EMBASE Cardiac Update AutoAlert: EPICORE Cardiac Surgery Blogger2

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<1>
Accession Number
2014709396
Authors
Takagi H. Umemoto T.
Institution
(Takagi, Umemoto) Department of Cardiovascular Surgery, Shizuoka Medical
Center, Shizuoka, Japan
Title
Worse long-term survival after off-pump than on-pump coronary artery
bypass grafting.
Source
Journal of Thoracic and Cardiovascular Surgery. 148 (5) (pp 1820-1831.e1),
2014. Date of Publication: 01 Nov 2014.
Publisher
Mosby Inc.
Abstract
Objective To determine whether off-pump coronary artery bypass grafting
(CABG) is associated with worse long-term survival compared with on-pump
CABG. We performed a meta-analysis of adjusted observational studies and
randomized controlled trials.
Methods MEDLINE, EMBASE, and the Cochrane Central Register of Controlled
Trials were searched through March 2014. Eligible studies were randomized
controlled trials and adjusted observational studies (in which appropriate
statistical methods adjusting for confounders had been used) of off-pump
versus on-pump CABG that had reported long-term (5-year) all-cause
mortality as an outcome.
Results Of 478 potentially relevant studies screened initially, 5
randomized trials and 17 observational studies, enrolling a total of
104,306 patients, were identified and included. A pooled analysis of all
22 studies demonstrated a statistically significant 7% increase in
long-term all-cause mortality with off-pump relative to on-pump CABG
(hazard ratio, 1.07; 95% confidence interval, 1.03-1.11; P =.0003).
Although a pooled analysis of 5 randomized trials (1486 patients)
demonstrated a statistically nonsignificant 14% increase in mortality with
off-pump relative to on-pump CABG (hazard ratio, 1.14; 95% confidence
interval, 0.84-1.56; P =.39), another pooled analysis of 17 observational
studies (102,820 patients) demonstrated a statistically significant 7%
increase in mortality with off-pump relative to on-pump CABG (hazard
ratio, 1.07; 95% confidence interval, 1.03-1.11; P =.0004).
Conclusions A meta-analysis of 22 studies, enrolling a total of >100,000
patients, showed that off-pump CABG is likely associated with worse
long-term (5-year) survival compared with on-pump CABG.

<2>
Accession Number
2014730632
Authors
Falk-Brynhildsen K. Soderquist B. Friberg O. Nilsson U.
Institution
(Falk-Brynhildsen, Friberg) Department of Cardiothoracic and Vascular
Surgery, Orebro University Hospital, Orebro, Sweden
(Falk-Brynhildsen, Nilsson) School of Health and Medical Sciences, Orebro
University, Orebro, Sweden
(Soderquist) Orebro University, Orebro, Sweden
(Soderquist) Department of Laboratory Medicine, Clinical Microbiology,
Orebro University Hospital, Orebro, Sweden
Title
Bacterial growth and wound infection following saphenous vein harvesting
in cardiac surgery: a randomized controlled trial of the impact of
microbial skin sealant.
Source
European Journal of Clinical Microbiology and Infectious Diseases. 33 (11)
(pp 1981-1987), 2014. Date of Publication: 19 Oct 2014.
Publisher
Springer Verlag
Abstract
The aim of the present study was to compare microbial skin sealant versus
bare skin on the leg regarding intraoperative bacterial presence in the
surgical wound and time to recolonization of the adjacent skin at the
saphenous vein harvesting site. A second aim was to evaluate the incidence
of leg wound infection 2 months after surgery. In this randomized
controlled trial, 140 patients undergoing coronary artery bypass grafting
(CABG) between May 2010 and October 2011 were enrolled. Bacterial samples
were taken preoperatively and intraoperatively at multiple time points and
locations. OF the patients, 125 (92.6 %) were followed up 2 months
postoperatively regarding wound infection. Intraoperative bacterial growth
did not differ between the bare skin (n = 68) and the microbial skin
sealant group (n = 67) at any time point. At 2 months postoperatively,
7/61 patients (11.5 %) in the skin sealant versus 14/64 (21.9 %) in the
bare skin group (p = 0.120) had been treated with antibiotics for a
verified or suspected surgical site infection (SSI) at the harvest site.
We found almost no intraoperative bacterial presence on the skin or in the
subcutaneous tissue, irrespective of microbial skin sealant use. In
contrast, we observed a relatively high incidence of late wound infection,
indicating that wound contamination occurred postoperatively. Further
research is necessary to determine whether the use of microbial skin
sealant reduces the incidence of leg wound infection at the saphenous vein
harvest site.

<3>
Accession Number
2014746686
Authors
Ohtaki Y. Shimizu K.
Institution
(Ohtaki, Shimizu) Department of Thoracic and Visceral Organ Surgery, Gunma
University Graduate School of Medicine, Maebashi, Gunma, Japan
Title
Anatomical thoracoscopic segmentectomy for lung cancer.
Source
General Thoracic and Cardiovascular Surgery. 62 (10) (pp 586-593), 2014.
Date of Publication: 04 Oct 2014.
Publisher
Springer-Verlag Tokyo
Abstract
Minimally invasive surgery for lung cancer has seen considerable progress.
A segmentectomy is less invasive than a lobectomy as it preserves lung
parenchyma. The preservation of pulmonary function can reduce
complications. The combination of a thoracoscopic approach with a
segmentectomy should be less invasive, and retrospective studies have
shown that the thoracoscopic approach is safe and feasible due to the
lower postoperative mortality and complication rates as compared to an
open thoracotomy. The validity of a segmentectomy for
ground-glass-opacity-type lung cancer has been demonstrated, and it has
also been evaluated for small, predominantly solid, lung cancers. Two
prospective studies of segmentectomy versus lobectomy for <2-cm
non-small-cell lung cancer are now underway (CALGB 140503 and
JCOG0802/WJTOG4607L) and should clarify the role of segmentectomy.
Regarding thoracoscopic segmentectomy, few retrospective studies have
reported the oncological outcome for lung cancer and there is inadequate
evidence regarding the long-term oncological outcome, although the
perioperative complication rate and duration of hospital stay seem to be
non-inferior to those of an open approach. For preoperative simulation,
three-dimensional multidetector computed tomography (3D-CT) is essential
for performing an atypical thoracoscopic segmentectomy safely.
Preoperative 3D-CT angiography and bronchography (3D-CTAB) enable accurate
identification of the venous branches in the affected segment and the
intersegmental vein. This review describes the surgical and oncological
outcomes, utility of 3D-CTAB, and surgical techniques and procedure used
for a thoracoscopic segmentectomy.

<4>
Accession Number
2014722040
Authors
Harskamp R.E. Williams J.B. Halkos M.E. Lopes R.D. Tijssen J.G.P. Ferguson
T.B. De Winter R.J.
Institution
(Harskamp, Williams, Lopes) Duke Clinical Research Institute, Durham, NC,
United States
(Harskamp, Tijssen, De Winter) Academic Medical Center-University of
Amsterdam, Amsterdam, Netherlands
(Halkos) Division of Cardiothoracic Surgery, Emory University School of
Medicine, Atlanta, GA, United States
(Ferguson) Department of Cardiovascular Sciences, East Carolina University
Brody School of Medicine, Greenville, NC, United States
Title
Meta-analysis of minimally invasive coronary artery bypass versus
drug-eluting stents for isolated left anterior descending coronary artery
disease.
Source
Journal of Thoracic and Cardiovascular Surgery. 148 (5) (pp 1837-1842),
2014. Date of Publication: 01 Nov 2014.
Publisher
Mosby Inc.
Abstract
Results From 230 publications, we identified 4 studies (2 randomized and 2
observational) with 941 patients (478 had undergone MINI-CAB and 463 DES
implantation). The incidence of target vessel revascularization at maximum
follow-up (range, 6-60 months) was significantly lower in the MINI-CAB
group (OR, 0.16; 95% CI, 0.08-0.30; P <.0001; number needed to treat, 13).
The incidence of cardiac mortality and MI was similar between the MINI-CAB
and DES groups during follow-up (OR, 1.05; 95% CI, 0.44-2.47; and OR,
0.83; 95% CI, 0.43-1.58, respectively). In addition, a similar incidence
of periprocedural death (OR, 0.85; 95% CI, 0.21-3.47; P =.82), myocardial
infarction (OR, 0.98; 95% CI, 0.38-2.58; P =.97), and stroke (OR, 1.36;
95% CI, 0.28-6.70; P =.70) was observed between the 2 treatment
modalities.
Conclusions Given the available evidence, MINI-CAB will result in lower
target vessel revascularization rates but otherwise similar clinical
outcomes compared with DESs in patients with left anterior descending
artery disease.
Objective To compare the outcomes between minimally invasive coronary
artery bypass (MINI-CAB) and drug-eluting stent (DES) implantation for
isolated left anterior descending artery disease.
Methods Randomized and observational comparative publications were
identified using MEDLINE and Google Scholar databases (January 2003 to
December 2013). Studies without outcomes data, without DES use, or using
conventional bypass surgery were excluded. The outcomes of interest were
cardiac death, myocardial infarction, target vessel revascularization, and
periprocedural stroke. Data were compared using the Mantel-Haenszel
methods and are presented as odds ratios (ORs), 95% confidence intervals
(CIs), and number needed to treat.

<5>
Accession Number
2014750118
Authors
Motoki H. Koyama J. Izawa A. Tomita T. Miyashita Y. Takahashi M. Ikeda U.
Institution
(Motoki, Koyama, Izawa, Tomita, Miyashita, Ikeda) Department of
Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1
Asahi, Matsumoto 390-8621, Japan
(Takahashi) Division of Bioimaging Sciences, Center for Molecular
Medicine, Jichi Medical University, Shimotsuke, Japan
Title
Impact of azelnidipine and amlodipine on left ventricular mass and
longitudinal function in hypertensive patients with left ventricular
hypertrophy.
Source
Echocardiography. 31 (10) (pp 1230-1238), 2014. Date of Publication: 01
Nov 2014.
Publisher
Blackwell Publishing Inc.
Abstract
Background: The impact of long-acting calcium channel blocker (CCB)
administration on serial changes in left ventricular (LV) function and
morphology in hypertensive patients with LV hypertrophy remains unclear.
This study attempted to clarify this impact by comparing the effects of
administration of azelnidipine with that of amlodipine using conventional
and speckle tracking echocardiography. Methods: An equal number (16) of 32
hypertensive patients was prospectively assigned to a group administered 5
mg of amlodipine/day or a group administered 16 mg of azelnidipine/day. LV
function and morphology was examined by conventional and speckle tracking
echocardiography at baseline and at 1, 3, 6, and 12 months after treatment
initiation. Results: Both groups were found to have experienced a
significant decrease in systolic blood pressure by 1 month after treatment
initiation; a significant reduction in septal thickness and LV mass index
at 6 and 12 months. Transmitral fl ow E/A ratio and early diastolic mitral
annular velocity at lateral wall significantly improved at 12 months. On
the other hand, a significant improvement of global longitudinal strain
was observed earlier than the above indexes at 3, 6, and 12 months. Ar-A
duration difference was significantly decreased at 3 months. The global
circumferential strain improved significantly at 3 months, but there were
no signifi cant changes in mid-/apical circumferential and radial strains
throughout the study period. Conclusion: Azelnidipine has beneficial
effects on LV mass regression, transmitral flow, tissue Doppler, and LV
longitudinal strain that are comparable to those of amlodipine on the same
parameters.

<6>
Accession Number
2014761038
Authors
Sundermann S.H. Sromicki J. Rodriguez Cetina Biefer H. Seifert B. Holubec
T. Falk V. Jacobs S.
Institution
(Sundermann, Sromicki, Rodriguez Cetina Biefer, Holubec, Falk, Jacobs)
Division of Cardiovascular Surgery, University Hospital Zurich, Zurich,
Switzerland
(Rodriguez Cetina Biefer) Transplantation Surgery Research Laboratory,
Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United
States
(Seifert) Division of Biostatistics, Institute of Social and Preventive
Medicine, University of Zurich, Zurich, Switzerland
Title
Mitral valve surgery: Right lateral minithoracotomy or sternotomy? A
systematic review and meta-analysis.
Source
Journal of Thoracic and Cardiovascular Surgery. 148 (5) (pp 1989-1995.e5),
2014. Date of Publication: 01 Nov 2014.
Publisher
Mosby Inc.
Abstract
Objective To update the current evidence on mitral valve surgery through a
lateral minithoracotomy versus median sternotomy.
Methods A comprehensive literature research was performed for studies
comparing mitral valve surgery through a right lateral minithoracotomy
(MIVS) and median sternotomy in MEDLINE, EMBASE, Cochrane Central, CTSnet,
and Google Scholar for the most recent literature up to April 2013. A
systematic review and meta-analysis was performed on the studies found in
the literature.
Results More than 20,000 patients from 45 studies were included in this
study. Stroke rate and all-cause mortality up to 30 days was similar in
both groups. The length of stay in the intensive care unit, respirator
dependence, and hospital stay were significantly shorter in the MIVS
group. Furthermore, blood drainage volume and blood transfusions were
decreased in the MIVS group. In contrast, cardiopulmonary bypass time,
crossclamp time, and procedure time were longer in the MIVS group.
Postoperative new atrial fibrillation was less in the MIVS group. More
aortic dissections occurred in the MIVS group. The rates of reexploration
and postoperative renal failure were similar in both groups.
Conclusions MIVS and conventional mitral valve surgery have a similar
perioperative outcome. Mitral valve surgery via a right lateral
minithoracotomy seems to be favorable with regard to resource-related
outcome.

