Title page:Title : Letter to the editor: Mitral valve repair with the edge‐to‐edge technique: A 20 years single‐center experienceArticle type : Letter to the editorCorrespondence : 1. Syed HussainContact : +923323230575 Email : email@example.comInstitute : Shaheed Mohtarma Benazir Bhutto Medical College Liyari KarachiAddress : R-75 Railway Housing Society, 13-D1, Gulshan-e-Iqbal, Karachi, 75300Co-authors : 2.Muhammad MaazContact : +923032194036 Email : firstname.lastname@example.orgInstitute : Shaheed Mohtarma Benazir Bhutto Medical College Liyari KarachiAddress : Flat No. B-16, Hasham Apartment, Rafa-e-aam, Malir Halt, Karachi, 752103. Dr. Sumeet KumarContact : +92-3337351513Email :Dr.email@example.comInstitute : Dow University of Health Sciences, KarachiAddress : Mission Rd, New Labour Colony Nanakwara, Karachi, Karachi City, Sindh 74200Word count : 482Conflict of interest : NoneDeclaration : NoneAcknowledgment : None
Functional role of ST6GALNAC1-mediated sialylation of mucins in preserving intestinal barrier integrity and ameliorating inflammation. Authors : Elisa Sánchez-Martínez1*, Manuel Garrido-Romero1,2,*, F. Javier Moreno21Department of Immunology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa, (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Madrid, Spain.2Department of Bioactivity and Food Analysis, Instituto de Investigación en Ciencias de la Alimentación, CIAL (CSIC-UAM), Madrid, Spain.*Equal contributionCorrespondence to:F. Javier Moreno. Department of Bioactivity and Food Analysis, Instituto de Investigación en Ciencias de la Alimentación, CIAL (CSIC-UAM), Nicolás Cabrera 9, 28049 Madrid, Spain.E-mail:firstname.lastname@example.orgAbbreviations:ST6GALNAC1, ST6; mucin-2, MUC2; dextran sulfate sodium, DSS; wild-type, WT; short-chain fatty acids, SCFA.Funding information : MGR is supported by an EFSA project (Grant agreement GP/EFSA/ENCO/2020/02 – 1) granted to FJM. Conclusions, findings and opinions expressed in this document reflect only the view of the authors and not the official position of EFSA.Keywords: epithelial barrier; MUC2; intestinal mucus; gut microbiota disruption; colitis.
Duke-Davidoff-Masson syndrome (DDMS) is a rare neurological condition with unknown global prevalence. It typically manifests with body asymmetry, drugs resistant epilepsy, mental retardation, cerebral atrophy, skull bone thickening and hyperpneumatization of the frontal sinuses. In this report, we present an unusual case of DDMS revealed by status epilepticus.
John Fitzgerald Kennedy (JFK), the 35th President of the USA, had chronic low back pain deemed to be centralized pain. Reportedly, attention deficit hyperactive disorder (ADHD) could associate with centralized pain. Based on his biographies, JFK could have had ADHD, being a plausible cause of pain that afflicted him.
Objectives: We sought to assess the safety of training in cardiothoracic surgery comparing outcomes of cases performed by trainees versus fully trained surgeons. Methods: EmBase, Scopus, PubMed, and OVID MEDLINE were searched in August 2021 independently by two authors. A third author arbitrated decisions to resolve disagreements. Inclusion criteria were articles on cardiothoracic surgery reporting on outcomes for trainees. Studies were assessed for appropriateness as per CBEM criteria. 892 results were obtained, 27 represented best evidence (2-Meta-analyses, 1-RCT and 24 retrospective cohort studies). Results: 474,160 operative outcomes were assessed for 434,535 CABG (431,329 on-pump vs 3206 off-pump), 3090 AVR, 1740 MVR/repair, 26,433 mixed, 3565 congenital and 4797 thoracic procedures. 398,058 cases were performed by trainees and 75,943 by consultants. 159 cases were indeterminate. There were no statistically significant differences in the patients’ pre-operative risk scores. All studies excluded extreme high-risk patients in emergency setting, patients with poor left ventricular function and re-operation cases that were undertaken by consultants. There were no differences in CPB and clamp times for CABG. Times for valve replacement and repair cases were longer for trainees. There were no differences in the post-operative outcomes including peri-operative myocardial infarction, resternotomy for bleeding, stroke, renal failure, ITU length of stay and total length of stay. One study reported no differences on angiographic graft patency at 1 year. There were no differences in in-hospital or mid-term mortality out to five-years. Discussion: Trainees can perform cardiothoracic surgery in dedicated high-volume units with outcomes comparable to those of fully trained surgeons.
