Clinical, neuropsychological and neurophysiological indices and predictors of hepatic encephalopathy (HE).

BACKGROUND AND AIMS: The occurrence of overt hepatic encephalopathy (HE) marks a significant progression in the natural history of liver disease. The aims of the present study were to: 1) describe a large cohort of patients with cirrhosis in terms of neuropsychological or neurophysiological HE indices, and 2) test if the severity of liver disease and/or any such indices [Psychometric Hepatic Encephalopathy Score (PHES), Scan test, electroencephalography (EEG)] predicted mortality/HE risk in a subgroup of such cohort. METHOD: Four hundred and sixty-one patients with cirrhosis (59 ± 10 years; 345 males) were included; information on previous overt HE episodes was available in 407. Follow-up information on mortality/HE-related hospitalization in 134/127 respectively. Information on previous overt HE episodes and both mortality and HE-related hospitalization over the follow-up in 124. RESULTS: Patients with a history of overt HE (60%) had poorer liver function, worse neuropsychiatric indices, higher ammonia levels and higher prevalence of portal-systemic shunt. The risk of HE-related hospitalization over the follow-up was higher in patients with higher MELD score and worse Scan performance. Mortality was higher in those with higher MELD. Among patients without a history of overt HE, those with worse PHES had higher HE risk. Among patients with a history, those with higher MELD, better PHES and worse Scan performance had higher HE risk. CONCLUSIONS: In patients without previous overt HE episodes, neuropsychological and neurophysiological tests predict HE, while in those with previous overt HE episodes, HE development largely depends on the severity of liver dysfunction.

Differential effects of peritoneal and hemodialysis on circulating regulatory T cells one month post initiation of renal replacement therapy.

Backgroundː Chronic kidney disease stage G5 (CKD G5) patients show an activated but impaired immune system. One function of the FOXP3+ regulatory T (Treg) cells is to preserve tolerance to self while maintaining the ability to fight infectious agents. The aim of this pilot study is to evaluate longitudinal changes in Treg cells before and 1 month after the first dialysis treatment. Materials and methodsː CKD G5 patients not yet on dialysis were enrolled and started on hemodialysis (HD) or peritoneal dialysis (PD). Tregs were analyzed by flow cytometry at two time points: T0 (before the first dialysis treatment) and T1 (1 month after the first dialysis session). Wilcoxon test for dependent samples was used to compare the mean percentage difference between T0 and T1: Δ% = 100 × [(T1 - T0) / T0]. Resultsː 21 patients were enrolled: 8 on HD and 13 on PD. The proportion of total lymphocytes (low side scatter lymphocyte gate) and T lymphocytes (in the CD3+CD4+ gate) did not change significantly 1 month after the start of dialysis in both groups. Treg cells (as CD25+FOXP3+, FOXP3+, or CD25+CD127-), analyzed as percentage of the lymphocyte gate, showed a significant increase post PD (CD25+FOXP3+: median = 35.92; p = 0.0425; FOXP3+: median = 30.85; p = 0.0479 and CD25+CD127-: median = 23.71; p = 0.0215). The same populations, did not change 1 month after the first dialysis session. Conclusionː Our study is the first to evaluate longitudinal effects of dialysis on Treg cells in uremia and suggests that PD was more effective in increasing Treg levels 1 month post initiation of dialysis and may contribute to improvement of inflammatory status. Thus, PD may contribute to better outcomes for patients with renal dysfunction, also maintaining homeostasis of peritoneal and renal tissues.

Surgical strategies for the management of end-stage heart failure in infants and children: A 15-year experience with a patient-tailored approach.

