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BACKGROUND: This study compared clinical and hemodynamic in-hospital outcomes of patients undergoing sutureless vs rapid deployment aortic valve replacement (SURD-AVR) in the large population of the Sutureless and Rapid Deployment International Registry (SURD-IR). METHODS: We examined 4695 patients who underwent isolated or combined SURD-AVR. The "sutureless" Perceval valve (LivaNova PLC, London, United Kingdom) was used in 3133 patients and the "rapid deployment" Intuity (Edwards Lifesciences, Irvine, CA) in 1562. Potential confounding factors were addressed by the use of propensity score matching. After matching, 2 well-balanced cohorts of 823 pairs (isolated SURD-AVR) and 467 pairs (combined SURD-AVR) were created. RESULTS: Patients who received Perceval and Intuity valves showed similar in-hospital mortality and rate of major postoperative complications. Perceval was associated shorter cross-clamp and cardiopulmonary bypass times. In the isolated SURD-AVR group, patients receiving Perceval were more likely to undergo anterior right thoracotomy incision. Postoperative transvalvular gradients were significantly lower for the Intuity valve compared with those of the Perceval valve, either in isolated and combined SURD-AVR. The Intuity valve was associated with a lower rate of postoperative mild aortic regurgitation. CONCLUSIONS: Our results confirm the safety and efficacy of SURD-AVR regardless of the valve type. The Perceval valve was associated with reduced operative times and increased anterior right thoracotomy incision. The Intuity valve showed superior hemodynamic outcomes and a lower incidence of postoperative mild aortic regurgitation. ispartof: ANNALS OF THORACIC SURGERY vol:114 issue:3 pages:758-+ ispartof: location:Netherlands status: published

Robotertechniken werden im Rahmen der Herzchirurgie in den Subdisziplinen der koronaren Bypass- und Mitralklappenchirurgie sowie ihrer assoziierten Operationsverfahren angewendet. Bisher werden diese nur an wenigen, hochspezialisierten Zentren durchgefuhrt. Standardisierte Ausbildung und kontinuierliches Training sind zur fehlerfreien Bedienung des Roboters erforderlich. Der Patientenselektion und dem perioperativen Monitoring kommt besondere Bedeutung zu. Neben dem an der Roboterkonsole tatigen Chirurgen ist ein weiterer geschulter Chirurg, der patientenseitig positioniert ist, erforderlich. Die klinischen Ergebnisse bei selektionierten Patienten sind hervorragend. Bisher ist ein Robotersystem klinisch verfugbar. Zukunftig werden weitere, innovative Modifizierungen der Robotersysteme die Akzeptanz der Roboterchirurgie im Rahmen der Herzchirurgie beeinflussen.

BACKGROUND: Minimally invasive aortic valve replacement (MiAVR) and transcatheter aortic valve implantation (TAVI) provide aortic valve replacement (AVR) by less invasive methods than conventional surgical AVR, by avoiding complete sternotomy. This study directly compares and analyses the available evidence for early outcomes between these two AVR methods. METHODS: Electronic databases were searched from inception until August 2019 for studies comparing MiAVR to TAVI, according to predefined search criteria. Propensity-matched studies with sufficient data were included in a meta-analysis. RESULTS: Eight studies with 9,744 patients were included in the quantitative analysis. Analysis of risk-matched patients showed no difference in early mortality (RR 0.76, 95% CI, 0.37–1.54, P=0.44). MiAVR had a signal towards lower rate of postoperative stroke, although this did not reach statistical significance (OR 0.42, 95% CI, 0.13–1.29, P=0.13). MiAVR had significantly lower rates of new pacemaker (PPM) requirement (OR 0.29, 95% CI, 0.16–0.52, P

Background Aortic valve surgery (AVS) is the gold standard treatment for symptomatic aortic valve (AV) disease patients. We report the temporal trends in the incidence of patients requiring isolated AVS in an unselected statewide population and their mortality outcomes over 17-years. Methods Patients were identified from the New South Wales, Australia, Admitted-Patient-Data-Collection registry between 1-July-2001 and 31-December-2018. Annual case-volumes and survival outcomes, adjusted for age, sex, referral source, endocarditis, concomitant coronary-artery-bypass-grafting, comorbidities including atrial fibrillation, hypertension and Charlson comorbidity index, were compared across calendar years. Results The study cohort comprised 16436 patients who underwent isolated AVS (mean age: 72.2 ± 11.3y; 67.5% males). Annual case-volume increased from 768 to 1048 cases between 2002 and 2017 (r2 = 0.82; p Conclusion The volume of AVS has increased progressively over time and has been associated with increased use of bioprosthetic valves and markedly improved 30-day and 1-year survival.

BACKGROUND: One of the most frequent complications of coronary artery bypass grafting (CABG) is pleural effusion. Limited previous studies have found post-CABG pleural effusion to be associated with increased length-of-stay and greater morbidity post-CABG. Despite this the associations of this common complication are poorly described. This study sought to identify modifiable risk factors for effusion post-CABG. METHODS: A retrospective cohort study of prospectively collected data assessed patients who underwent CABG over two-years. Data was collected for risk factors and sequelae related to pleural effusion requiring drainage. RESULTS: A total of 409 patients were included. Average age was 64.9±10.2 years, 330 (80.7%) were male. 59 (14.4%) patients underwent drainage of pleural effusion post-CABG. Effusions were drained on average 9.9±8.4 days post-CABG. Earlier removal of drain tubes and removal near time of extubation were associated with development of pleural effusion. Post-CABG pleural effusion was associated with post-operative renal impairment (P

OBJECTIVES Current evidence on sutureless and rapid deployment aortic valve replacement (SURD-AVR) is limited and does not allow for the assessment of the clinical impact and the evolution of procedural and clinical outcomes of this new valve technology. The Sutureless and Rapid Deployment International Registry (SURD-IR) represents a unique opportunity to evaluate the current trends and outcomes of SURD-AVR interventions. METHODS Data from 3682 patients enrolled between 2007 and 2018 were analysed. Patients were divided according to the date of surgery into 6 equal groups and by the type of intervention: isolated SURD-AVR (n = 2472) and combined SURD-AVR (n = 1086). RESULTS Across the 11-year study period, significant changes occurred in patient characteristics including a decrease in age and in estimated surgical risk. Less invasive approaches for isolated SURD-AVR increased considerably from 49.4% to 85.5%. The overall in-hospital mortality rate was 1.6% and 3.9% in isolated and combined procedures, respectively, with no change over time. The rate of perioperative stroke decreased significantly (from 4% to 0.5%), as did the rates of postoperative pacemaker implantation (from 12.8% to 5.9%) and aortic regurgitation (from 17.8% to 2.7%). CONCLUSIONS The present study provides a comprehensive analysis of the current trends and results of SURD-AVR interventions. The most notable changes over time were the increasing implantation of SURD valves in a younger population, with more frequent utilization of less invasive techniques. SURD-AVR demonstrated remarkable improvements in clinical outcomes with a significant reduction in the rates of stroke, pacemaker implantation and postoperative aortic regurgitation.

