Skin Reducing Mastectomy and Immediate Tissue Expander Reconstruction: A Critical Analysis.

BACKGROUND: Complications of implant-based reconstruction have been shown to be related to increasing body mass index (BMI) and breast size. The impact of skin reducing mastectomy (SRM) with a dermal flap is examined. METHODS: A retrospective review of a single surgeon's experience with immediate submuscular tissue expander (TE) reconstruction from 2011 to 2019 was performed. The outcomes of SRM were compared with those of skin sparing mastectomy (SSM). RESULTS: A total of 162 patients (292 breasts) were identified. Mastectomy types were as follows: SRM, 73 (136 breasts) and SSM, 89 (156 breasts). Acellular dermal matrix (ADM) was used to supplement TE coverage in 65.4% of SRM cases. Mean BMI was 29.2 among SRM patients and 25.9 in SSM patients (P < 0.001). Obesity (BMI ≥ 30) was more prevalent in the SRM group (SRM, 38.4% vs SSM, 22.5%; P = 0.03). Mean mastectomy weight was higher in the SRM group (SRM, 833.6 g vs SSM, 425.6 g; P < 0.001). Mean BMI and mastectomy weight were lower in SRM patients who were reconstructed with ADM (ADM, 28.1 vs no ADM, 30.8; P = 0.01; ADM, 746.1 g vs no ADM, 1006.3 g; P < 0.001). Minor complications were more prevalent in the SRM group (SRM, 22.8% vs SSM, 4.5%; P < 0.001). Mastectomy skin flap necrosis (MSFN) was more common in the SRM group (SRM, 22.8% vs SSM, 7.7%; P < 0.001), but MSFN necessitating operative debridement was similarly low in both groups (SRM: 1.9% vs SSM: 4.5%). Major complication rates (SRM 11.0% vs SSM 10.9%) and reconstructive failure rates (SRM 5.9% vs SSM 5.1%) were similar between groups. Mastectomy weight 800 g or higher and BMI of 30 or higher were found to be risk factors for complications on analysis of the SRM cohort (P < 0.05). CONCLUSIONS: Mastectomy weight and BMI were positive predictors of complications after immediate TE reconstruction. Mastectomy skin flap necrosis is more common after SRM than SSM. The use of SRM with a dermal flap has a similar major complication rate as SSM despite its use in obese, large-breasted women. The dermal flap provides soft tissue coverage, which prevents implant exposure and seroma. The use of ADM does not adversely affect the complication rate of SRM.

RBC Transfusion Strategies in the ICU: A Concise Review.

OBJECTIVES: To critically assess available high-level clinical studies regarding RBC transfusion strategies, with a focus on hemoglobin transfusion thresholds in the ICU. DATA SOURCES: Source data were obtained from a PubMed literature review. STUDY SELECTION: English language studies addressing RBC transfusions in the ICU with a focus on the most recent relevant studies. DATA EXTRACTION: Relevant studies were reviewed and the following aspects of each study were identified, abstracted, and analyzed: study design, methods, results, and implications for critical care practice. DATA SYNTHESIS: Approximately 30-50% of ICU patients receive a transfusion during their hospitalization with anemia being the indication for 75% of transfusions. A significant body of clinical research evidence supports using a restrictive transfusion strategy (e.g., hemoglobin threshold < 7 g/dL) compared with a more liberal approach (e.g., hemoglobin threshold < 10 g/dL). A restrictive strategy (hemoglobin < 7 g/dL) is recommended in patients with sepsis and gastrointestinal bleeds. A slightly higher restrictive threshold is recommended in cardiac surgery (hemoglobin < 7.5 g/dL) and stable cardiovascular disease (hemoglobin < 8 g/dL). Although restrictive strategies are generally supported in hematologic malignancies, acute neurologic injury, and burns, more definitive studies are needed, including acute coronary syndrome. Massive transfusion protocols are the mainstay of treatment for hemorrhagic shock; however, the exact RBC to fresh frozen plasma ratio is still unclear. There are also emerging complimentary practices including nontransfusion strategies to avoid and treat anemia and the reemergence of whole blood transfusion. CONCLUSIONS: The current literature supports the use of restrictive transfusion strategies in the majority of critically ill populations. Continued studies of optimal transfusion strategies in various patient populations, coupled with the integration of novel complementary ICU practices, will continue to enhance our ability to treat critically ill patients.

