Transcatheter aortic valve implantation in failed bioprosthetic surgical valves.

IMPORTANCE Owing to a considerable shift toward bioprosthesis implantation rather than mechanical valves, it is expected that patients will increasingly present with degenerated bioprostheses in the next few years. Transcatheter aortic valve-in-valve implantation is a less invasive approach for patients with structural valve deterioration; however, a comprehensive evaluation of survival after the procedure has not yet been performed. OBJECTIVE To determine the survival of patients after transcatheter valve-in-valve implantation inside failed surgical bioprosthetic valves. DESIGN, SETTING, AND PARTICIPANTS Correlates for survival were evaluated using a multinational valve-in-valve registry that included 459 patients with degenerated bioprosthetic valves undergoing valve-in-valve implantation between 2007 and May 2013 in 55 centers (mean age, 77.6 [SD, 9.8] years; 56% men; median Society of Thoracic Surgeons mortality prediction score, 9.8% [interquartile range, 7.7%-16%]). Surgical valves were classified as small (≤21 mm; 29.7%), intermediate (>21 and <25 mm; 39.3%), and large (≥25 mm; 31%). Implanted devices included both balloon- and self-expandable valves. MAIN OUTCOMES AND MEASURES Survival, stroke, and New York Heart Association functional class. RESULTS Modes of bioprosthesis failure were stenosis (n = 181 [39.4%]), regurgitation (n = 139 [30.3%]), and combined (n = 139 [30.3%]). The stenosis group had a higher percentage of small valves (37% vs 20.9% and 26.6% in the regurgitation and combined groups, respectively; P = .005). Within 1 month following valve-in-valve implantation, 35 (7.6%) patients died, 8 (1.7%) had major stroke, and 313 (92.6%) of surviving patients had good functional status (New York Heart Association class I/II). The overall 1-year Kaplan-Meier survival rate was 83.2% (95% CI, 80.8%-84.7%; 62 death events; 228 survivors). Patients in the stenosis group had worse 1-year survival (76.6%; 95% CI, 68.9%-83.1%; 34 deaths; 86 survivors) in comparison with the regurgitation group (91.2%; 95% CI, 85.7%-96.7%; 10 deaths; 76 survivors) and the combined group (83.9%; 95% CI, 76.8%-91%; 18 deaths; 66 survivors) (P = .01). Similarly, patients with small valves had worse 1-year survival (74.8% [95% CI, 66.2%-83.4%]; 27 deaths; 57 survivors) vs with intermediate-sized valves (81.8%; 95% CI, 75.3%-88.3%; 26 deaths; 92 survivors) and with large valves (93.3%; 95% CI, 85.7%-96.7%; 7 deaths; 73 survivors) (P = .001). Factors associated with mortality within 1 year included having small surgical bioprosthesis (≤21 mm; hazard ratio, 2.04; 95% CI, 1.14-3.67; P = .02) and baseline stenosis (vs regurgitation; hazard ratio, 3.07; 95% CI, 1.33-7.08; P = .008). CONCLUSIONS AND RELEVANCE In this registry of patients who underwent transcatheter valve-in-valve implantation for degenerated bioprosthetic aortic valves, overall 1-year survival was 83.2%. Survival was lower among patients with small bioprostheses and those with predominant surgical valve stenosis.

Response of day-to-day home blood pressure variability by antihypertensive drug class after transient ischemic attack or nondisabling stroke.