Cardiovascular disease is the leading cause of death in lower-income countries including Haiti. Environmental lead exposure is associated with high blood pressure and cardiovascular mortality in high-income countries but has not been systematically measured and evaluated as a potential modifiable cardiovascular risk factor in lower-income countries where 6.5 billion people reside. We hypothesized lead exposure is high in urban Haiti and associated with higher blood pressure levels. Blood lead levels were measured in 2504 participants ≥18 years enrolled in a longitudinal population-based cohort study in Port-au-Prince. Lead screening was conducted using LeadCare II (detection limit ≥3.3 µg/dL). Levels below detection were imputed by dividing the level of detection by √2. Associations between lead (quartiles) and systolic blood pressure and diastolic blood pressure were assessed, adjusting for age, sex, obesity, smoking, alcohol, physical activity, income, and antihypertensive medication use. The median age of participants was 40 years and 60.1% were female. The geometric mean blood lead level was 4.73µg/dL, 71.1% had a detectable lead level and 42.3% had a blood lead level ≥5 µg/dL. After multivariable adjustment, lead levels in quartile four (≥6.5 µg/dL) compared with quartile 1 ( Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03892265.

ObjectiveThere is a need to identify concerns unique to patients with cutaneous lupus erythematosus (CLE), which may not be captured by current common-practice dermatological quality-of-life tools. This study formally characterises what bothers patients with CLE about their disease by conducting semistructured, qualitative interviews.MethodsSixteen patients with CLE were interviewed about how their cutaneous findings impact their daily life. Each interview was transcribed, coded and categorised for recurrent themes. Current CLE activity and damage were also assessed by the Cutaneous Lupus Activity and Severity Index tool.ResultsResponses were categorised into six themes, including Fear of Disease Progression, Unwanted Attention, Self-Consciousness, Physical Signs/Symptoms, Emotional Symptoms and Functional Decline. The most commonly reported themes were Self-Consciousness, mentioned by 13 of 16 (81.3%) patients, Physical Symptoms, mentioned by 12 of 16 (75%), and then Fear of Disease Progression, by 11 of 16 (68.8%). Frequently mentioned physical signs/symptoms included erythema, itch, dyspigmentation, scar and alopecia. The physical signs/symptoms were categorised as activity signs/symptoms, damage signs and other. For activity signs, erythema was mentioned most frequently (5 of 16), then scale (2 of 16). For activity symptoms, itch was mentioned most frequently (6 of 16), then pain (5 of 16). For damage signs, dyspigmentation was mentioned most frequently (4 of 16), followed by scarring (3 of 16). Patients less than 60 years old were more likely to report emotional symptoms than older patients (pConclusionsThese patient experiences and resultant themes elucidated by this study are worth noting in future standardised estimations of the quality of life of patients with CLE. Additionally, the concerns shown by these interviews are important topics for providers to discuss when evaluating patient disease progression.

BackgroundHypertension is a major contributor to global morbidity and mortality. In South Africa, the government has employed a whole systems approach to address the growing burden of non-communicable diseases. We used a novel incident care cascade approach to measure changes in the South African health system’s ability to manage hypertension between 2008 and 2017.MethodsWe used data from Waves 1-5 of the National Income Dynamics Study (NIDS) to estimate trends in the hypertension care cascade and unmet treatment need across four successive cohorts with incident hypertension. We used a negative binomial regression to identify factors that may predict higher rates of hypertension control, controlling for socio-demographic and healthcare factors. The largest cascade attrition occurred prior to diagnosis.ResultsIn 2011, 19·6% (95%CI 14·2, 26·2) of individuals with incident hypertension were diagnosed, 15·4% (95%CI 10·8, 21·4) were on treatment and 7.1% had controlled blood pressure. By 2017, the proportion of individuals with diagnosed incident hypertension had increased to 24·4% (95%CI 15·9, 35·4) with increases in treatment (23·3%, 95%CI 15·0, 34·3) and control (22·1%, 95%CI 14·1, 33·.0) were also observed, translating to a decrease in unmet need from 92·9% in 2011 to 77·9% in 2017. Multivariable regression showed that participants with incident hypertension in 2017 were 3·01 (95%CI 1·77, 5·13) times more likely to have a controlled blood pressure compared to those in 2011.ConclusionsThe proportion of people with incident hypertension who successfully progressed to controlled blood pressure tripled between 2011 and 2017 in South Africa. Despite these improvements, a low absolute proportion of the population were able to control their blood pressure and a high burden of unmet need remains.Summary BoxWhat is already knownPrevalent cascades provide insight to where losses in care cascades occur.While mostly used in the management of HIV, recently they have also been adopted in studying the management of non-communicable diseases on a population level.Prevalent hypertension cascades in South Africa showed a high burden of unmet need, with the biggest losses where lost between disease development and diagnosis.What are the new findingsIncident hypertension cascades improved from 2008 to 2017 in South Africa.What do the new findings implyIncident cascades provide an improved means to measure changes in management cascades as this allows us to distinguish between historical and current health system performance.Our data show that while substantial improvements in the care cascade occurred between 2008 and 2017, a large burden of unmet need remains.

The commercial Computational Fluid Dynamics (CFD) software STAR-CCM+ was used to simulate the flow and breakup characteristics of a Liquid Jet Injected into the gaseous Crossflow (LJIC) under real engine operating conditions. The reasonable calculation domain geometry and flow boundary conditions were obtained based on a civil aviation engine performance model similar to the Leap-1B engine which was developed using the GasTurb software and the preliminary design results of its low-emission combustor. The Volume of Fluid (VOF) model was applied to simulate the breakup feature of the near field of LJIC. The numerical method was validated and calibrated through comparison with the public test data at atmospheric conditions. The results showed that the numerical method can capture most of the jet breakup structure and predict the jet trajectory with an error not exceeding ±5%. The verified numerical method was applied to simulate the breakup of LJIC at the real engine operating condition. The breakup mode of LJIC was shown to be surface shear breakup at elevated condition. The trajectory of the liquid jet showed good agreement with Ragucci’s empirical correlation.

Background People living with HIV (PLWH) are at increased risk of cardiovascular disease (CVD) and death, with greater burdens of both HIV and CVD in lower-middle income countries. Treating prehypertension in PLWH may reduce progression to hypertension, CVD risk and potentially mortality. However, no trial has evaluated earlier blood pressure treatment for PLWH. We propose a randomized controlled trial to assess the feasibility, benefits, and risks of initiating antihypertensive treatment among PLWH with prehypertension, comparing prehypertension treatment to standard of care following current WHO guidelines. Methods A total of 250 adults 18–65 years and living with HIV (PLWH) with viral suppression in the past 12 months, who have prehypertension will be randomized to prehypertension treatment versus standard of care. Prehypertension is defined as having a systolic blood pressure (SBP) 120–139 mmHg or diastolic blood pressure (DBP) 80–89 mmHg. In the prehypertension treatment arm, participants will initiate amlodipine 5 mg daily immediately. In the standard of care arm, participants will initiate amlodipine only if they develop hypertension defined as SBP ≥ 140 mmHg or DBP ≥ 90 mmHg. The primary outcome is the difference in mean change of SBP from enrollment to 12 months. Secondary outcomes include feasibility, acceptability, adverse effects, HIV viral suppression, and medication adherence. Qualitative in-depth interviews with providers and participants will explore attitudes about initiating amlodipine, satisfaction, perceived CVD risk, and implementation challenges. Discussion PLWH have a higher CVD risk and may benefit from a lower BP threshold for initiation of antihypertensive treatment. Trial registration Clinicaltrials.gov registration number NCT04692467, registration date December 15, 2020, protocol ID 20–03021735.