The Effect of BMI on Outcomes Following Complex Abdominal Wall Reconstructions.

BACKGROUND: The management of complex abdominal wall defects continues to be a challenging process secondary to the high potential for wound healing issues and ventral hernia recurrences. Body mass index (BMI) is a well-known risk factor when it comes to complications. We hypothesize that higher BMIs result in higher rates of postoperative complications in complex abdominal wall reconstructions (CAWRs). METHODS: We retrospectively reviewed all patients who underwent CAWR at Emory University Hospital over a 12-year period. Patients were divided into 4 cohorts based on BMI (15-24.9, 25-29.9, 30-34.9, and ≥35 kg/m). Complication rates among the 4 groups were evaluated as the primary outcome using Pearson χ analysis. Further analysis was done on specific complications including mesh exposure, skin necrosis, delayed healing, rate of fistula formation, seroma, hematoma, infection, rate of recurrence, and rate of reoperation. RESULTS: We included 313 patients with a mean follow-up of 15.6 months. The rate of overall complications demonstrated a nonsignificant increase with BMI of 15 to 24.9, 25 to 29.9, 30 to 34.9, and 35 kg/m or greater (31.7%, 35.0%, 47.6%, and 48.3%; P = 0.079, respectively). The rate of skin necrosis was significantly increased in the higher BMI groups (1.7%, 1.3%, 9.5%, and 13.5%; P = 0.004). The rate of ventral hernia recurrence was significantly increased in the higher BMI groups (8.3%, 12.5%, 29.8%, and 27.0%; P = 0.002). Rates of reoperation were also statistically increased in the higher BMI groups (25.0%, 22.5%, 41.7%, and 34.8%; P = 0.035). Rates of mesh exposure, delayed healing, fistula formation, seroma, hematoma, and infection were not statistically significant among the 4 BMI groups. CONCLUSIONS: Patients undergoing CAWR with BMIs greater than 30 kg/m have significantly higher rates of skin necrosis, hernia recurrence, and reoperation compared with subgroups of lower BMI. Rates of overall complications among all BMI groups are similar, although trended up with BMI. Surgeons should weight the risks and benefits of CAWR in patients with higher BMIs to reduce specific postoperative complications.

Enteric Distribution of Oral Contrast in Emergency Department Patients Undergoing Abdominal-Pelvic Computed Tomography.

PURPOSE: The study sought to assess the gastrointestinal (GI) distribution of oral contrast (OC) among emergency department (ED) patients and determine if contrast reaches the terminal ileum or site of pathology to assist in diagnosis. METHODS: Retrospectively, adults undergoing abdominal-pelvic computed tomography (APCT) in the ED at 2 hospitals were identified over a 3-month period. APCTs were reviewed for location of OC. Presence, site, type of bowel pathology, and prior gastrointestinal surgery were documented. When applicable, the site of bowel pathology was evaluated for the presence or absence of OC. RESULTS: There were 1349 exams with mean age 50.5 years (range 18-97 years), 41% male, with 530 (39%) receiving OC. In 271 of 530 (51%), OC reached the terminal ileum (TI). Bowel pathology was present in 31% of cases (165 of 530). When bowel pathology was present, 47% (77 of 165) had OC present at the pathology site. The GI tract was divided into 4 anatomic segments: OC most frequently reached pathology in stomach and duodenum (84%), but was present less frequently at sites of pathology from jejunum to TI (35%), proximal colon (57%), and distal colon (28%). In only 84 of 530 OC cases (16%) did contrast extend from the stomach to distal colon. OC administration contributed to longer mean APCT order to final report of 0.5 hours and longer mean ED length of stay of 0.8 hours compared with all patients who received APCT. CONCLUSIONS: Optimal OC distribution is not achieved in more than half of ED patients, raising questions about the continued use of OC in the ED.