BACKGROUND AND PURPOSE Visit-to-visit variability in systolic blood pressure (SBP) is associated with an increased risk of stroke and was reduced in randomized trials by calcium channel blockers and diuretics but not by renin-angiotensin system inhibitors. However, time of day effects could not be determined. Day-to-day variability on home BP readings predicts stroke risk and potentially offers a practical method of monitoring response to variability-directed treatment. METHODS SBP mean, maximum, and variability (coefficient of variation=SD/mean) were determined in 500 consecutive transient ischemic attack or minor stroke patients on 1-month home BP monitoring (3 BPs, 3× daily). Hypertension was treated to a standard protocol. Differences in SBP variability from 3 to 10 days before to 8 to 15 days after starting or increasing calcium channel blockers/diuretics versus renin-angiotensin system inhibitors versus both were compared by general linear models, adjusted for risk factors and baseline BP. RESULTS Among 288 eligible interventions, variability in SBP was reduced after increased treatment with calcium channel blockers/diuretics versus both versus renin-angiotensin system inhibitors (-4.0 versus 6.9 versus 7.8%; P=0.015), primarily because of effects on maximum SBP (-4.6 versus -1.0 versus -1.0%; P=0.001), with no differences in effect on mean SBP. Class differences were greatest for early-morning SBP variability (3.6 versus 17.0 versus 38.3; P=0.002) and maximum (-4.8 versus -2.0 versus -0.7; P=0.001), with no effect on midmorning (P=0.29), evening (P=0.65), or diurnal variability (P=0.92). CONCLUSIONS After transient ischemic attack or minor stroke, calcium channel blockers and diuretics reduced variability and maximum home SBP, primarily because of effects on morning readings. Home BP readings enable monitoring of response to SBP variability-directed treatment in patients with recent cerebrovascular events.

Collision tumor affecting the paranasal sinuses of a geriatric donkey

Tumours of the paranasal sinuses are relatively uncommon in the horse. A collision tumour occurs when 2 separate tumour types arise in close proximity to each other and encroach on one another. This report describes the presence of neoplasia comprising glandular tissue and spindle cells growing concurrently in the frontal and caudal maxillary sinus of a geriatric donkey. As far as the authors are aware, this is the first description of a possible collision tumour in an equid.

Bivalirudin Versus Heparin Anticoagulation in Transcatheter Aortic Valve Replacement: The Randomized BRAVO-3 Trial.

BACKGROUND Anticoagulation is required during transcatheter aortic valve replacement (TAVR) procedures. Although an optimal regimen has not been determined, heparin is mainly used. Direct thrombin inhibition with bivalirudin may be an effective alternative to heparin as the procedural anticoagulant agent in this setting. OBJECTIVES The goal of this study was to determine whether bivalirudin offers an alternative to heparin as the procedural anticoagulant agent in patients undergoing TAVR. METHODS A total of 802 patients with aortic stenosis were randomized to undergo transfemoral TAVR with bivalirudin versus unfractionated heparin during the procedure. The 2 primary endpoints were major bleeding within 48 h or before hospital discharge (whichever occurred first) and 30-day net adverse clinical events, defined as the combination of major adverse cardiovascular events (all-cause mortality, myocardial infarction, or stroke) and major bleeding. RESULTS Anticoagulation with bivalirudin versus heparin did not meet superiority because it did not result in significantly lower rates of major bleeding at 48 h (6.9% vs. 9.0%; relative risk: 0.77; 95% confidence interval [CI]: 0.48 to 1.23; p = 0.27) or net adverse cardiovascular events at 30 days (14.4% vs. 16.1%; relative risk: 0.89; 95% CI: 0.64 to 1.24; risk difference: -1.72; 95% CI: -6.70 to 3.25; p = 0.50); regarding the latter, the prespecified noninferiority hypothesis was met (pnoninferiority < 0.01). Rates of major adverse cardiovascular events at 48 h were not significantly different (3.5% vs. 4.8%; relative risk: 0.73; 95% CI: 0.37 to 1.43; p = 0.35). At 48 h, the bivalirudin group had significantly fewer myocardial infarctions but more acute kidney injury events than the heparin group; at 30 days, these differences were no longer significant. CONCLUSIONS In this randomized trial of TAVR procedural pharmacotherapy, bivalirudin did not reduce rates of major bleeding at 48 h or net adverse cardiovascular events within 30 days compared with heparin. Although superiority was not shown, the noninferiority hypothesis was met with respect to the latter factor. Given the lower cost, heparin should remain the standard of care, and bivalirudin can be an alternative anticoagulant option in patients unable to receive heparin in TAVR. (International, Multi-center, Open-label, Randomized Controlled Trial in Patients Undergoing TAVR to Determine the Treatment Effect [Both Safety and Efficacy] of Using Bivalirudin Instead of UFH [BRAVO-2/3]; NCT01651780).

