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<1>
Accession Number
2012609800
Authors
Zanjani K.S.
Institution
(Zanjani) Pediatric Center of Excellence, Children's Medical Center,
Tehran University of Medical Sciences, No 62, Dr Gharib St, 14194 Tehran,
Iran, Islamic Republic of
Title
Platelets in pulmonary hypertension: A causative role or a simple
association?.
Source
Iranian Journal of Pediatrics. 22 (2) (pp 145-157), 2012. Date of
Publication: June 2012.
Publisher
Tehran University of Medical Sciences (TUMS) (No. 31, Poursina St. Ghods
Ave, Tehran, Iran, Islamic Republic of)
Abstract
Pathophysiology of pulmonary arterial hypertension is based on three basic
mechanisms: thrombotic pulmonary vascular lesions, vasoconstriction and
vascular remodeling. Platelets are related to all of these mechanisms by
their aggregation, production, storage and release of several mediators.
The role of platelets is more prominent in some types of pulmonary
arterial hypertension, including those which are secondary to inflammatory
and infectious diseases, hemoglobinopathies, essential thrombocythemia,
drugs, thromboembolism, and cardiac surgery. Most pulmonary
antihypertensive drugs have a negative effect on platelets. In this
review, the mechanisms of platelets association with pulmonary arterial
hypertension, those types of pulmonary arterial hypertension with greatest
platelet contribution to their pathophysiology, and the effects of
pulmonary antihypertensive drugs on platelets are summarized. 2012 by
Pediatrics Center of Excellence, Children's Medical Center, Tehran
University of Medical Sciences.

<2>
Accession Number
2012609573
Authors
Melnikov A.L. Bjoergo S. Kongsgaard U.E.
Institution
(Melnikov, Bjoergo) Department of Anesthesiology, Division of Emergencies
and Critical Care, Oslo University Hospital, Montebello 0310, Oslo, Norway
(Kongsgaard) Department of Research and Development, Division of
Emergencies and Critical Care, Oslo University Hospital and Medical
Faculty, University of Oslo, Oslo, Norway
Title
Thoracic paravertebral block versus transversus abdominis plane block in
major gynecological surgery: Aprospective, randomized, controlled,
observer-blinded study.
Source
Local and Regional Anesthesia. 5 (1) (pp 55-61), 2012. Date of
Publication: 01 Oct 2012.
Publisher
Dove Medical Press Ltd (Beechfield House, Winterton Way, Macclesfield SK11
0JL, United Kingdom)
Abstract
Background and objectives: Patients undergoing abdominal surgery often
receive an epidural infusion for postoperative analgesia. However, when
epidural analgesia is contraindicated or unwanted, the administration of
opioids is the usual means used to relieve pain. Various regional
analgesia techniques used in conjunction with systemic analgesia have been
reported to reduce the cumulative postoperative opioid consumption and
opioid-induced side effects. The objective of this trial was to assess the
effectiveness of transversus abdominis plane block and paravertebral block
in women undergoing major gynecological surgery. Methods: We analyzed 58
patients scheduled for a midline vertical laparatomy due to gynecological
cancer. They were all equipped with a patient-controlled postoperative
analgesia pump that delivered ketobemidon. In addition, some patients were
randomized to receive either a bilateral transversus abdominis plane block
(n = 19) or a bilateral paravertebral block at the level of Th10 (n = 19).
Both blocks were performed preoperatively as a single injection of
bupivacaine. Results: Cumulative ketobemidon consumption, postoperative
pain scores at rest and while coughing, and postoperative nausea and
vomiting scores were assessed by a blinded observer at 2, 4, 6, 24, and 48
hours postoperatively. Both blocks were associated with significant
reductions in opioid consumption and pain scores throughout the study
period compared with the control patients. Postoperative nausea and
vomiting scores were low in all groups, but during the early postoperative
period more control group patients needed antiemetics. Conclusion: Both
methods of inducing block can serve as effective analgesia adjuncts in
women undergoing major gynecological surgery. Although thoracic
paravertebral block appeared to be more effective than transversus
abdomins block, the latter performed under ultrasound guidance seems to be
a more controlled and safe alternative. 2012 Melnikov et al, publisher
and licensee Dove Medical Press Ltd.

<3>
[Use Link to view the full text]
Accession Number
2012616233
Authors
Hanash J.A. Hansen B.H. Hansen J.F. Nielsen O.W. Rasmussen A. Birket-Smith
M.
Institution
(Hanash, Rasmussen) Department of Cardiology and Endocrinology,
Frederiksberg Hospital 2000-Copenhagen, Frederiksberg, Denmark
(Hansen, Birket-Smith) Liaison Psychiatry Research Clinic, Psychiatric
Centre Bispebjerg, Copenhagen, Denmark
(Hansen, Nielsen) Department of Cardiology, Bispebjerg University
Hospital, Copenhagen, Denmark
Title
Cardiovascular safety of one-year escitalopram therapy in clinically
nondepressed patients with acute coronary syndrome: Results from the
DEpression in Patients with Coronary ARtery Disease (DECARD) trial.
Source
Journal of Cardiovascular Pharmacology. 60 (4) (pp 397-405), 2012. Date of
Publication: October 2012.
Publisher
Lippincott Williams and Wilkins (530 Walnut Street,P O Box 327,
Philadelphia PA 19106-3621, United States)
Abstract
Selective serotonin reuptake inhibitors are commonly used for treatment of
depression in patients with cardiac diseases. However, evidence of
cardiovascular (CV) safety from randomized trials is based on studies of
no longer than 6-month duration. We examined the CV safety of 1-year
treatment with Selective serotonin reuptake inhibitor escitalopram
compared with placebo in patients with recent acute coronary syndrome
(ACS). METHODS:: The DECARD (DEpression in patients with Coronary ARtery
Disease) trial assessed the prophylactic effect of escitalopram on
depression after ACS. Two hundred forty patients were randomized to
escitalopram 10-mg daily or matching placebo for 1 year. Serial measures
of CV safety including clinical and biochemical parameters, 24-hour
electrocardiogram monitor, resting electrocardiogram, and
echocardiographic assessment were obtained. RESULTS:: Escitalopram and
placebo groups were comparable at baseline with regard to age, gender,
sociodemography, depression score, risk factor profile, severity of heart
disease, and medications. Dropout rates defined as withdrawal for any
reason or lost to follow-up during the 12-month study period was 27.2% in
the escitalopram group and 23.4% in the placebo group (NS). There were no
statistically significant differences between intervention groups in any
of CV safety measures including the incidence of ventricular arrhythmia
and episodes of ST-segment depression, length of QTc, and systolic and
diastolic echocardiographic measures at the 12-month follow-up between
groups. After 12 months, 16 and 13 major adverse events (death, recurrent
ACS, or acute revascularization) were recorded in the escitalopram and
placebo group, respectively (NS). CONCLUSIONS:: One-year escitalopram
treatment was safe and well tolerated in patients with recent ACS.
Copyright 2012 by Lippincott Williams & Wilkins.