Background: The average living age of the population is constantly increasing and so is the incidence and prevalence of aortic valve disease. Surgical aortic valve replacement (SAVR) is the current gold standard treatment. Nevertheless, the use of prosthetic valves in SAVR is associated with issues that impact patients’ quality of life. Aortic valve neocuspidization (AV Neo) offers a means to solve this dilemma by minimising foreign valve tissue. AV Neo can either be performed using glutaraldehyde-treated autologous pericardium (Ozaki procedure) or bovine pericardium (Batista procedure). Aims: This commentary aims to discuss the recent study by Chan and colleagues which highlighted the surgical approach, clinical outcomes and limitations of the Ozaki procedure, and compare this to the Batista procedure. Methods: A comprehensive literature search was performed using multiple electronic databases including PubMed, Ovid, Embase and Scopus in order to collate the relevant research evidence. Results: Although the Ozaki procedure can achieve favourable results whilst mainly avoiding the need for life-long oral anticoagulation with mechanical valves, it still has several limitations that may hinder results. AV Neo using glutaraldehyde-treated bovine pericardium, developed by pioneer cardiac surgeon Dr. Randas J. Vilela Batista, yields superior clinical outcomes to Ozaki’s, including excellent survival, lower complications and minimal need for reoperation as well as shorter operative times. Conclusion: AV Neo offers a means to perform SAVR whilst escaping the prosthetic valve issues. However, the Batista procedure has shown beyond doubt that it can be considered the superior approach for AV Neo over the Ozaki procedure.
Background: The introduction of the frozen elephant trunk (FET) technique for total arch replacement (TAR) has revolutionized the field of aortovascular surgery. However, although FET yields excellent results, the risk of certain complications requiring secondary intervention remains present, negating its one-step hybrid advantage over conventional techniques. This systematic review and meta-analysis sought to evaluate controversies regarding the incidence of FET-related complications, with a focus on aortic remodeling, distal stent-graft induced new entry (dSINE) and endoleak, in patients with type A aortic dissection (TAAD) and/or thoracic aortic aneurysm. Materials and methods: A comprehensive literature search was conducted using multiple electronic databases including EMBASE, Scopus, and PubMed/MEDLINE to identify evidence on TAR with FET in patients with TAAD and/or aneurysm. Studies published up until January 2022 were included, and after applying exclusion criteria, a total of 43 studies were extracted. Results: A total of 5068 patients who underwent FET procedure were included. The pooled estimates of dSINE and endoleak were 2% (95% CI 0.01-0.06, I 2 = 78%) and 3% (95% CI 0.01-0.11, I 2 = 89%), respectively. The pooled rate of secondary thoracic endovascular aortic repair (TEVAR) post-FET was 7% (95% CI 0.05-0.12, I 2 = 89%) whilst the pooled rate of false lumen thrombosis at the level of stent-graft was 91% (95% CI 0.75-0.97, I 2 = 92%). After subgroup analysis, heterogeneity for dSINE and endoleak resolved among European patients, where Thoraflex Hybrid and E-Vita stent-grafts were used (both I 2 = 0%). In addition, heterogeneity for secondary TEVAR after FET resolved among Asians receiving Cronus (I 2 = 15.1%) and Frozenix stent -grafts (I 2 = 1%). Conclusion: Our results showed that the FET procedure in patients with TAAD and/or aneurysm is associated with excellent results, with a particularly low incidence of dSINE and endoleak as well as highly favorable aortic remodeling. However the type of stent-graft and the study location were sources of heterogeneity, emphasizing the need for multicenter studies directly comparing FET grafts. Finally, Thoraflex Hybrid can be considered the primary FET device choice due to its superior results.
The koala, one of the most iconic Australian wildlife species, is facing several concomitant threats that are driving population declines. Some threats are well known and have clear methods of prevention (e.g. habitat loss can be reduced with stronger land-clearing control), whereas others are less easily addressed. One of the major current threats to koalas is chlamydial disease, which can have major impacts on individual survival and reproduction rates, and can translate into population declines. Effective management strategies for the disease in the wild are currently lacking, and to date we know little about the determinants of individual susceptibility to disease. Here we used a rare opportunity to investigate the genetic basis of variation in susceptibility to chlamydia using one of the most intensively studied wild koala populations. We combine data from veterinary examinations, chlamydia testing, genetic sampling and movement monitoring. Out of our sample of 342 wild koalas, 60 were found to have chlamydia. Using genotype information on 8649 SNPs to investigate the role of genetic characteristics in determining disease status, we found no evidence of inbreeding depression, but a heritability of 0.14 (95%CI: 0.06 – 0.23) for the probability that koalas had chlamydia. Heritability of susceptibility to chlamydia could be relevant for future disease management in koalas, as it suggests the potential to select for disease resilience through assisted breeding.
