Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease a systematic review and meta-analysis of comparative studies.

OBJECTIVES: The purpose of this study was to determine whether thoracic endovascular aortic repair (TEVAR) reduces death and morbidity compared with open surgical repair for descending thoracic aortic disease. BACKGROUND: The role of TEVAR versus open surgery remains unclear. Metaregression can be used to maximally inform adoption of new technologies by utilizing evidence from existing trials. METHODS: Data from comparative studies of TEVAR versus open repair of the descending aorta were combined through meta-analysis. Metaregression was performed to account for baseline risk factor imbalances, study design, and thoracic pathology. Due to significant heterogeneity, registry data were analyzed separately from comparative studies. RESULTS: Forty-two nonrandomized studies involving 5,888 patients were included (38 comparative studies, 4 registries). Patient characteristics were balanced except for age, as TEVAR patients were usually older than open surgery patients (p = 0.001). Registry data suggested overall perioperative complications were reduced. In comparative studies, all-cause mortality at 30 days (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.33 to 0.59) and paraplegia (OR: 0.42, 95% CI: 0.28 to 0.63) were reduced for TEVAR versus open surgery. In addition, cardiac complications, transfusions, reoperation for bleeding, renal dysfunction, pneumonia, and length of stay were reduced. There was no significant difference in stroke, myocardial infarction, aortic reintervention, and mortality beyond 1 year. Metaregression to adjust for age imbalance, study design, and pathology did not materially change the results. CONCLUSIONS: Current data from nonrandomized studies suggest that TEVAR may reduce early death, paraplegia, renal insufficiency, transfusions, reoperation for bleeding, cardiac complications, pneumonia, and length of stay compared with open surgery. Sustained benefits on survival have not been proven.

Endoleak and in-stent thrombus detection with CT angiography in a thoracic aortic aneurysm phantom at different tube energies using filtered back projection and iterative algorithms.

PURPOSE: To determine the lower limit of dose reduction with hybrid and fully iterative reconstruction algorithms in detection of endoleaks and in-stent thrombus of thoracic aorta with computed tomographic (CT) angiography by applying protocols with different tube energies and automated tube current modulation. MATERIALS AND METHODS: The calcification insert of an anthropomorphic cardiac phantom was replaced with an aortic aneurysm model containing a stent, simulated endoleaks, and an intraluminal thrombus. CT was performed at tube energies of 120, 100, and 80 kVp with incrementally increasing noise indexes (NIs) of 16, 25, 34, 43, 52, 61, and 70 and a 2.5-mm section thickness. NI directly controls radiation exposure; a higher NI allows for greater image noise and decreases radiation. Images were reconstructed with filtered back projection (FBP) and hybrid and fully iterative algorithms. Five radiologists independently analyzed lesion conspicuity to assess sensitivity and specificity. Mean attenuation (in Hounsfield units) and standard deviation were measured in the aorta to calculate signal-to-noise ratio (SNR). Attenuation and SNR of different protocols and algorithms were analyzed with analysis of variance or Welch test depending on data distribution. RESULTS: Both sensitivity and specificity were 100% for simulated lesions on images with 2.5-mm section thickness and an NI of 25 (3.45 mGy), 34 (1.83 mGy), or 43 (1.16 mGy) at 120 kVp; an NI of 34 (1.98 mGy), 43 (1.23 mGy), or 61 (0.61 mGy) at 100 kVp; and an NI of 43 (1.46 mGy) or 70 (0.54 mGy) at 80 kVp. SNR values showed similar results. With the fully iterative algorithm, mean attenuation of the aorta decreased significantly in reduced-dose protocols in comparison with control protocols at 100 kVp (311 HU at 16 NI vs 290 HU at 70 NI, P ≤ .0011) and 80 kVp (400 HU at 16 NI vs 369 HU at 70 NI, P ≤ .0007). CONCLUSION: Endoleaks and in-stent thrombus of thoracic aorta were detectable to 1.46 mGy (80 kVp) with FBP, 1.23 mGy (100 kVp) with the hybrid algorithm, and 0.54 mGy (80 kVp) with the fully iterative algorithm.

Transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves: results from the global valve-in-valve registry.

BACKGROUND: Transcatheter aortic valve-in-valve implantation is an emerging therapeutic alternative for patients with a failed surgical bioprosthesis and may obviate the need for reoperation. We evaluated the clinical results of this technique using a large, worldwide registry. METHODS AND RESULTS: The Global Valve-in-Valve Registry included 202 patients with degenerated bioprosthetic valves (aged 77.7±10.4 years; 52.5% men) from 38 cardiac centers. Bioprosthesis mode of failure was stenosis (n=85; 42%), regurgitation (n=68; 34%), or combined stenosis and regurgitation (n=49; 24%). Implanted devices included CoreValve (n=124) and Edwards SAPIEN (n=78). Procedural success was achieved in 93.1% of cases. Adverse procedural outcomes included initial device malposition in 15.3% of cases and ostial coronary obstruction in 3.5%. After the procedure, valve maximum/mean gradients were 28.4±14.1/15.9±8.6 mm Hg, and 95% of patients had ≤+1 degree of aortic regurgitation. At 30-day follow-up, all-cause mortality was 8.4%, and 84.1% of patients were at New York Heart Association functional class I/II. One-year follow-up was obtained in 87 patients, with 85.8% survival of treated patients. CONCLUSIONS: The valve-in-valve procedure is clinically effective in the vast majority of patients with degenerated bioprosthetic valves. Safety and efficacy concerns include device malposition, ostial coronary obstruction, and high gradients after the procedure.

Polymorphisms in tumor necrosis factor-α increase susceptibility to intra-abdominal Candida infection in high-risk surgical ICU patients*.

OBJECTIVES: To evaluate the influence of genetic polymorphisms on the susceptibility to Candida colonization and intra-abdominal candidiasis, a blood culture-negative life-threatening infection in high-risk surgical ICU patients. DESIGN: Prospective observational cohort study. SETTING: Surgical ICUs from two University hospitals of the Fungal Infection Network of Switzerland. PATIENTS: Eighty-nine patients at high risk for intra-abdominal candidiasis (68 with recurrent gastrointestinal perforation and 21 with acute necrotizing pancreatitis). MEASUREMENTS AND MAIN RESULTS: Eighteen single-nucleotide polymorphisms in 16 genes previously associated with development of fungal infections were analyzed from patient's DNA by using an Illumina Veracode genotyping platform. Candida colonization was defined by recovery of Candida species from at least one nonsterile site by twice weekly monitoring of cultures from oropharynx, stools, urine, skin, and/or respiratory tract. A corrected colonization index greater than or equal to 0.4 defined "heavy" colonization. Intra-abdominal candidiasis was defined by the presence of clinical symptoms and signs of peritonitis or intra-abdominal abscess and isolation of Candida species either in pure or mixed culture from intraoperatively collected abdominal samples. Single-nucleotide polymorphisms in three innate immune genes were associated with development of a Candida corrected colonization index greater than or equal to 0.4 (Toll-like receptor rs4986790, hazard ratio = 3.39; 95% CI, 1.45-7.93; p = 0.005) or occurrence of intra-abdominal candidiasis (tumor necrosis factor-α rs1800629, hazard ratio = 4.31; 95% CI, 1.85-10.1; p= 0.0007; β-defensin 1 rs1800972, hazard ratio = 3.21; 95% CI, 1.36-7.59; p = 0.008). CONCLUSION: We report a strong association between the promoter rs1800629 single-nucleotide polymorphism in tumor necrosis factor-α and an increased susceptibility to intra-abdominal candidiasis in a homogenous prospective cohort of high-risk surgical ICU patients. This finding highlights the relevance of the tumor necrosis factor-α functional polymorphism in immune response to fungal pathogens. Immunogenetic profiling in patients at clinical high risk followed by targeted antifungal interventions may improve the prevention or preemptive management of this life-threatening infection.