End-stage heart failure (ESHF) in pediatric age is an ongoing challenge. Heart transplantation is the final option, but its long-term outcomes are still suboptimal in children. An alternative patient-tailored surgical protocol to manage ESHF in children is described. Retrospective, single-center analysis of pediatric patients admitted to our institution between April 2004 and February 2021 for ESHF. Our current protocol is as follows: (a) Patients <1 year with isolated left ventricular dysfunction due to dilated cardiomyopathy underwent pulmonary artery banding (PAB). (b) Patients <10 years and <20 kg, who did not meet previous criteria were managed with Berlin Heart EXCOR. (c) Patients >10 years or >20 kg, underwent placement of intracorporeal Heartware. Primary outcomes were survival, transplant incidence, and postoperative adverse events. A total of 24 patients (mean age 5.3 ± 5.9 years) underwent 26 procedures: PAB in 6 patients, Berlin Heart in 11, and Heartware in 7. Two patients shifted from PAB to Berlin Heart. Overall survival at 1-year follow-up and 5-year follow-up was 78.7% (95%CI = 62%-95.4%) and 74.1% (95%CI = 56.1%-92.1%), respectively. Berlin Heart was adopted in higher-risk settings showing inferior outcomes, whereas a PAB enabled 67% of patients to avoid transplantation, with no mortality. An integrated, patient-tailored surgical strategy, comprehensive of PAB and different types of ventricular assist devices, can provide satisfactory medium-term results for bridging to transplant or recovery. The early postoperative period is critical and requires strict clinical vigilance. Selected infants can benefit from PAB that has demonstrated to be a safe bridge to recovery.

New ICA criteria for the diagnosis of acute kidney injury in cirrhotic patients: can we use an imputed value of serum creatinine?

BACKGROUND & AIMS: The new International Club of Ascites diagnostic criteria to diagnose acute kidney injury at hospital admission suggests the possibility of using a presumed baseline serum creatinine, defined as the last of at least two stable creatinine values during the last 3 months. Nevertheless, the possibility of the lack of such a value still remains. In these patients, the KDIGO criteria suggest to use an inverse application of MDRD equation assuming that baseline glomerular filtration rate is 75 ml/min per 1.73 m(2) (imputed baseline creatinine). We tested the accuracy of this approach to detect acute kidney injury at admission in patients with decompensated cirrhosis and creatinine <1.5 mg/dl. METHODS: We analysed 213 patients hospitalized for acute decompensation of cirrhosis. At admission, glomerular filtration rate was estimated using creatinine-based equations and measured by inulin clearance. A diagnosis of acute kidney injury was made using an imputed value of serum creatinine as baseline. RESULTS: The diagnosis of AKI based on an imputed baseline creatinine identified only 20.1% of patients with measured glomerular filtration rate ≤60 ml/min/1.73 m(2) without any predictive value on 90-day survival. CONCLUSIONS: In patients with cirrhosis and ascites with a creatinine <1.5 mg/dl without a baseline value on their records, the diagnosis of acute kidney injury at admission based on an imputed baseline creatinine is not accurate.

Predicting late recurrence in surgically treated patients with Cushing's disease.

OBJECTIVE: Cushing's disease (CD) has an uncertain prognosis because patients achieving remission after transsphenoidal pituitary neurosurgery (TSS) may relapse. We aimed to identify factors predicting relapse, focusing on desmopressin (DDAVP) and corticotropin-releasing hormone (CRH) tests after surgery. MATERIALS AND METHODS: Fifty-seven patients with CD (mean age 36 years) after TSS experienced remission (24 cases), late relapse (LR) (15 cases), or persistent disease (18 cases). RESULTS: The median time to relapse was 40 months. ACTH levels increased after both DDAVP and CRH stimulation, with a significantly higher response in the late recurrence group, showing this to be an indicator of increased risk of relapse. In the logistic regression model, a rise in ACTH >9 pg/ml after DDAVP and >36·7 pg/ml after CRH showed a sensitivity of 93% and 73%, respectively, a specificity of 82% and 76% in LR group. The area under the curve was 0·91 for DDAVP, 0·80 for CRH and 0·95 for DDAVP+CRH test, i.e. the combined tests performed better than each test alone, but not to a statistically significant degree. A response to both tests resulted in a positive predictive value (PPV) of 100%, while no response to either test in a negative predictive value (NPV) of 100%. CONCLUSIONS: ACTH hyper-responsiveness to DDAVP stimulation proved a valuable indicator of relapsing patients with high sensitivity and specificity; in selected cases when a clear high increment of ACTH level is not evident, the CRH test might be used as additional tool to confirm the risk of future relapses.