Meta-analysis of Air Versus Liquid Enema for Intussusception Reduction in Children.

OBJECTIVE: The purpose of this study was to assess the effectiveness and safety of air versus liquid enema reduction in the treatment of intussusception in children. MATERIALS AND METHODS: Literature searches of the PubMed, Embase, and Cochrane Library databases were conducted from January 1, 1966, through May 31, 2013. Articles on the use of air or liquid enema in children with a confirmed diagnosis of intussusception and reporting either a success rate for enema reduction of intussusception or a perforation rate were selected. Enema reduction success rate, perforation rate, and recurrence rate were the main outcomes and were calculated by random effects modeling. RESULTS: One hundred two articles (101 reporting success rate, 71 reporting perforation rate) were included that presented results for 32,451 children (age range, 1 day-22 years; boys, 66%; girls, 34%). In 44 studies (16,187 children), the combined estimate for success rate of air enema was 82.7% (95% CI, 79.9-85.6%; inconsistency index [I(2)] = 97%), and in 52 studies (13,081 children) of liquid enema, it was 69.6% (95% CI, 65.0-74.1%; I(2) = 98%). In 38 studies (15,752 children), the combined estimate of perforation rate for air enema was 0.39% (95% CI, 0.23- 0.55%; I(2) = 40%), and in 30 studies (9429 children) of liquid enema, it was 0.43% (95% CI, 0.24- 0.62%; I(2) = 9%). Among 10,494 children (26 studies) undergoing air enema reduction, the rate of first intussusception recurrence was 6% (95% CI, 4.5-7.5%; I(2) = 89%), similar to the 7.3% (95% CI, 5.8-8.8%; I(2) = 71%) found for 4004 children (24 studies) undergoing liquid enema reduction. CONCLUSION: Air enema was superior to liquid enema for intussusception reduction. The success rate was higher without a difference in perforation rate. Limitations included heterogeneity and publication bias.

The impact of introducing a no oral contrast abdominopelvic CT examination (NOCAPE) pathway on radiology turn around times, emergency department length of stay, and patient safety.

This investigation evaluates the impact of the no oral contrast abdominopelvic CT examination (NOCAPE) on radiology turn around time (TAT), emergency department (ED) length of stay (LOS), and patient safety metrics. During a 12-month period at two urban teaching hospitals, 6,409 ED abdominopelvic (AP) CTs were performed to evaluate acute abdominal pain. NOCAPE represented 70.9 % of all ED AP CT examinations with intravenous contrast. Data collection included patient demographics, use of intravenous (IV) and/or oral contrast, order to complete and order to final interpretation TAT, ED LOS, admission, recall and bounce back rates, and comparison and characterization of impressions. The NOCAPE pathway reduced median order to complete TAT by 32 min (22.9 %) compared to IV and oral contrast AP CT examinations (traditional pathway) (P < 0.001). Median order to final TAT was 2.9 h in NOCAPE patients and 3.5 h in the traditional pathway, a 36-min (17.1 %) reduction (P < 0.001). Overall, the NOCAPE pathway reduced ED LOS by a median of 43 min (8.8 %) compared to the traditional pathway (8.2 vs 7.5 h) (P = 0.003). Recall and bounce back rates were 3.2 %, and only one patient had change in impression after oral contrast CT was repeated. The NOCAPE pathway is associated with decreased radiology TAT and ED LOS metrics. The authors suggest that NOCAPE implementation in the ED setting is safe and positively impacts both radiology and emergency medicine workflow.