Aortic valve lesion after coronary angiography.

A 56-year-old patient admitted to hospital for the suspicion of an acute coronary syndrome underwent coronary angiography without detection of significant lesions. Seven days later the echocardiography showed acute severe aortic valve insufficiency. Intraoperatively we found a perforated leaflet probably due to lesion during transcatheter procedure.

Complicated intra-abdominal infections in Europe: preliminary data from the first three months of the CIAO Study.

The CIAO Study is a multicenter observational study currently underway in 66 European medical institutions over the course of a six-month study period (January-June 2012).This preliminary report overviews the findings of the first half of the study, which includes all data from the first three months of the six-month study period.Patients with either community-acquired or healthcare-associated complicated intra-abdominal infections (IAIs) were included in the study.912 patients with a mean age of 54.4 years (range 4-98) were enrolled in the study during the first three-month period. 47.7% of the patients were women and 52.3% were men. Among these patients, 83.3% were affected by community-acquired IAIs while the remaining 16.7% presented with healthcare-associated infections. Intraperitoneal specimens were collected from 64.2% of the enrolled patients, and from these samples, 825 microorganisms were collectively identified.The overall mortality rate was 6.4% (58/912). According to univariate statistical analysis of the data, critical clinical condition of the patient upon hospital admission (defined by severe sepsis and septic shock) as well as healthcare-associated infections, non-appendicular origin, generalized peritonitis, and serious comorbidities such as malignancy and severe cardiovascular disease were all significant risk factors for patient mortality.White Blood Cell counts (WBCs) greater than 12,000 or less than 4,000 and core body temperatures exceeding 38°C or less than 36°C by the third post-operative day were statistically significant indicators of patient mortality.

La fibrose rétropéritonéale, une maladie inflammatoire méconnue. Observations cliniques et revue de la littérature [Retroperitoneal fibrosis, an unrecognized inflammatory disease. Clinical observations and review of the literature]

Retroperitoneal fibrosis (RF) is a rare disease, typically with an insidious clinical course. The peak incidence is seen in patients 40 to 60 years of age and mostly in man. The characteristic finding in this disease is a periaortic fibrous mass that often surrounds the ureters. Although usually regarded as an obstructive uropathy, there has been growing recognition of the condition as a generalized disease. It may have a wide variety of manifestations including mediastinitis, thyroiditis and sclerosing cholangitis. The most common mode of presentation remains abdominal or flank pain with uremia, anemia and a high sedimentation rate. Although ultrasound and renal scintigraphy may contribute to the general evaluation of patients with RF, CT-scanner is the preferred imaging method. The multiplanar imaging capability of magnetic resonance may facilitate assessment of disease extent. The pathogenesis of the disease remains unknown. Steroids and, more recently tamoxifen, appear to be effective in the treatment of the RF. In most instances, RF does not lead to long-term morbidity or affect survival. The three cases of RF reported herein illustrate the varied mode of presentation and the response to the treatment.