<7>
Accession Number
2014766280
Authors
Cantinotti M. Law Y. Vittorini S. Crocetti M. Marco M. Murzi B. Clerico A.
Institution
(Cantinotti, Vittorini, Crocetti, Marco, Murzi, Clerico) Fondazione
Toscana G. Monasterio, Ospedale del Cuore, via Aurelia Sud, Massa, Pisa
54100, Italy
(Law) Seattle Children Hospital, University of Washington School of
Medicine, Seattle, WA, United States
(Clerico) Scuola Superiore Sant'Anna, Pisa, Pisa, Italy
Title
The potential and limitations of plasma BNP measurement in the diagnosis,
prognosis, and management of children with heart failure due to congenital
cardiac disease: an update.
Source
Heart Failure Reviews. 19 (6) (pp 727-742), 2014. Date of Publication: 11
Oct 2014.
Publisher
Kluwer Academic Publishers
Abstract
The aim of this article is to review the diagnostic and prognostic
relevance of measurement of brain natriuretic peptide (BNP) and N-terminal
pro-brain natriuretic peptide (NT-proBNP) in pediatric patients with heart
failure caused by various acquired and congenital heart diseases (CHD). In
January 2013, we performed a computerized literature search in the
National Library of Medicine (PubMed access to MEDLINE citations;
http://www.ncbi.nlm.nih.gov/PubMed/). The search strategy included a mix
of Medical Subject Headings and free-text terms for the key concepts,
starting from BNP assay and 'NT-proBNP assay', children, CHD. The search
was further refined by adding the keywords neonate/s, newborn/s, heart
failure, cardiomyopathy, screening, prognosis, follow-up, and management.
BNP values are age and method dependent, even in pediatric populations.
Regardless of age, there is great variability in BNP/NT-proBNP values
within CHD characterized by different hemodynamic and clinical conditions.
There is enough evidence to support the use of BNP/NT-proBNP as an
adjunctive marker in the integrated evaluation of patients with congenital
and acquired heart disease to help define severity and progression of
heart failure as well in the monitoring of response to treatment.
BNP/NT-proBNP can also be used for the screening of heart failure and as a
prognostic marker in children undergoing cardiac surgery; however, to
date, there are studies with heterogeneous patient groups, and diverse
outcome measures selected are still few. BNP/NT-proBNP can be used as
adjunctive markers in the integrated screening, diagnosis, management, and
follow-up of children with heart failure caused by various acquired and
congenital heart disease.

<8>
Accession Number
2014804849
Authors
Mark D.B. Knight J.D. Velazquez E.J. Wasilewski J. Howlett J.G. Smith P.K.
Spertus J.A. Rajda M. Yadav R. Hamman B.L. Malinowski M. Naik A. Rankin G.
Harding T.M. Drew L.A. Desvigne-Nickens P. Anstrom K.J.
Institution
(Mark, Knight, Velazquez, Rankin, Harding, Drew, Anstrom) Duke Clinical
Research Institute, PO Box 17969, Durham, NC 27715, United States
(Wasilewski) Silesian Center for Heart Diseases, M. Curie-Sklodowskiej 9,
Zabrze 41-800, Poland
(Howlett) Foothills Medical Center, University of Calgary, 1403 29th
Street NW, Calgary, AB T2N 2T9, Canada
(Smith) Duke University Medical Center, Box 3442, Durham, NC 27710, United
States
(Spertus) Saint Luke's Mid America Heart Institute, University of
Missouri-Kansas City, 4401 Wornall Road, Kansas City, MO 64111, United
States
(Rajda) Queen Elizabeth II Health Sciences Centre, Halifax Infimary Site
2261, 1796 Summer Street, Halifax, NS B3H 3A7, Canada
(Yadav) All India Institute of Medical Sciences, Ansari Nagar, New Dehli
110029, India
(Hamman) Baylor Soltero Cardiovascular Research Center, 621 North Hall
Street, Dallas, TX 75226, United States
(Malinowski) 2nd Department of Cardiac Surgery, Medical University of
Silesia, Ziolowa 47, Katowice 40-635, Poland
(Naik) Care Institute of Medical Sciences, Science City Road, Sola,
Ahmedabad Gujarat 380060, India
(Desvigne-Nickens) Division of Cardiovascular Sciences, National Heart,
Lung, and Blood Institute, National Institutes of Health, 6701 Rockledge
Drive, Bethesda, MD 20892, United States
Title
Quality-of-life outcomes with coronary artery bypass graft surgery in
ischemic left ventricular dysfunction: A randomized trial.
Source
Annals of Internal Medicine. 161 (6) (pp 392-399), 2014. Date of
Publication: 16 Sep 2014.
Publisher
American College of Physicians (190 N. Indenpence Mall West, Philadelphia
PA 19106-1572, United States)
Abstract
Measurements: A battery of QOL instruments at baseline (98.9% complete)
and 4, 12, 24, and 36 months after randomization (collection rates were
80% to 89% of those eligible). The principa prespecified QOL measure was
the Kansas City Cardiomyopathy Questionnaire, which assesses the effect of
heart failure on patients' symptoms, physical function, social
limitations, and QOL.
Results: The Kansas City Cardiomyopathy Questionnaire overall summary
score was consistently higher (more favorable) in the CABG group than in
the medical therapy group by 4.4 points (95% CI, 1.8 to 7.0 points) at 4
months, 5.8 points (CI, 3.1 to 8.6 points) at 12 months, 4.1 points (CI,
1.2 to 7.1 points) at 24 months, and 3.2 points (CI, 0.2 to 6.3 points) at
36 months. Sensitivity analyses to account for the effect of mortality on
follow-up QOL measurement were consistent with the primary findings.
Limitation: Therapy was not masked.
Conclusion: In this cohort of symptomatic high-risk patients with ischemic
left ventricular dysfunction and multivessel coronary artery disease, CABG
plus medical therapy produced clinically important improvements in quality
of life compared with medical therapy alone over 36 months.
Objective: To describe treatment-related quality-of-life (QOL) outcomes, a
major prespecified secondary end point in the STICH trial.
Background: The STICH (Surgical Treatment for Ischemic Heart Failure)
trial compared a strategy of routine coronary artery bypass grafting
(CABG) with guideline-based medical therapy for patients with ischemic
left ventricular dysfunction.
Design: Randomized trial. (ClinicalTrials.gov: NCT00023595).
Setting: 99 clinical sites in 22 countries.
Patients: 1212 patients with a left ventricular ejection fraction of 0.35
or less and coronary artery disease.
Intervention: Random assignment to medical therapy alone (602 patients) or
medical therapy plus CABG (610 patients).

<9>
Accession Number
2014797471
Authors
Christopoulos G. Menon R.V. Karmpaliotis D. Alaswad K. Lombardi W.
Grantham A. Patel V.G. Rangan B.V. Kotsia A.P. Lembo N. Kandzari D.
Carlson H. Garcia S. Banerjee S. Thompson C.A. Brilakis E.S.
Institution
(Christopoulos, Menon, Patel, Rangan, Kotsia, Banerjee, Brilakis) VA North
Texas Healthcare System, UT Southwestern Medical Center, Dallas VA Medical
Center (111A), 4500 South Lancaster Road, Dallas, TX 75216, United States
(Karmpaliotis) Columbia University, New York, NY, United States
(Alaswad) Appleton Cardiology, Appleton, WI, United States
(Lombardi) PeaceHealth Cardiology, Bellingham, WA, United States
(Grantham) Mid America Heart Institute, Kansas City, MO, United States
(Lembo, Kandzari, Carlson) Piedmont Hospital, Atlanta, GA, United States
(Garcia) Minneapolis VA Healthcare System, University of Minnesota,
Minneapolis, MN, United States
(Thompson) Yale University School of Medicine, New Haven, CT, United
States
Title
The efficacy and safety of the "hybrid" approach to coronary chronic total
occlusions: Insights from a contemporary multicenter US registry and
comparison with prior studies.
Source
Journal of Invasive Cardiology. 26 (9) (pp 427-432), 2014. Date of
Publication: 01 Sep 2014.
Publisher
HMP Communications
Abstract
BACKGROUND: Percutaneous coronary intervention (PCI) for chronic total
occlusion (CTO) is challenging and has been associated with low success
rates. However, recent advancements in equipment and the flexibility to
switch between multiple technical approaches during the same procedure
("hybrid" percutaneous algorithm) have dramatically increased the success
of CTO-PCI. We sought to compare the contemporary procedural outcomes of
hybrid CTO-PCI with previously published CTO-PCI studies. METHODS: The
procedural outcomes of 497 consecutive CTO-PCIs performed between January
2012 and August 2013 at five high-volume centers in the United States were
compared with the pooled success and complication rates reported in 39
prior CTO-PCI series that included >100 patients and were published after
2000. RESULTS: The baseline clinical and angiographic characteristics of
the study patients were comparable to those of previous studies. Technical
and procedural success was achieved in 455 cases (91.5%) and 451 cases
(90.7%), respectively, and were significantly higher than the pooled
technical and procedural success rates from prior studies (76.5%, P<.001
and 75.2%, P<.001, respectively). Major procedural complications occurred
in 9/497 patients (1.8%) overall and included death (2 patients), acute
myocardial infarction (5 patients), repeat target vessel PCI (1 patient),
and tamponade requiring pericardiocentesis (2 patients). The incidence of
major complications was similar to that of prior studies (pooled rate
2.0%; P<.72). CONCLUSION: Use of the hybrid approach to CTO-PCI is
associated with higher success and similar complication rates compared to
prior studies, supporting its expanded use for treating these challenging
lesions.

<10>
Accession Number
2014796031
Authors
Imazio M. Brucato A. Ferrazzi P. Pullara A. Adler Y. Barosi A. Caforio
A.L. Cemin R. Chirillo F. Comoglio C. Cugola D. Cumetti D. Dyrda O. Ferrua
S. Finkelstein Y. Flocco R. Gandino A. Hoit B. Innocente F. Maestroni S.
Musumeci F. Oh J. Pergolini A. Polizzi V. Ristic A. Simon C. Spodick D.H.
Tarzia V. Trimboli S. Valenti A. Belli R. Gaita F.
Institution
(Imazio, Belli) Department of Cardiology, Maria Vittoria Hospital,
University of Torino, Via Cibrario 72, Torino, Torino 10141, Italy
(Imazio, Pullara, Gaita) University of Torino, Torino, Italy
(Brucato, Ferrazzi, Cugola, Cumetti, Innocente, Maestroni, Simon, Valenti)
Ospedale Papa Giovanni XXIII, Bergamo, Italy
(Pullara, Gaita) AOU Citta Della Salute e Della Scienza di Torino, Torino,
Italy
(Adler) Chaim Sheba Medical Center, Tel Hashomer and Sacker University,
Tel Aviv, Israel
(Barosi, Gandino) Department of Internal Medicine and Cardiac Surgery,
Ospedale Niguarda, Milano, Italy
(Caforio, Tarzia) Department of Cardiological Thoracic and Vascular
Sciences, University of Padova, Padova, Italy
(Cemin) Cardiology Department, Ospedale Regionale San Maurizio, Bolzano,
Italy
(Chirillo) Department of Cardiology and Cardiac Surgery, Ca Foncello
Hospital, Treviso, Italy
(Comoglio, Dyrda, Trimboli) Department of Cardiac Surgery and
Rehabilitation, Villa Maria Pia Hospital, Torino, Italy
(Ferrua) Department of Cardiology, Ospedale degli Infermi, Rivoli, Italy
(Finkelstein) Department of Pediatrics, Hospital for Sick Children,
University of Toronto, Toronto, ON, Canada
(Flocco) Cardiac Surgery, Ospedale Mauriziano, Torino, Italy
(Hoit) Case Western Reserve University, Cleveland, OH, United States
(Hoit) University Hospitals Case Medical Center, Cleveland, OH, United
States
(Musumeci, Pergolini, Polizzi) Department of Cardiac Surgery, Ospedale San
Camillo, Roma, Italy
(Oh) Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN,
United States
(Ristic) Department of Cardiology, Belgrade University School of Medicine,
Clinical Centre of Serbia, Belgrade, Serbia
(Spodick) St Vincent Hospital, Worcester, MA, United States
Title
Colchicine for prevention of postpericardiotomy syndrome and postoperative
atrial fibrillation: The COPPS-2 randomized clinical trial.
Source
JAMA - Journal of the American Medical Association. 312 (10) (pp
1016-1023), 2014. Date of Publication: 10 Sep 2014.
Publisher
American Medical Association
Abstract
IMPORTANCE: Postpericardiotomy syndrome, postoperative atrial fibrillation
(AF), and postoperative effusions may be responsible for increased
morbidity and health care costs after cardiac surgery. Postoperative use
of colchicine prevented these complications in a single trial. OBJECTIVE:
To determine the efficacy and safety of perioperative use of oral
colchicine in reducing postpericardiotomy syndrome, postoperative AF, and
postoperative pericardial or pleural effusions. DESIGN, SETTING, AND
PARTICIPANTS: Investigator-initiated, double-blind, placebo-controlled,
randomized clinical trial among 360 consecutive candidates for cardiac
surgery enrolled in 11 Italian centers between March 2012 and March 2014.
At enrollment, mean age of the trial participants was 67.5 years (SD, 10.6
years), 69% were men, and 36% had planned valvular surgery. Main exclusion
criteria were absence of sinus rhythm at enrollment, cardiac
transplantation, and contraindications to colchicine. INTERVENTIONS:
Patients were randomized to receive placebo (n=180) or colchicine (0.5mg
twice daily in patients >70 kg or 0.5 mg once daily in patients <70 kg;
n=180) starting between 48 and 72 hours before surgery and continued for 1
month after surgery. MAIN OUTCOMES AND MEASURES: Occurrence of
postpericardiotomy syndrome within 3 months; main secondary study end
points were postoperative AF and pericardial or pleural effusion. RESULTS:
The primary end point of postpericardiotomy syndrome occurred in 35
patients (19.4%) assigned to colchicine and in 53 (29.4%) assigned to
placebo (absolute difference, 10.0%; 95% CI, 1.1%-18.7%; number needed to
treat = 10). There were no significant differences between the colchicine
and placebo groups for the secondary end points of postoperative AF
(colchicine, 61 patients [33.9%]; placebo, 75 patients [41.7%]; absolute
difference, 7.8%; 95% CI, -2.2% to 17.6%) or postoperative
pericardial/pleural effusion (colchicine, 103 patients [57.2%]; placebo,
106 patients [58.9%]; absolute difference, 1.7%; 95% CI, -8.5% to 11.7%),
although there was a reduction in postoperative AF in the prespecified
on-treatment analysis (placebo, 61/148 patients [41.2%]; colchicine,
38/141 patients [27.0%]; absolute difference, 14.2%; 95% CI, 3.3%-24.7%).
Adverse events occurred in 21 patients (11.7%) in the placebo group vs 36
(20.0%) in the colchicine group (absolute difference, 8.3%; 95% CI;
0.76%-15.9%; number needed to harm = 12), but discontinuation rates were
similar. No serious adverse events were observed. CONCLUSIONS AND
RELEVANCE: Among patients undergoing cardiac surgery, perioperative use of
colchicine compared with placebo reduced the incidence of
postpericardiotomy syndrome but not of postoperative AF or postoperative
pericardial/pleural effusion. The increased risk of gastrointestinal
adverse effects reduced the potential benefits of colchicine in this
setting. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01552187
Copyright 2014 American Medical Association. All rights reserved.