<4>
[Use Link to view the full text]
Accession Number
2012616459
Authors
Kim H.J. Lenke L.G. Shaffrey C.I. Van Alstyne E.M. Skelly A.C.
Institution
(Kim) Hospital for Special Surgery, New York, NY, United States
(Lenke) Department of Orthopaedic Surgery, Washington University, Campus
Box 8233, 660 S Euclid Ave., St. Louis, MO 63110, United States
(Shaffrey) Spine Division, University of Virginia, Medical Center,
Charlottesville, VA, United States
(Van Alstyne, Skelly) Spectrum Research, Inc., Tacoma, WA, United States
Title
Proximal junctional kyphosis as a distinct form of adjacent segment
pathology after spinal deformity surgery: A systematic review.
Source
Spine. 37 (SUPPL. 22) (pp S144-S164), 2012. Date of Publication: 15 Oct
2012.
Publisher
Lippincott Williams and Wilkins (530 Walnut Street,P O Box 327,
Philadelphia PA 19106-3621, United States)
Abstract
Study Design. Systematic review. Objective. To review the literature on
proximal junctional kyphosis (PJK) as a specific form for proximal
adjacent segment pathology and report on the incidence, timing, risk
factors, and effect on health-related quality of life (HRQOL) outcomes
reported for PJK. Summary of Background Data. PJK is a complication of
spinal deformity surgery that can compromise outcomes and necessitate
revision surgery. Multiple risk factors have been associated with PJK,
making the etiology multifactorial. Knowledge of the risk factors is
important for minimizing the occurrence of PJK and to allow surgeons to
take measures for its prevention when possible. Methods. A systematic
search of PubMed, CINAHL, EMBASE, the Cochrane Library, and Google Scholar
through February 15, 2012, was performed. The focus was on studies
designed to evaluate PJK in patients who had surgery for scoliosis and/or
kyphosis. Adjusted effect sizes and significance based on adjusting for
confounders were reported if available, otherwise, crude risk ratios and
95% confidence intervals were calculated. Results. The search yielded 85
citations and 8 met the criteria for inclusion. The incidence of PJK
ranged from 17% to 39% and the majority seemed to occur within 2 years of
surgery. The most common patient demographic associated with a higher PJK
risk was increased age. Surgery-related risk factors were fusions to the
sacrum, combined anterior/posterior surgery, thoracoplasty, and upper
instrumented vertebra at T1-T3. Postoperative hypokyphosis or
hyperkyphosis was associated with an increased risk of PJK. Despite the
presence of PJK, health-related quality of life outcomes were not
affected. Conclusion. Patients at higher risk for PJK are those who are of
older age, who had fusions to the sacrum, combined anterior/posterior
surgery, thoracoplasty, and an upper instrumented vertebra at T1-T3.
Despite the presence of PJK, no differences were noted in health-related
quality of life outcomes. Consensus Statement: 1. The risk of developing
PJK above a spinal deformity fusion is 17% to 39%, with most noted by 2
years postoperative. Level of Evidence: Moderate Strength of Statement:
Strong 2. The risk factors of PJK development include increased age,
fusion to sacrum, combined ASF/PSF, thoracoplasty, UIV at T1-T3, and
nonanatomic restoration of thoracic kyphosis. Level of Evidence: Low
Strength of Statement: Weak 3. The development of PJK does not seem to
have a detrimental effect on HRQOL outcomes, at least in
milder/nonrevision forms. Level of Evidence: Moderate Strength of
Statement: Weak. Copyright 2012 Lippincott Williams & Wilkins.

<5>
Accession Number
2012609409
Authors
Hashemi J. Ghaffari Nejad M.H. Baharestani B. Esfandiari R. Panahipoor A.
Institution
(Hashemi, Ghaffari Nejad, Baharestani, Esfandiari, Panahipoor) Head of
Cardiovascular Surgery Ward, Shaheed Rajaiee Cardiovascular, Medical and
Research Center, Tehran, Iran, Islamic Republic of
Title
Evaluation and comparison of use of low-dose aprotinin and tranexamic acid
in CABG: A double-blind, prospective, randomized study of 150 patients.
Source
Iranian Heart Journal. 12 (1) (pp 40-44), 2011. Date of Publication: 2011.
Publisher
Iranian Heart Association (P.O. Box 15745-1341, Tehran, Iran, Islamic
Republic of)
Abstract
Background- Cardiovascular operations are associated with an inherent
bleeding tendency that sometime leads to severe bleeding and transfusion
requirement. Pharmacologic intervention to minimize post-bypass bleeding
and blood product transfusions has received increasing attention for both
medical and economic perspectives. Methods- In this double-blind,
randomized, placebo-controlled clinical trial, three groups of patients,
each comprising 50 patients undergoing on-pump coronary artery bypass
grafting surgery (CABG) were blindly randomized to receive either low
aprotinin, tranexamic acid, or placebo; the results were subsequently
evaluated and compared between the groups. Results- The following
variables were similar in the groups, and there were no statistically
significant differences in these variables: age (p value=0.308), sex (p
value=0.973), hyperlipidemia (p value=0.720), hypertension (p
value=0.786), smoking (p value=0.72), and diabetes (p value=0.960). The
amounts of drainage from chest tubes were less in the aprotinin and
tranexamic acid groups compared to the placebo group, and this was
statistically significant (p value<0.001). There was no statistically
significant difference in need for reoperation for bleeding between the
three groups (p value=0.998). Complications following surgery in the three
groups were statistically the same and not significantly different (Table
below). All the complications had a good course, and all the patients were
discharged from hospital uneventfully. There was no mortality in any
group. Conclusions- Low-dose aprotinin and tranexamic acid can
significantly reduce blood loss and transfusion requirement in CABG
without importantly increasing mortality and morbidity.

<6>
Accession Number
2012609403
Authors
Mostafa Alavi S. Baharestani B. Farsad B.F. Bakhshandeh H. Babaee T.
Sdeghpur A. Faritus Z. Golpira R.
Institution
(Mostafa Alavi, Babaee, Faritus, Golpira) Department of Anesthesia, Rajaei
Cardiovascular, Medical and Research Center, Tehran, Iran, Islamic
Republic of
(Farsad) Department of Pharmacology, Rajaei Cardiovascular, Medical and
Research Center, Tehran, Iran, Islamic Republic of
(Bakhshandeh) Department of Epidemiology and Biostatistics, Tehran
University of Medical Sciences, Rajaei Cardiovascular, Medical and
Research Center, Tehran, Iran, Islamic Republic of
(Baharestani, Sdeghpur) Department of Cardiac Surgery, Rajaei
Cardiovascular, Medical and Research Center, Tehran, Iran, Islamic
Republic of
Title
Intraoperative magnesium sulfate can reduce narcotic requirement after
coronary bypass surgery.
Source
Iranian Heart Journal. 12 (1) (pp 6-11), 2011. Date of Publication: 2011.
Publisher
Iranian Heart Association (P.O. Box 15745-1341, Tehran, Iran, Islamic
Republic of)
Abstract
Background- Narcotics are the most common drugs used after cardiac surgery
and their side effects, including respiratory depression, hemodynamic
instability, nausea and vomiting, and itching are dose dependent.
Magnesium is both an N Methyl D Aspartate (NMDA)-receptor and a
calcium-receptor antagonist and can modify the important mechanisms of
nociception. The purpose of this study was to investigate the effect of
magnesium sulfate on the pain score and reducing narcotic requirement in
coronary artery bypass grafting surgery (CABG) patients. Methods- This
randomized, double blinded, placebo-controlled trial recruited 185
patients (105 male and 80 female) undergoing elective CABG. Mean age was
58+/-11 years (range= 24 to 79 years). The patients were divided into two
groups randomly: Group 1 received magnesium sulfate as an IV infusion (80
mg/kg) during a one-hour period post induction and Group 2 received the
same volume of normal saline as a placebo. During the postoperative
period, the patients' morphine requirement and pain score (visual analogue
scale= scaled as 0 to 10, 0=no pain and 10= worst possible pain) at
6^th, 12^th, 18^th, and 24^th
hours were recorded and documented. Results- There were no significant
differences between the two groups with respect to the baseline data. In
the magnesium sulfate group, only 30 (32%) patients needed morphine
sulfate, whereas 75 (83%) patients in the placebo group required some
doses of morphine sulfate (p value < 0.001). The odds ratio showed that
magnesium sulfate could strongly prevent the need for opioid analgesics
for pain control. Conclusion- The intraoperative use of magnesium sulfate
can reduce the need for opioids post CABG.

