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Autopsy after transcatheter aortic valve implantation (TAVI) is a new field of interest in cardiovascular pathology. To identify the cause of death, it is important to be familiar with specific findings related to the time interval between the procedure and death. We aimed to provide an overview of the autopsy findings in patients with TAVI in their medical history divided by the timing of death with specific interest in the added value of autopsy over a solely clinically determined cause of death. In 8 European centres, 72 cases with autopsy reports were available. Autopsies were divided according to the time interval of death and reports were analysed. In 32 patients who died ≤72 h postprocedure, mortality resulted from cardiogenic or haemorrhagic shock in 62.5 and 34.4%, respectively. In 31 patients with mortality >72 h to ≤30 days, cardiogenic shock was the cause of death in 51.6% followed by sepsis (22.6%) and respiratory failure (9.7%). Of the nine patients with death >30 days, 88.9% died of sepsis, caused by infective endocarditis in half of them. At total of 12 patients revealed cerebrovascular complications. Autopsy revealed unexpected findings in 61.1% and resulted in a partly or completely different cause of death as was clinically determined. Autopsy on patients who underwent TAVI reveals specific patterns of cardiovascular pathology that clearly relate to the time interval between TAVI and death and significantly adds to the clinical diagnosis. Our data support the role of autopsy including investigation of the cerebrum in the quickly evolving era of cardiac device technology. [ABSTRACT FROM AUTHOR]

C282Y homozygotes exposed to sustained elevated transferrin saturation (TS) may develop worsening clinical symptoms. This might be related to the appearance of non-transferrin bound iron (NTBI) when TS≥50% and labile plasma iron (LPI) when TS levels reach 75-80%. In this study, NTBI levels were examined in 219 randomly selected untreated and treated C282Y homozygotes. Overall, 161 of 219 had TS ≥ 50%, 124 of whom had detectable NTBI (≥0.47 µM, 1.81 µM [0.92-2.46 µM]) with a median serum ferritin 320 µg/L (226-442 µg/L). Ninety of 219 homozygotes had TS ≥ 75%, and all had detectable NTBI (2.21 µM [1.53-2.59 µM] with a median ferritin 338 µg/L [230-447 µg/L]). Of 125 homozygotes who last had phlebotomy ≥12 months ago (42 months [25-74 months], 92 had TS levels ≥ 50%, and 70 of these had NTBI ≥ 0.47 µM (2.06 µM [1.23-2.61µM]). Twenty-six of these 70 had a normal ferritin. Fifty-five of 125 had TS ≥ 75%, and NTBI was detected in all of these (2.32 µM [1.57-2.77 µM]) with a median ferritin 344 µg/L (255-418 µg/L). Eighteen of these 55 had a normal ferritin. In summary, NTBI is frequently found in C282Y homozygotes with TS ≥ 50%. Furthermore, C282Y homozygotes in the maintenance phase often have TS ≥ 50% together with a normal ferritin. Therefore, monitoring the TS level during the maintenance phase is recommended as an accessible clinical marker of the presence of NTBI., Competing Interests: The authors declare no competing financial interest. DWS is an employee of Radboudumc that offers analysis of iron biomarkers and reference material for a fee for service via its hepcidinanalysis.com initiative., (© 2022 The Authors. eJHaem published by British Society for Haematology and John Wiley & Sons Ltd.)

Background: Plate fixation is the treatment of choice for a midshaft clavicle non-union. Those non-unions that require >1 surgical procedure to heal are termed recalcitrant non-union . Regardless of the number of previously failed procedures, our surgical strategy is aimed at achieving an optimal mechanical and biological environment to facilitate healing., Materials and Methods: We performed a retrospective analysis of 14 patients with a recalcitrant clavicle non-union treated with open reduction and plate fixation combined with graft augmentation when indicated. Healing rates after index surgery were analysed. All patients were observed for at least 12 months., Results: All patients healed at a mean time of 193.2 days (range 90-390). Five of the 14 patients had at least one positive surprise culture, for which they received antibiotic treatment. At the latest follow-up, no patient reported pain or discomfort. Mean disability of the arm, shoulder and hand (DASH) score was 16.3 points (range 0-40), indicating only mild residual impairment. A possible link was found between the time between injury and definitive surgery and the time to healing [Pearson correlation 0.527, sig. (two-tailed) 0.000]., Conclusion: This study shows 100% bone healing and good functional outcomes after surgical revision for a recalcitrant clavicle non-union., How to Cite This Article: Grewal S, Baltes TPA, Wiegerinck E, et al. Treatment of a Recalcitrant Non-union of the Clavicle. Strategies Trauma Limb Reconstr 2022;17(1):1-6., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2022; The Author(s).)

