Surgical Options for Pulmonary Valve Pathology in the Current Era

Pulmonary valve pathology occurs mostly in the settings of congenital heart disease whether primary or as the result of repair of a variety of congenital heart defects. Acquired pulmonary valve disorders, albeit rare, can occur in the settings of endocarditis, tumors, carcinoid syndrome, or rheumatic fever. Surgical options include repair and replacement of pulmonary valve. Several options for replacement are available, which can be tailored based on the patient’s clinical profile and the primary valve pathology. In this chapter, we present the surgical options that are currently available for pulmonary valve disorders and the current outcomes

Surgery for Tricuspid Valve Endocarditis in the Current Era

Tricuspid valve endocarditis (TVE) continues to be on the rise and has been mostly attributed to the growing epidemic of intravenous drug abuse (IVDA). Other risk factors include long-term indwelling central venous catheters and implantable cardiac devices. While medical management continues to be the first line therapy, surgery is indicated when medical management fails, and in the presence of hemodynamic deterioration, recurrent septic pulmonary embolization and/or persistent sepsis. Tricuspid valve (TV) excision once was the main surgical strategy, but other options include TV repair/reconstruction and replacement. Remaining challenges include management of drug-induced endocarditis and the best strategy for recurrent infection

AMELIORATIVE EFFECT OF PHOENIX DACTYLIFERA ON ADVERSE EFFECTS OF LINEZOLID IN MALE ALBINO RATS

Objective: This study aimed to investigate the adverse effects of linezolid (LZD) on biochemical and hematological parameters and some organsincluding bone marrow, brain, and kidneys and to investigate the possibility of methanolic extract of Phoenix dactylifera (MEPD) to counteract theadverse effects of LZD.Methods: Forty-eight adult male albino rats were allocated into four equal groups (each of 12 animals). The first group received Tween 80 orally. Thesecond group received was given 0.5 ml of LZD suspension 4% in Tween 80 (100 mg/kg body weight) orally. The third group received the same doseof LZD suspension followed by 1 ml of MEPD orally. The rats in the last group were given 1 ml of MEPD (1000 mg/kg body weight) orally. Rats weresacrificed and blood samples were collected for hematological and biochemical study. Femur bones, brain, and kidneys were dissected and kept in ajar containing 10% formalin to perform the histopathological investigation.Results: The dose of LZD administered for 14 successive days induced a mild-to-moderate hematological abnormalities including decrease inhemoglobin content (7.88±0.18 g/L) on day-1 post-treatment. Significant increase in serum urea (59.75±0.85) and serum creatinine was observed(1.89±0.04). On day-14 post-treatment, LZD induced mild-to-moderate cellular abnormalities in bone marrow, brain, and kidneys. The concurrentoral administration of MEPD and LZD for the same period corrected the hematological, biochemical, and histopathological alterations induced by LZD. Conclusion: It was concluded that MEPD clearly ameliorated these damaging effects induced by LZD

Perspective Chapter: Ross Procedure in Adults with Congenital Aortic Valve Stenosis - New Perspectives

Congenital aortic valve stenosis represents 3–5% of patients with congenital heart disease. Management options include both transcatheter and surgical. Open valvotomy/valvuloplasty and aortic valve replacement represent the main surgical choices, and while aortic valve repair is preferred, replacement may be the only option for non-repairable valves. Current available replacement options include pulmonary autograft, homografts, and biological or mechanical prostheses. The Ross procedure first introduced in 1967 by Donald Ross utilizes the patient’s pulmonary valve (autograft) as an aortic valve substitute. Despite being technically challenging it carries the advantages of maintaining the growth potentials and freedom from anticoagulation which are important in young patients. The procedure gained wide interest initially, however it fell out of favor due to concerns related to its complexity and risks of creating “two-valve” disease. Recently, long-term data confirmed the Ross procedure excellent outcomes and better survival in comparison to other aortic valve replacement options. As a result, currently it is considered the procedure of choice for young adults with congenital aortic valve stenosis at many institutions. This chapter discusses the technical aspects of the Ross procedure, and its modifications, and available options for the failing Ross, in addition to outcomes and future directions

