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Several techniques for PEG-J tube placement have been described, commonly requiring fluoroscopic guidance and/or fixation of the jejunostomy tube (J-tube) into the small intestine. We describe a modified technique for placing jejunostomy tubes under direct visualization through a PEG with the use of ultra-thin endoscopes and steel guidewire. A retrospective study at a single tertiary academic center evaluating patients who underwent PEG-J placement between 2010 and 2020. All PEG tubes were placed with a pull-through technique. The Olympus GIF-N180 endoscope was advanced through the PEG to the jejunum and a Savary-Gilliard guidewire was used for placement of the J-tube extension. Fifty-eight patients underwent PEG-J placement (median age 61 years; women 52%). Surgically altered gastric anatomy was observed in 11 patients (19%). Median procedure time was 44 min for new PEG-J tube placement (range 26–103) and 20 min for placement of a J-tube extension through an existing PEG tube (range 9–86) or gastrostomy tract. Technical success rate was in 100%. Sixty-two repeat procedures were performed for J-tube exchange in 27 patients (46%, range 1–9 per patient), of which 51 procedures (82%) were done using the same technique. The most common indication for tube replacement was tube dysfunction (63%, n = 39). The median procedure time for tube exchange was 20 min (range 2–62). No major adverse events were encountered. PEG-J tubes can be placed effectively, rapidly, and safely using an ultra-thin caliber endoscope and a stiff steel wire through the PEG tube or mature gastrostomy site, precluding the need for fluoroscopy or oral access. J-tubes can be easily replaced utilizing the same technique.

Purpose In aortic stenosis patients referred for surgical and transcatheter aortic valve replacement (AVR), the evidence of diagnostic accuracy of coronary computed tomography angiography (CCTA) has been limited. The objective of this study was to investigate the diagnostic accuracy of CCTA for significant coronary artery disease (CAD) in patients referred for AVR using invasive coronary angiography (ICA) as the gold standard. Materials and methods We searched databases for all diagnostic studies of CCTA in patients referred for AVR, which reported diagnostic testing characteristics on patient-based analysis required to pool summary sensitivity, specificity, positive-likelihood ratio, and negative-likelihood ratio. Significant CAD in both CCTA and ICA was defined by >50% stenosis in any coronary artery, coronary stent, or bypass graft. Results Thirteen studies evaluated 1498 patients (mean age, 74 y; 47% men; 76% transcatheter AVR). The pooled prevalence of significant stenosis determined by ICA was 43%. Hierarchical summary receiver-operating characteristic analysis demonstrated a summary area under curve of 0.96. The pooled sensitivity, specificity, and positive-likelihood and negative-likelihood ratios of CCTA in identifying significant stenosis determined by ICA were 95%, 79%, 4.48, and 0.06, respectively. In subgroup analysis, the diagnostic profiles of CCTA were comparable between surgical and transcatheter AVR. Conclusions Despite the higher prevalence of significant CAD in patients with aortic stenosis than with other valvular heart diseases, our meta-analysis has shown that CCTA has a suitable diagnostic accuracy profile as a gatekeeper test for ICA. Our study illustrates a need for further study of the potential role of CCTA in preoperative planning for AVR.

Background Coronary artery calcium score (CACS) is a well-established test for risk stratifying asymptomatic patients for overall cardiovascular or coronary events. However; the prognostic value for incident stroke remains controversial. The objective of this study was to investigate the predictive value of CACS obtained by non-contrast electrocardiogram-gated computed tomography for incident stroke. Methods We searched PubMed, EMBASE, Cochrane databases for prospective longitudinal studies of CACS which reported the incidence of stroke. Incidence of stroke was compared in patients with and without coronary calcification. Results Three studies evaluated 13,262 asymptomatic patients (mean age=60years, 50% men) without apparent cardiovascular diseases. During a follow-up of 7.2years (median 5years, range 4.4–9.5years, 95,434patient-years), the overall pooled incidence of stroke was 0.26%/year. The pooled risk ratio of CACS>0 for incident stroke was 2.95 (95% CI: 2.18–4.01, p 2 =0%). The pooled incidence rate of stroke categorized by CACS was 0.12%/year for CACS 0, 0.26%/year for CACS 1–99, 0.41%/year for CACS 100–399 and 0.70%/year for CACS ≥400. Conclusions In asymptomatic patients without apparent cardiovascular diseases, the incidence of stroke was overall low. The presence and severity of coronary artery calcification were associated with incident stroke over mid-long term follow-up.