Background: In the past, elevated estradiol levels were reported to downregulate the iron regulatory hormone hepcidin, thereby potentially improving iron metabolism. As estrogen plays a role in regulating the menstrual cycle and can influence the cytokine interleukin-6 (IL-6; a hepcidin up-regulator), this investigation examined the effects of estradiol supplementation achieved by the use of a monophasic oral contraceptive pill (OCP) on IL-6, hepcidin levels and iron status during the hormone-deplete versus hormone-replete phases within an oral contraceptive cycle (OCC)., Methods: Fifteen healthy female OCP users were recruited and provided a venous blood sample on 2 separate mornings during a 28-day period. These included (a) days 2-4 of the OCC, representing a hormone-free withdrawal period (WD); (b) days 12-14 of the OCC, representing the end of the first week of active hormone therapy (AHT)., Results: IL-6 and hepcidin levels were not significantly different at WD and AHT. Serum ferritin was significantly higher (p = 0.039) during AHT as compared to WD., Conclusions: Fluctuations in OCP hormones (estradiol and/or progestogen) had no effect on basal IL-6 and hepcidin levels in young women. Nevertheless, elevated ferritin levels recorded during AHT may indicate that OCP hormones can positively influence iron stores within an OCC despite unchanged hepcidin levels., (© 2017 S. Karger AG, Basel.)

Transcatheter aortic valve implantation is currently a well-established minimal invasive treatment option for patients with severe aortic valve stenosis. CT Angiography is used for the pre-operative planning and sizing of the prosthesis. To reduce the inconsistency in sizing due to interobserver variability, we introduce and evaluate an automatic aortic root landmarks detection method to determine the sizing parameters. The proposed algorithm detects the sinotubular junction, two coronary ostia, and three valvular hinge points on a segmented aortic root surface. Using these aortic root landmarks, the automated method determines annulus radius, annulus orientation, and distance from annulus plane to right and left coronary ostia. Validation is performed by the comparison with manual measurements of two observers for 40 CTA image datasets. Detection of landmarks showed high accuracy where the mean distance between the automatically detected and reference landmarks was 2.81 ± 2.08 mm, comparable to the interobserver variation of 2.67 ± 2.52 mm. The mean annulus to coronary ostium distance was 16.9 ± 3.3 and 17.1 ± 3.3 mm for the automated and the reference manual measurements, respectively, with a mean paired difference of 1.89 ± 1.71 mm and interobserver mean paired difference of 1.38 ± 1.52 mm. Automated detection of aortic root landmarks enables automated sizing with good agreement with manual measurements, which suggests applicability of the presented method in current clinical practice.

Background: Replacing a stenotic aortic valve with 19-mm bioprostheses remains controversial owing to potential patient-prosthesis mismatch concerns. We report a single-center 10 year experience with 19-mm bioprosthetic valves implanted in elderly patients. We hypothesized patients would have acceptable in-hospital and long-term outcomes., Methods: Between January 2002 and December 2011, 257 patients underwent aortic valve replacement with a 19-mm prosthesis, of whom 182 had available follow-up echocardiographic studies. Mean age was 77.4 ± 8.4 years, and 10 of 257 (4%) were male. Outcomes of interest included early and late mortality, peak and mean aortic valve gradients, and left ventricular mass regression., Results: Operative mortality was 3.5% (9 of 257). Median postoperative echocardiographic time was 16 months. On follow-up echocardiography, mean peak aortic valve gradient decreased from 76 ± 27 mm Hg preoperatively to 32 ± 13 mm Hg and the mean gradient decreased from 46 ± 17 mm Hg to 18 ± 8 mm Hg (both p < 0.001) Mean left ventricular mass decreased from 191 g to 162 g (p < 0.001). Postoperative survival did not differ significantly between patients who met the criteria for patient-prosthesis mismatch and those who did not (p = 0.607)., Conclusions: In a series of elderly patients with aortic stenosis who were implanted with 19-mm bioprosthetic valves, long-term follow-up showed significant left ventricular mass regression and peak and mean aortic valve gradient reductions. The use of 19-mm aortic valves is safe and efficacious for elderly patients with a small aortic root., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Anemia is a common finding among patients with chronic heart failure (HF). Although comorbidities, such as kidney failure, might contribute to the pathogenesis of anemia, many patients with HF do not have any other obvious etiology for their anemia. We investigated whether anemia in HF is associated with an elevation in hepcidin concentration. We used time-of-flight mass spectrometry to measure hepcidin concentration in urine and serum samples of patients with HF and in control subjects. We found that the concentration of hepcidin was lower in urine samples of patients with HF compared with those of control subjects. Serum hepcidin was also reduced in HF but was not significantly lower than that in controls. There were no significant differences between hepcidin levels in patients with HF and anemia compared with patients with HF and normal hemoglobin level. We concluded that hepcidin probably does not play a major role in pathogenesis of anemia in patients with chronic HF.