Pulse wave analysis aortic pressure . distole should also be considered

La rigidité anormalement haute des artères à grande conductance est un marqueur de l'augmentation du risque cardiovasculaire et est typiquement retrouvée chez les patients diabétiques ou hypertendus. Ces vaisseaux deviennent plus rigides avec l'âge, expliquant la haute prévalence d'hypertension systolique chez les personnes âgées. Cette rigidification agit sur la pression sanguine de plusieurs façons. Notamment la fonction windkessel est gênée, menant à l'augmentation de la pression systolique et de la pression puisée, la diminution de la pression diastolique, et ainsi à l'augmentation de la postcharge ventriculaire gauche associée à une probable diminution de la perfusion coronarienne. De plus, la propagation des ondes de pression le long de l'arbre vasculaire est accélérée, de sorte que les ondes réfléchies générées au site de décalage d'impédance atteignent l'aorte ascendante plus tôt par rapport au début de l'éjection ventriculaire, aboutissant à une augmentation de la pression systolique centrale, ce qui n'arriverait pas en présence de vaisseaux moins rigides. Dans ce cas, au contraire, les ondes de pression antérogrades et réfléchies voyages plus lentement, de sorte que les ondes de réflexion tendent à atteindre l'aorte centrale une fois l'éjection terminée, augmentant la pression diastolique et contribuant à la perfusion coronarienne. La tonométrie d'applanation est une méthode non invasive permettant l'évaluation de la forme de l'onde de pression au niveau l'aorte ascendante, basée sur l'enregistrement du pouls périphérique, au niveau radial dans notre étude. Nous pouvons dériver à partir de cette méthode un index d'augmentation systolique (sAIX) qui révèle quel pourcentage de la pression centrale est du aux ondes réfléchies. Plusieurs études ont montré que cet index est corrélé à d'autres mesures de la rigidité artérielle comme la vitesse de l'onde de pouls, qu'il augmente avec l'âge et avec les facteurs de risques cardiovasculaires, et qu'il est capable de préciser le pronostic cardiovasculaire. En revanche, peu d'attention a été portée à l'augmentation de la pression centrale diastolique due aux ondes réfléchies (dAIX). Nous proposons donc de mesurer cet index par un procédé d'analyse développé dans notre laboratoire, et ce dans la même unité que l'index systolique. Etant donné que les modifications de la paroi artérielle modulent d'une part la vitesse de l'onde de pouls (PWV) et d'autre part le temps de voyage aller-retour des ondes de pression réfléchies aux sites de réflexion, toute augmentation de la quantité d'énergie réfléchie atteignant l'aorte pendant la systole devrait être associée à une diminution de l'énergie arrivant au même point pendant la diastole. Notre étude propose de mesurer ces deux index, ainsi que d'étudier la relation de l'index d'augmentation diastolique (dAIX) avec la vitesse de propagation de l'onde de pouls (PWV) et avec le rythme cardiaque (HR), ce dernier étant connu pour influencer l'index d'augmentation systolique (sAIX) . L'influence de la position couchée et assise est aussi étudiée. Les mesures de la PWV et des sAIX et dAIX est réalisée chez 48 hommes et 45 femmes âgées de 18 à 70 ans, classés en 3 groupes d'âges. Les résultats montrent qu'en fonction de l'âge, le genre et la position du corps, il y a une relation inverse entre sAIX et dAIX. Lorsque PWV et HR sont ajoutés comme covariables à un modèle de prédiction comprenant l'âge, le genre et la position du corps comme facteurs principaux, sAIX est directement lié à PWV (p<0.0001) et inversement lié à HR (p<0.0001). Avec la même analyse, dAIX est inversement lié à PWV (p<0.0001) et indépendant du rythme cardiaque (p=0.52). En conclusion, l'index d'augmentation diastolique est lié à la rigidité vasculaire au même degré que l'index d'augmentation systolique, alors qu'il est affranchi de l'effet confondant du rythme cardiaque. La quantification de l'augmentation de la pression aortique diastolique due aux ondes réfléchies pourrait être une partie utile de l'analyse de l'onde de pouls.

Bilateral symmetry of radial pulse in high-level tennis players : implications for the validity of central aortic pulse wave analysis