BackgroundCardiovascular diseases (CVD) are rapidly increasing in low-middle income countries (LMICs). Accurate risk assessment is essential to reduce premature CVD by targeting primary prevention and risk factor treatment among high-risk groups. Available CVD risk prediction models are built on predominantly Caucasian, high-income country populations, and have not been evaluated in LMIC populations.ObjectiveTo compare the predicted 10-year risk of CVD and identify high-risk groups for targeted prevention and treatment in Haiti.MethodsWe used cross-sectional data within the Haiti CVD Cohort Study, including 653 adults ≥ 40 years without known history of CVD and with complete data. Six CVD risk prediction models were compared: pooled cohort equations (PCE), adjusted PCE with updated cohorts, Framingham CVD Lipids, Framingham CVD Body Mass Index (BMI), WHO Lipids, and WHO BMI. Risk factors were measured during clinical exams. Primary outcome was continuous and categorical predicted 10-year CVD risk. Secondary outcome was statin eligibility.ResultsSeventy percent were female, 65.5% lived on a daily income of ≤1 USD, 57.0% had hypertension, 14.5% had hypercholesterolemia, 9.3% had diabetes mellitus, 5.5% were current smokers, and 2.0% had HIV. Predicted 10-year CVD risk ranged from 3.9% in adjusted PCE (IQR 1.7-8.4) to 9.8% in Framingham-BMI (IQR 5.0-17.8), and Spearman rank correlation coefficients ranged from 0.87 to 0.98. The percent of the cohort categorized as high risk using the uniform threshold of 10-year CVD risk ≥ 7.5% ranged from 28.8% in the adjusted PCE model to 62.0% in the Framingham-BMI model (χ2= 331, p value < 0.001). Statin eligibility also varied widely.ConclusionsIn the Haiti CVD Cohort, there was substantial variation in the proportion identified as high-risk and statin eligible using existing models, leading to very different treatment recommendations and public health implications depending on which prediction model is chosen. There is a need to design and validate CVD risk prediction tools for low-middle income countries that include locally relevant risk factors.Trial registrationclinicaltrials.govNCT03892265

Goal: COSMIC Medical, a Vancouver-based open-source volunteer initiative, has designed an accessible, affordable, and aerosol-confining non-invasive positive-pressure ventilator (NIPPV) device, known as the COSMIC Bubble Helmet (CBH). This device is intended for COVID-19 patients with mild-to-moderate acute respiratory distress syndrome. System Design : CBH is composed of thermoplastic polyurethane, which creates a flexible neck seal and transparent hood. This device can be connected to wall oxygen, NIPPVs including Continuous Positive Airway Pressure and Bi-level Positive Airway Pressure, and mechanical ventilators. Discussion : Justification of CBH design components relied on several factors, predominantly the safety and comfort of patients and healthcare providers. Conclusion: CBH has implications within and outside of the pandemic, as an alternative to invasive mechanical ventilation methods. We have experimentally verified that CBH is effective in minimizing aerosolization risks and performs at specified clinical requirements.

Tumoral calcinosis is a rare clinicopathological entity characterized by ectopic soft-tissue calcification, typically periarticular. Normophosphatemic tumoral calcinosis is seldom reported in East Asian populations, and the preoperative diagnosis is often elusive. This study was performed to characterize the clinical profile of normophosphatemic tumoral calcinosis and investigate the presence of the SAMD9 gene mutation. The clinical features, pathological examination findings, and outcomes of 19 subjects were retrospectively reviewed. All patients were analyzed for SAMD9 gene mutation using paraffin-embedded tumoral calcinosis specimens. Nineteen subjects were analyzed (7 males, 12 females). Their mean age at surgery, mean age at symptom onset, and median disease duration was 51.9 ± 17.3 (range 7–75) years, 49.1 ± 17.2 (range 7–74) years, and 1.3 (interquartile range 0.5–3.0) years, respectively. Lesions were located in the hand in 8 (42.1%) subjects; wrist in 5 (26.3%); shoulder in 2 (10.5%); and hip, knee, buttock, and scrotum in 1 (5.3%) subject each. The lesions in 17 (89.5%) subjects were located around the joints [small joints (hand and wrist) in 13 (68.4%) and large joints (shoulder, hip, and knee) in 4 (21.1%)]. Lesions occurred in the upper limbs in 15 (78.9%) subjects and in the lower limbs in 2 (10.5%). Multiple-lesion involvement (distal right index finger and middle finger) occurred in one (5.3%) subject. Symptoms included pain in 15 (78.9%) subjects, impaired mobility in 5 (26.3%), swelling in 5 (26.3%), numbness in 2 (10.5%), and an asymptomatic mass in 2 (10.5%). The serum inorganic phosphorus concentration was normal in all 19 subjects (mean 1.17 ± 0.15 mmol/L). The serum calcium concentration was normal in 18 subjects and low in 1. The serum alkaline phosphatase concentration was normal in all 19 subjects. Pathological examination indicated multiple nodules of calcified materials that manifested an amorphous or granular blue-purple crystal and were surrounded by proliferation of mononuclear or multinuclear macrophages, osteoclastic-like giant cells, fibroblasts, and chronic inflammatory cells. Notably, different phases of pathological manifestations were observed in the same microscopic field. During follow-up (0.5–65.0 months), no recurrence of tumoral calcinosis was observed in 18 (94.7%) subjects, but 1 subject developed in situ recurrence of an asymptomatic subcutaneous mass after 6 months postoperatively. Genetic analysis in all 19 subjects revealed no SAMD9 gene mutations. Most subjects were females and developed calcinosis in adulthood. Small joints (hand and wrist) and the upper limbs were frequently involved. The presence of different phases of pathological features in the same subject suggests that about half of the study participants had been misdiagnosed with another condition (such as gout, osteoarthritis, etc.). Complete surgical excision led to cure without recurrence during follow-up in majority of the study participants.

Background: Management of type A intramural hematoma (IMH) remains controversial, with opinions divided as to whether patients should be treated with early aggressive surgery or a more conservative approach. The present systematic review aims to evaluate the mortality and morbidities following surgery for type A IMH. Methods: Electronic searches were performed on five databases from dates of inception to December 2018. All studies with surgical outcomes for type A intramural hematoma were identified by two independent researchers and relevant data extracted. Random-effects meta-analysis of proportions or meta-analysis of means were performed to aggregate the data. Survival data were pooled using reconstructed individual patient data derived from Kaplan-Meier curves. Results: Fifteen studies with 744 patients were identified. Ten studies were from Asian countries (73% of patients). Overall mortality was 8.2% [95% confidence interval (CI): 4.6–13.9%]. Mortality from Asian centers was 5.3% (95% CI: 3.6–7.7%) and 18.9% (95% CI: 7.0–40.4%) in Western centers. Postoperative complications were poorly reported and hence not analyzable. Overall pooled survival of 343 patients from four studies at 1-, 2-, 3-, 5-, and 10-year was 91.8%, 90.2%, 89.2%, 87.7%, and 71.1%, respectively. Conclusions: There is an acceptable level of risk of death after surgery for type A IMH, though significant variations exist between results from Asian and Western centers. More detailed studies are required to clarify the controversies surrounding management of type A IMH.

