Feasibility and outcomes of combined transcatheter aortic valve replacement with other structural heart interventions in a single session: a matched cohort study

Background Concurrent cardiac diseases are frequent among elderly patients and invite simultaneous treatment to ensure an overall favourable patient outcome. Aim To investigate the feasibility of combined single-session percutaneous cardiac interventions in the era of transcatheter aortic valve implantation (TAVI). Methods This prospective, case–control study included 10 consecutive patients treated with TAVI, left atrial appendage occlusion and percutaneous coronary interventions. Some in addition had patent foramen ovale or atrial septal defect closure in the same session. The patients were matched in a 1:10 manner with TAVI-only cases treated within the same time period at the same institution regarding their baseline factors. The outcome was validated according to the Valve Academic Research Consortium (VARC) criteria. Results Procedural time (126±42 vs 83±40 min, p=0.0016), radiation time (34±8 vs 22±12 min, p=0.0001) and contrast dye (397±89 vs 250±105 mL, p<0.0001) were higher in the combined intervention group than in the TAVI-only group. Despite these drawbacks, no difference in the VARC endpoints was evident during the in-hospital period and after 30 days (VARC combined safety endpoint 32% for TAVI only and 20% for combined intervention, p=1.0). Conclusions Transcatheter treatment of combined cardiac diseases is feasible even in a single session in a high-volume centre with experienced operators.

Sleep disordered breathing and vascular function in patients with chronic mountain sickness and healthy high-altitude dwellers.

Background Chronic mountain sickness (CMS) is often associated with vascular dysfunction, but the underlying mechanism is unknown. Sleep disordered breathing (SDB) frequently occurs at high altitude. At low altitude SDB causes vascular dysfunction. Moreover, in SDB, transient elevations of right-sided cardiac pressure may cause right-to-left shunting in the presence of a patent foramen ovale (PFO) and, in turn, further aggravate hypoxemia and pulmonary hypertension. We speculated that compared to healthy high-altitude dwellers, in patients with CMS, SDB and nocturnal hypoxemia are more pronounced and related to vascular dysfunction. Methods We performed overnight sleep recordings, and measured systemic and pulmonary-artery pressure in 23 patients with CMS (mean±SD age 52.8±9.8 y) and 12 healthy controls (47.8±7.8 y) at 3600 m. In a subgroup of 15 subjects with SDB, we searched for PFO with transesophagal echocardiography. Results The major new findings were that in CMS patients, a) SDB and nocturnal hypoxemia was more severe (P<0.01) than in controls (apnea/hypopnea index, AHI, 38.9±25.5 vs. 14.3±7.8[nb/h]; SaO2, 80.2±3.6 vs. 86.8±1.7[%], CMS vs. controls), and b) AHI was directly correlated with systemic blood pressure (r=0.5216, P=0.001) and pulmonary-artery pressure (r=0.4497, P=0.024). PFO was associated with more severe SDB (AHI 48.8±24.7 vs. 14.8±7.3[nb/h], P=0.013, PFO vs. no PFO) and hypoxemia. Conclusion SDB and nocturnal hypoxemia are more severe in CMS patients than in controls and are associated with systemic and pulmonary vascular dysfunction. The presence of a PFO appeared to further aggravate SDB. Closure of PFO may improve SDB, hypoxemia and vascular dysfunction in CMS patients. Clinical Trials Gov Registration NCT01182792.

Evaluation of 3-dimensional superimposition techniques on various skeletal structures of the head using surface models.