<11>
Accession Number
2014796030
Authors
O'Donoghue M.L. Braunwald E. White H.D. Steen D.P. Lukas M.A. Tarka E.
Steg P.G. Hochman J.S. Bode C. Maggioni A.P. Im K. Shannon J.B. Davies
R.Y. Murphy S.A. Crugnale S.E. Wiviott S.D. Bonaca M.P. Watson D.F. Weaver
W.D. Serruys P.W. Cannon C.P.
Institution
(O'Donoghue, Braunwald, Steen, Im, Murphy, Crugnale, Wiviott, Bonaca,
Cannon) TIMI Study Group, Cardiovascular Division, Brigham AndWomen's
Hospital, 350 Longwood Ave, Boston, MA 02115, United States
(White) Green Lane Cardiovascular Service, Auckland City Hospital,
Auckland University, Auckland, New Zealand
(Lukas) Metabolic Pathways and Cardiovascular Therapeutic Area,
GlaxoSmithKline, Philadelphia, PA, United States
(Tarka, Davies) Metabolic Pathways and Cardiovascular Therapeutic Area,
GlaxoSmithKline, King of Prussia, PA, United States
(Steg) Departement Hospitalo-Universitaire FIRE, Hopital Bichat,
Universite Paris-Diderot, Paris, France
(Steg) NHLI Imperial College, ICMS Royal Brompton Hospital, United Kingdom
(Hochman) Department of Medicine, NYU Langone Medical Center, New York,
NY, United States
(Bode) Heart Center, Department for Cardiology and Angiology I, University
of Freiburg, Freiburg, Germany
(Maggioni) ANMCO Research Center, Florence, Italy
(Shannon, Watson) Metabolic Pathways and Cardiovascular Therapeutic Area,
GlaxoSmithKline, Research Triangle Park, NC, United States
(Weaver) Henry Ford Heart and Vascular Institute, Detroit, MI, United
States
(Serruys) Erasmus University, Thoraxcentrum, Rotterdam, Netherlands
(Serruys) International Center for Circulatory Health, Imperial College,
London, United Kingdom
Title
Effect of darapladib on major coronary events after an acute coronary
syndrome: The SOLID-TIMI 52 randomized clinical trial.
Source
JAMA - Journal of the American Medical Association. 312 (10) (pp
1006-1015), 2014. Date of Publication: 10 Sep 2014.
Publisher
American Medical Association
Abstract
IMPORTANCE: Lipoprotein-associated phospholipase
A₂(Lp-PLA₂) has been hypothesized to be involved in
atherogenesis through pathways related to inflammation. Darapladib is an
oral, selective inhibitor of the Lp-PLA₂enzyme. OBJECTIVE: To
evaluate the efficacy and safety of darapladib in patients after an acute
coronary syndrome (ACS) event. DESIGN, SETTING, AND PARTICIPANTS:
SOLID-TIMI 52was a multinational, double-blind, placebo-controlled trial
that randomized 13 026 participants within 30 days of hospitalization with
an ACS (non-ST-elevation or ST-elevationmyocardial infarction [MI]) at 868
sites in 36 countries. INTERVENTIONS: Patients were randomized to either
once-daily darapladib (160mg) or placebo on a background of
guideline-recommended therapy. Patients were followed up for a median of
2.5 years between December 7, 2009, and December 6, 2013. MAIN OUTCOMES
AND MEASURES: The primary end point (major coronary events)was the
composite of coronary heart disease (CHD) death, MI, or urgent coronary
revascularization formyocardial ischemia. Kaplan-Meier event rates are
reported at 3 years. RESULTS: During a median duration of 2.5 years, the
primary end point occurred in 903 patients in the darapladib group and 910
in the placebo group (16.3%vs 15.6%at 3 years; hazard ratio [HR], 1.00
[95%CI, 0.91-1.09]; P = .93). The composite of cardiovascular death, MI,
or stroke occurred in 824 in the darapladib group and 838 in the placebo
group (15.0%vs 15.0%at 3 years; HR, 0.99 [95%CI, 0.90-1.09]; P = .78).
There were no differences between the treatment groups for additional
secondary end points, for individual components of the primary end point,
or in all-cause mortality (371 events in the darapladib group and 395 in
the placebo group [7.3%vs 7.1%at 3 years; HR, 0.94 [95%CI, 0.82-1.08]; P =
.40). Patients were more likely to report an odor-related concern in the
darapladib group vs the placebo group (11.5%vs 2.5%) and also more likely
to report diarrhea (10.6%vs 5.6%). CONCLUSIONS AND RELEVANCE: In patients
who experienced an ACS event, direct inhibition of Lp-PLA₂with
darapladib added to optimal medical therapy and initiated within 30 days
of hospitalization did not reduce the risk of major coronary events. TRIAL
REGISTRATION: clinicaltrials.gov Identifier: NCT01000727 Copyright 2014
American Medical Association. All rights reserved.

<12>
Accession Number
2014798311
Authors
Libungan B. Hirlekar G. Albertsson P.
Institution
(Libungan, Hirlekar, Albertsson) Department of Cardiology, Sahlgrenska
University Hospital, Bla straket 3, van 1, Gothenburg SE-413 45, Sweden
Title
Coronary angioplasty in octogenarians with emergent coronary syndromes:
Study protocol for a randomized controlled trial.
Source
Trials. 15 (1) , 2014. Article Number: 349. Date of Publication: September
04, 2014.
Publisher
BioMed Central Ltd.
Abstract
Background: Invasive treatment (coronary angiography and intervention if
feasible) of patients with acute coronary syndrome (ACS) has been shown to
lead to better outcomes than medical therapy alone, but the elderly have
been under-represented in many of the studies. In the elderly, medical
therapy is common in ACS. Fear of complications related to the procedure
and unclear benefit in older patients are common reasons for invasive
procedures being withheld. Our hypothesis is that invasive treatment of
elderly patients with ACS will lead to a better outcome in terms of
survival and quality of life than medical therapy alone, with acceptable
risk. Methods/Design: This multicenter, randomized controlled trial of
patients 80 years of age and over has two parallel treatment arms, a
medical group and an invasive group. In Swedish hospitals, 200 patients
with non-ST elevation myocardial infarction or unstable angina will be
randomized to medical or invasive treatment strategy. The primary outcome
measure is the combined endpoint major adverse cardiac or cerebrovascular
event (MACCE) within one year. Secondary outcome measures include quality
of life, angina, and adverse events such as bleeding. Assessments will be
conducted during hospitalization, at 1 month after allocation, and at 12
months. Discussion: This study seeks to determine the efficacy and safety
of invasive and medical treatment strategies in the elderly with ACS. The
study is currently recruiting. Trial registration: ClinicalTrials.gov
trial identifier: NCT02126202. Registered on 7 January 2014.

<13>
Accession Number
2014700848
Authors
Khawaja M.Z. Wang D. Pocock S. Redwood S.R. Thomas M.R.
Institution
(Khawaja, Redwood) Rayne Institute, Cardiovascular Division, King's
College London, BHF Centre of Excellence, St Thomas' Hospital, Westminster
Bridge Road, London_apop SE1 7EH, United Kingdom
(Khawaja, Redwood, Thomas) Department of Cardiology, Guy's and St Thomas'
NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United
Kingdom
(Wang) Department of Clinical Sciences, Liverpool School of Tropical
Medicine, Pembroke Pl, Liverpool, Merseyside L3 5QA, United Kingdom
(Pocock) Department of Medical Statistics, London School of Hygiene and
Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, United Kingdom
Title
The percutaneous coronary intervention prior to transcatheter aortic valve
implantation (ACTIVATION) trial: Study protocol for a randomized
controlled trial.
Source
Trials. 15 (1) , 2014. Article Number: 300. Date of Publication: July 24,
2014.
Publisher
BioMed Central Ltd.
Abstract
Background: Current guidelines recommend treatment of significant coronary
artery disease by concomitant coronary artery bypass grafting (CABG) in
patients undergoing surgical aortic valve replacement. However there is no
consensus as to how best to treat coronary disease in high-risk patients
requiring transcatheter aortic valve implantation (TAVI).Methods/Design:
The percutaneous coronary intervention prior to transcatheter aortic valve
implantation (ACTIVATION) trial is a randomized, controlled open-label
trial of 310 patients randomized to treatment of significant coronary
artery disease by percutaneous coronary intervention (PCI - test arm) or
no PCI (control arm). Significant coronary disease is defined as >1 lesion
of >70% severity in a major epicardial vessel or 50% in a vein graft or
protected left main stem lesion. The trial tests the hypothesis that the
strategy of performing pre-TAVI PCI is non-inferior to not treating such
coronary stenoses with PCI prior to TAVI, with a composite primary outcome
of 12-month mortality and rehospitalization. Secondary outcomes include
efficacy end-points such as 30-day mortality, safety endpoints including
bleeding, burden of symptoms, and quality of life (assessed using the
Seattle Angina Questionnaire and the Kansas City Cardiomyopathy
Questionnaire).In conclusion, we hope that using a definition of coronary
artery disease severity closer to that used in everyday practice by
interventional cardiologists - rather than the 50% severity used in
surgical guidelines - will provide robust evidence to direct guidelines
regarding TAVI therapy and improve its safety and efficacy profile of this
developing technique. Trial registration: ISRCTN75836930,
http://www.controlled-trials.com/ISRCTN75836930 (registered 19 November
2011).

<14>
Accession Number
2014909739
Authors
Davierwala P.M. Mohr F.W.
Institution
(Davierwala, Mohr) Department of Cardiac Surgery, Heart Center, University
of Leipzig, Struempellstrase 39, Leipzig 04289, Germany
Title
Surgical Versus Percutaneous Revascularization in Patients with
Multivessel Coronary Artery Disease.
Source
Current Atherosclerosis Reports. 16 (12) (pp 1-13), 2014. Date of
Publication: 2014.
Publisher
Current Medicine Group LLC 1
Abstract
New-generation stents have been continually developed in order to improve
the safety and efficacy of percutaneous coronary intervention (PCI).
Several randomized clinical trials have been conducted over the last two
decades to compare the outcomes of PCI with coronary artery bypass
grafting (CABG), which has been the time-tested treatment of multivessel
coronary artery disease. The Synergy between PCI with Taxus and Cardiac
Surgery (SYNTAX) trial is one of the most recent and largest randomized
controlled trials comparing PCI using the paclitaxel-eluting
first-generation stent with CABG and was uniquely formulated to represent
"real world" daily practice. The final 5-year main results of this trial
and its various prespecified subgroups have been published in the past
year. These results will form the basis of the new guidelines that will be
published in the near future. This review is a compilation of the results
of the SYNTAX trial and comparisons with other contemporary trials,
meta-analyses, and retrospective studies of large registries and how these
results help cardiac surgeons and cardiologists in judicious
decision-making for their patients with multivessel coronary artery
disease requiring revascularization.

<15>
Accession Number
2014906016
Authors
Benedetto U. Ng C. Smith R. Raja S.G.
Institution
(Benedetto, Ng, Raja) Department of Cardiac Surgery, Harefield Hospital,
London, United Kingdom
(Smith) Department of Cardiology, Harefield Hospital, London, United
Kingdom
Title
Coronary artery bypass grafting is superior to first-generation
drug-eluting stents for unprotected left main coronary artery disease: An
updated meta-analysis of 4 randomized, controlled trials.
Source
Journal of Thoracic and Cardiovascular Surgery. 148 (5) (pp 2430-2432),
2014. Date of Publication: 01 Nov 2014.
Publisher
Mosby Inc.

<16>
Accession Number
2014890548
Authors
Cassese S. De Luca G. Ribichini F. Cernigliaro C. Sansa M. Versaci F.
Proietti I. Stankovic G. Stojkovic S. Fernandez-Pereira C. Tomai F.
Vassanelli C. Antoniucci D. Serruys P.W. Kastrati A. Rodriguez A.E.
Institution
(Cassese, Kastrati) Deutsches Herzzentrum, Technische Universitat Munchen,
Lazarettstr. 36, Munich 80636, Germany
(De Luca) Department of Clinical and Experimental Medicine, Eastern
Piedmont University, Novara, Italy
(Ribichini, Vassanelli) Department of Medicine, University of Verona,
Verona, Italy
(Cernigliaro) Interventional Cardiology, San Gaudenzio Clinic, Novara,
Italy
(Sansa) Catheterization Laboratory, Division of Cardiology, Maggiore
Hospital, Novara, Italy
(Versaci) Department of Cardiology, Cardarelli Hospital, Campobasso, Italy
(Versaci) Department of Cardiology, Veneziale Hospital, Isernia, Italy
(Proietti) Department of Cardiology, Vannini Hospital, Rome, Italy
(Stankovic, Stojkovic) Department of Diagnostics and Catheterization
Laboratory, Division of Cardiology, Clinical Center of Serbia, Medical
School of Belgrade, Serbia
(Fernandez-Pereira, Rodriguez) Cardiovascular Research Center, Sanatorio
Otamendi, Buenos Aires, Argentina
(Tomai) Department of Cardiovascular Sciences, European Hospital, Rome,
Italy
(Antoniucci) Division of Cardiology, Careggi Hospital, Florence, Italy
(Serruys) Thorax Center, Erasmus University Medical Center, Rotterdam,
Netherlands
Title
ORAl iMmunosuppressive therapy to prevent in-Stent rEstenosiS (RAMSES)
cooperation: A patient-level meta-analysis of randomized trials.
Source
Atherosclerosis. 237 (2) (pp 410-417), 2014. Date of Publication: December
01, 2014.
Publisher
Elsevier Ireland Ltd
Abstract
Objective: The role of oral immunosuppressive therapy (OIT) to prevent
restenosis after percutaneous coronary intervention (PCI) and stenting is
still controversial. This study evaluates the impact of oral
administration of prednisone or sirolimus to prevent restenosis. Methods:
We conducted a meta-analysis of trials in which PCI-patients were
randomized to bare metal stents (BMS) plus OIT (BMS+OIT group) versus BMS
or drug-eluting stents alone (BMS/DES group). Primary endpoints were
target lesion revascularization and death/myocardial infarction (MI).
Secondary endpoints were death, MI, stent thrombosis and in-stent late
lumen loss. Hazard ratio and weighted geometric mean difference [95%
confidence intervals] served as summary statistics. Results: Individual
data of seven trials (1246 patients [BMS+OIT, n=608 versus BMS/DES, n=638]
with 1456 coronary lesions) were merged. At a median follow-up of 360
days, BMS+OIT versus BMS/DES significantly reduced the risk of
revascularization (0.49 [0.24-0.98], P=0.04). In particular, BMS+OIT
reduced the risk of revascularization (0.38 [0.21-0.67], P<0.001) and late
lumen loss (-0.39mm [-0.67,-0.11], P<0.001) as compared with BMS alone.
BMS+OIT versus BMS/DES showed a similar risk of death/MI (0.67
[0.29-1.53], P=0.34), death (0.82 [0.25-2.69], P=0.71), MI (0.58
[0.24-1.39], P=0.22) and stent thrombosis (0.43 [0.10-1.87], P=0.26).
Conclusion: In patients undergoing PCI the use of BMS and oral
immunosuppressive therapy reduces the risk of revascularization as
compared with BMS alone but not as compared with DES alone, while these
therapies display a similar risk of death/MI. The advantage of adding oral
immunosuppressive therapy to BMS is due to a lower risk of restenosis as
compared with BMS alone.