Rapport de synthèse Ce travail de thèse s'articule autour de l'importance de l'évaluation de la fonction vasculaire et des répercussions au niveau central, cardiaque, des perturbations du réseau vasculaire. Les maladies cardiovasculaires sont prédominantes dans notre société et causes de morbidité et mortalité importante. La mesure de la pression artérielle classique reste le moyen le plus utilisé pour suivre la santé des vaisseaux, mais ne reflète pas directement ce qui se passe au niveau du coeur. La tonométrie d'aplanation permet depuis quelques années de mesurer l'onde de pouls radial, et par le biais d'une fonction mathématique de transfert validée, il est possible d'en déduire la forme et Γ amplitude de l'onde de pouls central, donc de la pression aortique centrale. Cette dernière est un reflet bien plus direct de la post-charge cardiaque, et de nombreuses études cliniques actuelles s'intéressent à cette mesure pour stratifier le risque ou évaluer l'effet d'un traitement vasculaire. Toutefois, bien que cet outil soit de plus en plus utilisé, il est rarement précisé si la latéralité de la mesure joue un rôle, sachant que certaines propriétés des membres supérieurs peuvent être affectées par un usage préférentiel (masse musculaire, densité osseuse, diamètre des artères, capillarisation musculaire, et même fonction endothéliale). On a en effet observé que ces divers paramètre étaient tous augmentés sur un bras entraîné. Dès lors on peut se poser la question de l'influence de ces adaptations physiologiques sur la mesure indirecte effectuée par le biais du pouls radial. Nous avons investigué les deux membres supérieurs de sujets jeunes et sédentaires (SED), ainsi que ceux de sujets sportifs avec un développement fortement asymétrique des bras, soit des joueurs de tennis de haut niveau (TEN). Des mesures anthropométriques incluant la composition corporelle et la circonférence des bras et avant-bras ont montré que TEN présente une asymétrie hautement significative aux deux mesures entre le bras dominant (entraîné) et l'autre, ce qui est aussi présent pour la force de serrage (mesurée au dynamomètre de Jamar). L'analyse des courbes centrales de pouls ne montre aucune différence entre les deux membres dans chaque groupe, par contre on peut observer une différence entre SED et TEN, avec un index d'augmentation diastolique qui est 50 % plus élevé chez TEN. Les index d'augmentation systolique sont identiques dans les deux groupes. On peut retenir de cette étude la validité de la méthode de tonométrie d'aplanation quel que soit le bras utilisé (dominant ou non-dominant) et ce même si une asymétrie conséquente est présente. Ces données sont clairement nouvelles et permettent de s'affranchir de cette variable dans la mesure d'un paramètre cardiovasculaire dont l'importance est actuellement grandissante. Les différences d'index diastolique sont expliquées par la fréquence cardiaque et la vitesse de conduction de l'onde de pouls plus basses chez TEN, causant un retard diastolique du retour de l'onde au niveau central, phénomène précédemment bien décrit dans la littérature.

Screening of illegal intracorporeal containers ("body packing"): is abdominal radiography sufficiently accurate? A comparative study with low-dose CT.

PURPOSE: To evaluate the diagnostic performance of abdominal radiography in the detection of illegal intracorporeal containers (hereafter, packets), with low-dose computed tomography (CT) as the reference standard. MATERIALS AND METHODS: This study was approved by the institutional ethical review board, with written informed consent. From July 2007 to July 2010, 330 people (296 men, 34 women; mean age, 32 years [range, 18-55 years]) suspected of having ingested drug packets underwent supine abdominal radiography and low-dose CT. The presence or absence of packets at abdominal radiography was reported, with low-dose CT as the reference standard. The density and number of packets (≤ 12 or >12) at low-dose CT were recorded and analyzed to determine whether those variables influence interpretation of results at abdominal radiography. RESULTS: Packets were detected at low-dose CT in 53 (16%) suspects. Sensitivity of abdominal radiography for depiction of packets was 0.77 (41 of 53), and specificity was 0.96 (267 of 277). The packets appeared isoattenuated to the bowel contents at low-dose CT in 16 (30%) of the 53 suspects with positive results. Nineteen (36%) of the 53 suspects with positive low-dose CT results had fewer than 12 packets. Packets that were isoattenuated at low-dose CT and a low number of packets (≤12) were both significantly associated with false-negative results at abdominal radiography (P = .004 and P = .016, respectively). CONCLUSION: Abdominal radiography is mainly limited by low sensitivity when compared with low-dose CT in the screening of people suspected of carrying drug packets. Low-dose CT is an effective imaging alternative to abdominal radiography.