Model for end-stage liver disease-sodium and survival benefit in liver transplantation.

There are currently no studies calculating the survival benefit of liver transplantation (LT) according to model for end-stage liver disease-sodium (MELD-Na) and based on the competing risk (CR) method. We enrolled consecutive adult patients with chronic end-stage liver disease entering the waiting list (WL) for primary LT (WL group = 337) and undergoing LT (LT group = 220) in the period 2006-2009. Two independent multivariable regressions (WL and LT models) were created to measure the prognostic power of MELD-Na with respect to MELD. For the WL model, both Cox and CR multivariable analyses were performed. Estimates were finally included in a Markov model to calculate 3-year survival benefit. WL Cox model: MELD-Na (P < 0.0001) and MELD (P < 0.0001) significantly predicted survival. WL CR model: MELD-Na (P = 0.0045) and MELD (P = 0.0109) significantly predicted survival. LT Cox model: MELD-Na (P = 0.7608) and MELD score (P = 0.9413) had not correlation with survival. Benefit model: MELD and MELD-Na had an overlapping significant impact on 3-year survival benefit; CR method determined a significant decrease in 3-year life expectancy (LE) estimations. MELD-Na and MELD scores similarly predicted 3-year LT survival benefit, but the gain in LE is significantly lower when a CR method is adopted.

Diagnostic accuracy of antiendomysial antibodies biopsy test for celiac disease in clinical practice.

BACKGROUND: The diagnosis of celiac disease (CD) is still challenging and tests that show an activation of the immune system against gluten are required. IgA antiendomysial antibodies detection in the supernatant of intestinal biopsies by immunofluorescence technique (AEA-biopsy) is a promising diagnostic tool. The aim of the present study was to evaluate the diagnostic accuracy of AEA-biopsy in a pediatric population with suspected CD. METHODS: All children who underwent upper gastrointestinal endoscopy at the Unit of Pediatrics of Treviso Hospital were enrolled and divided into 4 groups: classical CD, CD excluded, potential CD and control group. For each patient, serum autoantibodies and histological evaluation were determined. Two additional biopsy samples were taken to test for presence of AEA. RESULTS: A total of 92 patients were enrolled. All the classical CD cases (38) had a positive AEA-biopsy. In the CD excluded group (10 in total) AEA-biopsy was negative in all patients except 1. Among potential CD patients (which were 14), AEA-biopsy was negative in 4. In the control group (30 patients) AEA-biopsy was negative in all patients except 1. The sensitivity and specificity of AEA-biopsy were 100% and 96% respectively. CONCLUSIONS: AEA-biopsy has an excellent diagnostic accuracy in a routine clinical setting.

Surgery for Anomalous Aortic Origin of a Coronary Artery (AAOCA) in Children and Adolescents: A Meta-Analysis.

We conducted a systematic review and meta-analysis of the literature to assess the outcomes of surgery for the anomalous aortic origin of a coronary artery in children and young adults (<30 years). Thirteen publications were selected, including a total of 384 patients. Unroofing of the intramural segment was adopted in 92% (95% CI: 81%-98%) of cases, with pooled early and late mortality of 0% (95% CI: 0%-0.3%) and 0.1% (95% CI: 0%-1%), respectively. Reoperation for aortic regurgitation was anecdotal. Surgical management of anomalous aortic origin of coronary arteries can be achieved with excellent results in pediatric patients, but concerns remain about the durability of surgery.

Myofascial points treatment with focused extracorporeal shock wave therapy (f-ESWT) for plantar fasciitis: an open label randomized clinical trial.