Comparative effectiveness of elastographic and B-mode ultrasound criteria for diagnostic discrimination of thyroid nodules: a meta-analysis.

OBJECTIVE: The purpose of this article is to present, through systematic review of recent literature, a comparative effectiveness analysis of ultrasound elastography versus B-mode ultrasound features for differentiating thyroid nodules. MATERIALS AND METHODS: We conducted an extensive literature search of PubMed and other medical and general purpose databases from January 1966 through March 2012. Eligible studies were published in English, reported diagnostic performance of elastography (using elasticity score or strain ratio) with or without B-mode ultrasound in differentiation of thyroid nodules, and used histology or cytology as the reference standard. Summary diagnostic performance measures were assessed for each of the elasticity measuring methods and ultrasound features by means of a bivariate random effects model. RESULTS: Twenty-four studies provided relevant information on more than 2624 patients and 3531 thyroid nodules (927 malignant and 2604 benign). Six ultrasound features (echogenicity, calcifications, margins, halo sign, shape, and color Doppler flow pattern) were compared with elasticity score and strain ratio. The respective sensitivities and specificities were as follows: elasticity score, 82% and 82%; strain ratio, 89% and 82%; hypoechogenicity, 78% and 55%; microcalcifications, 50% and 80%; irregular margins, 66% and 81%; absent halo sign, 56% and 57%; nodule vertical development, 46% and 77%; and intranodular vascularization, 40% and 61%. CONCLUSION: Evaluation of thyroid nodules with ultrasound elastography appears to be both more sensitive and specific than each of the ultrasound features. The former is a safe and effective technique that warrants further rigorous investigation or use in the clinical diagnosis of thyroid nodules.

The Incidence of Occult Malignant and High-Risk Pathologic Findings in Breast Reduction Specimens.

BACKGROUND: The goal of this study was to determine the incidence of occult malignancy and high-risk breast pathologic findings in patients who undergo breast reduction procedures. METHODS: Medical records of consecutive patients who underwent reduction mammaplasty performed by the senior authors (A.L. and G.W.C.) at Emory University Hospital between 1997 and 2018 were reviewed. Data regarding patient demographics, personal or family history of malignancy, operative technique, pathologic findings, and follow-up were extracted. Patients were categorized into two groups, those with and those without breast cancer. Group A patients underwent reduction for symptomatic macromastia, and group B underwent contralateral reduction for unilateral breast cancer treated with oncoplastic partial or total breast cancer reconstruction. Pathologic findings were divided into four groups; normal, benign, high-risk, and malignant. RESULTS: A total 1014 patients (1419 breast reductions) were included in the study. Comparing groups A and B, mean age was 37.8 ± 16.2 years versus 54.5 ± 11.1 years (p < 0.001), mean body mass index was 34.1 ± 7.6 kg/m2 versus 33.3 ± 7.4 kg/m2 (p = 0.2), and average reduction weight was 875.6 ± 491 g versus 723.7 ± 438 g (p < 0.001). The incidence of high-risk or malignant lesions was 1.8 percent (n = 15) in group A and 8 percent (n = 49) in group B (p < 0.001). On multivariable logistic regression analysis, age and personal history of breast cancer were positive predictors for high-risk and malignant lesions. CONCLUSIONS: The incidence of abnormal pathologic findings in breast reduction specimens is not uncommon, and occult malignancy or high-risk lesions can be found, especially in patients with contralateral breast cancer. Appropriate specimen orientation, diligence with checking the pathologic findings, and open communication with the pathologist are crucial. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Sodium bicarbonate in preventing contrast nephropathy in patients at risk for volume overload: a randomized controlled trial.