To investigate incidence and timing, risk factors, prognostic significance, and electrophysiological mechanisms of atrial arrhythmia (AA) after lung transplantation.Although new-onset AA is common after thoracic surgery and is associated with poorer outcomes, prognostic and mechanistic data is sparse in lung transplant populations.A total of 293 consecutive isolated lung transplant recipients without known AA were retrospectively reviewed. Mean follow-up was 28±17 months. Electrophysiology studies (EPS) were performed in 25 patients with AA.The highest incidence of new-onset AA after lung transplantation occurred within 30 days postoperative AA, (25 % of all patients). In multivariable analysis, postoperative AA was associated with double lung transplantation (OR 2.79; p=0.005) and lower mean pulmonary artery pressure (OR 0.95; p=0.027). Patients with postoperative AA had longer hospital stays (21 days vs 12 days; p0.001). Postoperative AA was independently associated with late AA (HR 13.52; p0.001) but not mortality (HR 1.55; p=0.14). In EPS, there were 14 patients with atrial flutter alone and 11 with atrial flutter and fibrillation. Of all EPS patients, 20 (80%) had multiple AA mechanisms, including peritricuspid flutter (48%), perimitral flutter (36%), right atrial incisional reentry (24%), focal tachycardia from recipient pulmonary vein (PV) antrum (32 %), focal PV fibrillation (24%), and left atrial roof flutter (20%). Left atrial mechanisms were present in 80% (20/25) of EPS patients and originated from the anastomotic PV antrum.Postoperative AA was independently associated with longer length of stay and late AA but not mortality. Pleomorphic PV antral arrhythmogenesis from native PV antrum is the main cause of AA after lung transplantation.

Transcatheter mitral valve-in-valve implantation (TMVIV) is an option for patients with mitral prosthetic valve dysfunction who are at high risk for surgical valve replacement. Efficacy and safety of TMVIV is at its infancy. We report a high-risk symptomatic dialysis-dependent end-stage renal disease patient with severe bioprosthetic mitral valve stenosis who had TMVIV performed successfully.

Study objective Coronary artery calcium score (CACS) is a well-established test for risk stratifying asymptomatic patients. Recent studies also indicate that CACS may accurately risk stratify stable patients presenting to the emergency department (ED) with acute chest pain; however, many were underpowered. The purpose of this systematic review and meta-analysis is to evaluate the prognostic value and accuracy of a zero (normal) CACS for identifying patients at acceptable low risk for future cardiovascular events who might be safely discharged home from the ED. Methods We searched multiple databases for longitudinal studies of CACS in symptomatic patients without known coronary artery disease that reported major adverse cardiovascular events (MACEs), including death and myocardial infarction. Pooled risk ratios, sensitivity, specificity, and likelihood ratios were analyzed. Results Eight studies evaluated 3,556 patients, with a median follow-up of 10.5 months. Pooled prevalence of zero CACS was 60%. Patients with CACS=0 had a significantly lower risk of cardiovascular events compared with those with CACS greater than 0 (MACEs: relative risk 0.06, 95% confidence interval 0.04 to 0.11, I2=0%; death/myocardial infarction: relative risk 0.19; 95% confidence interval 0.08 to 0.47, I2=0%). The pooled event rates for CACS=0 (MACEs 0.8%/year; death/myocardial infarction 0.5%/year) were significantly lower than for CACS greater than 0 (MACEs 14.6%/year; death/myocardial infarction 3.5%/year). Analysis of summary testing parameters showed a sensitivity of 96%, specificity of 60%, positive likelihood ratio of 2.36, and negative likelihood ratio of 0.07. Conclusion Acute chest pain patients without history of coronary artery disease, ischemic ECG changes, or increased cardiac enzyme levels commonly have a CACS of zero, with a very low subsequent risk of MACEs or death or myocardial infarction. This meta-analysis proffers the potential role of initial CACS testing for avoiding unnecessary hospitalization and further cardiac testing in acute chest pain patients with a CACS of zero.

Transcatheter mitral valve-in-valve implantation (TMVIV) is an option for patients with mitral prosthetic valve dysfunction who are at high risk for surgical valve replacement. Efficacy and safety of TMVIV is at its infancy. We report a high-risk symptomatic dialysis-dependent end-stage renal disease patient with severe bioprosthetic mitral valve stenosis who had TMVIV performed successfully.