Systemic right ventricular failure after physiologic repair for dextro-transposition of the great arteries can be managed with durable mechanical circulatory support; however, the right ventricular morphology, such as intervening papillary muscles, presents challenges to inflow cannula positioning. Papillary muscle repositioning is an innovative technique to circumvent the obstructive anatomy.
In the work by Zheng Quan MD et al. about the Use of Intraoperative Transit Time Flow Measurement Can Reduce Preoperative Myocardial Injury (1), the authors did a retrospective, observational study of the effects of exposure to the TTFM procedure . Fifty-nine people received TTFM, while 47 did not. In total, 7 (6.6%) had at least one grafting vessel obstruction. Only 1 patient where the TTFM was used had an occlusion graft vs. 6 patients where the TTFM was not used and had postoperative injury. In 2001, the use of TTFM techniques for assessing the quality of grafts intraoperatively, on the basis of the presence and volume of flow were clearly described) In conclusion, the work of Zheng Quan MD et al. remarks the importance of the use of TTFM to reduce the incidence of preoperative myocardial injury during off-pump coronary bypass surgery. support of, in some ways, the recent expert opinion to promote the use of TTFM
The hemispherical aortic annuloplasty reconstructive technology (HAART) is an internal geometric annuloplasty ring designed to restore a natural elliptical shape to the aortic annulus as part of aortic valve repair. We present 4D flow hemodynamic analysis before and after implementation of the HAART ring in patients undergoing ascending aortic replacement. HAART patients displayed similar or improved flow profiles when compared to a patient undergoing ascending aortic replacement alone.
Background Combined ONCAB and SAVR is the treatment of choice for concomitant severe aortic stenosis and coronary artery disease not amenable to PCI intervention. Extensive aortic calcification and atheromatous disease may prohibit cardiopulmonary bypass and aortic cross clamping. In these cases Anaortic OPCAB is a Class I (EACTS 2018) and Class IIA (AHA 2021) indication for surgical coronary revascularization. TAVR has similar benefits when compared to SAVR for this population (Partner 2 & 3). Herewith we describe a case series of concomitant Anaortic OPCAB and TAVR via the transfemoral approach for patients with coronary artery and valve disease considered too high risk for traditional CABG and SAVR due to severe aortic disease. Methods/Results Eight patients underwent anaortic OPCAB and transfemoral TAVR during the same anesthetic in a hybrid operating room. Seven patients with multi-vessel disease had anaortic OPCAB via a sternotomy using composite grafts, one patient with LAD disease had anaortic OPCAB using a Da Vinci assisted MIDCAB approach. All patients then had an Edwards Sapien 3 TAVR placed percutaneously via the common femoral artery. There was no thirty-day mortality or CVA in the series and all patients were discharged to home or a rehabilitation facility on day 4-13. Conclusions Combined anaortic OPCAB and transfemoral TAVR is a safe and feasible approach to treating concomitant extensive coronary artery disease and severe aortic stenosis. The aortic no-touch technique provides benefits in the elderly high-risk patients by reducing the risk of post-operative myocardial infarction and cerebrovascular stroke.
Outcomes of operations for total anomalous pulmonary venous connection (TAPVC) have improved.However, postoperative pulmonary venous obstruction (PVO) remains the most significant complication, with high morbidity and mortality. We introduce a window anastomosis technique for repair of supracardiac TAPVC in infants. The mainstay of the surgical technique is to resect the anterior wall of the pulmonary vein confluence(PVC) and part of the posterior wall of the left atrium to form a large and undistorted “window to window” anastomosis.