BACKGROUND: Plantar fasciitis (PF) is a common cause of heel pain. Among the several conservative treatment options, extracorporeal shock wave therapy (ESWT) is considered the standard treatment. However, recent studies suggest that PF may be sustained by a myofascial impairment proximal to the pain area with a biomechanical disequilibrium of the entire limb and pelvis. AIM: By combining the concepts of fascial manipulation and ESWT, the purpose of this study was to evaluate the effectiveness of the ESWT on myofascial points in a sample of subjects with PF. DESIGN: Open label randomized controlled clinical trial. SETTING: Outpatient clinic. POPULATION: Patients with PF were randomly assigned to an experimental treatment group (EG), treated with focused ESWT on myofascial points, and a control group (CG), treated with the focused ESWT traditional approach on the medial calcaneal tubercle. METHODS: Every patient underwent a 3-session program and follow-up after 1 and 4 months. Outcome measures included the Foot and Ankle Outcome Score (FAOS) and the Italian Foot Functional Index (17-iFFI). RESULTS: Thirty patients were enrolled in the study. Four patients of the CG dropped out the study, therefore twenty-six patients were included in the final analysis. Improvement in 17-iFFI and FAOS scores was observed in both groups starting from the third treatment and confirmed at the 1-month and 4-month follow-ups, with earlier improvement in the score values observed in the EG. CONCLUSIONS: Treatment of the myofascial points with ESWT in subjects suffering from plantar fasciitis could be an effective treatment option. It fosters the hypothesis that a global biomechanical re-equilibrium of the body would be necessary to completely solve the pathology. CLINICAL REHABILITATION IMPACT: ESWT on myofascial points could provide an interesting alternative with better outcomes in terms of time needed for recovery compared to traditional ESWT for the conservative management of PF.

Quick change versus double pump while changing the infusion of inotropes: an experimental study.

BACKGROUND: Quick change (QC) and double pumping (DP) are common methods of substituting the infusion of inotropes given through intravenous pump. AIMS: The aim of the study was to compare two methods in respect with the variation in mean arterial pressure (MAP). The hypothesis was that the DP method could be the most effective in achieving haemodynamic stability. DESIGN: The study is a randomized research in an open randomized clinical trial. METHODS: The study took place at the Paediatric Intensive Care Unit of Padua Hospital. It considered patients of 0-36 months, not premature, treated with inotropic infusion with monitoring of blood pressure. The research obtained the approval of the Hospital Research Ethics committee and parents signed informed consent. Comparison of the two groups made use of the Wilcoxon test for the continuous variables and the Fisher's exact test for the comparison of frequencies, at significance value of 5%. The data were registered in an Excel spreadsheet and analysed with SAS. RESULTS: The sample comprised 30 patients of age between 1 and 27 months, of whom 13 (43%) were male. They were all affected by cardiac, respiratory or infective pathology, all of them intubated and on artificial respiratory support, sedated and infused with dopamine. The characteristics of the patients of the two groups did not differ significantly. The percentage variation of the baseline value of MAP after 30 min from starting the treatment between the two methods was not statistically significant (p = 0.85). The 95% confidence interval for the difference in the percentage variation of MAP between the two groups was (-3.1, +3.7). From a clinical perspective, the methods are to be considered equivalent. CONCLUSIONS: The study was conducted on a limited sample; no statistically significant differences were detected; QC is the quickest and more cost-effective method.

Temperatures generated during implant site preparation with conventional drilling versus single-drill method: an ex-vivo human mandible study.