Background: Aortic intramural hematoma constitutes one of the three classifications of acute aortic syndrome (AAS). Type B intramural hematoma (IMH-B) is localized to the descending thoracic aorta and can be managed through medical, endovascular or surgical means. Data comparing contemporary management with thoracic endovascular aortic repair (TEVAR) versus traditional medical management (MM) is sparse and only moderate strength recommendations for TEVAR are provided in guidelines. This meta-analysis aimed to pool available data from comparative studies between TEVAR and MM and examine differences in outcomes. Methods: Literature search of electronic medical databases was conducted to identify studies comparing TEVAR and MM for management of IMH-B. Data extraction from studies fulfilling the inclusion criteria was performed by two authors and meta-analysis using a random-effects model applied to pool baseline data and examine risk ratios (RR) for management outcomes. Results: Of the initial 2,349 studies, nine studies were identified for analysis. There were 161 TEVAR patients and 166 who were medically managed. The mean age of the cohort was 62.2 years [95% confidence interval (CI): 55.8–68.7 years]. Patients with complicating features of IMH-B at presentation were more likely to appear in the TEVAR group, with more penetrating atheromatous ulcer (PAU) [risk difference (RD), 0.565, 95% CI: 0.240–0.889, P=0.001], ulcer-like projection (ULP) (RD 0.240, 95% CI: 0.965–0.384, P=0.001), and greater IMH size (mean difference, MD 5.47 mm, 95% CI: 0.320–10.6, P=0.037). There was no statistical difference between TEVAR and MM for the primary endpoints of aortic-related death (RR 0.535, 95% CI: 0.191–1.5, P=0.234) or IMH-B regression (RR 1.25, 95% CI: 0.859–1.81, P=0.246). Of the secondary endpoints, TEVAR had both significantly less dissection during follow-up (RR 0.295, 95% CI: 0.0881–0.989, P=0.048) and less rupture during follow-up (RR 0.206, 95% CI: 0.0462–0.921, P=0.039). Conclusions: A small number of series comparing TEVAR and MM for management of IMH-B are available and random-effects meta-analysis did not reveal any statistically significant difference between treatments for aortic related death or IMH-B regression at a mean follow-up of 37 months. TEVAR was found to be associated with lower risk of dissection and lower risk of rupture during follow-up. Baseline data meta-analysis showed patients with complicating features of PAU, ULP, and larger IMH size were more likely to be managed with TEVAR.

Background The increasing use of antegrade cerebral perfusion (ACP) during aortic arch surgery has corresponded with a trend toward warmer target temperatures for hypothermic circulatory arrest. This meta-analysis examined the clinical outcomes using colder or warmer circulatory arrest targets with ACP. Methods Electronic searches were performed using four databases from their inception to February 2017. Comparative studies of adult patients who underwent aortic arch operations using ACP at different circulatory arrest temperatures were included. Data were extracted by 2 independent researchers and analyzed according to predefined end points using a random-effects model. Results The literature search identified 18 comparative studies, with 1,215 patients in the "cold" cohort and 1,417 in the "warm" cohort. Mean hypothermic circulatory arrest temperatures were 20.3°C and 26.5°C in the cold and warm groups, respectively. A trend existed for increased permanent neurologic deficit overall when colder targets were used (odds ratio, 1.45; 95% confidence interval, 0.98 to 2.13; p = 0.06); this became significant when adjusted estimates were aggregated (odds ratio, 1.65; 95% confidence interval, 1.06 to 2.55; p = 0.03). No difference in the mortality rate was seen when adjusted effects were aggregated. Temporary neurologic deficit, postoperative dialysis, ventilator time, and intensive care unit stay were significantly reduced in the warm cohort overall. No significant differences in reexploration for bleeding were found. Conclusions ACP with warmer circulatory arrest temperatures may reduce the incidence of permanent neurologic deficit as well as potentially other clinical outcomes. Further studies are required to determine the safe circulatory arrest durations for visceral organs at warmer temperatures.

OBJECTIVES: The impact of sutureless and rapid deployment (SURD) valves on the clinical outcomes of patients undergoing minimally invasive aortic valve replacement (MI-AVR) has still to be defined. The aim of this study was to assess clinical characteristics and in-hospital results of patients receiving SURD-AVR through less invasive approaches in the large population of the Sutureless and Rapid Deployment International Registry (SURD-IR). METHODS: Of the 1935 patients who received primary isolated SURD-AVR between 2009 and 2018, a total of 1418 (73.3%) underwent MI interventions and were included in this analysis. SURD-AVR was performed using upper ministernotomy in 56.4% (n = 800) of cases and anterior right thoracotomy in 43.6% (n = 618). Perceval S was implanted in 1011 (71.3%) patients and Edwards Intuity or Intuity Elite in 407 (28.7%) patients. RESULTS: Overall in-hospital mortality and stroke rates were 1.7% and 2%, respectively. A definitive pacemaker implantation was reported in 9% of cases and significantly decreased over the observational period, from 20.6% to 5.6% (P = 0.002). The Perceval valve was associated with shorter operative times and was more frequently implanted in patients receiving anterior right thoracotomy incision. The Intuity valve was preferred in younger patients and revealed superior postoperative haemodynamic results. CONCLUSIONS: SURD-AVR was largely performed through less invasive approaches and can be considered as a primary indication in MI surgery. In the SURD-IR cohort, MI SURD-AVR using both Perceval and Intuity valves appeared a safe and reproducible procedure associated with promising early results.

The COVID-19 pandemic has caused more than 168 million people to be infected and 3 million people to die[1] . Although the COVID-19 vaccination work for the general population has been started, herd immunity cannot be achieved in the short term term[2] . Wearing masks is still the most effective means for the public to prevent and control the spread of COVID-19. However, the occurrence of facial skin problems caused by wearing masks may, under some conditions, influence the maintenance of mask wearing among the public.

We describe the surgical management of a rare pulmonary angiomatoid fibrous histiosarcoma (AFH). A 62-year-old lady presented with shortness of breath and found to have a large left main pulmonary artery defect that was positron emission tomography-avid. Following discussion in a thoracic multidisciplinary team meeting it was deemed unsafe to biopsy considering its intravascular position. The patient proceeded to theatre for a left pneumonectomy. She was successfully discharged home by Day 7. On follow-up the patient is well, and free of malignancy. AFH is an incredibly rare form of sarcoma, and in particular in the thoracic region. We have demonstrated successful oncological resection of a rare intravascular lesion in the pulmonary artery.

Pulmonary artery intimal sarcoma (PAIS) is an extremely rare malignant tumour. It is often misdiagnosed as chronic pulmonary thromboembolism. We describe a complex case in a 70-year-old man with PAIS extending into his right ventricle undergoing salvage cytoreductive surgical resection utilizing bivalirudin for cardiopulmonary bypass anticoagulation due to heparin-induced thrombocytopenia and thrombosis syndrome. The prognosis for PAIS is extremely poor, with a median survival of 1.5 months without surgical resection. Cytoreductive surgical debulking can improve the median survival time to 17 months. The main aim of palliative surgical resection is to improve ventilation–perfusion mismatch and prevent haemodynamic collapse.