BACKGROUND: Sodium bicarbonate has been recently proposed as a prophylactic measure for the prevention of contrast-induced nephropathy (CIN). We aimed to compare the efficacy of the combination of sodium bicarbonate with half saline, and half saline alone in preventing CIN in patients having uncontrolled hypertension, compensated severe heart failure or a history of pulmonary edema. METHODS: Seventy-two patients undergoing elective coronary angiography with a serum creatinine level > or =1.5 mg/dL who had uncontrolled hypertension, compensated severe heart failure or a history of pulmonary edema were prospectively enrolled in a single-center, double-blind, randomized, controlled trial from August 2007 to July 2008 and were assigned to either an infusion of sodium bicarbonate plus half saline (n=36) or half saline alone (n=36). The primary end point was an absolute (> or =0.5 mg/dL) or relative (> or =25%) increase in serum creatinine 48 hours after the procedure (CIN). RESULTS: There were no significant differences between the groups regarding their baseline demographic and biochemical characteristics, as well as the underlying disease. A total of 6.1% of the patients receiving sodium bicarbonate plus half saline developed CIN as opposed to 6.3% of the patients in the half saline group, which was not statistically different (odds ratio = 0.97; 95% confidence interval, 0.13-7.3; p=1.0). CONCLUSION: The combination therapy of sodium bicarbonate plus half saline does not offer additional benefits over hydration with half saline alone in the prevention of CIN.

The association between coronary arterial dominancy and extent of coronary artery disease in angiography and paraclinical studies.

The association between coronary arterial dominance patterns and the coronary artery diameter, length, and valvular heart diseases were previously studied. However, its association with coronary artery disease (CAD) is unclear. We investigated to determine whether the extent and localization of CAD differ in right, left, or codominant coronary arterial patterns. Twelve thousand five hundred fifty-eight patients admitted to Tehran Heart Center for coronary angiography were studied retrospectively (2004-2006). The extent and localization of CAD and the dominant artery were determined. There were 62.7% males. The mean age was 57.6 +/- 10.3. 84.2% [95% confidence interval (CI); 83.6-84.8%], 10.9% (95% CI; 10.4-11.4%), and 4.8% (95% CI; 4.4-5.2%) of the patients were right, left, and codominant, respectively; No significant difference considering age, sex, positive family history, hypertension, hyperlipidemia, electrocardiography, exercise treadmill stress test, and perfusion scan were seen in the groups. The right-dominant patients tend to have three-vessel disease (33.1% vs. 27%, P < 0.0001), stenosis of more than 50% in right coronary artery (65.9% vs. 57.9%, P < 0.0001) and left circumflex territories (64% vs. 59.4%, P = 0.01), more than the left-dominant patients. The involvements of the left main coronary artery, left anterior descending artery territory, and posterior descending artery were not significantly different. This study demonstrates a relationship between angiographic CAD severity, and the involved arterial territory and dominancy patterns.

The Impact of Mesh Reinforcement with Components Separation for Abdominal Wall Reconstruction.

The goal in abdominal wall reconstruction (AWR) is to minimize morbidity and prevent hernia recurrence. Components separation and mesh reconstruction are two options, however, with advantages and disadvantages. The purpose of this review was to investigate outcomes in patients with abdominal wall hernia undergoing primary closure with component separation (CS) versus CS with acellular dermal matrix (ADM) reinforcement (CS + mesh). Medical records of consecutive patients who underwent abdominal wall reconstruction using CS with or without ADM reinforcement were retrospectively reviewed. Primary fascial closure was achieved in all patients. ADM reinforcement when used was performed using the underlay technique. Reconstructive technique and postoperative complications including delayed healing, skin necrosis, fistula, seroma, hematoma and surgical site infection, recurrence, and reoperation were recorded. Comparisons between the two groups were assessed. One hundred and seven patients were included (mean age, 55.7; 51.4% male; median follow-up 297 days). Twenty-six patients (24%) underwent CS alone; whereas 81 patients (76%) CS + mesh placement. Patient comorbidities, including smoking (26%), diabetes (20%), and hypertension (46%); body mass index (mean 32.3 ± 7.6); and albumin level on the day of surgery (mean 3.4 ± 0.5 mg/dL) were not significantly different between groups. Surgical site infection was significantly higher among CS + mesh patients (22.2%) versus CS only patients (3.9%) (P = 0.02). The recurrence rate of abdominal hernia was significantly lower in CS + mesh patients compared with CS only (14.8% vs 34.6%; P = 0.02). No significant differences in other postoperative complications were identified between the two groups. ADM reinforcement at the time of components separation is often selected in more complex, higher risk patients. Although the incidence of infection was higher in these patients, it was usually treated without mesh removal and recurrence rate was significantly lower when compared to CS alone.