Background: Iron deficiency anemia (IDA) affects many young women in sub-Saharan Africa. Its etiology is multifactorial, but the major cause is low dietary iron bioavailability exacerbated by parasitic infections such as malaria., Objective: We investigated whether asymptomatic Plasmodium falciparum parasitemia in Beninese women would impair absorption of dietary iron or utilization of circulating iron., Design: Iron absorption and utilization from an iron-fortified sorghum-based meal were estimated by using oral and intravenous isotope labels in 23 afebrile women with a positive malaria smear (asexual P. falciparum parasitemia; > 500 parasites/μL blood). The women were studied while infected, treated, and then restudied 10 d after treatment. Iron status, hepcidin, and inflammation indexes were measured before and after treatment., Results: Treatment reduced low-grade inflammation, as reflected by decreases in serum ferritin, C-reactive protein, interleukin-6, interleukin-8, and interleukin-10 (P < 0.05); this was accompanied by a reduction in median serum hepcidin of ≈ 50%, from 2.7 to 1.4 nmol/L (P < 0.005). Treatment decreased serum erythropoietin and growth differentiation factor 15 (P < 0.05). Clearance of parasitemia increased geometric mean dietary iron absorption (from 10.2% to 17.6%; P = 0.008) but did not affect systemic iron utilization (85.0% compared with 83.1%; NS)., Conclusions: Dietary iron absorption is reduced by ≈ 40% in asymptomatic P. falciparum parasitemia, likely because of low-grade inflammation and its modulation of circulating hepcidin. Because asymptomatic parasitemia has a protracted course and is very common in malarial areas, this effect may contribute to IDA and blunt the efficacy of iron supplementation and fortification programs. This trial was registered at clinicaltrials.gov as NCT01108939.

Background: This study reviews a single institution experience with the Carpentier-Edwards pericardial aortic valve bioprosthesis, concentrating on late outcomes., Methods: From December 1991 to June 2002, 1,000 patients underwent aortic valve replacement with the Carpentier-Edwards pericardial valve (mean follow-up 6.01 +/- 3.56 years). The institutional database was reviewed. Follow-up data were acquired through telephone interviews and mail-in questionnaires. Time-to-event analyses were performed by the Kaplan-Meier method. Mean age was 74.1 years; 545 patients (54.5%) were male. Mean preoperative ejection fraction was 52.5%. Isolated aortic valve replacement occurred in 372 cases (37.2%). Combined aortic valve replacement with coronary artery bypass grafting occurred in 443 cases (44.3%). The remaining 185 patients (18.5%) underwent complex procedures with concomitant mitral, tricuspid, or arch repair. One hundred forty patients (14.0%) had prior aortic valve surgery. Follow-up was 99.4% complete., Results: Overall operative mortality was 7.2% (72 of 1,000). There were 503 late deaths (50.3%). Age-stratified survival at 15 years was 43.7% for patients less than 65 years of age; 18.2% for patients aged 65 to 75; and 9.4% for patients aged more than 75 years. There were 26 failed bioprostheses (2.6%) requiring reoperation. Structural valve deterioration was the cause in 13 of 26 cases (50%), endocarditis in 11 of 26 (42%), and perivalvular leak in 2 of 26 (7.6%). Age-stratified freedom from reoperation due to structural valve deterioration at 15 years was 34.7% for patients less than 65 years of age; 89.4% for patients aged 65 to 75; and 99.5% for patients aged more than 75 years., Conclusions: The Carpentier-Edwards pericardial bioprosthesis shows long-term durability with low rates of structural failure., (Copyright (c) 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: This study analyzes a single institution experience with minimally invasive mitral valve repair and evaluates long-term surgical outcomes of morbidity, mortality, and rates of reoperation. Late follow-up of mitral regurgitation and left ventricular function were also assessed., Methods: Between August 1996 and October 2007, minimally invasive mitral valve repair was performed in 713 patients (mean follow-up 5.7 years). Excluding 6 repairs with robotic assistance, an perspective analysis of the remaining 707 patients was carried forth. Mean age was 57 +/- 13 years. Mean preoperative ejection fraction was 60% +/- 10%. Surgical access was through a lower ministernotomy (74%), right parasternal incision (24%), right thoracotomy (1.4%), or upper ministernotomy (0.7%). Exposure of the mitral valve was through the left atrium in 58% of the cases and transeptal in 42%. A ring annuloplasty was incorporated into 680 (96%) of 707 repairs. The Kaplan-Meier and Student t test for paired samples were used for statistical analysis., Results: There were 3 (0.4%) operative deaths. Perioperative morbidity included new-onset atrial fibrillation (20%), reoperation for bleeding (2%), stroke (1.9%), permanent pacemaker implantation (1.7%), deep sternal wound infection (0.7%), and aortic dissection (0.4%). Median hospital stay was 5 days. Only 31% of patients required blood transfusion during the hospital course. There were 49 (6.9%) late deaths and 34 (4.8%) failed repairs necessitating reoperation. At 11.2 years, survival was 83% (95% confidence intervals, 76.5-88.1); freedom from reoperation was 92% (95% confidence intervals, 86.2-94.9). Nine (1.3%) patients were lost to follow-up. A total of 2369 patient-years of echocardiography time were obtained in 544 patients (mean 4.36 years, range 0.47-11.09). Mean grade of mitral regurgitation decreased from 3.80 to 1.42 (P < .0001) Mean left ventricular ejection fraction decreased from 60.7% to 56.3% (P < .0001). Combined risk of death, reoperation, and recurrence of moderately severe to severe mitral regurgitation was 7.7% (43/555)., Conclusion: Minimally invasive mitral valve repair is safe, with low perioperative morbidity, low rates of recurrent mitral regurgitation, and low rates of reoperation and death at late follow-up.