BACKGROUND: New technologies such as sutureless or rapid deployment prosthetic valves and access via minimally invasive incisions offer alternatives to traditional full-sternotomy aortic valve replacement (SAVR). However, a comprehensive comparison of these surgical techniques along with alternative valve prosthesis has not been completed. METHODS: Electronic databases were searched for studies comparing outcomes for SAVR, minimally invasive AVR (MiAVR), sutureless/rapid-deployment AVR (SuAVR) via full-sternotomy, or minimally invasive SuAVR (MiSuAVR) from their inception until September 2018. Early postoperative outcomes and follow-up data were included in a Bayesian network meta-analysis. RESULTS: Twenty-three studies with 8,718 patients were identified. Compared with standard SAVR, SuAVR had significantly lower incidence of postoperative AF [odds ratio (OR) 0.33, 95% confidence interval (CI): 0.14-0.79, P=0.013] and MiSuAVR greater requirement for postoperative permanent pacemaker (OR 2.27, 95% CI: 1.25-4.14, P=0.008). All sutureless/rapid-deployment procedures had reduced cardiopulmonary bypass and cross-clamp times, by a mean of 25.9 and 25.0 min, respectively. Hospital length of stay (LOS), but not intensive care LOS, was reduced for all groups (MiAVR -1.53 days, MiSuAVR -2.79 days, and SuAVR 3.37 days). A signal towards reduced early mortality, wound infections, and acute kidney injury was noted in both sutureless/rapid-deployment and minimally invasive techniques but did not achieve significance. Sutureless/rapid-deployment procedures had favourable survival and freedom from valve related reoperation, however follow-up times were short and demonstrated significant heterogeneity between intervention groups. CONCLUSIONS: Minimally invasive and sutureless techniques demonstrate equivalent early postoperative outcomes to SAVR and may reduce ventilation time, hospital LOS and postoperative atrial fibrillation (POAF) burden. ispartof: ANNALS OF CARDIOTHORACIC SURGERY vol:9 issue:5 pages:347-+ ispartof: location:China status: published

Switching electric currents in high-voltage circuits involves mechanically separating two contacts to form an electric arc plasma which is then quenched. This operation is conducted in a tank containing a vacuum or one type of gas which has good arc-quenching properties. The quenching process may be enhanced by blowing the gas through the plasma or electromagnetically driving the arc through the gas.

Background Adherence to regular outpatient visits is vital to managing noncommunicable diseases (NCDs), a growing burden in low and middle-income countries. We characterized visit adherence among patients with NCDs in rural Haiti, hypothesizing higher poverty and distance from the clinic were associated with lower adherence. Methods We analyzed electronic medical records from a cohort of adults in an NCD clinic in Mirebalais, Haiti (April 2013 to June 2016). Visit adherence was: 1) visit constancy (≥1 visit every 3 months), 2) no gaps in care (> 60 days between visits), 3) ≥1 visit in the last quarter, and 4) ≥6 visits per year. We incorporated an adapted measure of intensity of multidimensional poverty. We calculated distance from clinic as Euclidean distance or self-reported transit time. We used multivariable logistic regressions to assess the association between poverty, distance, and visit adherence. Results We included 463 adult patients, mean age 57.8 years (SE 2.2), and 72.4% women. Over half of patients had at least one visit per quarter (58.1%), but a minority (19.6%) had no gaps between visits. Seventy percent of patients had a visit in the last quarter, and 73.9% made at least 6 visits per year. Only 9.9% of patients met all adherence criteria. In regression models, poverty was not associated with any adherence measures, and distance was only associated with visit in the last quarter (OR 0.87, 95% CI [0.78 to 0.98], p = 0.03) after adjusting for age, sex, and hardship financing. Conclusions Visit adherence was low in this sample of adult patients presenting to a NCD Clinic in Haiti. Multidimensional poverty and distance from clinic were not associated with visit adherence measures among patients seen in the clinic, except for visit in the last quarter. Future research should focus on identifying and addressing barriers to visit adherence.

BACKGROUND: Benefits of sutureless and rapid deployment (SURD) bioprostheses in bicuspid aortic valves (BAV) are controversial. The aim of this study is to report the outcomes of patients undergoing aortic valve replacement (AVR) for BAV from the Sutureless and Rapid-Deployment Aortic Valve Replacement International Registry (SURD-IR). METHODS: Of the 4,636 patients who received primary isolated SURD-AVR between 2007 and 2018, 191 (4.1%) BAV patients underwent AVR with SURD valve. RESULTS: Overall 30-day mortality was 1.6%. The Intuity valve was implanted in 53.9% of cases, whereas the Perceval was implanted in 46.1%. Rate of stroke for isolated AVR was 4.2%. No case of endocarditis, thromboembolism, myocardial infarction, valve dislocation or structural valve deterioration was reported in the early phase. Rate of pacemaker implantation and moderate-severe aortic regurgitation (AR) were 7.9% and 3.7%, respectively. CONCLUSIONS: BAV is not considered a contraindication for the implantation of SURD valves. However, detailed information of aortic root geometry as well as the knowledge of some technical considerations are mandatory for a good outcome. ispartof: ANNALS OF CARDIOTHORACIC SURGERY vol:9 issue:4 pages:298-304 ispartof: location:China status: published

Background: The frozen elephant trunks (FET) procedure remains an increasingly popular approach to address complex multi-segmental aortic pathologies, owing to their ability to promote false lumen thrombosis and reduce the need for second-stage operations. While the short-term outcomes of such procedures have been shown to be acceptable, much less is known regarding long-term outcomes. This systematic review evaluates long-term outcomes of the FET procedure. Methods: Studies with at least 12 months follow-up data on FETs were identified in four electronic databases. All studies were reviewed by two independent researchers and relevant data extracted. Long-term outcomes, including overall survival, freedom from reintervention, and freedom from aortic events, were evaluated using patient data recreated from digitized Kaplan-Meier curves. Results: Thirty-seven studies with 4,178 patients were identified. Majority of the studies focused solely on acute dissections. Average follow-up was 3.2 years. Overall survival at 1-, 3-, and 5-years were 89.6%, 85.2%, and 82.0%, respectively. Freedom from reintervention at the same timepoints were 93.9%, 89.3%, and 86.8%, respectively. Mortality, permanent neurological deficit and spinal cord injury were 10.2%, 7.7%, and 6.5%, respective. Conclusions: Survival after the FET procedure is favorable, though ongoing close serial monitoring is essential to assess for the need for further reintervention. Larger multi-institutional registries are required to provide more robust evidence to better elucidate the patient cohort that would most benefit from the FET.

Introduction The impact of Medicaid expansion on linkage to care, self-maintenance, and treatment among low-income adults with diabetes was examined. Methods A difference-in-differences design was used on data from the Behavioral Risk Factor Surveillance System, 2008–2018. Analysis was restricted to states with diabetes outcomes and nonpregnant adults aged 18–64 years who were Medicaid eligible on the basis of income. Separate analyses were performed for early postexpansion (1, 2, 3) and late postexpansion years (4, 5). Analyses were performed from September 2019 to March 2020. Results In comparing expansion with control states, low-income residents with diabetes had similar ages (48.9 vs 49.1 years) and similar proportions who were female (54.4% vs 55.0%) but were less likely to be Black, non-Hispanic (20.8% vs 29.2%, standardized difference= −16.3%). In expansion states, health insurance increased by 7.2 percentage points (95% CI=3.9, 10.4), and the ability to afford a physician increased by 5.5 percentage points (95% CI=1.9, 9.1) in the early years, but no difference was found in late years. Medicaid expansion led to a 5.3-percentage point increase in provider foot examinations in the early period (95% CI=0.14, 10.4) and a 7.2-percentage point increase in self-foot examinations in the late period (95% CI=1.1, 13.3). No statistically significant changes were detected in self-reported linkage to care, self-maintenance, or treatment. Conclusions Although health insurance, ability to afford a physician visit, and foot examinations increased for Medicaid-eligible people with diabetes, there was no statistically significant difference found for other care continuum measures.