OBJECTIVES To test the applicability, accuracy, precision, and reproducibility of various 3D superimposition techniques for radiographic data, transformed to triangulated surface data. METHODS Five superimposition techniques (3P: three-point registration; AC: anterior cranial base; AC + F: anterior cranial base + foramen magnum; BZ: both zygomatic arches; 1Z: one zygomatic arch) were tested using eight pairs of pre-existing CT data (pre- and post-treatment). These were obtained from non-growing orthodontic patients treated with rapid maxillary expansion. All datasets were superimposed by three operators independently, who repeated the whole procedure one month later. Accuracy was assessed by the distance (D) between superimposed datasets on three form-stable anatomical areas, located on the anterior cranial base and the foramen magnum. Precision and reproducibility were assessed using the distances between models at four specific landmarks. Non parametric multivariate models and Bland-Altman difference plots were used for analyses. RESULTS There was no difference among operators or between time points on the accuracy of each superimposition technique (p>0.05). The AC + F technique was the most accurate (D<0.17 mm), as expected, followed by AC and BZ superimpositions that presented similar level of accuracy (D<0.5 mm). 3P and 1Z were the least accurate superimpositions (0.790.05), the detected structural changes differed significantly between different techniques (p<0.05). Bland-Altman difference plots showed that BZ superimposition was comparable to AC, though it presented slightly higher random error. CONCLUSIONS Superimposition of 3D datasets using surface models created from voxel data can provide accurate, precise, and reproducible results, offering also high efficiency and increased post-processing capabilities. In the present study population, the BZ superimposition was comparable to AC, with the added advantage of being applicable to scans with a smaller field of view.

Anterior superior alveolar nerve (ASAN): A morphometric-anatomical Analysis

The anterior superior alveolar nerve (ASAN) is a branch of the infraorbital nerve. Only few studies have morphometrically evaluated the course of the ASAN. Midfacial segments of ten hemisectioned fresh adult cadaver heads were dissected to uncover the anterior wall of the maxilla. Specimens were subsequently decalcified and the bone overlying the ASAN was removed under a microscope to expose the ASAN. Its branching pattern from the infraorbital nerve was recorded, and the course of the ASAN within the anterior wall of the maxillary sinus was morphometrically assessed measuring distances to predefined landmarks using a digital caliper. A distinct ASAN was observed in all specimens. It arose lateral (six cases) or inferior (four cases) from the infraorbital nerve. The point of origin was located at a mean distance of 12.2 ± 5.79 mm posterior to the infraorbital foramen. The ASAN was located on average 2.8 ± 5.13 mm lateral to the infraorbital foramen. After coursing medially, the ASAN ran inferior to the foramen at a mean distance of 5.5 ± 3.07 mm. When approaching the nasal aperture, the loop of the ASAN was on average 13.6 ± 3.07 mm above the nasal floor. The horizontal mean distance from the ASAN to the nasal aperture was 4.3 ± 2.74 mm halfway down from the loop, and 3.3 ± 2.60 mm at the floor of the nose, respectively. In conclusion, the present study evaluated the course of the ASAN relative to the infraorbital foramen and nasal aperture. This information is helpful to avoid damage to this anatomical structure during interventions in the infraobrital region of the maxilla. Further, knowledge of the course of the ASAN and of its bony correlate (canalis sinuosus) may be valuable in interpreting anesthetic or radiologic findings in the anterior maxilla.

Evidence for endothermic ancestors of crocodiles at the stem of archosaur evolution

Physiological, anatomical, and developmental features of the crocodilian heart support the paleontological evidence that the ancestors of living crocodilians were active and endothermic, but the lineage reverted to ectothermy when it invaded the aquatic, ambush predator niche. In endotherms, there is a functional nexus between high metabolic rates, high blood flow rates, and complete separation of high systemic blood pressure from low pulmonary blood pressure in a four-chambered heart. Ectotherms generally lack all of these characteristics, but crocodilians retain a four-chambered heart. However, crocodilians have a neurally controlled, pulmonary bypass shunt that is functional in diving. Shunting occurs outside of the heart and involves the left aortic arch that originates from the right ventricle, the foramen of Panizza between the left and right aortic arches, and the cog-tooth valve at the base of the pulmonary artery. Developmental studies show that all of these uniquely crocodilian features are secondarily derived, indicating a shift from the complete separation of blood flow of endotherms to the controlled shunting of ectotherms. We present other evidence for endothermy in stem archosaurs and suggest that some dinosaurs may have inherited the trait.