BACKGROUND: Bone overheating during osteotomy is a potential cause of necrosis and consequent failure of dental implant osseointegration. The aim of this study is to identify any differences between conventional osteotomy with drills of increasing size and the use of a single drill in terms of the temperature increase in the bone during implant site preparation. METHODS: Thirty-eight implant sites were prepared in ex vivo human mandibles, 19 using the conventional method with drills of increasing diameter (group A) and 19 using a single-drill method (group B), with no irrigation in either procedure. An infrared thermometer was used to measure the temperature difference (T°) induced by the drills at each site. Student's t-test (with P<0.05) was used to compare the temperature increase induced by the last drill in group A, and by the single drill in group B. RESULTS: The mean ΔT° in group A was 0.64 °C, while in group B it was 1.47 °C. The difference between the temperatures obtained in the two groups was statistically significant (P=0.0073). CONCLUSIONS: In statistical terms, the two methods differ significantly in the temperature increase induced by the drilling procedure, but this difference is clinically irrelevant.

Transfemoral aortic valve implantation with new-generation devices: the repositionable Lotus vs. the balloon-expandable Edwards Sapien 3 valve.

BACKGROUND: New-generation transcatheter heart valves have been developed to reduce complications of transcatheter aortic valve implantation (TAVI). With this study we sought to compare procedural and 30-day outcomes of the new-generation repositionable Boston Scientific Lotus (Lotus) and the balloon-expandable Edwards Sapien 3 (ES3) transcatheter heart valves. METHODS: A total of 315 patients with severe symptomatic aortic stenosis undergoing transfemoral TAVI with Lotus or ES3 included in two large Italian registries were considered for this analysis. After propensity matching, 93 matched pairs of patients were included. Outcomes were evaluated according to Valve Academic Research Consortium-2 definition at discharge and 30 days. RESULTS: There were no differences in baseline characteristics, except for lower mean aortic gradient and larger mean aortic annulus in the ES3-treated patients. Valve Academic Research Consortium-2 defined device success was high and comparable between groups (97.8 for Lotus vs. 98.9% for ES3, P = 0.09). The frequency of moderate/severe paravalvular leak was low and similar for both devices (2.2 vs. 1.1%, P = 0.10). At 30 days, both groups showed low all-cause mortality (5.4 vs. 1.1%, P = 0.10) and rates of disabling stroke (3.2 vs. 1.1%, P = 0.31). New pacemaker implantation was more common after Lotus deployment (31.7 vs. 10.5%, P < 0.001). CONCLUSION: Transfemoral TAVI with both Lotus and ES3 resulted in favorable clinical and hemodynamic procedural and 30-day outcomes. Rates of significant paravalvular leak were low with both devices. The Lotus valve was associated with higher risk of pacemaker implantation.

Error count of radiopaque markers in colonic segmental transit time study.

OBJECTIVE: The objective of our study was to evaluate the feasibility and efficacy of a radiologic technique in increasing colon visibility in colonic transit time studies. Three radiologists counted segmental colonic radiopaque markers in two patient groups, based on classic criteria in the first group and also on a colonic barium trace in the second. Agreement between marker counts was assessed using method comparison analysis. CONCLUSION: With the barium trace technique, the anatomic conspicuity of colonic segments is improved, a correct segmental marker count can be obtained, and colonic inertia can be more easily distinguished from distal constipation.

Transcutaneous periorbital electrical stimulation in the treatment of dry eye.

PURPOSE: To evaluate efficacy and safety of transcutaneous application of electrical current on symptoms and clinical signs of dry eye (DE). METHODS: 27 patients with DE underwent transcutaneous electrostimulation with electrodes placed onto the periorbital region of both eyes and manual stimulation with a hand-piece conductor moved by the operator. Each patient underwent 12 sessions of 22 min spread over 2 months, two sessions per week in the first month and one session per week in the second month. Ocular Surface Disease Index (OSDI) questionnaire, tear break-up time (TBUT), fluorescein staining of the cornea, Schirmer I test and adverse events were evaluated at baseline, at end of treatment and at 6 and 12 months. RESULTS: OSDI improved from 43.0±19.2 at baseline to 25.3±22.1 at end of treatment (mean±SD, p=0.001). These effects were substantially maintained at 6-month and 12-month follow-up evaluations. Improvement of the values of TBUT was recorded for the right eye at the end of treatment (p=0.003) and found in the left eye after 12 months (p=0.02). The Oxford scores changed in both eyes at the end of treatment and at the 6-month evaluation (p<0.001), and in the right eye at the 12-month evaluation (p=0.035). Schirmer I improved significantly at the end of treatment in the left eye (p=0.001) and in both eyes at the 12-month evaluation (p=0.004 and p=0.039 for the left and right eye, respectively). A significant reduction of the use of tear substitutes was found at the end of treatment (p=0.003), and was maintained during the follow-up (p<0.001).No complications occurred and patients found the treatment satisfying. CONCLUSIONS: Transcutaneous electrical stimulation was shown to improve DE, both subjectively and objectively, without any adverse effects and has the potential to enlarge the armamentarium for treating DE.

