Introduction: Patients with hypertrophic cardiomyopathy (HCM) and atrial fibrillation (AF) require chronic anticoagulation due to a high thromboembolic risk. Evidence supporting use of non-vitamin K oral anticoagulants (NOACs) in patients with HCM remains sparse, and there are no data regarding the use of NOACs in HCM patients undergoing catheter ablation of AF. Methods: Observational non-randomised study in 4 European Centres. We aimed to investigate the safety and efficacy of NOACs compared with vitamin-K antagonists (VKAs) in patients with HCM undergoing catheter ablation for AF. Results: One hundred thirty-seven HCM patients (mean age 55.0±13.4, 29.1% female) underwent 230 catheter ablations for AF (1.7±1.0 per patient). A total of 55 patients (39.4%) underwent 70 procedures (30.4%) on NOAC, while the remaining were on VKA. Warfarin (97.6%) and rivaroxaban (56.4%) were the most frequently used agents in the respective groups. No procedure-related deaths were reported. We observed no significant difference in the rate of thromboembolism (VKA 0.6%; NOAC 0%; p=1.0) or minor bleeding (VKA 0.6%; NOAC 1.4%; p=0.54). There was a non-significant trend towards a lower incidence of major bleeding (VKA 6.8%; NOAC 1.4%; p=0.09). Conclusion: These preliminary data suggest that NOACs are at least as safe and effective as VKAs in patients with HCM undergoing catheter ablation for AF.
On March 11, 2020, the World Health Organization (WHO) declared the SARS-CoV-2 outbreak a pandemic: it took a toll of more than 300.000 deaths and more than 4.5 million cases, worldwide. The initial data pointed out the tight bond between cardiovascular diseases and worse outcomes in COVID19-patients. Epidemiologically speaking, there is an overlap between the age-groups more affected by COVID-related death and the age-groups in which Cardiac Surgery has its usual base of patients. The Cardiac Surgery Departments have to think to a new normal: since the virus will remain endemic in the society, dedicated pathways or even dedicated Teams are pivotal to treat safely the patients, in respect of the safety of the health care workers. Moreover, we need a keen eye on deciding which pathologies have to be treated with priority: Coronary Artery Disease (CAD) showed a higher mortality rate in patients affected by COVID19, but it’s however reasonable to think that all the cardiac pathologies affecting the lung circulation - such as symptomatic severe mitral diseases or aortic stenosis - might deserve a priority access to treatment, in order to increase the survival rate in case of an acquired-Coronavirus infection later on.
Redo multiple valve replacement is known to carry additional risk of morbidity and mortality. Currently, a transcatheter-based valve-in-valve approach could be useful in reducing potential serious consequences. On the other hand, this approach poses several technical challenges regarding the device and procedural aspects of the procedure. We present the case of a 78-year-old man who presented with symptoms of heart failure due to mitro-aortic bioprosthesis degenerations who was deemed to be at extremely high risk for conventional redo surgery. A two-steps single admission transcatheter-based approach was planned with a transfemoral aortic valve-in-valve procedure followed by a trans-apical mitral valve-in-valve implantation. The outcome was good and the recovery was fast.
Background and aim: The incidence of symptomatic cerebral infarction after minimally invasive cardiac surgery (MICS) with retrograde perfusion has been increasing. However, there is no report about silent brain infarction (SBI) after MICS with retrograde perfusion. Because SBI may cause delirium and decline of cognitive function, this condition is important clinically. Thus, the current study aimed to investigate the occurrence of SBI after MICS via magnetic resonance imaging (MRI). Methods: Between July 2014 and July 2018, 174 patients underwent MICS with retrograde perfusion and postoperative MRI in this study. Univariate and multivariate analyses were performed to examine the occurrence of SBI and to identify its risk factors. Results: Of 174 patients, 26 (14.9%) presented with SBI. The univariate analysis revealed that age and aortic valve stenosis (AS) are the risk factors of SBI. Meanwhile, multivariate analysis revealed AS as the only risk factor of SBI. Conclusions: At our institution, the incidence of SBI after MICS with retrograde perfusion was acceptable.