The future of transcatheter mitral valve interventions: competitive or complementary role of repair vs. replacement?

Transcatheter mitral interventions has been developed to address an unmet clinical need and may be an alternative therapeutic option to surgery with the intent to provide symptomatic and prognostic benefit. Beyond MitraClip therapy, alternative repair technologies are being developed to expand the transcatheter intervention armamentarium. Recently, the feasibility of transcatheter mitral valve implantation in native non-calcified valves has been reported in very high-risk patients. Acknowledging the lack of scientific evidence to date, it is difficult to predict what the ultimate future role of transcatheter mitral valve interventions will be. The purpose of the present report is to review the current state-of-the-art of mitral valve intervention, and to identify the potential future scenarios, which might benefit most from the transcatheter repair and replacement devices under development.

The care of adults with congenital heart disease across the globe: Current assessment and future perspective

The number of adults with congenital heart disease (CHD) has increased markedly over the past few decades as a result of astounding successes in pediatric cardiac care. Nevertheless, it is now well understood that CHD is not cured but palliated, such that life-long expert care is required to optimize outcomes. All countries in the world that experience improved survival in CHD must face new challenges inherent to the emergence of a growing and aging CHD population with changing needs and medical and psychosocial issues. Founded in 1992, the International Society for Adult Congenital Heart Disease (ISACHD) is the leading global organization of professionals dedicated to pursuing excellence in the care of adults with CHD worldwide. Recognizing the unique and varied issues involved in caring for adults with CHD, ISACHD established a task force to assess the current status of care for adults with CHD across the globe, highlight major challenges and priorities, and provide future direction. The writing committee consisted of experts from North America, South America, Europe, South Asia, East Asia, and Oceania. The committee was divided into subgroups to review key aspects of adult CHD (ACHD) care. Regional representatives were tasked with investigating and reporting on relevant local issues as accurately as possible, within the constraints of available data. The resulting ISACHD position statement addresses changing patterns of worldwide epidemiology, models of care and organization of care, education and training, and the global research landscape in ACHD.

Findings of the University of Texas Health Science Center at San Antonio's Dental School pilot mobile van program in Laredo, Texas

Lack of access to oral health care frequently affects those of lower socio-economic level; individuals in this group experience more dental decay, and the caries experience is more likely to be untreated. Inadequate dental care access may be attributed to exclusion that is due to income, geography, age, race or ethnicity. Objective: The present study aims were to: (1) determine how oral disease prevalence and access to dental services in four US-Mexico Border unincorporated low socioeconomic settlements identified as colonias compare to each other and Laredo, Texas, and (2) determine if insurance status affects dental care access and/or disease prevalence. Methods: A secondary analysis of data from a retrospective chart review of 672 patients attending a Mobile Dental Van Program in the Webb County colonias. Demographic information, (ethnicity, age, gender, insurance coverage and colonia site), dental visits within past year, insurance status, presence of dental sealants, prevalence of untreated dental decay (caries), and presence of gum disease (gingivitis and periodontitis) were extracted. Pearson's chi-square tests (χ2) were computed to compare the prevalence of these outcomes between colonias and Laredo and their potential association with insurance status. Results: For 6 - 11 year olds, dental visits in the past year were lower for colonias (39%), than Laredo (58.5%) (p<0.002). Caries prevalence was higher for colonias (56.6%), than Laredo (37.1%) (p<0.001). Gum disease prevalence was higher in colonias (73%), than in Laredo (21.4%) (p<0.001). No significant differences were noted for caries (χ2=1.73; p<0.188) and gum disease (χ2=0.0098; p<0.921) by patient's insurance status. For adults 36 - 64 years of age, dental visits in the past year were lower in colonias (22.4%), than Laredo (36.3%) (p<0.001). Caries prevalence was higher for colonias (78.3%), than Laredo (54.0%) (p<0.001). Gum disease prevalence was also higher among colonias (91.3%) than Laredo (61.3%) (p<0.001). No significant differences were noted for caries (χ2=0.0010; p<0.975) and gum disease (χ2=0.0607; p<0.805) by patient's insurance status. Conclusion: Colonia residents seeking dental care at a Mobile Dental Van Program in Webb County have significantly higher prevalence of oral disease regardless of insurance status.^