Comparison of circuit patency and exchange rates between 2 different continuous renal replacement therapy machines.

BACKGROUND: Continuous renal replacement therapy (CRRT) is an important tool in the care of critically ill patients. However, the impact of a specific CRRT machine type on the successful delivery of CRRT is unclear. The purpose of this study was to evaluate the effectiveness of CRRT delivery with an intensive care unit (ICU) bedside nurse delivery model for CRRT while comparing circuit patency and circuit exchange rates in 2 Food and Drug Administration-approved CRRT devices. This article presents the data comparing circuit exchange rates for 2 different CRRT machines. MATERIALS AND METHODS: A group of ICU nurses were selected to undergo expanded training in CRRT operation and empowered to deliver all aspects of CRRT. The ICU nurses then provided all aspects of CRRT on 2 Food and Drug Administration-approved CRRT devices for 6 months. Each device was used exclusively in the designated ICU for a 2-week run-in period followed by 3-month data collection period. The primary end point for the study was the differences in average number of filter exchanges per day during each CRRT event. RESULTS: A total of 45 unique patients who underwent 64 separate CRRT treatment periods were included. Four CRRT events were excluded (see text for details). Twenty-eight CRRT events occurred in the NxStage System One arm (NxStage Medical, Lawrence, Mass) and 32 events in the Gambro Prismaflex arm (Gambro Renal Products, Boulder, Colo). Average (SD) filter exchanges per day was 0.443 (0.60) for the NxStage System One machine and 0.553 (0.65) for Gambro Prismaflex machine (P = .09). CONCLUSIONS: There was no demonstrable difference in circuit patency as defined by the rate of filter exchanges per day of CRRT therapy.

Reduced red blood cell transfusion in cardiothoracic surgery after implementation of a novel clinical decision support tool.

BACKGROUND: Packed red blood cell (PRBC) transfusion can increase short- and long-term adverse outcomes and health care costs. We compared the transfusion practices in cardiothoracic surgery before and after implementation of a novel clinical decision support (CDS) tool. STUDY DESIGN: The transfusion CDS tool was implemented within computerized provider order entry of a multi-institutional urban hospital system in September 2012. Data were queried for 12 months pre-intervention and for another 12 months post-intervention to compare transfusion practices for all adult patients having isolated coronary artery bypass grafting (CABG) or isolated surgical aortic valve replacement (SAVR). RESULTS: The total number of patients undergoing either isolated CABG or isolated SAVR was 744 pre-intervention and 765 post-intervention (p = 0.84). There was no significant difference in age (64 ± 11.4 years vs 64.5 ± 11.2 years, p = 0.37) or sex (30.2% vs 32.2% female, p = 0.42) between the 2 groups. The number of postoperative transfusions (374 [50.3%] vs 312 [40.8%], p < 0.001), postoperative PRBC units given (1.59 ± 2.9 vs 1.25 ± 2.5, p = 0.01), pre-transfusion hemoglobin level (8.09 ± 1.5 g/dL vs 7.65 ± 1.4 g/dL, p < 0.001), and incidence of surgical site infection (3.1% vs 1.1%; p = 0.005) were significantly reduced after implementation of the transfusion CDS tool. There were no significant differences in intraoperative transfusions (206 [27.7%] vs 180 [23.5%], p = 0.06), intraoperative PRBC units given (0.73 ± 1.5 vs 0.65 ± 1.4, p = 0.28), ICU length of stay (3.29 ± 3.9 days vs 3.37 ± 4.8 days, p = 0.74), or in-hospital mortality (1.3% vs 1.4%, p = 0.87). CONCLUSIONS: Implementation of a transfusion CDS tool was associated with lower pre-transfusion hemoglobin levels, fewer transfusions, decreased infection rates, and decreased health care costs, without an increase in short-term mortality.