This study examined the correlation between pre-operative coronary artery disease (CAD) and post-operative cardiovascular events in lung transplant recipients.Consecutive isolated lung transplant recipients from 2007 to 2013 in our institution were identified and categorized as having significant CAD (≥ 50% coronary stenosis in at least 1 artery or history of coronary revascularization) or no-mild CAD. Patient records and death index data were analyzed for a median of 2 years for death or cardiovascular events, including coronary, cerebrovascular, and peripheral artery events.The study comprised 280 patients (62% male) with mean age of 60 ± 10 years. Cardiovascular events occurred in 5.7% (16 of 280) of the entire cohort. Patients with significant CAD had a higher annualized rate of cardiovascular events than those with no-mild CAD (11.9% vs 0.6%; p0.001). Significant CAD was an independent predictor of cardiovascular events (hazard ratio, 20.32; 95% confidence interval, 5.79-71.26; p0.001) but not all-cause mortality (log-rank p = 0.66). Adding significant CAD to clinical risk factors gave incremental prognostic performance compared with clinical risk factors alone (p0.001 for increase in global chi-square).Selected lung transplant candidates with significant CAD can undergo transplantation with equal mortality risk to those without CAD but are at a higher risk of non-fatal cardiovascular events. These data support the current practice of accepting a selected group of patients with CAD for lung transplantation and suggest that they should be monitored early and treated to prevent cardiovascular complications.

Background: Prognostic value of body mass index (BMI) and cardiorespiratory fitness (CRF) has been described extensively in various populations. The objective of this study was to examine impact of BMI and CRF on all-cause mortality in isolated lung transplant recipients. Methods: Consecutive isolated lung transplant recipients from 2008 to 2013 were identified. Pre-transplant cardio-metabolic risk factors were collected. The cohort was categorized using BMI into normal (BMI 18.5-24.9 kg/m 2 ), underweight (BMI < 18.5 kg/m 2 ), overweight (BMI 25.0-29.9 kg/m 2 ) and obese (BMI ≥ 30 kg/m 2 ). Fit patient was defined as those who had pre-transplant six-minute-walk distance > 300 m. Results: The study comprised of 324 patients with mean age of 57 ± 13 years. Fifty eight percent were male. Primary lung pathologies were 26.9% obstructive, 2.5% vascular, 6.5% cystic fibrosis and 64.2% restrictive lung diseases. Pertinent cardio-metabolic risk factors included 36.7% normal weight, 9.9% underweight, 33.6% overweight, 19.8% obese, 21.9% unfit, 13.9% coronary artery disease, 55.6% hypertension, 29.6% diabetes mellitus, 42.3% hyperlipidemia, 42.9% smoking history. Annualized mortality rate stratified by BMI exhibited J-shaped distribution with lowest mortality in overweight group (p 0.005). Kaplan Meier analysis correspondingly showed highest survival in overweight strata (p 0.006). In subgroup analysis by CRF, paradoxical impact of overweightness on mortality was diminished in fit patients (p>0.05) but not in those who were unfit (p Conclusion: In our lung transplant cohort, BMI and mortality had J-shaped relationship with highest survival in overweight group. This paradoxical impact was diminished in patients who were fit. Our findings extend the paradigm of obesity paradox into lung transplantation arena.

The objective of this study was to investigate the predictive value of CACS obtained by noncontrast electrocardiogram-gated CT for incident ischemic stroke. We search Pubmed, Embase, Cochrane databases for prospective longitudinal studies of CACS which reported the incidence of ischemic stroke.

Background Gastroesophageal reflux disease (GERD) has been identified as a possible contributor of aspiration after lung transplantation that leads to graft failure and increased mortality. This study was designed to investigate whether the usage of proton pump inhibitor (PPI) pre-transplant is associated with decreased posttransplant mortality and/or retransplant. Methods A total of 324 consecutive patients who underwent lung transplant from January 2009 to June 2012 were retrospectively reviewed. Demographic information and baseline clinical characteristics of lung transplant recipients were collected. Clinical variables were compared between patients with and without clinical events determined as all-cause mortality and/or re-transplant. Usage of PPI were analyzed between recipients with clinical events (n= 78) and those without events (n= 246). Perioperative events were defined as events that occurred within 30 days after transplant. Results The cohort comprised of 58.3% male (189 of 324) with mean age (SD) of 58(13). Majority of patients had double lung transplant (62.8%; 203 of 324). Mean (SD) follow up interval was 2.0 (1.2) year. Idiopathic pulmonary fibrosis was the leading primary lung pathology (46.9%), followed by COPD (23.1%) and cystic fibrosis (6.5%). Prevalence of GERD prior to transplant was 42% (137 of 324). Clinical events occurred in 25% (78 of 324) of the cohort (66 death and 12 retransplants). Of those, 29.5% (23 of 78) were perioperative. There was no statistically significant difference in percentage use of PPI between patients with and without events (54.7% VS 53.0% respectively; p 0.927). Subgroup analysis in patients with diagnosis of GERD pre-transplant also demonstrated no significant difference in PPI use in the two groups (78.8% VS 83.7%; p 0.522). Kaplan Meier survival analysis revealed no significant difference in both mortality (p 0.874) and overall graft survival (p 0.806) as shown in Figure 1. Conclusion Use of proton pump inhibitors prior to transplantation is not associated with increased allografts survival in lung transplant recipients. Baseline characteristics and study variables categorized by clinical events.