Proceedings of the Twenty-Sixth Annual Biochemical Engineering Symposium

This volume contains the Proceedings of the Twenty-Sixth Annual Biochemical Engineering Symposium held at Kansas State University on September 21, 1996. The program included 10 oral presentations and 14 posters. Some of the papers describe the progress of ongoing projects, and others contain the results of completed projects. Only brief summaries are given of some of the papers; many of the papers will be published in full elsewhere. A listing of those who attended is given below. ContentsForeign Protein Production from SV40 Early Promoter in Continuous Cultures of Recombinant CHO Cells - Gautam Banik, Paul Todd, and Dhinakar Kampala Enhanced Cell Recruitment Due to Cell-Cell Interactions - Brad Farlow and Matthias Nollert The Recirculation of Hybridoma Suspension Cultures: Effects on Cell Death, Metabolism and Mab Productivity - Peng Jin and Carole A. Heath The Importance of Enzyme Inactivation and Self-Recovery in Cometabolic Biodegradation of Chlorinated Solvents - Xi-Hui Zhang, Shanka Banerji, and Rakesh Bajpai Phytoremediation of VOC contaminated Groundwater using Poplar Trees - Melissa Miller, Jason Dana, L.C. Davis, Murlidharan Narayanan, and L.E. Erickson Biological Treatment of Off-Gases from Aluminum Can Production: Experimental Results and Mathematical Modeling - Adeyma Y. Arroyo, Julio Zimbron, and Kenneth F. Reardon Inertial Migration Based Separation of Chlorella Microalgae in Branched Tubes - N.M. Poflee, A.L. Rakow, D.S. Dandy, M.L. Chappell, and M.N. Pons Contribution of Electrochemical Charge to Protein Partitioning in Aqueous Two-Phase Systems - Weiyu Fan and Charles C. Glatz Biodegradation of Some Commercial Surfactants Used in Bioremediation - Jun Gu, G.W. Preckshot, S.K. Banerji, and Rakesh Bajpai Modeling the Role of Biomass in Heavy Metal Transport Ln Vadose Zone - K.V. Nedunuri, L.E. Erickson, and R.S. Govindaraju Multivariable Statistical Methods for Monitoring Process Quality: Application to Bioinsecticide Production by 73 89 Bacillus Thuringiensis - c. Puente and M.N. Karim The Use of Polymeric Flocculants in Bacterial Lysate Streams - H. Graham, A.S. Cibulskas and E.H. Dunlop Effect of Water Content on transport of Trichloroethylene in a Chamber with Alfalfa Plants - Muralidharan Narayanan, Jiang Hu, Lawrence C. Davis, and Larry E. Erickson Detection of Specific Microorganisms using the Arbitrary Primed PCR in the Bacterial Community of Vegetated Soil - X. Wu and L.C. Davis Flux Enhancement Using Backpulsing - V.T. Kuberkar and R.H. Davis Chromatographic Purification of Oligonucleotides: Comparison with Electrophoresis - Stephen P. Cape, Ching-Yuan Lee, Kevin Petrini, Sean Foree, Micheal G. Sportiello and Paul Todd Determining Singular Arc Control Policies for Bioreactor Systems Using a Modified Iterative Dynamic Programming Algorithm - Arun Tholudur and W. Fred Ramirez Pressure Effect on Subtilisins Measured via FTIR, EPR and Activity Assays, and Its Impact on Crystallizations - J.N. Webb, R.Y. Waghmare, M.G. Bindewald, T.W. Randolph, J.F. Carpenter, C.E. Glatz Intercellular Calcium Changes in Endothelial Cells Exposed to Flow - Laura Worthen and Matthias Nollert Application of Liquid-Liquid Extraction in Propionic Acid Fermentation - Zhong Gu, Bonita A. Glatz, and Charles E. Glatz Purification of Recombinant T4 Lysozyme from E. Coli: Ion-Exchange Chromatography - Weiyu Fan, Matt L. Thatcher, and Charles E. Glatz Recovery and Purification of Recombinant Beta-Glucuronidase from Transgenic Corn - Ann R. Kusnadi, Roque Evangelista, Zivko L. Nikolov, and John Howard Effects of Auxins and cytokinins on Formation of Catharanthus Roseus G. Don Multiple Shoots - Ying-Jin Yuan, Yu-Min Yang, Tsung-Ting Hu, and Jiang Hu Fate and Effect of Trichloroethylene as Nonaqueous Phase Liquid in Chambers with Alfalfa - Qizhi Zhang, Brent Goplen, Sara Vanderhoof, Lawrence c. Davis, and Larry E. Erickson Oxygen Transport and Mixing Considerations for Microcarrier Culture of Mammalian Cells in an Airlift Reactor - Sridhar Sunderam, Frederick R. Souder, and Marylee Southard Effects of Cyclic Shear Stress on Mammalian Cells under Laminar Flow Conditions: Apparatus and Methods - M.L. Rigney, M.H. Liew, and M.Z. Southard