Incidence of postoperative stroke using the Heartstring device in 1,380 coronary artery bypass graft patients with mild to severe atherosclerosis of the ascending aorta.

BACKGROUND: Atherosclerotic disease of the ascending aorta during coronary artery bypass graft surgery (CABG) increases the risk for postoperative stroke. The objective of this study was to examine the incidence of postoperative stroke in CABG utilizing the Heartstring (Maquet Cardiovascular, San Jose, CA) proximal anastomotic device. METHODS: Intraoperative epiaortic ultrasonography was used to grade atherosclerosis in CABG patients at Emory University from April 2003 to December 2012. The Heartstring device was utilized in 1,380 patients: 407 (29.5%) grade I (minimal atherosclerosis), 367 (26.6%) grade II, 437 (31.7%) grade III, 110 (8.0%) grade IV, and 59 (4.3%) grade V (severe atherosclerosis). Logistic regression analysis was used to estimate the effect of aortic grade on outcomes adjusted for Society of Thoracic Surgeons predicted risk of mortality and predicted risk of stroke scores. RESULTS: The mean age of all patients was 66.7 ± 10.5 years, and 31.9% were female. An increasing risk profile was apparent with rising aortic grade. Most CABG was done off pump (n = 1,277, 92.5%). There was no significant association between aortic grade and frequency of postoperative stroke (p = 0.83). In all patients, use of the Heartstring device reduced the predicted risk of stroke by 44% (O:E risk 0.56). The benefit for postoperative stroke was least apparent in the grade I aorta patients (O:E 0.8) compared with patients having grade II and greater. There were no strokes among patients with severe atherosclerosis using the Heartstring device. CONCLUSIONS: Compared with the Society of Thoracic Surgeons predicted risk for stroke, the Heartstring proximal anastomotic device can be safely used with all aortic grades. The most prominent benefit appears to be for patients with grade II disease and greater.

Transcatheter aortic valve replacement has improved short-term but similar midterm outcomes in isolated aortic valve replacement after prior coronary artery bypass grafting.

BACKGROUND: An increasing number of patients with prior coronary artery bypass grafting (CABG) now present with severe aortic stenosis. The proposed benefit of surgical (SAVR) vs transcatheter aortic valve replacement (TAVR) is unknown. The objective of this study was to compare short-term and midterm outcomes of patients undergoing isolated SAVR vs TAVR in those with prior CABG. METHODS: A retrospective analysis was performed of 255 patients who underwent isolated SAVR after prior CABG from January 2002 to February 2013 at Emory University. Outcomes of 148 patients undergoing SAVR (2002 to 2013) and 107 undergoing TAVR (2007 to 2013) were compared using multivariable logistic regression and analysis of variance techniques, adjusting for The Society of Thoracic Surgeons (STS) risk score. Kaplan-Meier plots were used to determine survival rates, and midterm survival between groups was compared using the Cox proportional hazards model. RESULTS: TAVR patients were older (79.8 ± 7.9 years vs 72.5 ± 8.8 years, p < 0.001) but were gender equivalent (female: 24% vs 22%, p = 0.61). The preoperative ejection fraction was similar between groups (TAVR: 0.433 ± 0.131 vs SAVR: 0.469 ± 0.148%, p = 0.60). The TAVR group had a significantly higher the STS risk scores (11.8% vs 7.1%, p < 0.001). All-cause 30-day mortality was 1.9% for TAVR and 4.1% for SAVR (p = 0.32), a result that marginally favors TAVR after risk adjustment (adjusted odds ratio, 0.19; p = 0.07). Postoperative morbidity and resource utilization was significantly higher in the SAVR patients. Midterm survival was similar between the two groups after adjustment (adjusted hazard ratio, 0.78, p = 0.46). CONCLUSIONS: Excellent outcomes can be achieved in SAVR or TAVR after prior CABG. Although TAVR improves short-term outcomes and resource utilization compared with SAVR, midterm mortality outcomes are similar.