The nano/microelectromechanical systems (N/MEMS) have been caught much attention in the past few decades for their attractive properties such as small size, high reliability, batch fabrication, and low power consumption. The dynamic oscillatory behavior of these systems is very complex due to strong nonlinearities in these systems. The basic aim of this manuscript is to investigate the nonlinear vibration property of N/MEMS oscillators by the homotopy perturbation method coupled with Laplace transform (also called as He-Laplace method in literature). A generalized N/MEMS oscillator is systematically studied, and a fairly accurate analytic solution is obtained. Three special cases for electrically actuated MEMS, multi-walled Carbon nanotubes-based MEMS, and MEMS subjected to van der Waals attraction are considered for comparison, and a good agreement with exact solutions is observed.
Background: The rapid spread of COVID-19 has placed tremendous strain on the American healthcare system. Few prior studies have evaluated the well-being of or changes to training for American resident physicians during the COVID-19 pandemic. We aim to study predictors of trainee well-being and changes to clinical practice using an anonymous survey of American urology residents. Methods: An anonymous, voluntary, 47-question survey was sent to all ACGME-accredited urology programs in the United States. We executed a cross-sectional analysis evaluating risk factors of perception of anxiety and depression both at work and home and educational outcomes. Multiple linear regressions models were used to estimate beta coefficients and 95% confidence intervals. Results: Among approximately 1,800 urology residents in the USA, 356 (20%) responded. Among these respondents, 24 had missing data leaving a sample size of 332. Important risk factors of mental health outcomes included perception of access to PPE, local COVID-19 severity, and perception of susceptible household members. Risk factors for declination of redeployment included current redeployment, having children, and concerns regarding ability to reach case minimums. Risk factors for concern of achieving operative autonomy included cancellation of elective cases and higher level of training. Conclusions: Several potential actions, which could be taken by urology residency program directors and hospital administration, may optimize urology resident well-being, morale, and education. These include advocating for adequate access to PPE, providing support at both the residency program and institutional levels, instituting telehealth education programs, and fostering a sense of shared responsibility of COVID-19 patients.
According with latest guidelines, percutaneous mitral commissurotomy (PMC) represents the first-line treatment for symptomatic severe mitral valve stenosis (SMVS) with favourable morphology, We report a successful surgical treatment of a potential life-threatening complication occurred during PMC. Heart-Team discussion and closed collaboration with Centres are crucial for decision-making and Cardiac Surgery onsite should be ensured for high-risk procedures.
Background: Cardiac surgeries use 10%–15% of red blood cells transfused in the United States, despite benefits of limiting transfusions. We sought to evaluate the the feasibility and impact of a restrictive transfusion protocol on blood use and clinical outcomes in patients undergoing isolated primary coronary artery bypass grafting (CABG). Methods: Blood conservation measures, instituted in 2012, include preoperative optimization, intraoperative anesthesia and pump fluid restriction with retrograde autologous priming and vacuum-assisted drainage, use of aminocaproic acid and cell saver, intra- and postoperative permissive anemia, and administration of iron and lowdose vasopressors if needed. Medical records of patients who underwent isolated primary CABG from 2009–2012 (group A; n=375) and 2013–2016 (group B; n=322) were compared. Results: CABG with grafting to 3 or 4 coronary arteries was performed in 262 (70%) and 222 (69%) patients and bilateral internal thoracic artery grafting in 202 (54%) and 196 (61%) patients in groups A and B, respectively. Mean preoperative and intraoperative hematocrit was 40.3% and 40.7%, 28.9% and 29.4% in groups A and B, respectively. Total blood transfusion was 24% and 6.5%, intraoperative transfusion 10% and 1.2%, postoperative transfusion 19% and 5.3% (p<0.0001 for all) in groups A and B, respectively. Median postoperative length of stay was 5.0 days in group A and 4.5 days in group B (p =.02), with no significant differences between groups in mortality or morbidity. Conclusions: A restrictive transfusion protocol reduced blood transfusions and postoperative length of stay without adversely affecting outcomes following isolated primary CABG.