Title:Tranexamic acid-associated fatal status epilepticus in a paediatric patientAuthor:Dr Santosh Patel MD, FRCA, PG Dip (Med Edu)Consultant AnaesthetistDepartment of anaesthesiaTawam hospitalAl AinUnited Arab EmiratesCorrespondence address: as above.Email: email@example.comFunding: No source of funding to declareConflicts of interest: Nothing to declareDear Editor,I have read with interest a case report and literature review published in the British journal of pharmacology on tranexamic acid (TXA) associated SE in a 4-year child who underwent tonsillectomy.1 I would like to congratulate the authors for reporting the case despite the fatal outcome. Considering that the use of TXA is expanding to minimise blood loss in a wide range of surgeries, an evidence-based therapeutic approach for its associated seizures is of paramount importance.The authors described in their report (also mentioned in Table 2) and concluded that general anaesthetics, propofol and halogenated inhaled anaesthetics are considered the first line of management of TXA-associated seizures due to their direct activity at glycine receptors. In support of their statement, they have quoted three references (references 35,45,46 in their report). However, in their articles, the authors did not recommend the use of general anaesthetics (propofol and halogenated inhalational anaesthetics) as the first line of treatment for TXA-related seizures. It is valuable to point out to the readers that their conclusion is not valid and needs clarification and correction.TXA-associated hyperexcitability of neural networks is because it is a competitive antagonist of glycine and GABAA receptors.2 Following IV TXA administration, not all seizures progress to status epilepticus. Although TXA-related seizures commonly manifest as generalised tonic-clonic activity, focal seizures have been reported; which are not an indication for the use of general anaesthetics. Refractory status epileptics (RSE) and super RSE are uncommon following IV TXA although this is a common feature following intrathecal TXA.3Propofol’s anticonvulsant, hypnotic, sedative and anaesthetic effects are mediated via multiple complex molecular mechanisms, including modulation of GABAA and glycine receptors. GABAA receptor modulation by propofol has distinct dose-dependent effects likely involving multiple sites of action; clinical concentrations of propofol potentiate GABA-activated currents, increase open channel frequency, and reduce the rate of desensitization, while intermediate concentrations directly activate GABAA channels, and even higher concentrations inhibit receptor function.4Propofol can cause neuroexcitatory effects, including tonic-clonic seizures, particularly during the start or weaning from propofol infusion.5 Among the various mechanisms that have been proposed for these neuroexcitatory symptoms are antagonism of glycine and dopamine receptors, hyposensitization of GABAergic pathways and dysregulated inhibition of NMDA glutamate receptors.6Its use is associated with side effects, including hypotension (and the associated use of vasopressors) and respiratory depression. With prolonged infusion, propofol infusion syndrome (PIS) may occur, which may contribute to morbidity and mortality of RSE. Children are more susceptible to developing this complication. Propofol infusion therapy is not recommended as the first line of treatment for TXA-associated seizures, and its use is reserved for severe cases in children.Inhalational anaesthetics are beneficial for the control of seizure activity via inhibition of NMDA excitotoxicity and potentiation of inhibitory functions of GABAA and glycine receptors. However, it is essential to highlight that there are several limitations to the use of inhalational anaesthetic agents. First, the only clinical evidence of their use is from the minimal number of case reports. Second, TXA-related seizures often manifest in the postoperative period in the recovery room or in ICU, where delivery and scavenging of inhalational agents via ventilator may not be feasible. Third effective end-tidal concentration and optimal therapeutic duration are not known. Finally, in higher concentrations, they cause cardiac depression and cerebral vasodilation. Therefore, their use is limited as salvage therapy for the management of TXA-associated RSE and super RSE.In summary, the authors’ conclusion is incorrect, and clinicians should follow currently available evidence-based professional guidelines to manage TXA-associated status epilepticus.8,9References:1. Aboul-Fotouh S, Habib MZ, Magdy SM, Hassan BEE. Tranexamic acid-associated fatal status epilepticus in a paediatric non-cardiac surgery: A case report and literature review. Bri J Clin Pharmacol 2022;1-6. doi:10.1111/bcp.152962. Lecker I, Wang D, Whissell P, et al. Tranexamic acid-associated seizures: causes and treatment. Ann of Neurol 2015;79(1):18-26. doi:10.1002/ana.245583. Patel S, Robertson B, McConachie I. (2019). Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia.Anaesthesia ,74(7),904-14 https://doi.org/10.1111/anae.146624. Platholi J, Hemmings H. (2022). Effects of general anesthetica on synaptic transmission and spasticity. Currt Neuropharmacol2022;20(1):27-54. doi: 10.2174/1570159X19666210803105232.5. Walder B, Tramèr MR, Seeck M. (2002). Seizure-like phenomena and propofol: a systematic review. Neurology 2002; 58(9):1327-32. 10.1212/wnl.58.9.13276. Pantelakis L, Alvarez V, Gex G, Godio M. Severe neuroexcitatory reaction: A rare and underrecognized life-threatening complication of propofol-induced anesthesia. The Neurohospitalist2021;11(1):49-53. doi: 10.1177/1941874420929536.7. Godec S, Gradisek MJ, Mirkovic T etal. Ventriculolumbar perfusion and inhalational anesthesia with sevoflurane in an accidental intrathecal injection of tranexamic acid: unreported treatment options. Reg Anesthe Pain Med 2022;47(1):65-68 10.1136/rapm-2021-1024988. Nelson SE, Varelas PN. Status epilepticus, refractory status epilepticus, and super-refractory status epilepticus. Continuum (Minneap Minn). 2018;24(6):1683-1707.9. Vossler DG, Bainbridge JL, Boggs JG etal.. Treatment of refractory convulsive status epilepticus: a comprehensive review by the American Epilepsy Society Treatments Committee. Epilepsy Curr.2020;20(5):245-64.
CT-imaging vs. high-density mapping in ischemic cardiomyopathy VT ablation: in whom do we trust?Thomas Fink, MD1, Vanessa Sciacca, MD1, Philipp Sommer, MD11Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany.Disclosures: PS is advisory board member of Abbott, Biosense Webster, Boston Scientific and Medtronic.Funding: (None)