The "basic" approach: a single-centre experience with a cost-reducing model for paediatric cardiac extracorporeal membrane oxygenation.

Objectives: Extracorporeal membrane oxygenation (ECMO) is a lifesaving but expensive therapy in terms of financial, technical and human resources. We report our experience with a 'basic' ECMO support model, consisting of ECMO initiated and managed without the constant presence of a bedside specialist, to assess safety, clinical outcomes and financial impact on our health system. Methods: We did a retrospective single-centre study of paediatric cardiac ECMO between January 2001 and March 2014. Outcomes included postimplant complications and survival at weaning and at discharge. We used activity based costing to compare the costs of current basic ECMO with those of a 'full optional' dedicated ECMO team (hypothesis 1); ECMO with a bedside nurse and perfusionist (hypothesis 2), and ECMO with a bedside perfusionist (hypothesis 3). Results: Basic cardiac ECMO was required for 121 patients (median age 75 days, median weight 4.4 kg). A total of 107 patients (88%) had congenital heart disease; 37 had univentricular physiology. The median duration of ECMO was 7 days (interquartile range [IQR], 4-15 days). Overall survival at weaning and at 30 days in the neonatal and paediatric age groups was 58.6% and 30.6%, respectively; these results were not significantly different from Extracorporeal Life Support Organization data. Cost analysis revealed a saving of €30 366, €22 144 and €13 837 for each patient on basic ECMO for hypotheses 1, 2 and 3, respectively. Conclusions: Despite reduced human, technical and economical resources, a basic ECMO model without a bedside specialist was associated with satisfactory survival and lower costs.

TLR7 Gln11Leu single nucleotide polymorphism and response to treatment with imiquimod in patients with basal cell carcinoma: a pilot study.

AIM: The Toll-like receptor 7 (TLR7) agonist, imiquimod, offers a topical and noninvasive therapeutic method for the clinical treatment of superficial basal cell carcinoma (BCC). In this study we explored the relationship between the functional X-linked TLR7 rs179008/Gln11Leu polymorphism and the response to imiquimod in patients with BCC. PATIENTS & METHODS: Thirty-four BCC patients treated with imiquimod were included in the study. SNP genotyping of the TLR7 promoter polymorphism was performed by TaqMan allelic discrimination assay. RESULTS: In the group of female nonresponders to imiquimod a higher frequency of the altered genotype compared with responders was observed. Similarly, in the group of male nonresponders to imiquimod both patients with the mutated genotype were nonresponders. CONCLUSION: The results of this study show that patients carrying at least one T allele of the TLR7 promoter polymorphism are associated with an increased probability to be resistant to imiquimod therapy.

Development and Validation of a Distal Embolization Risk Score During Primary Angioplasty in ST-Elevation Myocardial Infarction.