<17>
Accession Number
2014905677
Authors
Hellhammer K. Zeus T. Balzer J. Van Hall S. Rammos C. Wagstaff R. Kelm M.
Rassaf T.
Institution
(Hellhammer, Zeus, Balzer, Van Hall, Rammos, Wagstaff, Kelm, Rassaf)
University Hospital Dusseldorf, Medical Faculty, Dept. of Medicine,
Dusseldorf, Germany
Title
Safety and efficacy of percutaneous mitral valve repair using the
MitraClip system in patients with diabetes mellitus.
Source
PLoS ONE. 9 (11) , 2014. Article Number: e111178. Date of Publication: 06
Nov 2014.
Publisher
Public Library of Science
Abstract
Background: Patients with diabetes mellitus show a negative outcome in
percutaneous coronary intervention, aortic valve replacement and cardiac
surgery. The impact of diabetes on patients undergoing treatment of severe
mitral regurgitation (MR) using the MitraClip system is not known. We
therefore sought to assess whether percutaneous mitral valve repair with
the MitraClip system is safe and effective in patients with diabetes
mellitus.
Methods and Results: We included 58 patients with severe and
moderate-to-severe MR in an open-label observational single-center study.
Ninteen patients were under oral medication or insulin therapy for type II
diabetes mellitus. MitraClip devices were successfully implanted in all
patients with diabetes and in 97.4% (n = 38) of patients without diabetes
(p = 0.672). Periprocedural major cardiac adverse and cerebrovascular
events (MACCE) occurred in 5.1% (n = 2) of patients without diabetes
whereas patients with diabetes did not show any MACCE (p = 0.448). 30-day
mortality was 1.7% (n = 1) with no case of death in the diabetes group.
Short-term follow up of three months showed a significant improvement of
NYHA class and quality of life evaluated by the Minnesota Living with
Heart Failure Questionnaire in both groups, with no changes in the
6-minute walk test.
Conclusions: Mitral valve repair with the MitraClip system is safe and
effective in patients with type II diabetes mellitus.

<18>
Accession Number
2014877258
Authors
Nistor C. Ranetti A.-E. Ciuche A. Pantile D. Constantin L. Brincoveanu R.
Institution
(Nistor, Ciuche, Pantile) Department of Thoracic Surgery, Dr. Carol Davila
Central Military Emergency University Hospital, Bucharest, Romania
(Ranetti) Department of Endocrinology, Dr. Carol Davila Central Military
Emergency University Hospital, Bucharest, Romania
(Constantin) Department of Laboratory Medicine, Dr. Carol Davila Central
Military Emergency University Hospital, Bucharest, Romania
(Brincoveanu) Carol Davila University of Medicine and Pharmacy, Bucharest,
Romania
Title
Betadine in chemical pleurodesis.
Source
Farmacia. 62 (5) (pp 897-906), 2014. Date of Publication: 01 Sep 2014.
Publisher
Romanian Society for Pharmaceutical Sciences (Str. Traian Vuia 6, sector
2, Bucharest 020956, Romania)
Abstract
Malignant pleural effusions (MPEs) represent a common complication which
can occur in any neoplastic disease. Between October 2012 and December
2013 we performed a prospective study aimed to establish the adequate
treatment for malignant pleural effusions. 85 patients were included in
this study, diagnosed and treated in the Thoracic Surgery Department of
the Central Military Emergency University Hospital. 46 patients underwent
chemical pleurodesis with betadine (through thoracoscopic
surgery - 30 patients - or through a chest drainage tube - 16 patients),
while for 39 patients talcum powder was chosen as the agent for
pleurodesis (through thoracoscopic surgery - 28 patients - or through a
chest drainage tube - 11 patients with major surgical risk). The most
frequent cancers with secondary MPEs were lung cancers (50 patients). The
efficiency of the two methods was the same. The most used chemical
pleurodesis procedure was the thoracoscopic surgery (58 patients). The
most used agent for pleurodesis was Betadine (30 patients).
Chemical pleurodesis with Betadine is a safe procedure, which
can be used intraoperative (thoracoscopic surgery) or through a chest
drainage tube (for patients with major surgical risk). Chemical
pleurodesis with Betadine plays an important role in addressing
MPEs because of its high therapeutic efficiency and lower complications
rate when compared to other agents (talcum powder).

<19>
Accession Number
2014719135
Authors
Raval J. Nagaraja V. Eslick G.D. Denniss A.R.
Institution
(Raval, Denniss) Department of Cardiology, Blacktown Hospital, University
of Western Sydney, Sydney, NSW, Australia
(Nagaraja, Eslick) The Whiteley-Martin Research Centre, Discipline of
Surgery, The University of Sydney, Nepean Hospital, Sydney, NSW, Australia
Title
Transcatheter valve-in-valve implantation: A systematic review of
literature.
Source
Heart Lung and Circulation. 23 (11) (pp 1020-1028), 2014. Date of
Publication: 01 Nov 2014.
Publisher
Elsevier Ltd
Abstract
Introduction: Transcatheter aortic valve implantation (TAVI) has become an
alternative to open surgery in those deemed high risk. The purpose of this
study was to evaluate the effectiveness and outcomes of this emerging
procedure. We have examined available literature to provide an overview of
valve-in-valve implantation using transcatheter heart valves (THVs) in
aortic, mitral, pulmonary, tricuspid positions. Methods: A systematic
search was conducted using MEDLINE, PubMed, EMBASE, Current Contents
Connect, Cochrane library, Google Scholar, Science Direct, and Web of
Science. Results: Only 61 studies met full criteria and were included the
review. This included 31 studies reporting transcatheter aortic
valve-in-valve implantation, mitral valve-in-valve implantation (13
studies), tricuspid valve-in-valve implantation (12 studies), and pure
native aortic valve regurgitation (nine studies). One of the limitations
of this review is that most of the studies included were case reports,
together with some case series. Conclusion: Valve-in-valve implantation
can be considered as an acceptable alternative to conventional open heart
surgery for elderly high-risk surgical patients with bioprosthetic
degeneration. Long-term follow-up of treated patients will be necessary to
establish the true role of valve-in-valve implantation for bioprosthetic
degeneration. Patients should be evaluated on an individual basis until
outcomes are proven in large cohort studies or randomised trials.

<20>
Accession Number
2014736557
Authors
Wu H.B. Hu R. Wang Z.W. Hu Z.P. Li L.C. Wu Z.Y. Xu P. Deng H.P.
Institution
(Wu, Hu, Wang, Hu, Li, Wu, Xu, Deng) Department of Cardiovascular Surgery,
Renmin Hospital of Wuhan University, Wuhan 430060, China
Title
Endoscopic radial artery harvesting does not compromise graft patency for
coronary artery bypass graft: A meta analysis of 2782 patients.
Source
Heart Lung and Circulation. 23 (11) (pp 1084-1090), 2014. Date of
Publication: 01 Nov 2014.
Publisher
Elsevier Ltd
Abstract
Background: Endoscopic radial artery harvesting is a favourable harvesting
technique which provides excellent cosmetic result and low incidence of
incision related complications, however the impact of this technique on
graft quality is less well-explained. We sought to evaluate the impact of
harvesting technique on graft patency and relevant clinical outcomes in
patients undergoing coronary artery bypass graft (CABG). Method: A
systematic literature search was conducted to identify publications
containing comparisons between different sampling skills in CABG, data was
extracted and analysed with Revman, Downs and Black score was applied to
evaluate the methodological quality of included studies. Result: Ten
studies containing 2782 patients were undertaken, the quality was
generally acceptable. Pooled analysis results indicate endoscopic radial
artery harvesting was associated with a lower incidence of wound infection
and a similar incidence of haematoma formation compared with open
harvesting. The difference in graft patency and all-cause mortality was
insignificant between two cohorts. Conclusion: Endoscopic radial artery
harvesting is a safe technique and provides equivalent graft patency as
compared with open harvesting, further investigation is required to
confirm the aforementioned conclusion and evaluate the impact of
harvesting technique on hand sensory and motor function.

<21>
Accession Number
2014898535
Authors
El-Hayek G. Benjo A. Uretsky S. Al-Mallah M. Cohen R. Bamira D. Chavez P.
Nascimento F. Santana O. Patel R. Cavalcante J.L.
Institution
(El-Hayek, Cohen, Bamira, Chavez) Mount Sinai Saint Luke's Hospital, New
York, NY, United States
(Benjo, Patel) Ochsner Medical Center, New Orleans, LA, United States
(Uretsky) Morristown Medical Center, Morristown, NJ, United States
(Al-Mallah) Wayne State University, Detroit, MI, United States
(Al-Mallah) King Abdul Aziz Cardiac Center, Riyadh, Saudi Arabia
(Nascimento, Santana) Mount Sinai Medical Center, Miami Beach, FL, United
States
(Cavalcante) University of Pittsburgh, Heart and Vascular Institute-UPMC,
Scaife Hall, S-558, 200 Lothrop Street, Pittsburgh, PA 15213, United
States
Title
Meta-analysis of coronary computed tomography angiography versus standard
of care strategy for the evaluation of low risk chest pain: Are randomized
controlled trials and cohort studies showing the same evidence?.
Source
International Journal of Cardiology. 177 (1) (pp 238-245), 2014. Date of
Publication: 15 Nov 2014.
Publisher
Elsevier Ireland Ltd
Abstract
Background Randomized control trials (RCTs) have established the use of
Coronary Computed Tomography Angiography (CCTA) for the evaluation of low
to intermediate risk patients presenting with acute chest pain to the
emergency department (ED). However, concerns remain regarding the
downstream resource utilization and the clinical impact of such strategy.
Methods We performed a meta-analysis of existing studies to compare CCTA
to the standard of care (SOC) strategies in the low to intermediate risk
chest pain patients. We abstracted the reported incidence of acute
coronary syndromes (ACS), the total number of invasive coronary
angiography (ICA) and subsequent revascularization procedures, the rates
of hospital readmissions and repeat ED visits. We stratified the results
according to the type of the studies (randomized or not) and used random
effect analysis for the studied outcomes.
Results Four RCTs and 3 case-control studies with 3306 patients undergoing
CCTA and 2752 assigned to SOC were included in the analysis. Following the
index visit, we observed a significant reduction in the risk of ACS (RR:
0.26, 95% CI, 0.08 to 0.87; p = 0.03) and in the rates of repeat ED visits
(RR: 0.58, 95% CI: 0.36 to 0.94; p = 0.03). In addition, a trend toward
less hospital readmission (p = 0.07) was noted. There was no difference in
ICA (p = 0.99) but an increase in revascularization procedures (RR: 1.46,
95% CI: 1.09 to 1.94; p = 0.01).
Conclusion CCTA use in the ED for the triage of low to intermediate risk
patients reduces the risk of future ACS and subsequent ED visits for chest
pain.

<22>
Accession Number
2014898520
Authors
Lim H.-S. Tonino P.A.L. De Bruyne B. Yong A.S.C. Lee B.-K. Pijls N.H.J.
Fearon W.F.
Institution
(Lim, Yong, Lee, Fearon) Interventional Cardiology, H2103, Stanford
University Medical Center, 300 Pasteur Drive, Stanford, CA, United States
(Lim) Department of Cardiology, Ajou University School of Medicine, Suwon,
South Korea
(Tonino, Pijls) Catharina Hospital, Eindhoven, Netherlands
(De Bruyne) Cardiovascular Center, Aalst, Belgium
(Lee) Division of Cardiology, Kangwon National University School of
Medicine, Chuncheon, South Korea
Title
The impact of age on fractional flow reserve-guided percutaneous coronary
intervention: A FAME (Fractional Flow Reserve versus Angiography for
Multivessel Evaluation) trial substudy.
Source
International Journal of Cardiology. 177 (1) (pp 66-70), 2014. Date of
Publication: 15 Nov 2014.
Publisher
Elsevier Ireland Ltd
Abstract
Background Fractional flow reserve (FFR)-guided percutaneous coronary
intervention (PCI) improved outcomes compared with an angiography-guided
strategy in patients with multivessel coronary artery disease (CAD).
However, the effect of age on FFR has not been well-studied. We aimed to
evaluate the impact of age on the favorable results of routine FFR-guided
PCI for multivessel CAD.
Methods We compared 1 year outcomes between FFR-guided PCI and
angiography-guided PCI in the 512 patients enrolled in the FAME study < 65
years old compared to the 493 patients > 65 years old. We also evaluated
the effect of age on the FFR result of varying degrees of visually
estimated coronary stenosis.
Results The 1-year rate of death, myocardial infarction or repeat
revascularization in the angiography-guided group tended to be higher than
in the FFR-guided group for both those patients < 65 (17.2% vs. 12.0%, P =
0.098) and those > 65 years old (19.7% vs. 14.3%, P = 0.111) with no
significant interaction based on age (P = 0.920). Older patients had
higher FFR in vessels with 50% to 70% stenosis (0.83 + 0.11 vs. 0.80 +
0.13, P = 0.028) and in vessels with 71% to 90% stenosis (0.69 + 0.15 vs.
0.65 + 0.16, P = 0.002). The proportion of functionally significant
lesions (FFR < 0.80) in vessels with 71% to 90% stenosis was significantly
lower in elderly compared to younger patients (75.3% vs. 84.1%, P =
0.013).
Conclusions FFR-guided PCI is beneficial regardless of age, however, older
patients have fewer functionally significant lesions, despite a similar
angiographic appearance.