Investigation of Pliocene foraminifera on sediment core CRP-1 from the Ross Sea, Antarctica

Mixed assemblages of Pliocene and Quaternary foraminifera occur within the Quaternary succession of the CRP-1 drillhole. Pliocene foraminifera are not present in the lowermost Unit 4.1. are rare in Unit 3.1 and 2.3, are relatively common in Units 2.2 and 2.1, and are absent in Unit 1.1. Fifteen and twelve species were documented in two of the samples from Units 2.2 and 2.1 respectively. A census count of foraminifera in a sample at 26.89 mbsf (Unit 2.2) indicated that 39% of the tests were from a Pliocene source, with the remaining 61% tests assigned to the in situ Quaternary assemblage. There appears to be a close correlation between the stratigraphic distribution of ice-rafted sediments and the test number and diversity of Pliocene taxa. It is concluded that Pliocene assemblages were not derived from submarine outcrops on Roberts Ridge, but are more likely to have been rafted to the site via major trunk valley drainage systems such as operated within the Mackay and Ferrar glacial valleys. The co-occurrence of marine biota (including foraminifera), fossil wood, pollen, and igneous clasts in the Quaternary succession of CRP-l, points to the marine and terrestrial facies of the Pliocene Sirius Group as a likely source. A major episode of erosion and transport of sediment into the offshore marine basins at about ~1 Ma may have been triggered by dynamism in the ice sheet-glacier system, an episode of regional uplift in the Transantarctic Mountains, sea level oscillations and associated changes in the land-to-sea drainage baselines, or some combination of these factors.

Investigation of Quaternary foraminifera in sediment core CRP-1 from the Ross Sea, Antarctica

Foraminifera are examined in twenty-six samples from a 44 metre succession of Quaternary glacial sediments recovered from the CRP-1 drillhole on Roberts Ridge, southwestern Ross Sea, Antarctica. In situ marine assemblages were documented in at least three of the six lithostratigraphic units, and it is likely that the remaining three interbedded diamicton units are also marine in origin. Peak foraminiferal diversities are documented in Unit 3.1 (73 species) and Unit 2.2 (32 species). Calcareous benthics dominate the assemblages, but may be accompanied by abundant occurrences of the planktonic Neogloboquadrina pachyderma. Low diversity agglutinated faunas appear in the uppermost strata of Units 4.1 and 2.2. A close relationship between lithofacics and foraminiferal biofacies points to marine environments that alternated between proximity to and distance from active glaciers and iceshelf fronts, with associated variations in salinity, sea-surface ice cover and the levels of rainout from debris-laden ice.