Minimally-invasive surgery presents its own unique set of challenges, especially when applied to treatment of aortic arch disease. The key components of mini-access aortic arch surgery include safe circulatory control, adequate organ protection, and meticulous surgical technique. This article describes how to perform branch-first total arch replacement with the frozen elephant trunk (FET) procedure for distal arch aneurysms. The strategy employed offers the advantages of mini-access surgery, as well as sound cerebral and systemic organ protection strategies.

Objectives: Serum carcinoembryonic antigen is a tumor marker often found to be elevated in colorectal cancer patients. Elevated carcinoembryonic antigen has been strongly associated with poor prognosis. However, little is known about the patient and tumor characteristics between carcinoembryonic antigen-secreting and non-secreting tumors. Methods: We performed a retrospective analysis of all patients (N=164,187) in the Surveillance, Epidemiology and End Results database diagnosed with colorectal adenocarcinoma from 2010 to 2014. All patients were designated as having either positive/elevated (C1) or negative/normal (C0) pretreatment serum carcinoembryonic antigen level. Results: Of the 164,187 patients, 68,833 (57.0%) had available carcinoembryonic antigen information, and 33,412 (48.5%) had positive/elevated (C1) antigen levels. Median age was 65 years, and 36,464 (53.0%) were male. Patients with C1 cancers were more likely to be female (Odds ratio 1.06), black (Odds ratio 1.62), separated or never married (Odds ratios 1.50 and 1.49, respectively), higher grade (Odds ratios 1.35, 1.64, and 1.72 of moderately, poorly, and undifferentiated cancers, respectively), and of signet ring cell histology (Odds ratio 1.47) compared to males, whites, married participants, well differentiated grade, and adenocarcinoma histology respectively (P

To analyze presentation, management, and outcomes of acute aortic dissections with proximal entry tear in the arch.Patients enrolled in the International Registry of Acute Aortic Dissection and entry tear in the arch were classified into 2 groups: arch A (retrograde extension into the ascending aorta with or without antegrade extension) and arch B (only antegrade extension into the descending aorta or further distally). Presentation, management, and in-hospital outcomes of the 2 groups were compared.The arch A (n = 228) and arch B (n = 140) groups were similar concerning the presence of any preoperative complication (68.4% vs 60.0%; P = .115), but the types of complication were different. Arch A presented more commonly with shock, neurologic complications, cardiac tamponade, and grade 3 or 4 aortic valve insufficiency and less frequently with refractory hypertension, visceral ischemia, extension of dissection, and aortic rupture. Management for both groups were open surgery (77.6% vs 18.6%; P .001), endovascular treatment (3.5% vs 25.0%; P .001), and medical management (16.2% vs 51.4%; P .001). Overall in-hospital mortality was similar (16.7% vs 19.3%; P = .574), but mortality tended to be lower in the arch A group after open surgery (15.3% vs 30.8%; P = .090), and higher after endovascular (25.0% vs 14.3%; P = .597) or medical treatment (24.3% vs 13.9%; P = .191), although the differences were not significant.Acute aortic dissection patients with primary entry tear in the arch are currently managed by a patient-specific approach. In choosing the management type of these patients, it may be advisable to stratify them based on retrograde or only antegrade extension of the dissection.

BACKGROUND: While extended criteria lung donation has helped expand the lung donor pool, utilization of lungs from donors of at least one other solid organ is still limited to around 15–30%. Ex-vivo lung perfusion (EVLP) offers the ability to expand the number of useable lung grafts through assessment and reconditioning of explanted lungs, particularly those not initially meeting criteria for transplantation. This meta-analysis aimed to examine the mid- to long-term survival and other short-term outcomes of patients transplanted with EVLP-treated lungs versus standard/cold-storage protocol lungs. METHODS: Literature search of ten medical databases was conducted for original studies involving “ex-vivo lung perfusion” and “EVLP”. Included articles were assessed by two independent researchers, survival data from Kaplan-Meier curves digitized, and individual patient data imputed to conduct aggregated survival analysis. Meta-analyses of suitably reported outcomes were conducted using a random-effects model. RESULTS: Thirteen studies met inclusion criteria, with a total of 407 EVLP lung transplants and 1,765 as per standard/cold storage protocol. One study was a randomized controlled trial while the remainder were single-institution cohort series of varying design. The majority of donor lungs were from brain death donors, with EVLP lungs having significantly worse PaO(2)/FiO(2) ratio and significantly greater rate of abnormal chest X-ray. Aggregated survival analysis of all included studies revealed no significant survival difference for EVLP or standard protocol lungs (hazard ratio 1.00; 95% confidence interval: 0.79–1.27, P=0.981). Survival at 12, 24, and 36 months for the EVLP cohort was 84%, 79%, and 74%, respectively. Survival at 12, 24, and 36 months for the standard protocol cohort was 85%, 79%, and 73%, respectively. Meta-analysis did not find a significant difference in risk of 30-day mortality or primary graft dysfunction grade 3 at 72 hours between cohorts. CONCLUSIONS: There was no significant difference in mid- to long-term survival of EVLP lung transplant patients when compared to standard protocol donor lungs. The incidence of 30-day mortality and primary graft dysfunction grade 3 at 72 hours did not differ significantly between groups. EVLP offers the potential to increase lung donor utilization while providing similar short-term outcomes and mid- to long-term survival.

Background The use of stereotactic body radiotherapy (SBRT) for early-stage primary non-small cell lung cancer (NSCLC) reported excellent local control rates. But the optimal SBRT dose for oligometastatic lung tumors (OLTs) from colorectal cancer (CRC) has not yet been determined. This study aimed to evaluate whether SBRT to a dose of 48–60 Gy in 4–5 fractions could result in similar local outcomes for OLTs from CRC as compared to early-stage NSCLC, and to examine potential dose-response relationships for OLTs from CRC. Methods OLTs from CRC and primary NSCLCs treated with SBRT to 48–60 Gy in 4–5 fractions at a single institution were evaluated, and a matched-pair analysis was performed. Local recurrence-free survival (LRFS) was estimated by the Kaplan-Meier method. Univariate Cox regression was performed to identify significant predictors. Results There were 72 lung lesions in 61 patients (24 OLTs from CRC in 15 patients and 48 NSCLCs in 46 patients) were analyzed with a median follow-up of 30 months. LRFS for OLTs from CRC was significantly worse than that of NSCLC when treated with 48–60 Gy/4–5 fx (p = 0.006). The 1, 3 and 5-year LRFS of OLTs from CRC vs NSCLC were 80.6% vs. 100%, 68.6% vs. 97.2%, and 68.6% vs. 81.0%, respectively. On univariate analysis, OLTs from CRC treated with higher dose (BED10 = 132 Gy) exhibited significantly better local recurrence-free survival than those treated to lower doses (BED10 ≤ 105.6 Gy) (p = 0.0022). The 1 and 3-year LRFS rates for OLTs treated to a higher dose (BED10 = 132 Gy) were 88.9% and 81.5%, vs 33.3%, and not achieved for lower doses (BED10 ≤ 105.6 Gy). Conclusion The LRFS of OLTs from CRC after SBRT of 48–60 Gy/4–5 fx was significantly worse than that of primary NSCLC. Lower dose SBRT appeared to have inferior control for OLTs of CRC in this cohort. Further studies with larger sample sizes are needed.