<23>
Accession Number
2014896446
Authors
Sachdeva J. Dai W. Gerczuk P.Z. Kloner R.A.
Institution
(Sachdeva, Dai, Gerczuk, Kloner) Heart Institute of Good Samaritan
Hospital, Division of Cardiovascular Medicine, University of Southern
California, 1225 Wilshire Boulevard, Los Angeles, CA 90017, United States
Title
Combined remote perconditioning and postconditioning failed to attenuate
infarct size and contractile dysfunction in a rat model of coronary artery
occlusion.
Source
Journal of Cardiovascular Pharmacology and Therapeutics. 19 (6) (pp
567-573), 2014. Date of Publication: 11 Nov 2014.
Publisher
SAGE Publications Ltd
Abstract
Objective: Although preconditioning remains one of the most powerful
maneuvers to reduce myocardial infarct size, it is not feasible in the
clinical setting to pretreat patients prior to acute myocardial infarction
(MI). The purpose of this study was to investigate the effect of more
clinically relevant therapies of remote perconditioning, postconditioning,
and the combined effect of remote perconditioning and postconditioning on
myocardial infarct size in an anesthetized rat model.
Methods: Anesthetized rats were subjected to 45 minutes of proximal left
coronary artery occlusion followed by 2 hours of reperfusion. Remote
perconditioning was performed 5 minutes after left coronary occlusion with
4 cycles of 5 minutes of occlusion and reperfusion of both the femoral
arteries. Postconditioning was applied immediately prior to 2 hours of
full reperfusion with 6 cycles of 10 seconds occlusionreperfusion of the
coronary artery. The combined effect was produced by preceding the
postconditioning regimen with remote perconditioning, after 5 minutes of
left coronary occlusion.
Results: Remote perconditioning and postconditioning alone failed to
reduce infarct size expressed as percentage of the risk zone (42.2% +3.9%
and 45.0%+ 4.3%). The combination of remote perconditioning and
postconditioning also failed to reduce infarct size (45.3%+4.1%) as
compared to the untreated ischemiareperfusion group (48.7% + 3.4%).
Hemodynamics including left ventricular end-systole and end-diastolic
pressures, +dP/dt, -dP/dt, and heart rate did not show any improvement in
the conditioning groups.
Conclusion: This study shows that remote perconditioning and
postconditioning alone or combined neither improve hemodynamics nor reduce
infarct size in the rat model of MI.

<24>
Accession Number
71687564
Authors
Moka E. Argyra E. Siafaka I. Vadalouca A.
Institution
(Moka) Anaesthesiology Department, Creta InterClinic Hospital, Heraklion
Crete, Greece
(Argyra, Siafaka, Vadalouca) Anaesthesiology Department, Chronic Pain and
Palliative Care Centre, Aretaieion University Hospital, Athens, Greece
Title
Cardiovascular patients: Regional anesthesia revisited.
Source
Regional Anesthesia and Pain Medicine. Conference: 33rd Annual European
Society of Regional Anaesthesia and Pain Therapy, ESRA Congress 2014
Seville Spain. Conference Start: 20140903 Conference End: 20140906.
Conference Publication: (var.pagings). 39 (5 SUPPL. 1) (pp e93-e96), 2014.
Date of Publication: September-October 2014.
Publisher
Lippincott Williams and Wilkins
Abstract
Introduction The role of Regional Anaesthesia (RA) techniques in the
anaesthetic management of cardiovascular patients still remains a subject
of discussion and continuous debate, despite the fact that multiple
related references have appeared in literature the last 20 - 25 years,
however, with inconclusive or even contradictory results. Nevertheless, as
opposed to General Anaesthesia (GA) alone, many clinicians continue to
apply RA as well, for intraoperative anaesthesia/analgesia and
postoperative pain management, in combination with a general anaesthetic,
sufficient to produce unconsciousness, amnesia, and tolerance of the
endotracheal tube. Currently, RA advantages are claimed to be improved
postoperative pulmonary function, with shorter time to extubation,
possibly a reduction in pulmonary infections, and superior postoperative
pain control over systemic opioid - based analgesic regimens, with a
significant reduction in postoperative pain, still representing a
worthwhile outcome. Additionally, RA results in a reduced incidence of
deep venous thrombosis and pulmonary embolism, as well as a reduction in
postoperative gastrointestinal ileus. Among the physiological effects of
RA, primarily of Central Neuraxial Blocks (CNBs), but also of Peripheral
Nerve Blocks (PNBs) a possible decrease in the postoperative stress
response, a decrease in postoperative hypercoagulability, a possible
increase inmyocardial oxygen delivery, and decrease in oxygen consumption
could potentially have beneficial effects on cardiac morbidity. Based on
the above, recent developments in technical aspects of RAhave the
potential to provide significant advantages for many categories of
cardiovascular patients in all age groups, with the majority of studies
focusing on specific outcomes and potential RA benefits, when used for
surgery and postoperative analgesia. One of the biggest challenges for
anaesthetists is the safe conduct of anaesthesia for patients who might be
elderly, have pre - existing cardiovascular diseases and are scheduled to
undergo not only cardiovascular, but also minor or major non - cardiac
surgery. During the previous decades, numerous studies have attempted to
determine whether RA offers convincing benefits over GA, often with really
promising results. Nowadays, there is a tendency to interpret literature
reports and meta - analyses more carefully, and it still remains unclear
whether RAis finally beneficialwhen applied to the group of cardiovascular
patients. Anaesthesiologists have debated for many years whether RA is
better or at least equally effective and protective when compared to GA
applied in such patients. According to literature research, many studies
in this area are weak in experimental design and therefore have not
produced any definite answers. Due to the rarity of some situations like
valvular disease, especially in subpopulations of patients (eg obstetrics,
paediatrics), the literature offers many anecdotal cases or case series,
but not enough controlled studies; as such, guidelines are still needed to
sum up best evidence for these challenging situations. Until then, we must
rely more on the understanding of the pathophysiology of cardiovascular
diseases, of surgical needs and of the effects of the anaesthetic
technique in every different situation. RA & Ischaemic Heart Disease -
CNBs (High TEA) Cardioprotective Effects: RA application, as an adjunct to
GA continues to enjoy enthusiasts among clinicians. The successful
application of High Thoracic Epidural Analgesia (High TEA), for the
treatment of angina - Ischaemic Heart Disease and the achievement of
improved analgesia after thoracotomy, have both prompted its use during
cardiac surgery. In several animal studies, it has been shown that High
TEA may redistribute myocardial blood flow in favor of subendocardial
layers at risk of ischemic events and may reduce the size of
experimentally induced myocardial infarction. TEA has also been shown to
decrease adverse perioperative cardiac events. Better pain relief with
concomitant reduction in the postoperative stress response and systemic
sympathetic activity may contribute to this effect. Regional sympathetic
block including the cardiac sympathetic nerves reduces not only ischaemic
pain but preserves coronary perfusion during cold pressor testing. This
effect was most pronounced in stenotic vessels. These data further support
findings of perioperative anti - ischaemic effects of High TEA, in cardiac
as well as non - cardiac surgery. TEA improved diastolic as well as
systolic function in patients with coronary artery disease undergoing
operative revascularization. Diastolic dysfunction has been reported to be
an early sign of cardiac ischaemia. Troponin release and long - term
survival after coronary artery bypass grafting further underline the
cardioprotective potential of high TEA, especially at the experimental
level. Clinical data on myocardial ischaemia and mortality are still
inconclusive, in reference to complications rate, survival and general
outcome. High TEA for coronary artery bypass graft (CABG) surgery promotes
perioperative analgesia and attenuates the stress response to surgery; it
provides effective pain relief for patients with unstable angina and
myocardial infarction. The beneficial effects of local anaesthetics
administration through a high TEA catheter in patients with severe angina
who are not candidates for surgical revascularization have also been
documented. Surgery of the coronary arteries in patients with co -
morbidities is fraught with difficulties. Minimally invasive direct CABG
surgery and conscious off - pump CABG surgery (COP - CAB) has been
performed in conscious patients with acceptable results, initially engaged
with much enthusiasm by many skillful clinicians for obvious reasons. At
this point, one must never underestimate that, although GA is considered a
safe option, it is not without complications, especially in high risk
cardiovascular surgical patients. A protective effect of TEA against
arrythmogenesis has been seen in animal, as well as in human studies (CABG
patients), in an effort to evaluate and assess the postoperative impact of
high TEA on cardiac function, using a combination of bupivacaine 0.5%and
clonidine epidurally. Among other findings, according to studies results,
a reduction of supraventricular arrhythmias has been indicated, with lower
catecholamine levels and slower heart rates after CABG in High TEA treated
patients also being reported in previous literature references. In
addition, High TEA effects on myocardial ischaemia or infarction ECG/
Biochemical Markers are not clear yet. In a prospective randomized
controlled trial for elective CABG surgery Barrington et al found that
High TEA had no effect on the release of troponin I, whereas it improved
time to tracheal extubation and analgesia. In this study according to
authors, infusion of ropivacaine 0.2% did not maintain a dense sympathetic
block, when compared with bupivacaine 0.75% in another study by Loick et
al, who reported reduced troponin T release with High TEA. However, the
same results were noted by Priestley et al, who used ropivacaine 1% and
also found no effect on troponin levels with High TEA. Despite the
theoretical advantages of High TEA, factors such as technical difficulty
in grafting and myocardial protection during the ischaemic period may have
a more significant effect than High TEA on troponin release. The potential
and well known advantage of RA over GA should be an asset in cardiac
patients. RA disadvantages include hypotension from uncontrolled
sympathetic blockade and need for volume loading, which eventually may
result in ischaemia.

<25>
Accession Number
71687545
Authors
Beaussier M.
Institution
(Beaussier) Anesthesia and Intensive Care, Hopital St-Antoine. Assistance
Publique - Hopitaux de Paris, Paris, France
Title
Continuous wound infusion in abdominal surgery: How: When, why?.
Source
Regional Anesthesia and Pain Medicine. Conference: 33rd Annual European
Society of Regional Anaesthesia and Pain Therapy, ESRA Congress 2014
Seville Spain. Conference Start: 20140903 Conference End: 20140906.
Conference Publication: (var.pagings). 39 (5 SUPPL. 1) (pp e72-e73), 2014.
Date of Publication: September-October 2014.
Publisher
Lippincott Williams and Wilkins
Abstract
Abdominal surgery is characterized for a long time ago by moderate to
severe postoperative pain, mainly induced by mobilization. Postoperative
pain relief, besides to improving patient's comfort, is likely to have
beneficial effects on postoperative recovery course (1). But abdominal
surgery is moving to less invasive procedures, as illustrated by the
development of laparoscopic approach. In this context, anesthesiologists
have to think about the development of new strategies to manage
postoperative pain. Epidural analgesia (EA) is a well-established
technique and has been for a long time the gold standard for pain
management after major abdominal surgery (2). Besides to analgesic
effects, EA has demonstrated beneficial impact on postoperative outcomes,
including a decrease on pulmonary complications, a reduction of the
duration of intestinal ileus, and some beneficial metabolic properties
(3). The development of parietal infiltration (Surgical Site Catheter
Analgesia = SSCA) was based on the recognition that a major component of
postoperative pain arises from surgicalwound incision (4), and also from
the need for our analgesic strategies to follow the surgical evolution
toward less invasive procedures (5). Above all, unlike EA, SSCA is very
easy to implement, can be performed in almost all patients, has a very low
failure rate and is quite harmless. Undoubtedly, EA remains the best
analgesic technique for a lot of procedures, such as major perineal
surgery, upper abdominal and esophageal surgery as well as thoracic
surgery. In these indications, the benefit/risk ratio is clearly in favor
of doing EA as the first line analgesic treatment. Conversely, the
beneficial effect of EA is questionable after less invasive procedure. For
instance, EA after laparoscopic colorectal resection seems worthless (6)
and not better than intravenous lidocaine (7). Consistently, international
recommendation for pain treatment after laparoscopic colorectal surgery do
not mention EA anymore (8). This is an illustration of the concept of "no
pain - no gain" associating EA to an unfavorable benefit-risk ratio in the
setting of mini-invasive surgery. Some recent reports have shown SSCA to
be able to be an efficient alternative to EA after abdominal surgery
(9).When the same local anesthetic regimen (10 ml/h ropivacaine 0.2%) was
administered either by SSCA or EA routes, no difference was observed on
pain relief or recovery course, with SSCA administration being associated
with a faster return of gastrointestinal function than EA (10). On the
other side, and as it could have been totally expected, when epidural
analgesia was used "optimally" (i.e. patientcontrolled administration with
a mixture of ropivacaine/sufentanil during intraoperative and
postoperative period), a significant better effect on pain relief and
recovery course was observed as compared to the preperitoneal continuous
administration of ropivacaine during the postoperative period (10). Recent
pathophysiologic data have highlighted that at least a part of the
nociceptive inputs coming from the peritoneum and abdominal viscera do not
passed along the spinal nociceptive pathway and could be blocked by direct
peritoneal application of local anesthetics (11). In this perspective,
SSCAwould be able to provide additional benefits in combination with EA
(12). The place of SSCA is still the subject of many controversies.
Firstly because there is still a lot of unresolved questions about the
bestmodality to use it. There is huge discrepancies between trials on SSCA
(catheter placement, flow rate, type of surgery), making meta-analysis not
really informative (13,14). The preperitoneal placement of the catheter
(i.e. between the peritoneum and the musculo-aponeurosis layer) seems
associated with a better efficacy than the subcutaneous placement (15). A
high flow rate of local anesthetic (5-10 ml/h) seems associated with
better analgesic results. Data on the benefit of using SSCA for pain
relief after laparoscopic colorectal resection (surgical piece removal
incision) are still lacking. In conclusion, SSCA presents a favorable
benefit/risk ratio, especially during mini-invasive surgery or in several
specific populations (antithrombotic therapy, elderly patients). SSCA has
to be viewed as a component of a multimodal analgesic strategy that could
be considered as a suitable and efficient analgesic technique. Still a lot
of works have to be done on SSCA in order to improve our knowledge about
the best way to use it.