<7>
Accession Number
2012608128
Authors
Varenhorst C. Alstrom U. Scirica B.M. Hogue C.W. Asenblad N. Storey R.F.
Steg P.G. Horrow J. Mahaffey K.W. Becker R.C. James S. Cannon C.P.
Brandrup-Wognsen G. Wallentin L. Held C.
Institution
(Varenhorst, Asenblad, James, Wallentin, Held) Department of Medical
Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala
University, Uppsala, Sweden
(Alstrom) Department of Cardiothoracic Surgery and Anesthesiology, Uppsala
University, Uppsala, Sweden
(Scirica, Cannon) TIMI Study Group, Cardiovascular Division, Brigham and
Women's Hospital, Boston, MA, United States
(Hogue) Department of Anesthesiology and Critical Care Medicine, Johns
Hopkins University, School of Medicine, Baltimore, MD, United States
(Storey) Department of Cardiovascular Science, University of Sheffield,
Sheffield, United Kingdom
(Steg) Hopital Bichat, Assistance Publique-Hopitaux de Paris, Paris,
France
(Steg) INSERM U-698, Universite Paris-Diderot, Paris, France
(Horrow) AstraZeneca LP, Wilmington, DE, United States
(Mahaffey, Becker) Duke Clinical Research Institute, Durham, NC, United
States
(Brandrup-Wognsen) AstraZeneca, Molndal, Sweden
Title
Factors contributing to the lower mortality with ticagrelor compared with
clopidogrel in patients undergoing coronary artery bypass surgery.
Source
Journal of the American College of Cardiology. 60 (17) (pp 1623-1630),
2012. Date of Publication: 23 Oct 2012.
Publisher
Elsevier USA (6277 Sea Harbor Drive, Orlando FL 32862 8239, United States)
Abstract
Objectives: This study investigated the differences in specific causes of
post-coronary artery bypass graft surgery (CABG) deaths in the PLATO
(Platelet Inhibition and Patient Outcomes) trial. Background: In the PLATO
trial, patients assigned to ticagrelor compared with clopidogrel and who
underwent CABG had significantly lower total and cardiovascular mortality.
Methods: In the 1,261 patients with CABG performed within 7 days after
stopping study drug, reviewers blinded to treatment assignment classified
causes of death into subcategories of vascular and nonvascular, and
specifically identified bleeding or infection events that either caused or
subsequently contributed to death. Results: Numerically more vascular
deaths occurred in the clopidogrel versus the ticagrelor group related to
myocardial infarction (14 vs. 10), heart failure (9 vs. 6), arrhythmia or
sudden death (9 vs. 3), and bleeding, including hemorrhagic stroke (7 vs.
2). Clopidogrel was also associated with an excess of nonvascular deaths
related to infection (8 vs. 2). Among factors directly causing or
contributing to death, bleeding and infections were more common in the
clopidogrel group compared with the ticagrelor group (infections: 16 vs.
6, p < 0.05, and bleeding: 27 vs. 9, p < 0.01, for clopidogrel and
ticagrelor, respectively). Conclusions: The mortality reduction with
ticagrelor versus clopidogrel following CABG in the PLATO trial was
associated with fewer deaths from cardiovascular, bleeding, and infection
complications. (Platelet Inhibition and Patient Outcomes [PLATO];
NCT00391872) 2012 American College of Cardiology Foundation.

<8>
Accession Number
2012602226
Authors
Chung W.-Y. Kang J. Cho Y.-S. Park H.-J. Yang H.-M. Seo J.-B. Suh J.-W.
Kim K.-I. Youn T.-J. Kim S.-H. Chae I.-H. Zo J.-H. Kim M.-A. Choi D.-J.
Institution
(Chung, Seo, Kim, Kim, Zo, Kim) Seoul National University Boramae
Hospital, Seoul, South Korea
(Kang, Cho, Park, Suh, Youn, Chae, Choi) Seoul National University Bundang
Hospital, 300 Gumi-dong, Bundang, Seongnam, Gyeonggi, 463-707, South Korea
(Kang, Yang) Seoul National University Hospital, Seoul, South Korea
Title
A randomized, prospective, two-center comparison of sirolimus-eluting
stent and zotarolimus-eluting stent in acute ST-elevation myocardial
infarction: The SEZE trial.
Source
Chinese Medical Journal. 125 (19) (pp 3373-3381), 2012. Date of
Publication: 20121005.
Publisher
Chinese Medical Association (42 Dongsi Xidajie, Beijing 100710, China)
Abstract
Background The zotarolimus-eluting stent has shown larger in-stent late
lumen loss compared to sirolimus-eluting stents in previous studies.
However, this has not been thoroughly evaluated in ST elevation myocardial
infarction. Methods This was a prospective, randomized, controlled trial
evaluating angiographic outcomes in patients presenting with ST elevation
myocardial infarction, treated with zotarolimus-eluting stents or
sirolimus-eluting stents. From March 2007 to February 2009, 122 patients
were randomized to zotarolimus-eluting stents or sirolimus-eluting stents
in a 1:1 fashion. The primary endpoint was 9-month in-stent late lumen
loss confirmed by coronary angiography, and secondary endpoints were
percent diameter stenosis, binary restenosis rate, major adverse cardiac
events (a composite of cardiac death, non-fatal myocardial infarction, and
target vessel revascularization), and late-acquired incomplete stent
apposition. Results Angiographic in-stent late lumen loss was
significantly higher in the zotarolimus-eluting stent group compared to
the sirolimus-eluting stent group ((0.49+/-0.65) mm vs. (0.10+/-0.46) mm,
P=0.001). Percent diameter stenosis at 9-month follow-up was also larger
in the zotarolimus-eluting stent group ((30.0+/-17.9)% vs. (17.6+/-14.0)%,
P <0.001). In-segment analysis showed similar findings. There were no
significant differences in binary restenosis rate, major adverse cardiac
events, and late-acquired incomplete stent apposition. Conclusions
Compared to sirolimus-eluting stents, the zotarolimus-eluting stent is
associated with significantly higher in-stent late lumen loss at 9-month
angiographic follow-up in the treatment of ST elevation myocardial
infarction. Although there was no significant difference in 1-year
clinical outcomes, the clinical implication of increased late lumen loss
should be further studied.

<9>
Accession Number
22172922
Authors
Rideout A. Lindsay G. Godwin J.
Institution
(Rideout) School of Health Glasgow Caledonian University, Glasgow, UK.
Title
Patient mortality in the 12 years following enrolment into a pre-surgical
cardiac rehabilitation programme.
Source
Clinical rehabilitation. 26 (7) (pp 642-647), 2012. Date of Publication:
Jul 2012.
Abstract
This study examined whether involvement in a pre-surgical cardiac
rehabilitation programme conferred a long-term survival benefit. Patients
randomly allocated to a pre-surgical cardiac rehabilitation programme
intervention or a control group were tracked through national databases at
a point approximately 12 years later, and all causes of mortality were
identified from death records. Kaplan-Meier survival analyses based on
involvement in a cardiac rehabilitation programme and known pre-surgical
risk factors were carried out. Two health boards in the west of Scotland,
referring to a single cardiothoracic tertiary centre. Patients admitted to
the waiting list for coronary artery bypass surgery. Patients were
randomly allocated to a control group ('usual' care) or an intervention
group (nurse-led cardiac rehabilitation) in the pre-operative phase. They
were followed up at 12 years post surgery. The only outcome measure used
for analysis was survival. Measures of anxiety and depression, and
physiological and lifestyle risk factors were included as independent
variables in analysis of death. The initial study included 110
patients--none were lost to follow-up. Relative risk of death associated
with inclusion in the cardiac rehabilitation programme was 0.814; risk of
death increased with increasing pre-surgical depression (RR 1.07) and
anxiety (RR 1.09). Undertaking pre-surgical cardiac rehabilitation confers
a long-term survival advantage over patients not offered this service.
Increased anxiety and depression in the pre-surgical phase are additional
risk factors for increased mortality.