Background: Numerous agents have been trialed following coronary artery bypass grafting (CABG) to maintain long-term graft patency. While clear evidence exists for the use of aspirin in maintaining graft patency, the role of dual-antiplatelet therapy in CABG patients is not as well established. This network meta-analysis aimed to compare the short-term post-CABG graft patency outcomes for patients with none, one or two antiplatelet agents. Methods: Electronic databases were queried for randomized controlled trials comparing CABG graft patency rates at three months and beyond using various antiplatelet agents or placebo. Drug and graft patency data were compared using a mixed treatment comparison under a Bayesian hierarchical framework. A random-effects consistency model was applied. Direct and indirect comparisons were made between drugs and used to determine the relative efficacy for graft patency. Results: The literature search identified 16 papers fulfilling the inclusion criteria, including a total of 3,133 patients with an average of 2.43 [95% confidence interval (CI): 2.20–2.66] grafts per patient. Graft types were incompletely reported, however, saphenous vein grafts (SVGs) were predominantly used [where specifically reported: 4,490 SVG, 1,226 internal mammary artery (IMA) grafts]. In all, five different agents and placebo in various regimens were compared by results of angiographic follow-up conducted at a mean of 10.4 months (95% CI: 9.28–11.5 months). Compared to placebo, aspirin alone [odds ratio (OR) 1.9; 95% credible interval (CrI): 1.3–2.8], aspirin + dipyridamole (OR 1.9; 95% CrI: 1.3–2.6), aspirin + clopidogrel (OR 2.9; 95% CrI: 1.5–5.7) and aspirin + ticagrelor (OR 3.8; 95% CrI: 1.2–13.0) significantly improved graft patency. When compared to aspirin monotherapy, aspirin + clopidogrel (OR 1.6; 95% CrI: 0.86–2.7) and aspirin + ticagrelor (OR 2.0; 95% CrI: 0.69–6.3) had OR that suggested a trend favoring patency compared to aspirin monotherapy, however, these results did not reach significance. Sub-group analysis of SVG graft patency was unable to reach significance (only eight studies with six treatment comparisons were evaluated). Secondary endpoints of death, bleeding, myocardial infarction and cerebrovascular accident were incompletely reported and were pooled but not compared between drug treatment arms. Conclusions: Aspirin monotherapy and dual antiplatelet therapy (DAPT) provided significant all-graft patency benefit compared to placebo at three months and beyond. A trend existed for DAPT to improve graft patency compared to aspirin, although this did not reach statistical significance. Further randomized controlled studies comparing aspirin monotherapy to DAPT are required to determine the utility of DAPT in CABG patients for maintaining graft patency.

INTRODUCTION Atrial fibrillation (AF) is increasing in prevalence and is associated with significant morbidity and mortality. The optimal diagnostic and treatment strategies for AF are continually evolving and care for patients requires confidence in integrating these new developments into practice. These clinical practice guidelines will assist Australian practitioners in the diagnosis and management of adult patients with AF. Main recommendations: These guidelines provide advice on the standardised assessment and management of patients with atrial fibrillation regarding: screening, prevention and diagnostic work-up; acute and chronic arrhythmia management with antiarrhythmic therapy and percutaneous and surgical ablative therapies; stroke prevention and optimal use of anticoagulants; and integrated multidisciplinary care. Changes in management as a result of the guideline: Opportunistic screening in the clinic or community is recommended for patients over 65 years of age. The importance of deciding between a rate and rhythm control strategy at the time of diagnosis and periodically thereafter is highlighted. β-Blockers or non-dihydropyridine calcium channel antagonists remain the first line choice for acute and chronic rate control. Cardioversion remains first line choice for acute rhythm control when clinically indicated. Flecainide is preferable to amiodarone for acute and chronic rhythm control. Failure of rate or rhythm control should prompt consideration of percutaneous or surgical ablation. The sexless CHA2DS2-VA score is recommended to assess stroke risk, which standardises thresholds across men and women; anticoagulation is not recommended for a score of 0, and is recommended for a score of ≥ 2. If anticoagulation is indicated, non-vitamin K oral anticoagulants are recommended in preference to warfarin. An integrated care approach should be adopted, delivered by multidisciplinary teams, including patient education and the use of eHealth tools and resources where available. Regular monitoring and feedback of risk factor control, treatment adherence and persistence should occur.

Background: Surgical interventions for aortic aneurysm and dissection remain associated with high risk of mortality and morbidity. Advances in operative techniques have led to a variety of options for the cardiac surgeon, including endovascular and hybrid approaches. Debate remains over which of these techniques provide optimal outcomes for the patient. The present systematic review and meta-analysis aims to evaluate long term patient survival and identify short-term outcomes for conventional (open) aortic arch repair and hybrid aortic arch repair (HAR). Methods: An electronic literature search was conducted according to predefined inclusion criteria for hybrid and conventional aortic arch repair surgery. Digitized survival data was extracted from identified studies’ Kaplan-Meier curves and used to re-create individual patient data for aggregated survival analysis. Post-operative morbidity and mortality were analyzed using random-effects model meta-analysis. Results: Nine studies were included, containing 841 hybrid arch repair and 1,182 conventional arch repair patients. Pooled Kaplan-Meier analysis of all patients demonstrated higher survival in hybrid arch repair patients than conventional arch repair patients, however, this was noted to be sensitive to results from a particular study. Overall results showed for the hybrid repair cohort, survival at 1, 2, 3, 5 and 7 years was 87%, 85%, 83%, 78% and 75%, respectively. Survival in the conventional repair cohort at 1, 2, 3, 5 and 7 years was 84%, 82%, 80%, 75% and 71%, respectively. Statistically significant findings from meta-analysis showed hybrid arch repair was associated with lower risk of re-operation for bleeding, while conventional arch repair was associated with reduced risk of spinal cord injury. Conclusions: Pooled Kaplan-Meier analysis of all studies showed long-term survival outcomes for hybrid and conventional aortic arch repair patients are heterogeneous and sensitive to the results of particular studies. Superior results from particular centres and the low number of comparative studies mean that more data is required to make definitive findings with regards to the long-term survival outcomes of either procedure. Hybrid arch repair was associated with lower risk of re-operation for bleeding, while conventional arch repair was associated with lower risk of spinal cord injury. Surgeons should consider their own center’s experience and patient suitability when deciding between hybrid or conventional aortic repair techniques.

Objective To review the evidence on neurologic complications in adult extracorporeal membrane oxygenation (ECMO) patients with regard to incidence, pathophysiology, risk factors, diagnosis, monitoring techniques, prevention, and management. Design Literature review. Setting Observational studies and case reports from a variety of institutions. Participants Adult ECMO patients. Interventions Six electronic databases were searched from their dates of inception to October 2016. Measurements and Main Results The range of neurologic complications reported in adult ECMO patients included stroke, intracranial hemorrhage, and brain death. Due to a lack of standardized reporting, their true incidence may have been underestimated significantly. A variety of pathophysiologic mechanisms and risk factors have been proposed. Some of these are specific to venoarterial ECMO, whereas others may be more relevant to venovenous ECMO (eg, rapid correction of hypercarbia). With regard to diagnosis and monitoring, clinical examination alone can be challenging and insufficiently sensitive, particularly for the confirmation of brain death. Computed tomography is the main imaging modality for acute neurologic assessment because magnetic resonance imaging is not feasible in these patients. Options for neuromonitoring are limited, although cerebral near-infrared spectroscopy may be useful. There are very limited data to guide the management of specific complications such as intracranial hemorrhage, which remains a leading cause of mortality in ECMO patients. Conclusions ECMO can be lifesaving and is being used increasingly for severe respiratory and/or cardiac failure. However, it remains associated with significant neurologic morbidity and mortality. Greater research clearly is needed to determine the best approach to the assessment and management of neurologic complications in this rapidly growing patient population.