This study aims to develop and validate a new angiographic risk score to predict the risk of distal embolization (DE) during primary percutaneous coronary intervention (p-PCI) for ST-elevation myocardial infarction. Study included data from 1,200 patients who underwent p-PCI. The cohort was randomly split into a derivation cohort (n = 814) and a validation cohort (n = 386). Logistic regression was used to examine the relation between risk factors and the occurrence of DE. To each covariate in the model was assigned an integer score based on the regression coefficients. Variables included in the risk score, according to multivariable analysis, were occlusion pattern of infarct-related artery, Thrombolysis In Myocardial Infarction Thrombus Score 2 to 4, reference vessel diameter ≥3.5 mm, and lesion length >20 mm. To each variable was assigned a 0- to +2-point score according to the strength of the statistical association. Rates of DE in low-, intermediate-, and high-risk groups were 5.6%, 15.8%, and 40% in the derivation cohort (p for trend <0.0001; C-statistic 0.70) and 7.5%, 12.1%, and 37.9% in the validation cohort (p for trend <0.0001; C-statistic 0.62), respectively. In conclusion, the individual risk of DE in patients who underwent p-PCI can be predicted using a simple 4-variables model based on angiographic features.

Early and mid-term clinical experience with extracellular matrix scaffold for congenital cardiac and vascular reconstructive surgery: a multicentric Italian study.

OBJECTIVES: The aim of this multicentric study was to outline surgical indications and evaluate mid-term outcomes of porcine extracellular matrix (ECM) in surgery for congenital heart disease (CHD). METHODS: The use of ECM was categorized into four major groups: A, valve repair; B, septal reconstruction; C, arterial plasty; D, other use. Primary endpoints of analysis were reintervention (either surgical or interventional) when related to ECM, and functional ECM failure. Secondary endpoints were evidence of calcification and of persistent inflammation at follow-up. RESULTS: One hundred and three patients (M/F = 61/42, median age 19.7 months, 1 day-62 years) underwent surgical repair for CHD. Among ECM use categories, 38 patients were in Group A, 16 in Group B, 71 in Group C and 7 in Group D. There were neither complications nor deaths related to ECM. At a median follow-up of 23.3 months (0.3-55.2), 19 patients underwent reoperation (ECM-related in 6); 11 patients underwent interventional cardiology procedures (ECM-related in 8). Reinterventions were significantly more frequent on the aortic valve (surgical, P = 0.0056) and pulmonary arteries (interventional, P = 0.0159). In addition, interventional procedures on pulmonary arteries were significantly more frequent in infants <12 months (P = 0.0474). No calcifications were detected. CONCLUSIONS: Surgical use of ECM in CHD repair is characterized by a suboptimal functional late performance on reconstruction of valve leaflet or pulmonary artery wall. Longer follow-up and larger clinical experience may support these preliminary results on mid-term outcomes, so as to assess the optimal indication for an ECM graft.

Meta-analysis of randomized trials of postconditioning in ST-elevation myocardial infarction.

Clinical benefit of postconditioning in patients with ST-elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention is still controversial. We performed a meta-analysis of available randomized clinical trials (RCTs) to define the role of postconditioning in STEMI. Fourteen RCTs evaluating postconditioning in a total of 778 patients with STEMI were identified in PubMed, EMBase, and Cochrane databases from January 1998 to February 2014. Overall, postconditioning was found to be cardioprotective in term of infarct size reduction (weighted standardized mean differences -0.5837, 95% confidence interval -0.9609 to -0.2066, p <0.05), but significant heterogeneity across the trials was detected (I(2) = 84%). Univariate meta-regression analysis did not identify clinical or procedural variables associated with a more pronounced effect of postconditioning effects on infarct size with the exception of using cardiac magnetic resonance (CMR) to evaluate infarct size (p <0.01). Restricting the analysis to 6 RCTs including a total of 448 patients and evaluating the postconditioning effect on infarct size by means of CMR led to the disappearance of benefit of postconditioning on infarct size. In conclusion, the results of this meta-analysis of RCTs suggested that postconditioning reduces infarct size, as expressed by weighted standardized mean differences. However, if the analysis was limited to trials with a more accurate quantification of infarct size reduction, namely by CMR, the benefit was lost. More data are required before adoption of postconditioning in clinical practice.