<10>
Accession Number
2012607495
Authors
Ibanez B. Fuster V. MacAya C. Sanchez-Brunete V. Pizarro G. Lopez-Romero
P. Mateos A. Jimenez-Borreguero J. Fernandez-Ortiz A. Sanz G.
Fernandez-Friera L. Corral E. Barreiro M.-V. Ruiz-Mateos B. Goicolea J.
Hernandez-Antolin R. Acebal C. Garcia-Rubira J.C. Albarran A. Zamorano
J.L. Casado I. Valenciano J. Fernandez-Vazquez F. De La Torre J.M. Perez
De Prado A. Iglesias-Vazquez J.A. Martinez-Tenorio P. Iniguez A.
Institution
(Ibanez, Fuster, Pizarro, Lopez-Romero, Mateos, Jimenez-Borreguero,
Fernandez-Ortiz, Sanz, Fernandez-Friera) Epidemiology, Atherothrombosis
and Imaging Department, Centro Nacional de Investigaciones
Cardiovasculares Carlos III (CNIC), Melchor Fernandez Almagro, 3, 28029,
Madrid, Spain
(Ibanez, MacAya, Fernandez-Ortiz, Ruiz-Mateos, Hernandez-Antolin, Acebal)
Hospital Clinico San Carlos, Madrid, Spain
(Fuster) Mount Sinai School of Medicine, New York, NY, United States
(Sanchez-Brunete, Mateos, Valenciano, Martinez-Tenorio) Servicio de
Urgencia Medica de MAdrid (SUMMA 112), Madrid, Spain
(Pizarro) Hospital Universitario Quiron, Madrid, Spain
(Jimenez-Borreguero) Hospital Universitario de la Princesa, Madrid, Spain
(Fernandez-Friera, De La Torre) Hospital Universitario Marques de
Valdecilla, Santander, Spain
(Corral, Casado) Servicio de Atencion Medica URgente (SAMUR)- Proteccion
Civil, Madrid, Spain
(Barreiro, Iglesias-Vazquez) Servicio de Emergencia Medica 061 de
Galicia-Sur, Galicia, Spain
(Goicolea) Hospital Universitario Puerta de Hierro, Madrid, Spain
(Garcia-Rubira) Hospital Virgen de la Macarena, Sevilla, Spain
(Albarran) Hospital Universitario Doce de Octubre, Madrid, Spain
(Zamorano) Hospital Universitario Ramon y Cajal, Madrid, Spain
(Fernandez-Vazquez, Perez De Prado) Hospital Universitario Leon, Leon,
Spain
(Iniguez) Complejo Hospitalario Universitario de Vigo-Meixoeiro,
Pontevedra, Spain
Title
Study design for the effect of METOprolol in CARDioproteCtioN during an
acute myocardial InfarCtion (METOCARD-CNIC): A randomized, controlled
parallel-group, observer-blinded clinical trial of early pre-reperfusion
metoprolol administration in ST-segment elevation myocardial infarction.
Source
American Heart Journal. 164 (4) (pp 473-480.e5), 2012. Date of
Publication: October 2012.
Publisher
Mosby Inc. (11830 Westline Industrial Drive, St. Louis MO 63146, United
States)
Abstract
Background: Infarct size predicts post-infarction mortality. Oral
beta-blockade within 24 hours of a ST-segment elevation acute myocardial
infarction (STEMI) is a class-IA indication, however early intravenous
(IV) beta-blockers initiation is not encouraged. In recent magnetic
resonance imaging (MRI)-based experimental studies, the
beta₁-blocker metoprolol has been shown to reduce infarct size
only when administered before coronary reperfusion. To date, there is not
a single trial comparing the pre- vs. post-reperfusion beta-blocker
initiation in STEMI. Objective: The METOCARD-CNIC trial is testing whether
the early initiation of IV metoprolol before primary percutaneous coronary
intervention (pPCI) could reduce infarct size and improve outcomes when
compared to oral post-pPCI metoprolol initiation. Design: The
METOCARD-CNIC trial is a randomized parallel-group single-blind (to
outcome evaluators) clinical effectiveness trial conducted in 5 Counties
across Spain that will enroll 220 participants. Eligible are 18- to
80-year-old patients with anterior STEMI revascularized by pPCI <=6 hours
from symptom onset. Exclusion criteria are Killip-class >=III,
atrioventricular block or active treatment with
beta-blockers/bronchodilators. Primary end point is infarct size evaluated
by MRI 5 to 7 days post-STEMI. Prespecified major secondary end points are
salvage-index, left ventricular ejection fraction recovery (day 5-7 to 6
months), the composite of (death/malignant ventricular
arrhythmias/reinfarction/admission due to heart failure), and myocardial
perfusion. Conclusions: The METOCARD-CNIC trial is testing the hypothesis
that the early initiation of IV metoprolol pre-reperfusion reduces infarct
size in comparison to initiation of oral metoprolol post-reperfusion.
Given the implications of infarct size reduction in STEMI, if positive,
this trial might evidence that a refined use of an approved inexpensive
drug can improve outcomes of patients with STEMI. 2012 Mosby, Inc.

<11>
Accession Number
2012607478
Authors
Bansilal S. Farkouh M.E. Hueb W. Ogdie M. Dangas G. Lansky A.J. Cohen D.J.
Magnuson E.A. Ramanathan K. Tanguay J.-F. Muratov V. Sleeper L.A. Domanski
M. Bertrand M.E. Fuster V.
Institution
(Bansilal, Farkouh, Dangas, Domanski, Fuster) Mount Sinai School of
Medicine, 1 Gustave L Levy Place, New York 10029-6574, United States
(Farkouh) Peter Munk Cardiac Centre, University of Toronto, Toronto,
Canada
(Hueb) Heart Institute, University of Sao Paulo, Sao Paulo, Brazil
(Ogdie, Muratov, Sleeper) New England Research Institutes, Watertown, MA,
United States
(Lansky) Yale University School of Medicine, New Haven, CT, United States
(Cohen, Magnuson) Saint Luke's Mid America Heart Institute, Kansas City,
MO, United States
(Ramanathan) University of British Columbia, Vancouver, BC, Canada
(Tanguay) Montreal Heart Institute, Universite de Montreal, Montreal, QC,
Canada
(Bertrand) Hopital Cardiologique, Lille, France
(Fuster) Centro Nacional de Investigaciones Cardiovasculares (CNIC),
Madrid, Spain
Title
The Future REvascularization Evaluation in patients with Diabetes
mellitus: Optimal management of Multivessel disease (FREEDOM) trial:
Clinical and angiographic profile at study entry.
Source
American Heart Journal. 164 (4) (pp 591-599), 2012. Date of Publication:
October 2012.
Publisher
Mosby Inc. (11830 Westline Industrial Drive, St. Louis MO 63146, United
States)
Abstract
Background: The optimal revascularization strategy for diabetic patients
with multivessel coronary artery disease (MVD) remains uncertain for lack
of an adequately powered, randomized trial. The FREEDOM trial was designed
to compare contemporary coronary artery bypass grafting (CABG) to
percutaneous coronary intervention (PCI) with drug-eluting stents in
diabetic patients with MVD against a background of optimal medical
therapy. Methods: A total of 1,900 diabetic participants with MVD were
randomized to PCI or CABG worldwide from April 2005 to March 2010. FREEDOM
is a superiority trial with a mean follow-up of 4.37 years (minimum 2
years) and 80% power to detect a 27.0% relative reduction. We present the
baseline characteristics of patients screened and randomized, and provide
a comparison with other MVD trials involving diabetic patients. Results:
The randomized cohort was 63.1 +/- 9.1 years old and 29% female, with a
median diabetes duration of 10.2 +/- 8.9 years. Most (83%) had 3-vessel
disease and on average took 5.5 +/- 1.7 vascular medications, with 32% on
insulin therapy. Nearly all had hypertension and/or dyslipidemia, and 26%
had a prior myocardial infarction. Mean hemoglobin A1c was 7.8 +/- 1.7
mg/dL, 29% had low-density lipoprotein <70 mg/dL, and mean systolic blood
pressure was 134 +/- 20 mm Hg. The mean SYNTAX score was 26.2 with a
symmetric distribution. FREEDOM trial participants have baseline
characteristics similar to those of contemporary multivessel and diabetes
trial cohorts. Conclusions: The FREEDOM trial has successfully recruited a
high-risk diabetic MVD cohort. Follow-up efforts include aggressive
monitoring to optimize background risk factor control. FREEDOM will
contribute significantly to the PCI versus CABG debate in diabetic
patients with MVD. 2012 Mosby, Inc.