Morfometria dos forames mandibular, mentual e infraorbital de Lobo-guará Chrysocyon brachyurus, Illiger, 1815 aplicada a bloqueios anestésicos

CHAPTER II - The Chrysocyon brachyurus is the biggest South American canid which has a high frequency of dental injuries, both in wild and captivity. Thus, veterinary procedures are necessary to preserve the feeding capacity of hundreds of captive specimens worldwide. The aim of this study was to study the mandibular morphometry of maned wolf with emphasis on the establishment of anatomic references to the anesthetic blockage of the inferior alveolar and mental nerves. Therefore, 15 measurements in 22 hemimandibles of C. brachyurus adults were taken. For extra-oral technique of blockage of the inferior alveolar nerve at the level of the mandibular foramen, it is stated that the needle should be advanced, close to the medial surface of the mandibular ramus, by 11.4 mm perpendiculary from the palpable concavity. Alternatively, the needle can be introduced for 30.4 mm from the angular process at 20-25 degrees angle with the ventral margin. For blocking only the mentual nerve, it is recommended the introduction of needle for 10 mm, close to the lateral aspect of the mandibular body, at the level of the lower first premolar. The mandibular foramen showed similars position, size and symmetry in the maned wolfs specimens examined. The comparison of the data with those available for other carnivores reflects the necessity for determining these anatomical references specifically for each species.

Two Cases of Arnold-Chiari Malformation with Respiratory Failure

Arnold–Chiari malformation is defined as downward displacement of the brainstem and cerebellum through the foramen magnum. It has different clinical presentations and four subtypes. It is known that downward migration of posterior fossa components through the foramen magnum and associated lower cranial nerve palsy and brainstem compression can cause respiratory failure. Acute respiratory failure could mark the onset of the disease. Posterior fossa decompression performed to treat primary disease can improve the central sleep abnormalities. As respiratory failure is rarely seen, this paper presents two cases of Arnold–Chiari malformation with respiratory failure.

Description of a new species of skate of the genus Malacoraja Stehmann, 1970: the first species from the southwestern Atlantic Ocean, with notes on generic monophyly and composition (Chondrichthyes: Rajidae)

O primeiro registro para o Atlântico Sul ocidental de uma espécie do gênero Malacoraja Stehmann, 1970 é feita com base na descrição de Malacoraja obscura, espécie nova, proveniente do talude continental do Sudeste brasileiro dos estados do Espírito Santo e Rio de Janeiro em profundidades de 808-1105 m. A espécie nova é conhecida através de cinco exemplares e é distinta de seus congêneres pela sua coloração dorsal composta por numerosas manchas esbranquiçadas e pequenas na região do disco e nadadeiras pélvicas, por apresentar uma fileira irregular de espinhos ao longo da superfície dorsal mediana da cauda a qual persiste em espécimes maiores (desde a base da cauda até dois-terços do seu comprimento numa fêmea de 680 mm de comprimento total, CT) e uma região pequena desprovida de dentículos na base ventral da cauda (estendendo somente até a margem distal da nadadeira pélvica). Outros caracteres diagnósticos em combinação incluem a ausência de espinhos escapulares em indivíduos maiores, número elevado de fileiras dentárias (64/62 fileiras num macho subadulto de 505 mm de CT e 76/74 numa fêmea de 680 mm de CT) e de vértebras (27-28 Vtr, 68-75 Vprd), coloração ventral do disco uniformemente castanha escura, duas fenestras pós-ventrais na cintura escapular, fenestra pós-ventral posterior grande, forame magno circular e dois forames para a carótida interna na placa basal ventral do neurocrânio. Machos adultos não são conhecidos, porém uma descrição anatômica de M. obscura, sp. nov., é fornecida. Comparações são realizadas com todo o material conhecido de M. kreffti, com a literatura sobre M. senta e com material abundante de M. spinacidermis da África do Sul; M. obscura, sp. nov., assemelha-se mais a M. spinacidermis do Atlântico Sul oriental em esqueleto dérmico, coloração e tamanho. Malacoraja é monofilético devido à sua espinulação e apêndices rostrais conspícuos e é aparentemente composta por dois grupos de espécies, um para M. obscura e M. spinacidermis e outro para M. kreffti e M. senta, porém a elucidação das relações filogenéticas entre as espécies necessita de mais informações anatômicas, principalmente das duas últimas espécies.