Hypertrophic Cardiomyopathy: Surgical Perspectives

Hypertrophic cardiomyopathy is a unique myocardial disorder that can present in all ages from neonate to adults and has strong genetic basis. Several key features characterize hypertrophic cardiomyopathy. These include: the presence of left ventricular hypertrophy that can not be explained by another etiology, and left ventricular outflow tract obstruction secondary to systolic anterior motion of the anterior mitral valve leaflet with varying degrees of mitral valve regurgitation. Surgical septal myectomy continues to be the standard line of treatment when medical therapy fails or become intolerable. We summarize in the current chapter the technical tips and pitfall of septal myectomy, its alternatives/adjuncts and its outcomes

When should a mechanical tricuspid valve replacement be considered?

BackgroundIsolated mechanical tricuspid valve replacement (mTVR) is uncommon, early mortality is reported to be high, and little is known regarding the long-term outcome. We sought to evaluate the long-term outcome of mTVR.MethodsFrom 1980 to 2007, isolated mTVR was performed in 64 patients (33 men) at our institution; the median age was 45.5 years (6-71 years). There were 2192 tricuspid valve (TV) repairs and 137 isolated bioprosthetic TV replacements during the same time interval. Valve dysfunction was caused by congenital TV abnormality in 45 patients (70%), carcinoid heart disease in 13 (20%), traumatic TV regurgitation in 3 (5%), and other reason in 3 (5%). Twenty-three patients (36%) had at least 1 previous cardiac procedure (TV repair in 8 and bioprosthetic TV replacement in 7).ResultsMechanical prostheses used included Starr-Edwards (before 1993) in 36 patients (56%) and bileaflet prostheses in 28 (44%). Concomitant procedures included atrial septal defect closure in 28 (44%), arrhythmia surgery in 11 (17%), and pulmonary valvectomy for carcinoid disease in 10 patients (16%). Early mortality occurred in 5 patients (7.8%). Early morbidity included a permanent pacemaker in 9 (14%) and reexploration for bleeding in 2 patients (3%). Mean follow-up was 6 years (maximum 22.4 years). Five- and 10-year survival was 65% and 58%, respectively. There was no valve-related mortality. Late morbidity included valve thrombosis in 5 patients (8%); 3 were managed nonoperatively and 2 underwent TV rereplacement.ConclusionsIsolated mTVR still leads to increased early mortality. A mechanical valve can be considered in select situations when anticoagulation is necessary and in the presence of good right ventricular function

Late outcome of repair of congenital coronary artery fistulas—a word of caution

ObjectivesWe reviewed our experience with repair of congenital coronary artery fistulas.MethodsFrom June 1983 to December 2009, 46 patients (median age, 59 years; range, 1-84 years) underwent surgical repair. The presenting symptoms included angina in 16 patients (35%), congestive heart failure in 11 (24%), and bacterial endocarditis in 5 (11%). Preoperatively, 9 patients (20%) had at least moderate tricuspid regurgitation. Coronary artery dominance was right in 38 patients (83%). Coronary artery aneurysms were found in 8 patients (17%). The most common pattern was right coronary artery-to-coronary sinus fistula (18 patients, 39%); 11 patients had (23%) more than 1 fistula. One patient had undergone previous coil embolization.ResultsCardiopulmonary bypass was used in 39 patients (85%), with extracardiac and intracardiac repair performed in 30 (65%) and 16 (35%), respectively. The most common associated procedures were coronary artery bypass in 13 patients (28%). Early mortality occurred in 1 patient (2%). Postoperative myocardial infarction occurred in 5 patients (11%); 4 of these patients underwent simple ligation or division of their fistulas. The mean follow-up was 6 ± 5.8 years (maximum, 22 years). Late mortality occurred in 11 patients (24%). Two patients underwent reoperation for severe tricuspid regurgitation. Survival was significantly reduced compared with the age- and gender-matched population (P = .03). Residual fistulas were detected in 3 patients (6%), with no reintervention needed.ConclusionsPerioperative myocardial infarction is an important complication of ligation of coronary artery fistulas and can contribute to reduced late survival. The tricuspid valve should be evaluated carefully at repair because of the relatively high rate of residual regurgitation in survivors

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London