<26>
Accession Number
71687541
Authors
Hollmann M.W. Picardi S. Lirk P.B.
Institution
(Hollmann, Picardi, Lirk) Anesthesiology, AcademicMedical Center (AMC)
Amsetrdam, Amsterdam, Netherlands
Title
The immunomodulator properties of la and its significance.
Source
Regional Anesthesia and Pain Medicine. Conference: 33rd Annual European
Society of Regional Anaesthesia and Pain Therapy, ESRA Congress 2014
Seville Spain. Conference Start: 20140903 Conference End: 20140906.
Conference Publication: (var.pagings). 39 (5 SUPPL. 1) (pp e67-e69), 2014.
Date of Publication: September-October 2014.
Publisher
Lippincott Williams and Wilkins
Abstract
Blockade of voltage-gated sodium channels, leading to inhibition of nerve
impulse conduction, is probably the most important effect of local
anaesthetics (LA) and is the major mechanism underlying their well-known
antinociceptive and antiarrhythmic effects. However, LA affect other
cellular systems as well, amongst others K+ and Ca++ channels, G-protein
coupled (e.g. muscarinic m1 and m³, thromboxane A2,
lysophosphatidate and platelet-activating factor receptors) and ionotropic
receptors (e.g. NMDA receptors).1, 2 These interactions may contribute to
antinociception and antiarrhythmic actions, but could also explain some
other LA properties and side effects. In this lecture, I will highlight
some actions of LA that are less well known to most anaesthesiologists.
Most important, I would like to focus on the immunomodulatory properties
of LA, that might contribute to their clinically observed effects on
(inflammatory) pain, shortened recovery of gastro-intestinal function
after surgery and their possible beneficial modulation of tumour biology.
Using systemic lidocaine perioperatively has been shown to reduce opioid
consumption, decrease resting and dynamic pain, improve postoperative
nausea and vomiting, fasten recovery of bowel function and shorten length
of hospital stay by one day in numerous systematic reviews and
meta-analyses.3-6 These beneficial effects hold primarily true for
patients undergoing open or laparoscopic abdominal surgery. Less
favourable results were reported for tonsillectomy, hip replacement and
cardiac surgery.6 Although this pain improvement does at least partially
result from LA interaction with NMDAreceptor signaling, modulation of the
inflammatory response leading to a reduction in inflammatory pain might
also contribute to this phenomenon.1-2, 7 In particular, the long lasting
effects reported for a short acting drug like lidocaine point to a
different direction than just a pure agonist-receptor interaction.
Modulation of the inflammatory response is a potential underlying
mechanism for the long lasting pain improving effects of lidocaine
described in literature. This hypothesis is supported by the fact that
patients undergoing surgery associated with a marked (excessive)
stimulation of the inflammatory response (e.g. abdominal surgery)
benefitmore from systemic administration of lidocaine than patients with
minor surgery and as such less pro-inflammatory stimulation.6 Koppert et
al. and Groudine and coworkers report a significant and clinically
relevant improvement in painmanagement even 36 and 72 hours after
discontinuation of intravenous lidocaine.8-9 Moreover, 3 months after
surgery, less chronic post surgical pain (CPSP) was reported for patients
undergoing breast cancer and complex spine surgery, following a short
lasting perioperative administration of systemic lidocaine, suggesting a
mode of action independent of LA being present in the blood, such as
modulation of the inflammatory response at a molecular level.10-11 In the
latter study even a significant reduction in overall 30 day complication
and an improved SF-12 score after 3 month have been reported.11 With
respect to modulation of inflammation, LA have been shown to interfere
with almost all steps of the inflammatory cascade at least in vitro.1 In
short, various LA were shown to inhibit leukocyte adhesion by an impaired
expression of adhesion molecules (e.g. CD11b).12-13 Lidocaine pretreatment
was shown to inhibit leukocyte chemotaxis, thus directed motility in a
concentration-dependent manner.14Within the innate immune response,
pathogens are coated (opsonized) with specific serum proteins and
neutrophils are primed. Priming refers to a process whereby the response
of neutrophils to a subsequent activating stimulus is potentiated. Release
of oxygen metabolites is markedly enhanced when activated neutrophils have
been primed previously. Importantly, the priming process has been shown to
be a critical component of neutrophil-mediated tissue injury both in vitro
and in vivo. LA have been shown to block the priming of neutrophils by
lysophosphatidic acid (LPA) and PAF with half-maximal inhibition
concentrations (IC₅₀) of approximately 1 mM. NADPH-oxidase
activity, Ca²⁺ and PKC, all likely to be involved in the
priming process, have also been described to be inhibited by several LA.
It is conceivable that inhibition of priming contributes to the
anti-inflammatory action of LA, and in particular suppresses the
deleterious effects of the uncontrolled, overactive response of
inflammatory cells to a stimulating agent. A specific interaction of LA
with G-protein subunits, most likely the Gq subunit, underlies this
inhibition of neutrophil priming.15-16 Beneficial effects of LA have been
reported for three different types of inflammatory lung injury, namely
hydrochloric acid (HCl)-, endotoxin- and hyperoxia-induced lung injury in
various animal models. Not only neutrophil accumulation, free radical
production, pulmonary edema and cytokine levels in bronchoalveolar fluid
were reduced, but also lung function was improved, indicated by an
increase in PaO₂ and attenuation of both decreased compliance
and increased resistance.17-19 In addition, in a murine septic peritonitis
model, LA were shown to reduce mortality and protect against renal and
hepatic dysfunction supposedly by lowering cytokine levels and a reduced
expression of adhesion molecules.20 One of the main causes of morbidity
and prolonged convalescence after major surgery was found to be
postoperative ileus. LA also shortened the duration of postoperative ileus
in patients undergoing major abdominal surgery.12 In this era of evidence
based medicine, where measurable improvements in patient outcome become
ever more the yardstick by which therapeutic interventions are evaluated,
the study by Groudine et al. is of great importance.9 They demonstrated in
patients undergoing radical retropubic prostatectomy, that systemic
lidocaine administration during and shortly after the procedure (plasma
concentration between 1.3-3.7 mg/ml) shortens return of bowel function,
reduces postoperative pain and, most impressively, decreases hospital
stay. The return to normal bowel function in this regard might be
explained in part by a direct excitatory effect on intestinal smooth
muscle as a result of a blockade of inhibitory reflexes from the myenteric
plexus.

<27>
Accession Number
71687531
Authors
Tighe S.
Institution
(Tighe) Countess of Chester Hospital NHS Foundation Trust, Chester, United
Kingdom
Title
Paravertebral blocks: Single shots and catheters: Indications and
limitations.
Source
Regional Anesthesia and Pain Medicine. Conference: 33rd Annual European
Society of Regional Anaesthesia and Pain Therapy, ESRA Congress 2014
Seville Spain. Conference Start: 20140903 Conference End: 20140906.
Conference Publication: (var.pagings). 39 (5 SUPPL. 1) (pp e55-e56), 2014.
Date of Publication: September-October 2014.
Publisher
Lippincott Williams and Wilkins
Abstract
PVB has a considerable evidence base of clinical effectiveness for several
unilateral thoraco-abdominal procedures, and many bilateral ones, in a
variety of respects[i],[2]. PVB is not just an analgesic technique, but
may also reduce PONV, chronic pain, tumour recurrence, flap hypoxia and
length of hospital stay1-[3]. Significant complications are rare and there
are very few contraindications1-3. Alternative non-neuraxial techniques do
not have such a robust evidence base and should therefore be used with
caution until they have been adequately compared with the PVB gold
standard in all the above respects3. When deciding between a single shot
PVB and catheter insertion, the primary consideration will be the duration
of analgesia required. A catheter may be indicated when acceptable
analgesia cannot be achieved for a sufficient duration after a single shot
block and multi-modal oral analgesics (MMA),without excessive use of
systemic opiates. A further consideration in this latter respect might be
to minimize the risk of local anaesthetic toxicity in susceptible
patients, or when patients are intolerant of MMA (oral opiates or NSAIDS).
Acceptable analgesia has been defined as an average NRS of <4/10 and an
NRS of 6/10 on movement[4]. At these levels, the majority of patients do
not request additional analgesia and are highly satisfied (NRS 10-15/15).
It is likely therefore, that the benefits of analgesic therapy to achieve
a mean NRS <4 will be outweighed by the risks. The duration of sensory
block after single shot PVB is less relevant than the duration of
acceptable analgesia achieved, probably explaining the paucity of studies
which have specifically assessed sensory block. Duration of detectable
sensory block varies from 2.5[5] to 24[6] hours, but much depends on the
choice of local anaesthetic, the dose and the use of additives.
Ropivacaine, bupivacaine and L-bupivacaine have been widely used in
concentrations from 0.25 to 0.5% and in volumes from 135 to 30[7] mls. It
seems logical that higher doses and volumes of longer acting agents will
result in wider spread and longer duration, but this has not been
assessed. Higher doses are associated with significantly improved
analgesia8. Various additives have been shown to increase analgesia[8],
including clonidine[9], fentanyl [10]and magnesium5. Dexamethasone has not
been studied, other than in a combination which included epinephrine,
clonidine and fentanyl [11], but it has been shown to extend the duration
of other blocks considerably[12]. None of the studies involving additives
have included a systemic control, so it is unknown if any effects are
locally or centrally mediated. Epinephrine is used widely to reduce
LAT[13], but no study has examined the effect on analgesia. The technique
of single shot PVB may also be relevant. Multiple blocks may result in
wider dermatomal spread than a single landmark injection and are therefore
more likely to cover the surgical stimulus[14], but this has been
challenged5. Ultrasound may result in more reliable block, but this has
not been compared to the landmark approach for single shot PVB. It is
currently unknown which exact technique of single shot PVB results in the
longest duration of analgesic action or sensory block. For breast surgery,
Moller et al demonstrated in an elegant placebo controlled RCT, that a
single shot PVB with 30 mls of ropivacaine 0.5% provided significant
analgesia for up to 2 hours only7. However, using MMA in addition, 75% +
of control patients had NRS <4 for all subsequent time periods and more
patients in the control group had simple mastectomy. Only 25% of patients
would have benefitted from a catheter according to the above definition of
acceptable analgesia. If a multiple level block had been performed, using
additional epinephrine, clonidine, fentanyl, magnesium and/or
dexamethasone, the number of patients with an NRS < 4 would probably have
increased further. In the meta-analysis by Schnabel et al, it is notable
that the control group mean NRS at 2-24 and 24-48 hours was near 4 or less
in all but one RCT with single shot blocks[15]. Buckenmaier et al
performed a double blind RCT of multiple level PVB for mastectomy,
followed by a PVB catheter infusion of ropivacaine or saline, plus
MMA[16]. There were no significant differences in any measured parameters.
Ilfield et al performed a similar study, but reported significantly
improved pain scores on day one with a catheter infusion of ropivacaine
(mean NRS 2 v 4, max 5 v 7 on movement)[17]. In addition, the Brief Pain
Inventory measured 14 v 57. There were no other differences up to 8 days
postoperatively and there was no difference in chronic pain incidence at 4
weeks. However, the initial PVB was a single shot with only 15 mls, 60% of
patients had bilateral mastectomy and MMA was not added. The control group
NRS was < 4, suggesting that they already had acceptable pain scores and
any significant additional catheter benefit was for 12 hours only. It
would therefore seem that on the balance of the evidence available, PVB
catheters are not necessary for most major breast surgery. For major
breast reconstruction, Buggy et al have shown that a catheter may be
indicated, both to extend the duration of analgesia, minimize toxicity and
increase flap viability [18]. However, dynamic pain scores in the control
group were within the above definition of acceptability (NRS <6). For
thoracotomy, there seems little doubt that PVB catheters are indicated.
The PROSPECT report on thoracic surgery stated that 5 of 9 PVB RCTs
provided significant catheter based analgesia lasting for 2 days or more,
although the control group NRS was not much greater than 4[19]. For other
less invasive thoracic procedures, single shot PVB is usually
described[20]. For rib fractures, there is no doubt that the stimulus
exceeds the duration of even the most prolonged single shot block and that
PVB catheters are strongly indicated10,[21]. PVB has been described for a
variety of other procedures, including open nephrectomy[22],
nephrolithotomy[23], laparoscopic[24]/open cholecystectomy[ 25], inguinal
hernia repair[26], major abdominal procedures[27],[28] and major
gynaecological surgery[29]. Most of these descriptions have been with
single shot approaches. The more major, open procedures may benefit from
catheter techniques, but within the concept of Enhanced Recovery After
Surgery (ERAS), this is debatable[30]. PVB catheters have several
limitations. Full sterile precautions are essential and ultrasound
catheter insertion takes a lot more time than a landmark single shot
block. Luyet et al have shown that with landmark catheter insertion to 5
cms, 29% were misplaced and 23% provided insufficient analgesia[31]. The
same authors have increased the success rate to 100% in cadavers with the
use of ultrasound and a coiled catheter[32], but this needs confirmation
in vivo. It is likely that catheter insertion should be < 2cms to prevent
epidural or other misplacement2,[33]. Catheters require either
intermittent boluses or an expensive infusion pump. Pump attachments
inhibit mobility and are against ERAS principles30. Catheters are easily
displaced and often leak. Most PVB LAT 6,8,10,[34], [35], and all but one
total spinal descriptions 2,[36] have been associated with catheters
inserted by surgeons under direct vision. Catheters are also associated
with an infection risk[37]. The initial block, not catheter prolongation,
is associated with any chronic pain reduction16 and this may be the same
for tumour recurrence, if this exists[38]. Taking the above into account,
the risk to benefit ratio is probably in favor of PVB catheters for rib
fractures and thoracotomy, as absolute indications. Relative indications
include major breast reconstruction, open nephrectomy, open
cholecystectomy, laparotomy, patients intolerant of MMA (eg NSAIDs,
opiates) and those at risk of LAT with a single shot block34. There is
considerable potential to increase the duration of action of single shot
PVBs. If this duration is insufficient to provide mean pain NRS <4 without
systemic opiates, then a catheter should be considered. This should be
inserted <2cm with full sterile precautions using ultrasound and a coiled
catheter. The block should be established with the catheter to prove
effectiveness, using a low concentration of local anaesthetic. Care should
be taken to prevent misplacement and leakage. The catheter should be
removed as soon as mean pain NRS is <4 using MMA.