<12>
Accession Number
2012607131
Authors
Ruetzler K. Sima B. Mayer L. Golescu A. Dunkler D. Jaeger W. Hoeferl M.
You J. Sessler D.I. Grubhofer G. Hutschala D.
Institution
(Ruetzler, Sima, Mayer, Golescu, Grubhofer, Hutschala) Department of
Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine,
Section of Clinical Biometrics, Medical University of Vienna, Waehringer
Guertel 18-20, A-1090 Vienna, Austria
(Dunkler) Core Unit for Medical Statistics and Informatics, Section of
Clinical Biometrics, Medical University of Vienna, Waehringer Guertel
18-20, A-1090 Vienna, Austria
(Jaeger, Hoeferl) Department of Clinical Pharmacy and Diagnostics,
University of Vienna, Vienna, Austria
(You) Department of Quantitative Health Sciences, Cleveland Clinic, OH,
United States
(You, Sessler) Department of Outcomes Research, Cleveland Clinic, OH,
United States
(Sessler) Population Health Research Institute, McMaster University,
Hamilton, ON, Canada
Title
Lidocaine/tetracaine patch (Rapydan) for topical anaesthesia before
arterial access: A double-blind, randomized trial.
Source
British Journal of Anaesthesia. 109 (5) (pp 790-796), 2012. Date of
Publication: November 2012.
Publisher
Oxford University Press (Great Clarendon Street, Oxford OX2 6DP, United
Kingdom)
Abstract
Background: Arterial catheterization is painful and is associated with
patient stress and anxiety. Analgesia is usually provided by subcutaneous
injection of local anaesthetic. An alternative is topical anaesthesia,
such as Rapydan which is a novel topical anaesthetic patch containing 70
mg each of lidocaine and tetracaine. We therefore tested the hypothesis
that Rapydan patch analgesia is non-inferior to subcutaneous local
anaesthetic. Methods: Ninety patients undergoing elective major cardiac
surgery were included in this prospective, double-blind clinical trial.
Patients were randomly assigned to receive either a lidocaine/tetracaine
patch, followed by subcutaneous injection 0.5 ml of normal saline
solution, or placebo patch with subsequent subcutaneous injection of 0.5
ml of lidocaine 1%. Pain during arterial catheterization using 100-mm-long
visual analogue scale (VAS) was the primary outcome. Other outcomes were
pain during anaesthetic/saline injection and plasma tetracaine
concentrations. Results: VAS pain scores during arterial puncture were
comparable in both groups and Rapydan was non-inferior to subcutaneous
lidocaine. Pain scores at the time of subcutaneous injection were
significantly lower (better) in patients assigned to the
lidocaine/tetracaine patch than to lidocaine (P=0.001). Plasma tetracaine
concentrations never exceeded the detection limit of 25 ng ml^-1
at any time in any patient. Conclusions: Both the lidocaine/tetracaine
patch and subcutaneous injection of lidocaine provided comparable pain
control during arterial catheter insertion. Subcutaneous lidocaine caused
discomfort during injection, whereas the lidocaine/tetracaine patch
required placement 20 min before the procedure. Given adequate time, the
patch provided better overall analgesia by obviating the need for
subcutaneous infiltration. 2012 The Author [2012].

<13>
Accession Number
2012603801
Authors
Zhu J. Wang C. Gao D. Zhang C. Zhang Y. Lu Y. Gao Y.
Institution
(Zhu, Wang, Gao, Zhang, Zhang, Lu, Gao) Department of Cardiovascular
Medicine, Second Affiliated Hospital of Medical School, Xi'an Jiaotong
University, Xi'an, Shaanxi, China
Title
Meta-analysis of amiodarone versus beta-blocker as a prophylactic therapy
against atrial fibrillation following cardiac surgery.
Source
Internal Medicine Journal. 42 (10) (pp 1078-1087), 2012. Date of
Publication: October 2012.
Publisher
Blackwell Publishing (550 Swanston Street, Carlton South VIC 3053,
Australia)
Abstract
Background: Current guidelines recommend beta-blocker as the first-line
preventive treatment of atrial fibrillation (AF) after cardiac surgery; if
beta-blocker therapy is contraindicated, then amiodarone is recommended.
There is still lack of strong evidence of directly comparing the efficacy
of amiodarone and beta-blocker in preventing postoperative AF (POAF). Aim:
This meta-analysis was to determine whether amiodarione and beta-blocker
are equally effective and safe, or one is superior in preventing POAF.
Methods: We searched the Medline, Web of Science, Cochrane Library
databases and clinical trial databases for related articles published from
January 1990 to October 2011. The primary outcome was development of AF
after cardiac surgery. We used random-effects model when there was
significant heterogeneity between trials and fixed-effects method when
heterogeneity was negligible. Moreover, subgroup and sensitivity analyses
were also performed. Results: We identified totally six trials, which
involved 1033 patients. The amiodarone group did not significantly differ
from the beta-blocker group in AF occurrence (risk ratio 0.77, 95%
confidence interval 0.55 to 1.06, P = 0.11) or the length of hospital stay
(weighted mean difference -0.05 day, 95% confidence interval -0.64 to
0.54, P = 0.86). Subgroup analysis stratified by different beta-blockers
revealed that amiodarone significantly improved POAF as compared with
propranolol. In addition, there was no difference in adverse events after
operation. Conclusion: These data indicate that the occurrence of AF and
length of hospital stay after surgery are similar in the amiodarone and
beta-blocker groups. 2012 The Authors. Internal Medicine Journal 2012
Royal Australasian College of Physicians.

<14>
Accession Number
70902872
Authors
Strachan L. Osnabrugge R.L.J. Busca R. Brasseur P. Le Reun C.
Institution
(Strachan) Medtronic Australasia Pty Ltd, North Ryde, NSW, Australia
(Osnabrugge) Erasmus University Medical Center, Rotterdam, Netherlands
(Busca, Brasseur) Medtronic International Trading Sarl, Tolochenaz,
Switzerland
(Le Reun) Biostatistician, Carrigaline, Ireland
Title
Epidemiology of severe aortic stenosis in the elderly: A systematic review
and meta-analysis of published prevalence estimates.
Source
Journal of the American College of Cardiology. Conference: 24th Annual
Symposium of the Transcatheter Cardiovascular Therapeutics, TCT 2012
Miami, FL United States. Conference Start: 20121022 Conference End:
20121026. Conference Publication: (var.pagings). 60 (pp B242), 2012. Date
of Publication: 23 Oct 2012.
Publisher
Elsevier USA
Abstract
Background: The prevalence of degenerative Aortic Stenosis (AS) is
strongly linked to the phenomenon of population aging. While elderly
patients form the majority of patients treated with AS, comorbidities
place them at high for surgical aortic valve replacement (SAVR). With the
new treatment option of transcatheter aortic valve implantation (TAVI),
also patients formerly deemed inoperable can now be treated. Robust
estimates in an elderly population remain unclear. The objective of this
study is to perform a systematic review (SR) and meta-analysis (MA) to
identify observational populationbased studies that report prevalence of
severe AS in persons > 70yrs. Methods: A search of the published
literature was conducted in Feb 2012 using Medical databases. General
population observational studies, surveys, registries that reported the
prevalence of degenerative severe AS in elderly persons (>70yrs) were
included. Although the methods used to diagnose severe AS differed
slightly between studies, the cut-off diagnostic criteria used in this
analysis, where severe AS is defined as aortic valve area <1
cm² was taken from the ESC AS guidelines. A MA of prevalence
estimates was conducted in order to provide a point estimate (with
confidence interval) of severe AS prevalence. Heterogeneity was quantified
using the I2 measure and its significance was tested with the Q test.
Results: A total of 1524 citations were retrieved for review and 7
observational studies reported severe AS in an elderly population. Five
studies reported severe AS separately (from other forms of AS) and were
included in the MA. The pooled prevalence of severe AS in persons >75yrs
was 4.3% (95% CI 3.1%, 5.5%; heterogeneity, I2=52.8%, chi-square
p-value=0.095). In persons >80yrs the pooled prevalence of severe AS was
4.8% (95% CI 3.4%, 6.3%; heterogeneity, I2=48.2%, chi-square
p-value=0.122). Due to the moderate amount of heterogeneity in the
estimates, which was deemed statistically non-significant, a fixed-effect
approach was used. Conclusions: Our unique SR shows a prevalence of almost
5% in the octogenarians have severe AS. These figures reconfirm AS as a
major disease and form a starting point in light of new less invasive TAV
implantation.

