heritage and the legacy of environmental pollution in the Derbyshire Derwent catchment: quantifying contamination at a regional scale and developing integrated strategies for management of the wider historic environment

The Derwent Valley Mills World Heritage Site (DVMWHS) exemplifies and records the 18th century birth of the factory or mill technology, and for the industrial spinning of cotton. The site is therefore a key global heritage asset. The Derbyshire Derwent catchment also contains another significant cultural asset with a long history – that of mining and, in particular, lead (Pb) mining. In this paper research on mining- and non-mining related Pb contamination of the Derwent catchment is reviewed and used to identify the risks it poses to the DVMWHS. The upper Derwent soils, though not impacted by mining, have high sediment-borne Pb concentrations, and the Pb is sourced from local conurbations (principally Manchester) and carried to the upper Derwent on the wind. River sediments in the middle and lower parts of the Derwent catchment are contaminated with Pb mined mainly between the 18th and 19th centuries and before, possibly as far back to the Bronze Age. The potential for large-scale, acidity-related chemical remobilization of this Pb is low in the Derwent catchment due to the largely alkaline nature of the underlying soils, but the potential for oxidation-reduction-related, and physical (flood-related), remobilization, is higher. Management guidelines for mining heritage assets and the DVMWHS are developed from the reviewed information, with the view that these will provide a framework for future work in, and management of, the DVMWHS that will be applicable to other World Heritage Sites affected by ongoing and past metal-mining. Focused collaborative work between archaeologists, geochemists, geomorphologists and mineralogistsis vital if the risks to the DVMWHS and other similarly-affected World Heritage Sites are to be quantified and, if necessary, mitigated

The active inference approach to ecological perception: general information dynamics for natural and artificial embodied cognition

The emerging neurocomputational vision of humans as embodied, ecologically embedded, social agents—who shape and are shaped by their environment—offers a golden opportunity to revisit and revise ideas about the physical and information-theoretic underpinnings of life, mind, and consciousness itself. In particular, the active inference framework (AIF) makes it possible to bridge connections from computational neuroscience and robotics/AI to ecological psychology and phenomenology, revealing common underpinnings and overcoming key limitations. AIF opposes the mechanistic to the reductive, while staying fully grounded in a naturalistic and information-theoretic foundation, using the principle of free energy minimization. The latter provides a theoretical basis for a unified treatment of particles, organisms, and interactive machines, spanning from the inorganic to organic, non-life to life, and natural to artificial agents. We provide a brief introduction to AIF, then explore its implications for evolutionary theory, ecological psychology, embodied phenomenology, and robotics/AI research. We conclude the paper by considering implications for machine consciousness