Impact of varying degrees of renal dysfunction on transcatheter and surgical aortic valve replacement.

BACKGROUND: Renal impairment portends adverse outcomes in patients undergoing valvular heart surgery. The relationship between renal dysfunction in patients undergoing transcatheter aortic valve replacement (TAVR) is incompletely understood. METHODS: A retrospective review of 1336 patients undergoing surgical aortic valve replacement (SAVR; 2002-2012) and 321 patients undergoing TAVR (2007-2012) was performed. Patients were divided into 3 glomerular filtration rate (GFR) groups: GFR greater than 60 mL/min, GFR 31 to 60 mL/min, and GFR 30 mL/min or less. Logistic and linear regression analysis was performed to estimate the TAVR effect on outcomes. Risk adjustments were made using the Society for Thoracic Surgeons (STS) predicted risk of mortality (PROM). RESULTS: TAVR patients were older (82 vs 65 years; P < .001), had a poorer ejection fraction (48% vs 53%; P < .001), were more likely female (45% vs 41%; P = .23), and had a higher STS PROM (11.9% vs 4.6%; P < .001). In-hospital mortality rates for TAVR and SAVR were 3.5% and 4.1%, respectively (P = .60), a result that marginally favors TAVR after risk adjustment (adjusted odds ratio = .52, P = .06). In SAVR patients, worsening preoperative renal failure was associated with increased in-hospital mortality (P = .004) and hospital (P < .001) and intensive care unit (ICU) (P < .001) lengths of stay. In contrast, worsening renal function did not influence in-hospital mortality (P = .78) and hospital (P < .23) and ICU (P = .88) lengths of stay in TAVR patients. CONCLUSIONS: Worsening renal function was associated with increased in-hospital mortality, hospital length of stay, and ICU length of stay in SAVR patients, but not in TAVR patients. This unexpected finding may have important clinical implications in patients with aortic stenosis and preoperative renal dysfunction.

Comparative effectiveness of imaging modalities for the diagnosis of upper and lower urinary tract malignancy: a critically appraised topic.

RATIONALE AND OBJECTIVES: The purpose of this study was to critically appraise and compare the diagnostic performance of imaging modalities that are used for the diagnosis of upper and lower/bladder urinary tract cancer, transitional cell carcinoma (TCC). METHODS: A focused clinical question was constructed and the literature was searched using the patient, intervention, comparison, outcome (PICO) method comparing computed tomography (CT) urography, magnetic resonance (MR) urography, excretory urography, and retrograde urography in the detection of TCC of the upper urinary tract. The same methods were used to compare CT cystography, MR cystography, and ultrasonography in the diagnosis of bladder cancer. Retrieved articles were appraised and assigned a level of evidence based on the Oxford University Centre for Evidence-Based Medicine hierarchy of validity for diagnostic studies. RESULTS: The retrieved sensitivity/specificity for the detection of TCC of upper urinary tract for CT urography, MR urography, excretory urography, and retrograde urography were 96%/99%, 69%/97%, 80%/81%, and 96%/96%, respectively. For detecting bladder cancer, the retrieved sensitivity/specificity for CT cystography, MR cystography, and ultrasonography were 94%/98%, 91%/95%, and 78%/96%, respectively. CONCLUSIONS: CT urography is the best imaging technique for confirming or excluding malignancy in the upper urinary tract, whereas CT cystography has the best diagnostic performance for diagnosing bladder cancer.