<15>
Accession Number
70902741
Authors
Karrowni W. Dhaliwal A. Makki N. Dughman S. Blevins A. Cram P. Horwitz P.
Institution
(Karrowni, Dhaliwal, Makki, Dughman, Blevins, Cram, Horwitz) University of
Iowa Carver, College of Medicine, Iowa City, IA, United States
Title
A systematic review and meta-analysis of ostial and trunk versus distal
lesions in unprotected left main coronary artery stenting.
Source
Journal of the American College of Cardiology. Conference: 24th Annual
Symposium of the Transcatheter Cardiovascular Therapeutics, TCT 2012
Miami, FL United States. Conference Start: 20121022 Conference End:
20121026. Conference Publication: (var.pagings). 60 (pp B203), 2012. Date
of Publication: 23 Oct 2012.
Publisher
Elsevier USA
Abstract
Background: The effectiveness of left main coronary artery (LMCA)
percutaneous coronary intervention (PCI) is inferior to coronary artery
bypass surgery (CABG), mostly due to the higher risk of repeat
revascularization. The LMCA has typically been treated as a single entity
in studies comparing PCI and CABG. However, interventionalists recognize
that there are differences in the technical complexity of LMCA PCI
depending upon the lesion's location. The influence of lesion location on
outcomes is not clear. Methods: We performed a systematic review and
meta-analysis of percutaneous drug-eluted stent (DES) implantation in
ostial and trunk versus distal unprotected LMCA lesions. Our co-primary
endpoints were the incidence of major adverse cardiac events (MACE) and
target lesion/vessel revascularization (TLR/TVR). We included studies that
enrolled >100 patients and had >6 months follow-up. Results: We identified
11 studies involving 4,236 patients. Mean duration of follow-up was 26
months (range 20-36). We adopted the random effect model when computing
the combined hazard ratio (HR) (test for heterogeneity p < 0.001).
Compared with non-distal stenting, distal LMCA PCI was associated with
increased MACE (17.7%; 175/986 versus 25.6%; 576/2242) [HR (95% CI)- 2.07
(1.47-2.92)] and TLR/TVR (8.4%; 163/1931 versus 15.7%; 363/2305) [HR (95%
CI)- 3.09 (2.02-4.73)] (figure). (Figure presented) Conclusions: Patients
with ostial and trunk LMCA lesions treated with DES have better outcomes
than patients with distal lesions. Our findings may support unprotected
non-distal LMCA stenting as a primary approach in selected patient
subsets.

<16>
Accession Number
70902490
Authors
Patel V. Brayton K. Mogabgab O. Michael T. Lo N. Alomar M. Shorrock D.
Abdullah S. Banerjee S. Brilakis E.
Institution
(Patel, Brayton, Mogabgab) University of Texas at Southwestern, Dallas,
TX, United States
(Michael) University of Texas, Southwestern Medical Center, Dallas, TX,
United States
(Lo, Shorrock, Abdullah) UTSW Medical Center/Dallas VAMC, Dallas, TX,
United States
(Alomar) Dallas VA Medical Center, Dallas, TX, United States
(Banerjee) UT Southwestern Medical Center, VA North Texas Health Care
System, Dallas, TX, United States
(Brilakis) VA North Texas Healthcare System, UT Southwestern Medical
Center, Dallas, United States
Title
Incidence of procedural complications in patients undergoing percutaneous
coronary chronic total occlusion interventions: A systematic review and
meta-analysis.
Source
Journal of the American College of Cardiology. Conference: 24th Annual
Symposium of the Transcatheter Cardiovascular Therapeutics, TCT 2012
Miami, FL United States. Conference Start: 20121022 Conference End:
20121026. Conference Publication: (var.pagings). 60 (pp B126), 2012. Date
of Publication: 23 Oct 2012.
Publisher
Elsevier USA
Abstract
Background: Successful percutaneous coronary intervention (PCI) of chronic
total occlusions (CTO) is associated with improvement in angina, left
ventricular function, and increased survival. However, the safety profile
of CTO PCI has been poorly studied. Methods: We conducted a systematic
review and meta-analysis of 65 studies published between 2000 and 2011
reporting procedural complications of CTO PCI. Data on the frequency of
death, emergent coronary artery bypass graft surgery (CABG), stroke,
myocardial infarction (MI), perforation, tamponade, stent thrombosis,
major vascular or bleeding events, contrast nephropathy, and radiation
skin injury were collected. Results: We aggregated data from 19,191
patients who underwent CTO PCI of 20,050 target vessels. Mean age was 62.4
years, 82% were men, and 15% had prior CABG. The CTO artery was the right
coronary (42%), left anterior descending (34%), circumflex (21%) or a
bypass graft (0.6%). Angiographic success was achieved in 76.5% of
patients. The incidence of procedural complications is shown in the Table.
Compared to angiographically successful procedures, unsuccessful
procedures had higher rates of death (0.42% vs 1.54%, p<0.0001),
perforations (3.65% vs 10.70%, p<0.0001), and tamponade (0% vs 1.65%,
p<0.0001). In patients with successful procedures there was a trend
towards lower rates of emergent CABG (0.04% vs 0.17%, p<0.77), stroke
(0.14% vs 0.54%, p<0.15), and Q wave MI (0.26% vs 0.54%, p<0.26). In 886
lesions treated with a retrograde approach, the success rate was 79.8%
with no deaths and low rates of emergent CABG (0.17%) and tamponade
(1.2%). Conclusions: This systematic review and meta-analysis of CTO PCI
complications demonstrates low risk for major procedural complications
suggesting that CTO PCI may be associated with a favorable risk/benefit
profile. (Table presented).

<17>
Accession Number
70902390
Authors
Zhou Y.J. Gao F. Wang Z.
Institution
(Zhou) An Zhen Hospital, Capital Medical University, Beijing, China
(Gao, Wang) Anzhen Hospital Affiliated, Capital Medical University,
Beijing, China
Title
Meta-analysis of percutaneous coronary intervention versus coronary artery
bypass graft surgery in patients with diabetes and left main and/or
multivessel coronary artery disease.
Source
Journal of the American College of Cardiology. Conference: 24th Annual
Symposium of the Transcatheter Cardiovascular Therapeutics, TCT 2012
Miami, FL United States. Conference Start: 20121022 Conference End:
20121026. Conference Publication: (var.pagings). 60 (pp B95-B96), 2012.
Date of Publication: 23 Oct 2012.
Publisher
Elsevier USA
Abstract
Background: The optimal coronary revascularization strategy for patients
with diabetes and left main and/or multivessel disease is undetermined.
The aim of our study was to evaluate percutaneous coronary intervention
(PCI) versus coronary artery bypass graft (CABG) in those patients.
Methods: We identified 13 articles, published before Oct 2011 enrolling
6992 patients, follow-up period ranged from 1 to 5 years. Results:
Patients with PCI had a significant reduction in cerebral vascular attack
(CVA) (OR 0.29, 95% CI 0.16 to 0.51 p<0.0001 I2 =0%) as compared with
CABG, whereas there was a four-fold increased risk of repeat
revascularization associated with PCI even using drug-eluting stent (OR
4.44, 95% CI 3.42 to 5.78, chi2 =4.92 p<0.00001 I2 =0%). The overall
mortality (OR 0.97, 95% CI 0.81 to 1.15, p=0.70, I2 =0%) was comparable
between the PCI and CABG. However, in subgroup analysis, the composite
outcome (death/myocardial infarction/CVA) was significantly reduced in
favor of DES implantation (OR 0.79, 95% CI 0.63 to 0.99, chi2 =1.07,
p=0.04, I2 =0%). (Table Presented) Conclusions: Our study confirmed the
cerebral vascular benefits of PCI by significantly reducing CVA risks, and
the composite outcome was better in patients undergoing PCI with
drug-eluting stent despite a higher repeat revascularization rate. It
poses imperative demands for future prospective randomized studies to
define the optimal strategy in patients with diabetes and left main and/or
multivessel disease.