Even though antimicrobial-resistant bacteria have begun to be detected in wildlife, raising important issues related to their transmission and persistence of clinically important pathogens in the environment, little is known about the role of these bacteria on wildlife health, especially on endangered species. The Brazilian merganser (Mergus octosetaceus) is one of the most threatened waterfowl in the world, classified as Critically Endangered by the International Union for Conservation of Nature. In 2019, a fatal case of sepsis was diagnosed in an 8-day-old Brazilian merganser inhabiting a zoological park. At necropsy, major gross lesions were pulmonary and hepatic congestion. Using microbiologic and genomic methods, we identified a multidrug-resistant (MDR) extended-spectrum β-lactamase (ESBL) CTX-M-8-producing Escherichia coli (designed as PMPU strain) belonging to the international clone ST58, in celomic cavity, esophagus, lungs, small intestine and cloaca samples. PMPU strain harbored a broad resistome against antibiotics (cephalosporins, tetracyclines, aminoglycosides, sulfonamides, trimethoprim, and quinolones), domestic/hospital disinfectants, and heavy metals (arsenic, mercury, lead, copper, and silver). Additionally, the virulence of E. coli PMPU strain was confirmed using a wax moth (Galleria mellonella) infection model, and it was supported by the presence of virulence genes encoding toxins, adherence factors, invasins and iron acquisition systems. Broad resistome and virulome of PMPU contributed to therapeutic failure and death of the animal. In brief, we report for the first time a fatal colibacillosis by MDR-ESBL-producing E. coli in critically endangered Brazilian merganser, highlighting that besides colonization, critical priority pathogens are threatening wildlife. E. coli ST58 clone has been previously reported in humans, food-producing animals, wildlife, and environment, supporting broad adaptation and persistence at human-animal-environment interface.
We have explored the structural and energetic properties of a series of RMX3–NH3 (M=Si, Ge; X=F, Cl; R=CH3, C6H5) complexes using density functional theory and low-temperature infrared spectroscopy. In the minimum-energy structures, the NH3 binds axially to a halogen, while the organic group resides in equatorial site about the metal. Remarkably, the primary mode of interaction in several of these systems seems to be hydrogen bonding (C-H–N), rather than a tetrel N-M interaction. This is particularly clear for the RMCl3–NH3 complexes, and analyses of the charge distributions of the acid fragment corroborate this assessment. We also identified a set of metastable geometries in which the ammonia binds axial to the organic substituent. Acid fragment charge analysis also provide a clear rationale as to why these configurations are less stable than their R-equatorial counterparts. In matrix-IR experiments, we see clear evidence of the minimum-energy form of CH3SiCl3–NH3, but analogous results for CH3GeCl3–NH3 are less conclusive. Computational scans of the M-N distance potentials for CH3SiCl3–NH3 and CH3GeCl3–NH3, both in the gas phase and bulk dielectric media reveal a great deal of anharmonicity, and a propensity for condensed-phase structural change.
Survivorship care is a major area of focus in the holistic management of childhood cancer with current knowledge and information almost exclusively from high-income countries. In this review, we summarize the state of scientific knowledge, service delivery, advocacy initiatives and research efforts in this field in India. 21 single centre studies published till date (20 in the last decade) confirm some of the well-documented issues in childhood cancer survivors and also highlight the high prevalence of hepatitis B and hepatitis C infection in our survivors. Heterogeneity in methodology, outcome metrics and quality precludes drawing further conclusions and the ongoing multicenter Indian Pediatric Oncology Group study would address this. Besides the usual model of follow-up clinics in hospital settings, innovative models of service delivery led by not-for-profit organisations are being developed. Advocacy initiatives driven by survivors and support groups are also underway. All of these portend a promising future.