<28>
Accession Number
71687509
Authors
Zaugg M. Lucchinetti E.
Institution
(Zaugg, Lucchinetti) Anesthesiology and Pain Medicine, University of
Alberta, Edmonton, Canada
Title
Impact of RA on organ / endothelial protection.
Source
Regional Anesthesia and Pain Medicine. Conference: 33rd Annual European
Society of Regional Anaesthesia and Pain Therapy, ESRA Congress 2014
Seville Spain. Conference Start: 20140903 Conference End: 20140906.
Conference Publication: (var.pagings). 39 (5 SUPPL. 1) (pp e20-e22), 2014.
Date of Publication: September-October 2014.
Publisher
Lippincott Williams and Wilkins
Abstract
Introduction: Trauma and surgical stress and their related pain elicit
endocrine and metabolic changes, which have been demonstrated to influence
the immune response [1]. This hormonal and metabolic stress response is
inhibited by blockade of afferent neuronal input when using regional
anesthetic techniques (epidural or spinal anesthesia). Regional anesthesia
alone or provided as intra- and postoperative analgesia for postoperative
pain control clearly modulates the cytokine production (see e.g., [2-6]).
More recently, novel approaches for post-operative immunomodulation by
chemical afferentectomy have been proposed. In the setting of an
established enhanced recovery after surgery (ERAS) program, Kahokehr et
al. [7] applied the local anesthetic ropivacaine intraperitoneally before
colon resection and added a postoperative ropivacaine infusion for 3 days.
Patients receiving ropivacaine showed significant blunting of postsurgical
systemic cytokines and cortisol release. These patients also had markedly
reduced pain and use of opioids as compared with patients receiving an
epidural anesthetic [7]. Organ protection through sympatho-modulation by
regional anesthetics: Approximately one-third of patients undergo regional
anesthesia for surgery. Some meta-analyses suggest that regional
anesthesia may be superior to general anesthesia with respect to
cardiovascular outcomes and outcomes related to other vital organs such as
the lungs, infections, transfusion requirements, renal failure and stroke)
[8-10]. However, most large-scale randomized trials demonstrate that the
choice of anesthesia does not influence cardiac morbidity and mortality
[11-14]. It should be also noted that cardiac arrest due to sympatho-vagal
dysbalance is not a very rare event (1:10'000) with spinal anesthesia
[15]. But serious complications such as post-dural puncture headache,
neurological injury and epidural hematoma with paraplegia are very rare
(1:100'000) with epidural anesthetics. In contrast to lumbar epidural
anesthesia, thoracic epidural anesthesia may be more effective in
protecting the heart against ischemia. They were reported to effectively
blunt myocardial ischemia in patients refractory to conventional medical
treatment [16]. Nonetheless, current evidence supports the view that
factors other than the type of anesthesia may be more important for at
least cardiovascular outcome in even high-risk patients. Hence benefits
from regional anesthesia may by rather related to improved pulmonary
outcomes [8] and maybe to reduced incidence in perioperative stroke, acute
renal failure and acute confusion in patients undergoing coronary artery
bypass graft surgery [17]. Thoracic epidural anesthesia may also prevent
bowl dysfunction after abdominal surgery and improve gastrointestinal
recovery. Endothelial protection: effects of regional anesthesia: The
vascular endothelium not only represents a barrier between the vessel
lumen and surrounding tissue. It actively controls vascular permeability
and plays an important role in cell adhesion, inflammatory responses,
immune reactions, and hemostasis, all of which are affected by surgical
stress. A recent study found in a rat model that thoracic epidural
anesthesia attenuates the endotoxin-induced increase of IL-1beta
concentration, adhesion molecule expression and leukocyte-adhesion with
subsequent endothelial injury [18]. Likewise, thoracic epidural anesthesia
reverses sepsis-induced alterations in hepatic perfusion and ameliorates
hepatic leukocyte recruitment [19] and exerts positive effects on
pulmonary endothelial integrity via the NO pathway [20] in rat models of
sepsis. During hemorrhagic hypotension and after resuscitation, thoracic
epidural anesthesia favourably affects intestinal perfusion [21]. Another
study in patients undergoing coronary artery bypass graft surgery reported
that thoracic epidural anesthesia increased internal thoracic artery free
blood flow markedly via increased VEGF, iNOS and adenosine-A2B receptor
expressions [22]. Regional anesthesia also favourably reduces oxidative
stress under ischemia-reperfusion conditions [23]. However, it should be
kept in mind that volatile anesthetics also exert a strong endothelial
protection in humans [24]. Mechanisms of endothelial protection by local
anesthetics: Local anesthetics interfere with neutrophil function Local
anaesthetics such as lidocaine inhibit chemotaxis, adhesion, phagocytosis,
and burst activity of neutrophils [25-28]. Also, pre-treatment with
intravenous lidocaine attenuated acute lung injury in rabbits [29, 30].
Most recently, lidocaine was shown to modulate inflammation in septic
patients by decreasing chemokine-induced neutrophil arrest and
transendothelial migration [31]. However, some caveats are warranted.
First, one has to bear in mind that the neutrophil functions shown to be
inhibited by lidocaine are ultimately necessary for microbial clearance
during infection and this may actually worsen outcome [32]. In the
clinical trial by Berger and colleagues [31], clinical outcome or patient
recovery data were not presented. As such, we do not know to datewhether
bacterial clearance was affected. Also, septic patients may suffer from
myocardial dysfunction but the potential cardiovascular effects of
lidocaine were not evaluated. In an interesting study, Chiang and
co-workers used a murine peritonitis model to study the impact of
different anesthetics on the resolution of the inflammatory response [33].
The authors elegantly showed the anti-inflammatory properties of
isoflurane, which reduced leukocyte infiltration and promoted inflammation
resolution. In contrast, lidocaine delayed the onset of resolution by
impairing leukocyte removal. Local anesthetics and cell adhesion molecule
expression The vascular endothelium not only represents a barrier between
the vessel lumen and surrounding tissue. It actively controls vascular
permeability and plays an important role in cell adhesion, inflammatory
responses, immune reactions, and hemostasis, all of which are affected by
surgical stress. The loss of barrier function results in tissue
inflammation, an important component of ischemia- reperfusion injury.
Inflammatory mediators such as thrombin, bradykinin, and vascular
endothelial growth factor (VEGF) disturb the organization of
interendothelial junctions opening the barrier [34]. Endothelial
hyperpermeability and intercellular adhesion molecule-1 (ICAM-1) are
markers of endothelial activation [35]. ICAM-1 is upregulated on the
surface of endothelial cells after exposure to inflammatory cytokines such
as tumor necrosis factor-alpha. ICAM-1 mediates the firm adhesion of
leukocytes to the endothelium and therefore facilitates the endothelial
transmigration of leukocytes. Lidocaine pre-treatment has been shown to
reduce ICAM-1 expression in activated human umbilical vein endothelial
cells (HUVECs) [36]. However, this was shown only at concentrations larger
than clinically relevant. Piegeler et al. [37] demonstrate in an in vitro
setting that concomitant treatment of human lung microvascular endothelial
cells with ropivacaine and tumor necrosis factor-alpha reduced neutrophil
adhesion and endothelial hyperpermeability via a reduction of Akt, eNOS,
and Src activation. The authors argue that local anesthetics may be
helpful in reducing inflammatory endothelial hyperpermeability [37].
Although lidocaine (but not tetracaine) pre-treatment attenuates
cytokine-induced endothelial cell injury (death) [38], the protective
effects of local anesthetics have not been firmly established. In fact,
pre-treatment with local anesthetics in vivo has been shown to exacerbate
renal ischemia-repefusion injury in rats [39] by increasing both necrotic
and apoptotic kidney cell death. On the other hand, lidocaine can reduce
inflammatory responses and protect tissues from local injury in other
experimental settings (sepsis) [40]. Local anesthetics and cell viability
and function In vitro, local anesthetics have been shown to directly
protect cells (endothelial cells, vascular smooth muscle cells, neural
cells) from cytokine-induced injury [38, 41, 42]. Tissue protection,
however, may also result from improved perfusion. However, amide local
anesthetics are known to cause vasoconstriction [43]. Summary: Regional
anesthetics provide excellent analgesia and protect the function of vital
organs. However, there is little evidence that regional anesthetics are
superior to general anesthetics so far and more research is required in
this area. While local anesthetics may have organ/endothelium protective
properties and thus positively impact outcomes bymodulating
and/ormitigating the stress response, there are currently insufficient
data to make any clinical recommendations.

<29>
Accession Number
71685118
Authors
Cardillo G. Lococo A. De Massimi A.R. D'Agostino A. Carleo F. Larocca V.
Santini P.F. Gonfiotti A.
Institution
(Cardillo, De Massimi, Carleo) Thoracic Surgery, Azienda Ospedaliera San
Camillo Forlanini, Rome, Italy
(Lococo) Thoracic Surgery, Pescara Hospital, Pescara, Italy
(D'Agostino, Larocca, Santini, Gonfiotti) Thoracic Surgery, Careggi
Hospital, Florence, Italy
Title
ADverse effects of fibrin sealants in thoracic surgery. The safety of a
new fibrin sealant: Multicentre, controlled, prospective, parallel group
randomised clinical trial.
Source
Interactive Cardiovascular and Thoracic Surgery. Conference: 19th European
Conference on General Thoracic Surgery Marseille France. Conference Start:
20110605 Conference End: 20110608. Conference Publication: (var.pagings).
13 (pp S56), 2011. Date of Publication: August 2011.
Publisher
Oxford University Press
Abstract
Objectives: The safety of fibrin sealants has been questioned in the light
of recent reports of adverse effects, mainly thromboembolic events and
fatal anaphylaxis. We evaluated the safety of a new fibrin sealant (FS) in
a randomised controlled trial (RCT). Methods: Multicentre, prospective,
open-label phase II/III RCT to evaluate the safety of FS. The trial was
approved by the Ethic Committee. FS includes two components (component 1:
fibrinogen; component 2: thrombin), each of them subjected to two viral
inactivation procedures. Out of 200 screened patients, 185 eligible
patients (49 females, 136 males), aged between 18 and 75 years, undergoing
major thoracic surgery were randomised to receive FS (# 91 patients) as an
adjuvant for air leak control or no treatment (#94 patients). Safety
variables were: percentage of subjects with adverse events associated with
the therapy; formation of antibodies against bovine aprotinin; vital signs
(blood pressure, body temperature, heart and respiratory rate); laboratory
parameters (haematology and blood chemistry). Results: None of the adverse
events was considered as treatment-related. Atrial fibrillation (five
patients in the FS group and four in the control group) and hyperpyrexia
(five and seven patients, respectively in the two groups) were the most
common adverse events. No patient reported thromboembolic events
(pulmonary embolism or deep vein thrombosis) during the inhospital stay or
within one month from discharge. The formation of bovine aprotinin
antibodies was reported in a total of 34 patients (37.4%) in the FS group
and was not related to any adverse effect. Conclusions: The present RCT
did not show any increased risk of serious and non-serious adverse events,
and of surgical complications, related to the use of FS. The proportion of
treated patients that developed bovine aprotinin antibodies was in
compliance with literature data.

<30>
Accession Number
71685114
Authors
Lang-Lazdunski L. Waller D. Tan C. Edwards J. Kilburn L. Treasure T.
Institution
(Lang-Lazdunski) Thoracic Surgery, Guy's Hospital, London, United Kingdom
(Waller) Thoracic Surgery, Glenfield Hospital, Leicester, United Kingdom
(Tan) Thoracic Surgery, St Georges Hospital, London, United Kingdom
(Edwards) Cardiothoracic Surgery, Northern General Hospital, Sheffield,
United Kingdom
(Kilburn) Statistics Unit, Clinical Trials, Institute of Cancer Research,
Sutton, United Kingdom
(Treasure) Mathematics, UCL, London, United Kingdom
Title
Can extrapleural pneumonectomy still be offered to patients with malignant
pleural mesothelioma after the mars trial?.
Source
Interactive Cardiovascular and Thoracic Surgery. Conference: 19th European
Conference on General Thoracic Surgery Marseille France. Conference Start:
20110605 Conference End: 20110608. Conference Publication: (var.pagings).
13 (pp S55), 2011. Date of Publication: August 2011.
Publisher
Oxford University Press
Abstract
Objectives: The role of extrapleural pneumonectomy (EPP) has come into
question in patients with malignant pleural mesothelioma (MPM). Results of
randomised controlled trials (RCT) may be rejected as not applicable to
'real world' outcomes, either because RCT outcomes may not be replicated
subsequently in clinical practice or because the RCT reported outcomes are
inferior to those previously reported in cohort studies. We compared the
outcomes of the mesothelioma and radical surgery (MARS) trial with so
called 'real world' data. Methods: Cohorts reporting median survival for
patients undergoing EPP in large studies in the last decade were sought.
For non-operated patients, median survival in studies published before or
during MARS were retrieved. Outcomes for patients in the non-treated arm
of a chemotherapy RCT and a large institutional report were also
extracted. Results: Large studies or phase II trials including 45 to 385
patients reported median survival of 10 to 23 months after EPP. Data
superpose on MARS EPP survival data and were inferior to the median
survival of non-operated patients in MARS. Survival of non-operated
patients in two pilot studies for MARS were seven and 13 months which
bracketed the 10 month survival in two non-operated cohorts reported
during MARS recruitment. Conclusions: MARS EPP outcomes are comparable
with those reported in cohort studies and therefore the evidence from MARS
can be relied upon as applicable to 'real world' practice. Survival of
non-operated patients is highly dependent on the source of the data and
factors, such as lead time bias. However, there is no evidence from MARS,
cohort studies, or phase II trials that EPP offers a survival advantage
over the natural or otherwise treated survival in malignant pleural
mesothelioma.

<31>
Accession Number
71685054
Authors
Abdelaziz M.Z. Bradley A. Agostini P. Bishay E. Steyn R.S. Kalkat M.S.
Rajesh P.B. Naidu B.
Institution
(Abdelaziz) Regional Thoracic Surgical Department, Birmingham Heartlands
Hospital, Heart of England NHS Foundation Trust, Birmingham, United
Kingdom
(Bradley, Agostini, Bishay, Steyn, Kalkat, Rajesh, Naidu) Regional
Thoracic Department, Birmingham Heartlands Hospital, Heart of England NHS
Foundation Trust, Birmingham, United Kingdom
Title
A pre and postoperative rehabilitation programme for lung resection
surgery reduces post operative complications and hospital readmission
rates.
Source
Interactive Cardiovascular and Thoracic Surgery. Conference: 19th European
Conference on General Thoracic Surgery Marseille France. Conference Start:
20110605 Conference End: 20110608. Conference Publication: (var.pagings).
13 (pp S40), 2011. Date of Publication: August 2011.
Publisher
Oxford University Press
Abstract
Objectives: Chronic obstructive pulmonary disease (COPD), smoking, and
exercise capacity are potentially modifiable independent risk factors for
developing postoperative pulmonary complications (PPC) after lung
resection. This pragmatic enriched cohort study examines the effect of a
multidisciplinary pre and postoperative complex intervention and its
effect on patient and health care outcomes. Methods: Based on a COPD type
rehab template, the programme consists of an exercise programme, targeted
smoking cessation therapy, dietary assessment and intervention, and
patients' self-management education sessions. Patients identified as
potential candidates for curative lung surgery from two referring
hospitals to a regional thoracic unit were invited into the programme.
Patients referred for surgery from eight other hospitals to the same unit
served as control. Surgery was not delayed by the programme, hence the
time spent in rehabilitation varied. Postoperative care was carried as per
unit protocol. On discharge, the intervention group returned to the
programme for up to six months. Results: All but one of 29 patients
enrolled, completed the programme. A further two patients enrolled but did
not receive surgery because subsequent investigation demonstrated disease
was more advanced. Patients in the intervention group (n=29) were
significantly older than those who did not receive the intervention
(n=138); 69 (+6) vs. 65 (+12) years (P<0.001). The groups were matched for
lung function, COPD, comorbidities, smoking history and nutritional
status. The interventional group received an average of six preoperative
rehabilitation and seven educational sessions in the average of 29 days
waiting for surgery. Primary outcome measures of PPC and hospital
readmission rate were significantly better in the intervention group.
Secondary outcome measures, e.g. exercise capacity also improved.
Conclusions: A COPD type rehabilitation programme for patients undergoing
curative lung resection is feasible and shows promising results and a
large multicentre randomised controlled trial is warranted to test
efficacy, mechanism and subgroups.