<18>
Accession Number
70901342
Authors
Schmitz-Rode T.
Institution
(Schmitz-Rode) Institute of Applied Medical Engineering, University
Hospital Aachen, Aachen, Germany
Title
Robotics: Potential major IR role or an expensive research tool?.
Source
CardioVascular and Interventional Radiology. Conference: Cardiovascular
and Interventional Radiological Society of Europe, CIRSE 2012 Lisbon
Portugal. Conference Start: 20120915 Conference End: 20120919. Conference
Publication: (var.pagings). 35 (pp S143-S145), 2012. Date of Publication:
September 2012.
Publisher
Springer New York
Abstract
Learning Objectives 1. To describe rationale and advantages of robotics 2.
To review the current literature 3. To analyse the potential role of this
technique in patient management Introduction Robotics in medicine is an
evolving field with an enormous potential for beneficial applications, in
order to improve diagnostics and therapy. There are quite a number of
projects in service robotics, which are dedicated to health care and may
contribute to home care in future scenarios of "ambient assisted living".
Other projects underline that robotics may play a role in physiotherapy
and musculoskeletal rehabilitation. Besides these activities, there are
two areas in the medical field, where robotic components are part of
innovative treatment concepts, which may have the potential to be included
into new clinical standards: minimal-invasive surgery and radiotherapy. It
is very probable that these trends will have a stimulating effect on
robotic applications in interventional radiology. Robotics in radiotherapy
A linear particle accelerator is mounted on a robotic arm to improve
accuracy of radiotherapy by improved dynamic adjustment of the radiation
beam to the target (CyberKnife, Accuracy [1]). Targeted radiotherapy can
be further supported by robot-assisted automatic patient alignment. A
patient table, connected to a robot arm, is designed to increase accuracy
of positioning during radiotherapy (robotic couch [2]). Movement
compensation of moving targets (due to patient movement or breathing) is a
matter of research. An additional option of a robotic couch is
robot-assisted patient transfer between different imaging modalities for
trauma patients or patients with limited mobility. Robotics in
minimal-invasive surgery In the surgical disciplines there is another
field of advanced research in medical robotics. Several concepts are close
to clinical implementation. The main purpose is to improve the performance
of minimally invasive surgery [3], especially in laparoscopic and
endoscopic instrumentation. Examples of robot tasks are automatic
adjustment of endoscope and light source [4], robotic retaining and
support functions and automation of suction function. In addition, there
are precision tasks through narrow working channels like suturing or
stapling of (micro-)anastomoses. The daVinci system (Intuitive Surgical)
is a robotic surgical system, controlled by a surgeon from a console.
Originally developed for heart and coronary bypass surgery, it is now
clinically established in urologic surgery, mainly for minimal-invasive
removal of the prostate gland. However, it gains increasing acceptance in
other surgical disciplines, like gynecology, abdominal and pediatric
surgery. There are also applications in the cardiovascular field like
mitral valve repair. In a clinical pilot study, the creation of a
robotically assisted aortofemoral anastomosis was examined [5]. The
following advantages of robotics are pointed out: increased precision in
suturing of anastomoses, increased flexibility of the robotic-wristed
instruments, and the ability of motion scaling of hand movements. An
alternative approach to establish a robotic surgical system is the DLR
MiroSurge project [6]. Similar to the daVinci it includes an operator
console, which was recently improved by a tactile and kinesthetic feedback
of robotic instrumentation [7]. Robotics in interventional radiology (IR)
In interventional radiology (IR) currently two major fields of application
of robotics are perceivable: (a) robotics as a guidance modality for
instruments (needles, catheters) in percutaneous interventions and (b)
robotics as a component of imaging devices. The main goals of robotics in
interventional radiology are to increase accuracy of the procedure, to
optimize procedure time and to reduce radiation doses to patient and
interventionalist. This is achieved, for instance, by utilization of
planning scans or preoperative imaging data, which serve as reference data
for high accuracy actuators of the robotic component. An additional aspect
is the possibility to manipulate the interventional device by remote
control from outside the interventional room. For instance, percutaneous
pedicle screw implantation may represent substantial radiation exposure
risk to patients and surgeons. Lieberman et al. [8] could demonstrate a
36% reduction in procedure time and a tremendous (97.8%) reduction in
fluoroscopy time with robotically assisted remote control implantation.
Robotics in non-vascular interventions There is nearly a decade of
research in robotic components for percutaneous non-vascular interventions
[9]. A robotic guidance system, dedicated for percutaneous placement of
interventional instruments, can be used for CT- or fluoroscopy-guided
interventions. Clinical trials were conducted testing the device for
spinal nerve blocks and CT-based puncture of pulmonary nodules [3,10]. A
more recent concept is the so-called Light-Weight Robot LWR III (DLR/
KUKA, Augsburg, Germany). A prototype setting was tested in a feasibility
study of a robotic flat detector CT-guided navigation system for needle
placement [11]. The Innomotion system (Innomedic, Herxheim, Germany) was
designed to be fully compatible with a magnetic resonance imaging
environment by utilizing solely pneumatic robotic components. The robot
can be used to place a needle holder at the skin entry level, according to
a plan defined on preprocedurally acquired CT or MR imaging. Various
phantom-based experiments and a limited clinical study have been carried
out [12]. In a recent study, the Innomotion system was investigated in
exvivo experiments for transapical aortic valve replacement under MRI
guidance [13]. Robotics in vascular interventions In a recent
meta-analysis of robotics in vascular interventions, 15 of 17 references
dealt with laparoscopic procedures for AAA repair, aortic dissection
treatment and endoleak repair [14]. To date, there is only limited
experience with endovascular robotic applications to maneuver catheters. A
robotic remote navigation system (Hansen Medical, Mountain View,
California) was clinically tested for cardiac radiofrequency ablation in
40 patients with atrial fibrillation and flutter [15]. The study suggests
the feasibility of remote control of the robotic catheter for mapping and
ablation. The same system was tested in a phantom setting for cannulation
of branches in fenestrated stent grafts. The findings were that, in
comparison to conventional treatment, the robotic procedure is
significantly faster, requires less catheter movements, and yields higher
performance scores [16]. In a single case study, the Sensei system was
applied clinically for AAA endovascular repair [17]. In a recent study,
Riga et al. state that robotically steerable endovascular catheters offer
improved manoeuvrability at the catheter tip, enhanced positional control
and "off-the-wall" centerline navigation in a remote-control fashion [18].
Robotics in imaging systems The introduction of imaging systems for
interventional radiology or minimal-invasive surgery based on industry
robotics is probably the most visible recent development (Artis zeego,
Siemens Healthcare, Forchheim, Germany). The system consists of a standard
flat panel detector and an x-ray tube mounted on a robot suspended C-arm.
While the system allows standard projection imaging the industrial robot's
high placement accuracy is used to perform CT-grade large volume
cross-sectional imaging scans by specific rotational patterns of the
C-arm. 3-D imaging enables, for instance, pre- and post-interventional
scans for TACE within the IR suite. The robot offers versatile,
reproducible and fast movements of the C-arm, which is especially
beneficial in an interdisciplinary OR environment (e.g. for neurosurgical
and orthopedic interventions). However, there are only few publications,
which evaluate the practical value of the system. One report is on the
clipping of an aneurysm [19]. Intraoperative flat panel detector CT and 3D
rotational angiography images were acquired, fused and sent to a
neuronavigation system to provide intraoperative image guidance. Our team
examined the combination of a robot arm-based flat panel detector with
electromagnetic tracking for CT-guided spine interventions in phantom and
animal model experiments [20]. Feasibility of this combination could be
demonstrated for interventions such as facet joint punctures and
intervertebral disc punctures. Robotics in IR: the future Is there a
potential major IR role of robotics or is it just an expensive research
tool? My prediction is that robotics will not stay merely a "research
tool". I see robotics as an indispensable component of imaging devices, IR
image guidance, navigation and instrumentation in the future. We will have
robotically moved imaging devices with increased versatility and
precision. For instance, in x-ray image guidance of interventions it is
conceivable to move x-ray tube and flat panel detector separately, both
robotically suspended, which obviates the need of a C-arm and allows more
degrees of freedom. In non-vascular interventions, robotically assisted
guidance of instruments to the target lesion will be implemented in
clinical routine. In vascular interventions, robotics will provide
improved manoeuvrability and enhanced positional control of catheters. In
laparoscopic vascular procedures, the benefits of robotics are increased
flexibility by robotic-wristed instrumentation and precision suturing.
General advantages for all applications are the ability of motion scaling
of hand movements and the reduction of radiation by remote control.
However, in order to reach this level of clinical implementation, there is
still a way to go. Current research tasks are the optimization of
interoperability and workflow integration of robotic components, and the
improvement of haptic feedback for the operator.