A small proportion of patients with malignant pleural mesothelioma (MPM) achieve pathological complete response (CR) following treatment with current practice induction chemotherapy. Our analysis of 58 patients with MPM treated with platinum-based chemotherapy showed 4 patients (7%) attained pathological CR at subsequent extrapleural pneumonectomy (EPP). Patient and tumour factors such as age, gender, smoking habit, histological subtype, and clinical stage were not found to be associated with pathological CR. Patients with pathological CR had longer disease-free survival (29.2 vs. 13.8 months; p = 0.08) and overall survival (76.4 vs. 23.4 months; p = 0.06) but this did not reach statistical significance. Our study suggests that patients who achieve pathological CR after chemotherapy may have improved survival in MPM.

Background: We evaluated the safety and effectiveness of the hybrid thoracoscopic endocardial epicardial ablation technique for the treatment of atrial fibrillation (AF) in obese versus non-obese patients.Methods: Between January 2010 and January 2015, a cohort of 61 patients were retrospectively identified to undergo ablation of AF as a stand-alone procedure using a thoracoscopic, hybrid epicardial-endocardial technique. All patients underwent continuous 7-day Holter monitoring at 3, 6 months, 1 year and yearly thereafter.Results: A total of 40% of the obese cohort had persistent or long-standing AF, compared to 54.9% of the non-obese cohort. There were no deaths or conversion to cardiopulmonary bypass required. At 3-year follow-up, 60% of the obese group were in sinus rhythm (SR) with no episode of AF, atrial flutter or atrial tachycardia lasting 30 s off anti-arrhythmic drugs. This was compared to 70.6% in the non-obese group, with no significant difference between the groups (P= 0.468). For success rates on anti-arrhythmic drugs, this was 80% in the obese group compared to 86% in the non-obese group at 3-year follow-up (P= 0.637). No patient died and no thromboembolic/bleeding events or procedure-related complications occurred during the follow-up.Conclusions: In a retrospective cohort with approximately half with persistent or long-standing AF, thoracoscopic hybrid epicardial endocardial ablation proved to be equally effective and safe in obese versus non-obese patients. Current preliminary findings require further validation in multi-institutional prospective studies with larger sample sizes.

Background: Since the introduction of the implantable cardioverter-defibrillator (ICD) in patients with hypertrophic cardiomyopathy (HCM), the incidence of sudden cardiac death (SCD) has been significantly reduced. Given its widespread use, it is important to identify the outcomes associated with ICD use in patients with HCM. The present paper is a systematic review and meta-analysis of the rates of appropriate and inappropriate interventions, mortality, and device complications in HCM patients with an ICD. Methods: We conducted a systematic review and meta-analysis on 27 studies reporting outcomes and complications after ICD implantation in patients with HCM. ICD interventions, device complications, and mortality were extracted for analysis. Results: A total of 3,797 patients with HCM and ICD implantation were included (mean age, 44.5 years; 63% male), of which 83% of patients had an ICD for primary prevention of SCD. The cardiac mortality was 0.9% (95% CI: 0.7–1.3) per year and non-cardiac mortality was 0.8% (95% CI: 0.6–1.2) per year. Annualized appropriate intervention rate was 4.8% and annualized inappropriate intervention was 4.9%. The annual incidence of lead malfunction, lead displacement and infection was 1.4%, 1.3%, and 1.1%, respectively. Conclusions: ICD use in patients with HCM produces low rates of cardiac and non-cardiac mortality, and an appropriate intervention rate of 4.8% per year. However, moderate rates of inappropriate intervention and device complications warrant careful patient selection in order to optimize the risk to benefit ratio in this select group of patients.

Numerical simulation and experimental methods were conducted to study the non-uniform thickness during hydroforming of a rectangular cross-sectional component by using a bent tube, which is thickened inside and thinned outside. A method of changing the contact sequence of the tube to the die surface is proposed to improve thickness distribution of hydroformed part. There are four contact sequences, Side-and-Side (SS), Side-and-Fillet (SF), Fillet-and-Side (FS) and Fillet-and-Fillet (FF), that are proposed through the preform shape for a rectangular section. The effect of contact sequence on thickness distribution was studied. The results show that SF or FF contact sequence makes the fillet corner contact with the die surface first and suppresses the further thinning in hydroforming. On the contrary, SF or SS contact sequence makes the straight side of the bend inside contact with the die surface first and benefits the full deformation of the thickening region in hydroforming. Among them, the SF contact sequence is the best for the uniformity of thickness, and SF and FF contact sequences are useful to ensure the minimum thickness of the section and help to avoid cracking defects. On the basis of it, two contact sequences, SS and FF, were applied to an instrument panel bar, respectively. There is a cracking defect in the circular section for the SS sequence, while there is no defect in the straight and circular sections for the FF sequence. And the sound part is successfully developed and applied to the assembly of the instrument panel bar of Chrysler 300C car in mass production.

Graves thyrotoxicosis rarely presents with painless jaundice resulting from hyperthyroidism-associated hepatotoxicity, without preexisting liver disease. Management in patients with this presentation is challenging, given that the thionamides, methimazole and propylthiouracil, have both been associated with drug-induced liver injury. Radioactive iodine ablation and thyroidectomy are well-established alternatives, but each have their associated risks and contraindications. We present an unusual case of severe hyperthyroidism-associated hepatotoxicity, in which adjuvant therapies, including glucocorticoids, saturated solution of potassium iodide, and cholestyramine, were used as a bridge to definitive therapy with thyroidectomy., Patient presented with jaundice and transaminitis. Workup revealed Graves disease, with no separate hepatic pathology. Thionamides was avoided; dexamethasone, SSKI and cholestyramine were used.

Background Diabetes is a growing challenge in Thailand. Data to assess health system response to diabetes is scarce. We assessed what factors influence diabetes care cascade retention, under universal health coverage. Methods We conducted a cross-sectional analysis of the 2014 Thai National Health Examination Survey. Diabetes was defined as fasting plasma glucose ≥126mg/dL or on treatment. National and regional care cascades were constructed across screening, diagnosis, treatment, and control. Unmet need was defined as the total loss across cascade levels. Logistic regression was used to examine the demographic and healthcare factors associated with cascade attrition. Findings We included 15,663 individuals. Among Thai adults aged 20+ with diabetes, 67.0% (95% CI 60.9% to 73.1%) were screened, 34.0% (95% CI 30.6% to 37.2%) were diagnosed, 33.3% (95% CI 29.9% to 36.7%) were treated, and 26.0% (95% CI 22.9% to 29.1%) were controlled. Total unmet need was 74.0% (95% CI 70.9% to 77.1%), with regional variation ranging from 58.4% (95% CI 45.0% to 71.8%) in South to 78.0% (95% CI 73.0% to 83.0%) in Northeast. Multivariable models indicated older age (OR 1.76), males (OR 0.65), and a higher density of medical staff (OR 2.40) and health centers (OR 1.58) were significantly associated with being diagnosed among people with diabetes. Older age (OR 1.80) and higher geographical density of medical staff (OR 1.82) and health centers (OR 1.56) were significantly associated with being controlled. Conclusions Substantial attrition in the diabetes care continuum was observed at diabetes screening and diagnosis, related to both individual and health system factors. Even with universal health insurance, Thailand still needs effective behavioral and structural interventions, especially in primary health care settings, to address unmet need in diabetes care for its population.