<32>
Accession Number
71684854
Authors
Paparella D. Rotunno C. Cappabianca G. Scrascia G. De Palo M. Marraudino
N. Schinosa L.D.L.T.
Institution
(Paparella, Rotunno, Cappabianca, Scrascia, De Palo, Marraudino, Schinosa)
Division of Cardiac Surgery, University of Bari, Bari, Italy
Title
A closed phosphorylcholine-coated cardiopulmonary bypass circuit reduces
inflammatory response and coagulopathy following coronary artery bypass
grafting operation: A randomised controlled trial.
Source
Interactive Cardiovascular and Thoracic Surgery. Conference: 25th Annual
Meeting of the European Association for Cardio-Thoracic Surgery, EACTS
2011 Lisbon Portugal. Conference Start: 20111001 Conference End: 20111005.
Conference Publication: (var.pagings). 13 (pp S115-S116), 2011. Date of
Publication: September 2011.
Publisher
Oxford University Press
Abstract
Objectives: Miniaturised cardiopulmonary bypass (CPB) systems without
venous reservoir are effective in reducing CPB-induced inflammatory
reaction and coagulopathy but are rarely clinically adopted because of
their elevated costs and complexity. The effects of a standard CPB system
with collapsible closed venous reservoir and phosphorylcholine coating
were evaluated on the release of Interleukin-6 (IL-6, marker of
inflammation), pro-thrombin fragment 1-2 (PF-1.2, marker of thrombin
generation), plasmin-antiplasmin complex (PAP, marker of fibrinolysis) and
Platelet Factor 4 (PF4, marker of platelet activation). The DNA binding
activity of pro-inflammatory transcription factor nuclear factor-kB
(NF-kB) was quantified in the isolated lymphomonocyte cells. Methods:
Eighty-six coronary artery bypass graft patients were randomly assigned to
Physio Group (closed reservoir, phosphorylcholine coating, no cardiotomy
suction) or Standard Group (open, non-coated CPB, cardiotomy suction
used). Blood samples were obtained preoperatively (T0), 30 min after CPB
(T1), 15 min after declamping (T2); 2 h after the end of CPB (T3) and in
postoperative day 1 (T4) and 5 (T5). NF-kB activity was evaluated before
and 24 h after the operation. Results: The operations caused changes of
all plasma biomarkers. This reaction was strongly attenuated in the physio
group: IL-6 was significantly lower at T2, PF-1.2 was significantly lower
at T1 and T2, PAP was significantly lower at T1, T2 and T3 and PF4 was
significantly decreased at T1, T2 and T4. A significantly lower cardiac
Troponin I was observed at T3. Twenty-four hours after the operation NF-kB
activity was reduced in the physio group. Postoperative inotropic use and
length of stay in the ICU were significantly reduced in the physio group.
Conclusions: A closed and phosphorylcholine coated CPB circuit, without
changing routine CPB management, reduces the inflammatory response. The
activation of the coagulation systems and platelets is also reduced and
consequently the fibrinolytic response is strongly attenuated. On a larger
scale these results may lead to clinical advantages.

<33>
Accession Number
71685405
Authors
Tan C. Utley M. Paschalides C. Pilling J. Robb J.D. Harrison-Phipps K.
Lang-Lazdunski L. Routledge T. King J. Treasure T.
Institution
(Tan) Department of Thoracic Surgery, St George's Hospital, London, United
Kingdom
(Utley, Paschalides, Treasure) Clinical Operational Research Unit,
University College London, London, United Kingdom
(Pilling, Robb, Harrison-Phipps, Lang-Lazdunski, Routledge, King)
Department of Thoracic Surgery, Guy's Hospital, London, United Kingdom
Title
A prospective randomized controlled study to assess the effectiveness of
coseal to seal air leaks in lung surgery.
Source
Interactive Cardiovascular and Thoracic Surgery. Conference: 18th European
Conference on General Thoracic Surgery Valladolid Spain. Conference Start:
20100530 Conference End: 20100602. Conference Publication: (var.pagings).
11 (pp S8), 2010. Date of Publication: August 2010.
Publisher
Oxford University Press
Abstract
Objectives: Air leak mandates ongoing drainage in two thirds of patients
after lung resection. We conducted an investigator led randomized trial to
evaluate the effectiveness of CoSeal surgical sealant for the closure of
alveolar air leak after anatomical pulmonary resection. Methods: Patients
with a demonstrable air leak following open lobectomy, bilobectomy or
segmentectomy were randomised to either standard care or standard care
plus CoSeal application (with a second application used if air leak
persisted). Unbiased allocation was by minimization at the point of entry
to the study to ensure balance between the groups with respect to age,
sex, surgeon, number of segments resected, preoperative FEV₁
and grade of air leak. Kaplan-Meier analysis of air leak duration and a
log-rank test were performed on an intention-to-treat basis, with
observations censored at death, transfer to ICU or discharge. Results:
Sixty patients were allocated to control and 61 to CoSeal. Data were
missing for one CoSeal patient. In 57% of CoSeal patients the demonstrable
air leak stopped at the first application; a quarter continued to leak
after two applications. Air leak persistence was similar at 24 h but
persisted after 48 h in 49% of CoSeal and 39% of control patients (P=0.09
log-rank test). Median drain time and length of stay were longer in the
CoSeal arm. Conclusions: In this randomized trial, there was longer
duration of air leak among patients treated with CoSeal following
anatomical lung resection. We cannot recommend changing from the standard
practice.

<34>
Accession Number
71685348
Authors
Diez C. Stiller M. Silber R. Hofmann H.
Institution
(Diez, Stiller) Cardiothoracic Surgery, University Medical Centre,
Regensburg, Germany
(Silber) Cardiothoracic Surgery, Martin-Luther-University, Halle/Saale,
Germany
(Hofmann) Thoracic Surgery, University Medical Centre, Regensburg, Germany
Title
Euroscore-guided preoperative elective intra-aortic balloon pump
implantation in high-risk patients does not reduce inhospital mortality
after cardiac surgery.
Source
Interactive Cardiovascular and Thoracic Surgery. Conference: 24th Annual
Meeting of the European Association for Cardio-Thoracic Surgery, EACTS
2010 Geneva Switzerland. Conference Start: 20100911 Conference End:
20100915. Conference Publication: (var.pagings). 11 (pp S118-S119), 2010.
Date of Publication: September 2010.
Publisher
Oxford University Press
Abstract
Objectives: Intra-aortic balloon pumping (IABP) is considered to
facilitate CABG in high-risk patients. However, the impact of prophylactic
preoperative implantation in those patients still remains unclear.
Methods: Randomised controlled trial with 104 high-risk patients (45
females, 59 males) with a preoperative additive EuroSCORE >8. Group A
(n=52) received an IABP 2 h preoperatively, whereas Group B did not.
Primary outcome was in-hospital mortality. Results: Patients had a mean
age of 72+12 years and a mean additive EuroSCORE of 9.8+2.0 (95% CI
9.4-10.2). Logistic EuroSCORE was calculated as 18.4% (95% CI 16.1-20.4).
There were 64 isolated bypass graft procedures and 40 combined
bypass/valve operations. In-hospital mortality did not differ between
group A (7/52, 13.4%) and group B (8/52, 15.3%; P=1.0). Median hospital
stay (13 days) proved to be insignificant between both groups. Ventilation
time, urine output and postoperative requirement of temporary dialysis
(18%) showed no significant differences. Cumulative median adrenaline and
noradrenaline values also did not differ and cardiac index 24 h after
surgery was insignificant (Group A: 2.7+0.6 vs. Group B: 2.7+0.5). The
frequency of low cardiac output syndrome within the first 24 h was similar
in both groups (13 vs. 12%). IABP-related complications occurred in 6.4%
of patients in Group A. Conclusions: EuroSCORE is not an appropriate score
system for decisionmaking in preoperative IABP implantation. It cannot
discriminate between patients who benefit from IABP and those who do not.

<35>
Accession Number
71685301
Authors
Glower D. Mauri L. Foster E. Feldman T.
Institution
(Glower) Cardiovascular Surgery, Duke University Medical Center, Durham,
United States
(Mauri) Harvard Clinical Research Institute, Boston, United States
(Foster) Cardiology, University of California, San Francisco, San
Francisco, CA, United States
(Feldman) Cardiology, Evanston Northwestern Healthcare, Evanston, IL,
United States
Title
Everest ii randomised clinical trial: Twelve-month outcomes in surgical
versus percutaneous therapy for mitral regurgitation.
Source
Interactive Cardiovascular and Thoracic Surgery. Conference: 24th Annual
Meeting of the European Association for Cardio-Thoracic Surgery, EACTS
2010 Geneva Switzerland. Conference Start: 20100911 Conference End:
20100915. Conference Publication: (var.pagings). 11 (pp S107), 2010. Date
of Publication: September 2010.
Publisher
Oxford University Press
Abstract
Objectives: EVEREST II is a prospective, multicentre, randomised
controlled trial to compare the safety and effectiveness of the MitraClip
System with mitral valve surgery in the treatment of mitral regurgitation
(MR). Eligibility criteria specified patients with 3+ or 4+ MR who met the
ACC/AHA guidelines for mitral valve surgery. Patients were randomised to
treatment with the MitraClip device (Device) or mitral valve repair or
replacement surgery (Surgery). The study was designed to demonstrate
non-inferiority of effectiveness compared to surgery, and superiority of
safety of the MitraClip device. Details on the surgical patients enrolled
in EVEREST II will be presented. Methods: Two hundred and seventy-nine
patients were randomised 2:1 (Device vs. Surgery). The primary
effectiveness endpoint was freedom from the combined outcomes of death,
surgery for mitral valve dysfunction, or MR >2+ at 12 months. The primary
safety endpoint was major adverse events at 30 days, defined as a combined
endpoint of death, myocardial infarction, reoperation, non-elective
cardiovascular surgery for adverse events, stroke, renal failure, deep
wound infection, ventilation >48 h, gastrointestinal complication
requiring surgery, new onset of permanent atrial fibrillation,
septicaemia, or transfusion >2 or more units of blood. The primary
endpoints were based on the per protocol population, including patients
with discharge MR <2+ in the Device group, and patients who had operation
in the Surgery group. Additional safety and effectiveness analysis were
performed on the intention-to-treat population. Echocardiography and
clinical follow-up was performed at discharge, 30 days, six, and 12 months
and evaluated by a core laboratory and clinical events committee,
respectively. Results: For the primary endpoints in the per protocol
analyses, the Device group experienced superior safety at 30 days (9.6 vs.
57.0% major adverse events). The primary effectiveness endpoint at 12
months showed non-inferiority of the Device (67.4 vs. 73.0% effectiveness)
compared to surgery. Additional clinical endpoints will be presented and
discussed, with an emphasis on the surgical outcomes. Conclusions: The
EVEREST II Randomised Clinical Trial 12 month data demonstrate superior
safety and non-inferior effectiveness of the Device relative to Surgery,
and improved clinical benefit in selected patients with mitral
regurgitation following either therapy.

<36>
Accession Number
71685215
Authors
Jin Z. Duan W. Yi D.
Institution
(Jin, Duan, Yi) Cardiovascular Surgery, Xijing Hospital, Xi'an, China
Title
Randomised controlled trial of the effects of adenosine pretreatment on
children undergoing cardiac surgery.
Source
Interactive Cardiovascular and Thoracic Surgery. Conference: 24th Annual
Meeting of the European Association for Cardio-Thoracic Surgery, EACTS
2010 Geneva Switzerland. Conference Start: 20100911 Conference End:
20100915. Conference Publication: (var.pagings). 11 (pp S85), 2010. Date
of Publication: September 2010.
Publisher
Oxford University Press
Abstract
Objectives: Adenosine pretreatment reduces injury caused by
ischaemiareperfusion. We hypothesised that adenosine pretreatment would
modulate injury induced by cardiopulmonary bypass (CPB), and conducted a
randomised controlled trial of the effects of adenosine pretreatment in
children undergoing repair of congenital heart defects. Methods: Children
undergoing repair of congenital heart defects were randomised to adenosine
pretreatment or control treatment. Adenosine pretreatment was induced by
10 min infusion of adenosine with a total amount of 1.5 mg/kg. Serum
troponin I was measured pre- and postoperatively, and clinical data such
as postoperative inotrope use, duration of intensive care unit (ICU) stay,
etc., were recorded. Results: Eighty-two patients were studied. There were
42 control patients and 40 patients in the adenosine pretreatment group.
The mean age and weight of the adenosine pretreatment and control patients
were not different. Bypass and cross-clamp times were not different.
Levels of troponin I postoperatively were greater in the control patients
compared with the adenosine pretreatment group (P=0.02), indicating
greater myocardial injury in control patients. Postoperative inotropic
requirement was greater in the control patients compared with adenosine
pretreatment patients at 0, 1 and 3 h (3.7+1.6 vs. 4.5+1.3, P=0.011; and
4.7+3.6 vs. 6.7+3.7, P=0.017, 4.7+3.6 vs. 6.6+3.7, P=0.021, respectively).
The adenosine pretreatment group had significantly shorter ICU stay time
compared with control group (3.2+1.2 vs. 3.9+1.2 days, P=0.013).
Conclusions: This study demonstrates the myocardial protective effects of
adenosine pretreatment in open-heart surgery in children.