Sea-surface reconstruction of the east-equatorial South Atlantic

In order to reconstruct Late Quatemary variations of surface oceanography in the eastequatorial South Atlantic, time series of sea-surface temperatures (SST) and paleoproductivity were established from cores recovered in the Guinea and Angola Basins, and at the Walvis Ridge. These records, based on sedimentary alkenone and organic carbon concentrations, reveal that during the last 350,000 years surface circulation and productivity changes in the east-equatorial South Atlantic were highiy sensitive to climate forcing at 23- and 100-kyr periodicities. Covarying SST and paleoproductivity changes at the equator and at the Walvis Ridge appear to be driven by variations in zonal trade-wind intensity, which forces intensification or reduction of coastal and equatorial upwelling, as well as enhanced Benguela cold water advection from the South. Phase relationships of precessional variations in the paleoproductivity and SST records from the distinct sites were evaluated with respect to boreal summer insolation over Africa, movements of southem ocean thermal fronts, and changes in global ice volume. The 23-kyr phasing implies a sensitivity of eastem South Atlantic surface water advection and upwelling to West African monsoon intensity and to changes in the position ofthe subtropical high pressure cell over the South Atlantic, both phenomena which modulate zonal strength of southeasterly trades. SST and productivity changes north of 20°S lack significant variance at the 41-kyr periodicity; and at the Walvis Ridge and the equator lead changes in ice volume. This may indicate that obliquity-driven clirnate change, characteristic for northem high latitudes, e.g fluctuations in continental ice masses, did not substantially influence subtropical and tropical surface circulation in the South Atlantic. At the 23-kyr cycle SST and productivity changes in the eastern Angola Basin lag those in the equatorial Atlantic and at the Walvis Ridge by about 3500 years. This lag is explained by variations in cross-equatorial surface water transport and west-east countercurrent retum flow modifying precessional variations of SST and productivity in the eastem Angola Basin relative to those in the mid South Atlantic area under the central field of zonal trade winds. Sea level-related shifts of upwelling cells in phase with global clirnate change may be also recorded in SST and productivity variability along the continental margin off Southwest Africa. They may account for the delay of the paleoceanogreaphic signal from continental margin sites with respect to that from the pelagic sites at the equator and the Walvis Ridge.

La écfrasis en la ficción del modernismo europeo : Entre las leyes de la perspectiva y el arte abstracto

Acercarse al período modernista en las artes europeas implica enfrentarse al cuestionamiento del concepto de representación. Las artes plásticas -la pintura y más tarde la escultura- se liberan gradualmente del mandato que regía desde el Renacimiento en cuanto a su dependencia de las leyes de la perspectiva; se deja de lado la figuración hasta arribar a la abstracción. Asimismo, la experimentación en literatura se aprecia en cada uno de sus géneros, siguiendo ahora la mayoría de ellos el modelo de la pintura. En este contexto, la definición de écfrasis con mayor aceptación entre la crítica actual: "la representación verbal de una representación visual", debe revisarse al estudiar este momento histórico si, tal como demuestra Ruth Webb en "Ekphrasis ancient and modern: the invention of a genre", su definición refleja las relaciones entre las artes de cada período. Se propone, entonces, un recorrido por textos teóricos sobre la écfrasis para examinar luego textos en prosa del período modernista en lengua inglesa, y así intentar dilucidar a qué tipo de texto o fragmento de texto se puede aplicar la categoría de ecfrástico según su propio contexto histórico y artístico

La écfrasis en la ficción del modernismo europeo : Entre las leyes de la perspectiva y el arte abstracto

Acercarse al período modernista en las artes europeas implica enfrentarse al cuestionamiento del concepto de representación. Las artes plásticas -la pintura y más tarde la escultura- se liberan gradualmente del mandato que regía desde el Renacimiento en cuanto a su dependencia de las leyes de la perspectiva; se deja de lado la figuración hasta arribar a la abstracción. Asimismo, la experimentación en literatura se aprecia en cada uno de sus géneros, siguiendo ahora la mayoría de ellos el modelo de la pintura. En este contexto, la definición de écfrasis con mayor aceptación entre la crítica actual: "la representación verbal de una representación visual", debe revisarse al estudiar este momento histórico si, tal como demuestra Ruth Webb en "Ekphrasis ancient and modern: the invention of a genre", su definición refleja las relaciones entre las artes de cada período. Se propone, entonces, un recorrido por textos teóricos sobre la écfrasis para examinar luego textos en prosa del período modernista en lengua inglesa, y así intentar dilucidar a qué tipo de texto o fragmento de texto se puede aplicar la categoría de ecfrástico según su propio contexto histórico y artístico