To the Editor:We enjoyed reading the case, authored by Janus and Hoit, of a 67-year-old woman with a subarachnoid hemorrhage (SAH) who presented with three different variants of takotsubo (TT).[i] We congratulate the authors on their interesting contribution to the literature. We would like to share some comments and questions on the chronology and management of the events between the first two episodes, which occurred a few days apart. Although fascinating, this is not the first case of TT with a rapidly evolving pattern. We previously described a case of mid-ventricular takotsubo which replaced apical ballooning in 6 hours.[ii] A recent meta-analysis showed that almost 80% of TT recurrences exhibit a ballooning pattern different from the first presentation.[iii] In this regard, regional cardiac sympathetic innervation remodeling or denervation could hypothetically justify why the same territory is usually spared from further relapses. Even though images were not provided, the authors stated that “echocardiographic wall motion abnormalities quickly resolved after each acute stressor”. One could therefore argue that this was not a case of multiple TT variants during the same episode, as noted by Madias,iii but rather an example of early recurrences. Additionally, if cardiac innervation remodeling were responsible for the different locations of the ballooning, we believe that the change in pattern would have taken longer to manifest. This would not support the observation of two distinct ballooning patterns emerging within days, let alone hours.i, ii In this case, a short-term change from the mid-ventricular to apical pattern could be reasonably explained by different β adrenergic-receptor (β-AR) subtype downregulation. We know that norepinephrine can downregulate β1-AR after a few hours. Beta1-ARs are markedly lower on biopsied patients with acute TT compared to healthy controls,[iv] whilst in the same study β2-ARs expression—which is predominant in the apical and mid-ventricular segments and thought to be involved in typical takotsubo pathogenesis[v]—was equivalent to normal. Thus, the sequence of events could be interpreted as a relative local β2 prevalence due to dynamic β1 downregulation (β1:β2 mismatch), following a base:mid-ventricle, and ultimately a mid-ventricle:apex progression. What do the authors think about this theory? Is it possible that multi-faceted presentations might simply be under-recognized? Should this be the case, how do they think we could better understand this phenomenon in a noninvasive fashion? Could dobutamine stress echocardiography have utility to identify areas of β-AR downregulation and sympathetic denervation? It would also be interesting to know more about the patient’s medical therapy. Did she receive nonselective β-blockers, such as labetalol or carvedilol, usually prescribed after SAH? If so, this might indicate that β-blockers do not prevent recurrences,[vi] but rather create a maladaptive imbalance in regional β1:β2 distribution favoring early relapse(s), as this case suggests.References[i] Janus SE, Hoit BD. The three faces of takotsubo cardiomyopathy in a single patient. Echocardiography. 2020 Jan;37(1):135-138. doi: 10.1111/echo.14560. Epub 2019 Dec 16.[ii] Casavecchia G, Zicchino S, Gravina M, et al. Fast 'wandering' Takotsubo syndrome: atypical mixed evolution from apical to mid-ventricular ballooning. Future Cardiol. 2017 Nov;13(6):529-532. doi: 10.2217/fca-2017-0018. Epub 2017 Oct 12.[iii] Madias JE. Comparison of the first episode with the first recurrent episode of takotsubo syndrome in 128 patients from the world literature: Pathophysiologic connotations. Int J Cardiol. 2020 Mar 3. pii: S0167-5273(20)30215-1. doi: 10.1016/j.ijcard.2020.03.003.[iv] Nakano T, Onoue K, Nakada Y, et al. Alteration of β-Adrenoceptor Signaling in Left Ventricle of Acute Phase Takotsubo Syndrome: a Human Study. Sci Rep 8, 12731 (2018). https://doi.org/10.1038/s41598-018-31034-z.[v] Paur H, Wright PT, Sikkel MB, et al. High levels of circulating epinephrine trigger apical cardiodepression in a β2-adrenergic receptor/Gi-dependent manner: a new model of Takotsubo cardiomyopathy. Circulation. 2012 Aug 7;126(6):697-706. doi: 10.1161/CIRCULATIONAHA.112.111591. Epub 2012 Jun 25.[vi] Santoro F, Ieva R, Musaico F, et al. Lack of efficacy of drug therapy in preventing takotsubo cardiomyopathy recurrence: a meta-analysis. Clin Cardiol. 2014 Jul;37(7):434-9. doi: 10.1002/clc.22280. Epub 2014 Apr 3.
The present investigation is concerned with high-cycle axial fatigue testing of a 2 mm AA6060-T6 HYB butt weld produced in the solid state using AA6082 filler metal addition. The results complement the three-point bend testing and the tensile testing done in two previous studies. In this study, optical microscope and scanning electron microscope examinations have been carried out to reveal the joint macro/microstructure and document possible surface and root defects deemed to affect fatigue life. In the as-welded condition, the HYB weld suffers from surface irregularities at the weld face and “kissing” bond formation in the root region. Despite of this, the subsequent testing shows that the fatigue properties exceed those reported for comparable AA6082-T6 gas metal arc butt welds and matching those reported for corresponding high-strength laser beam and friction stir weldments.