<19>
Accession Number
70901289
Authors
Carrafiello G. Fontana F. Mangini M. Ierardi A.M. Nocchi Cardim L.
Piacentino F. Pellegrino C. Floridi C. Fugazzola C.
Institution
(Carrafiello, Fontana, Mangini, Ierardi, Nocchi Cardim, Piacentino,
Pellegrino, Floridi, Fugazzola) Radiology, University of Insubria, Varese,
Italy
Title
How to select patients for tumour ablation.
Source
CardioVascular and Interventional Radiology. Conference: Cardiovascular
and Interventional Radiological Society of Europe, CIRSE 2012 Lisbon
Portugal. Conference Start: 20120915 Conference End: 20120919. Conference
Publication: (var.pagings). 35 (pp S95-S97), 2012. Date of Publication:
September 2012.
Publisher
Springer New York
Abstract
Learning Objectives 1. To discuss the rationale and the indications of
ablation in lung cancer 2. To discuss what is the role of imaging in
patient selection 3. To clarify the complementary role of ablation in the
management of lung cancer as compared with other treatments Lung tumour
represents the neoplasm with the major incidence and mortality rates
worldwide (1.35 million new cases annually and 1.18 million of deaths),
with the highest frequency in Europe and the United States of America [1].
In Italy, from 1998 to 2002, lung cancer was found to be the fourth tumour
in frequency among cancers diagnosed in women (4.6% of all female cancers)
and third in males (14.2% of all male cancers), establishing the most
frequent cause of cancer death in men [2]. Among the different
histological types, the most common are non-small cell lung cancer (NSCLC)
and among these, adenocarcinoma is the most frequent (30-40%) [2, 3]. The
lung is a frequent site also for metastases, which occur in 30% of all
cancers, especially from haematogenous spread. Patients with non-small
cell lung cancer (NSCLC) have a median survival of 6 to 8 months, and
1-year survival rate for only 10-20% [4]. The standard treatment for
stages I, II and IIIa NSCLC is surgical resection, the unique approach
with cure prospective and long-term survival [5]. Radiotherapy and
chemotherapy are frequently used as adjuvant and/ or neoadjuvant therapies
to surgery [6, 7, 8]. However, only about one-third of the patients are
eligible for surgery, and most of them have advanced disease at diagnosis
[9]. Almost all patients have some comorbidities as poor pulmonary
function, poor clinical conditions or advanced age and do not have
sufficient clinical reserves to withstand a lobectomy or pneumonectomy
[10]. Therefore, these patients are often treated with radiation therapy
or palliative treatment [11,12]. Unfortunately, chemotherapy and external
beam radiation therapy did not influence significantly the outcomes of
patients with unresectable disease; in addition, greater efficacy in these
therapies is often accompanied by significant toxicity, especially for
patients with associated comorbidities. There is no gold standard
treatment for inoperable patients both, thanks to their advanced disease
and also owing to high surgical risk due to poor clinical conditions [13].
Therefore, the use of alternatives to conventional therapies such as
percutaneous ethanol injection (PEI), thermal laser ablation,
cryoablation, radiofrequency (RFA) and microwave (MWA), proves to be a
good treatment option. Among these different therapies, the RFA has
enjoyed a longer application and greater success, and was promptly
introduced into clinical practice [14,15]. The latest advancements in
minimally invasive treatment for lung cancer are the MWA, which offer many
of the RF benefits associated with theoretical advantages [16]. Rose et
al. [17] proposed guidelines for papers about lung tumours thermal
ablation. Patient selection was emphasized once thermal ablation is not a
gold standard treatment of lung cancer; the patient selection criteria
should always be clearly described. The first point is regarding biopsy;
that should always be performed to confirm the diagnosis of malignancy
[18]. In our study, biopsy was performed in all patients as for the
majority of papers in Literature, though some of them use only clinical
evidence as disease confirmation in case of metastatic lesions
histologically known or recurrences, without performing biopsy [19- 30].
Coagulation disorders may exclude patients from selection for thermal
ablation therapy [31-33], as reported in 9 papers, and some of them
defined also an maximum INR value. CLINICAL CRITERIA: All patients who are
supposed to undergo ablative therapies should not be subjected to
conventional treatment or should have not answered to these treatments
[32,34,35]. This decision is usually undertaken by a multidisciplinary
team; in our case, the reference clinician (oncologist or pneumologist),
the thoracic surgeon, the interventional radiologist and the
anesthesiologist. Of the 24 studies analyzed, this information is found
only in 12 studies [13,23,27-30,36-40]. The clinical criteria
fundamentally consist in poor lung function (for which most centres
establish an inferior limit of 1 L,), the chronic obstructive pulmonary
disease, and the different comorbidities changeable from Centre to Centre,
responsible, in most of the cases, for ascertaining inoperability; the
detected comorbidities were cardiopathies, haepatic cirrhosis, chronic
renal insufficiency, hemodynamic disorders, multiple sclerosis, aortic
aneurysm, carotid stenosis, congestive heart failure, low "performance
status", stable angina, valvular heart disease and high cardiac risk
[13,19,20,24,26-30,36,39,41-46]. It is paramount that the decease risk for
comorbidities do not exceed the decease risk for the tumour; otherwise,
the patient automatically cannot be considered a candidate for thermal
ablation [47]. Advanced age is considered in few studies [13,21,22,47] as
an inoperability criterion; in our study it is indirectly considered. The
employment of thermal ablation for lung metastasis is widespread and shows
excellent results [13,20,48,49], in accordance with our study results.
None of our patients underwent the thermal ablation procedure for surgical
refuse; this "inoperability" reason was present in 18
[19,20,22,23,26-30,36-45] of the 24 reported studies. RADIOLOGICAL
CRITERIA: Radiological selection criteria are lesions diameter, disease
extension (number of lesions per hemithorax and extrapulmonary lesions)
and adjacency to large vessels (>3 mm), heart and trachea [9,49,50]. The
lesion diameter should not overcome 6cm if with a curative purpose, and
when lager than 3 cm, it is preferable the MWA employment [20-22,51-57].
There are some divergences about the maximum number of lesions accepted
for hemithorax; some centres accept until 9 lesions, our centre until 4
[34,35]. Extrapulmonary lesions are another divergence issue; some centres
consider it as an inclusion criterion [13,19,28,30,32,34,3644,58,59] and
other ones, as an exclusion criterion [27,40-42,46,60]. Our centre
understands that, if controlled and recent, the extrapulmonary lesion does
not exclude thermal ablation therapy, even if with palliative purpose, in
accordance with findings of other studies [9,32,34,58,59]. The majority of
the Centres exclude the patients with lesions in adjacency to heart, large
vessels and trachea [13,19,22,29,30,38,39,47,60]; some studies report
central ablations with success [60] as our study, which reports the
success of a case in adjacency to supra-aortic trunks. In our study, there
is the choice between RFA and MWA. Multiple are the advantages offered by
microwave technology: lager volume of necrosis, reduction of procedure
duration, mayor temperature to target lesions, the possibility to employ
multiple antenna simultaneously, efficacy in lesions with cystic component
and/or in adjacency to vessels > 3cm and less intraprocedural pain
[49,51,61,62,63]. For minor lesions (< 3 cm) not close to vessels > 3 mm,
it is immaterial whether one or the other technique [51] is employed. The
failure of conventional therapies is another indication to thermal
ablation [13,20-22,24,26,29,37- 39,41,42,45,48,59,64]. The refusal to
undergo surgery [31,35] is another important thermal ablation criterion
related in Literature despite there being no cases in our study.A clear
exposition of selection criteria is still not a routine for Authors. For
that reason is not momentarily possible to establish unambiguous thermo
ablative therapies indications criteria. Whereas, it is necessary a
randomized controlled study to comparing RFA and MWA to evaluate the best
choice for the patient. In a near future, could be interesting to perform
a randomized study comparing surgery and thermal ablation.