Percutaneous vertebroplasty: a new animal model.

Background Context Percutaneous vertebroplasty (PVP) is a minimally invasive surgical procedure and is frequently performed in humans who need surgical treatment of vertebral fractures. PVP involves cement injection into the vertebral body, thereby providing rapid and significant pain relief. Purpose The testing of novel biomaterials depends on suitable animal models. The aim of this study was to develop a reproducible and safe model of PVP in sheep. Study Design This study used ex vivo and in vivo large animal model study (Merino sheep). Methods Ex vivo vertebroplasty was performed through a bilateral modified parapedicular access in 24 ovine lumbar hemivertebrae, divided into four groups (n=6). Cerament (Bone Support, Lund, Sweden) was the control material. In the experimental group, a novel composite was tested—Spine-Ghost—which consisted of an alpha-calcium sulfate matrix enriched with micrometric particles of mesoporous bioactive glass. All vertebrae were assessed by micro-computed tomography (micro-CT) and underwent mechanical testing. For the in vivo study, 16 sheep were randomly allocated into control and experimental groups (n=8), and underwent PVP using the same bone cements. All vertebrae were assessed postmortem by micro-CT, histology, and reverse transcription-polymerase chain reaction (rt-PCR). This work has been supported by the European Commission under the 7th Framework Programme for collaborative projects (600,000–650,000 USD). Results In the ex vivo model, the average defect volume was 1,275.46±219.29 mm3. Adequate defect filling with cement was observed. No mechanical failure was observed under loads which were higher than physiological. In the in vivo study, cardiorespiratory distress was observed in two animals, and one sheep presented mild neurologic deficits in the hind limbs before recovering. Conclusions The model of PVP is considered suitable for preclinical in vivo studies, mimicking clinical application. All sheep recovered and completed a 6-month implantation period. There was no evidence of cement leakage into the vertebral foramen in the postmortem examination.

Percutaneous Cement Discoplasty: Biomechanical and clinical assessment of a minimally invasive treatment of lumbar intervertebral disc disease

With population ageing, spine diseases have an increasing prevalence and induce high economic and social costs. The development of minimally invasive surgeries allows reducing the surgery-associated risks in elderly and polymorbid patients, and save costs by treating more patients in shorter time and reducing the complications. Percutaneous Cement Discoplasty (PCD) is a minimally invasive technique developed to treat highly degenerated intervertebral discs exhibiting a vacuum phenomenon. Filling the disc with bone cement creates a stand-alone spacer which partially restores the disc height and re-opens the foraminal space. PCD has recently been introduced to clinical use. However, the spine biomechanics following this treatment remained unravelled. The aim of this PhD thesis is to bridge the clinical experience with in vitro methodologies, to provide a multilateral evaluation of PCD outcome and a better understanding of its impact on the spine biomechanics, and of its possible contraindications. Firstly, a suitable in vitro porcine model to test the biomechanics of discoplasty by comparing specimens in the preoperative and postoperative conditions was developed. The methodology was then applied to investigate the biomechanics of discoplasty in cadaveric human segments. The in vitro specimens were mechanically investigated in flexion and extension, while a DIC system quantified the range of motion, disc height, and strains on the disc surface. Then, a versatile tool to measure the impact of discoplasty on the foramen space was developed and applied both to clinical and experimental work. The vertebrae reconstructed from CT scans were registered to match the loading configuration, using ex vivo DIC measurements under loading. The foramen volumetric changes caused by PCD was measured using a 3D geometrical method clinically developed by the research group. In conclusion, this project significantly extended the understanding of PCD biomechanics, highlighting its benefits in the treatment of advanced cases of intervertebral disc degeneration.