RESUMO
We provide an update regarding the differences between men and women in short-term postoperative mortality after coronary artery bypass grafting (CABG) and highlight the differences in postoperative risk of stroke, myocardial infarction, and new onset atrial fibrillation. We included 23 studies, with a total of 3,971,267 patients (70.7% men, 29.3% women), and provided results for groups of unbalanced studies and propensity matched studies. For short-term mortality, the pooled odds ratio (OR) from unbalanced studies was 1.71 (with 95% CI 1.69-1.74, I2 = 0%, p = 0.7), and from propensity matched studies was 1.32 (95% CI 1.14-1.52, I2 = 76%, p < 0.01). For postoperative stroke, the pooled effects were OR = 1.50 (95% CI 1.35-1.66, I2 = 83%, p < 0.01) and OR = 1.31 (95% CI 1.02-1.67, I2 = 81%, p < 0.01). For myocardial infarction, the pooled effects were OR = 1.09 (95% CI = 0.78-1.53, I2 = 70%, p < 0.01) and OR = 1.03 (95% CI = 0.86-1.24, I2 = 43%, p = 0.18). For postoperative atrial fibrillation, the pooled effect from unbalanced studies was OR = 0.89 (95% CI = 0.82-0.96, I2 = 34%, p = 0.18). The short-term mortality risk after CABG is higher in women, compared to men. Women are at higher risk of postoperative stroke. There is no significant difference in the likelihood of postoperative myocardial infarction in women compared to men. Men are at higher risk of postoperative atrial fibrillation after CABG.
Assuntos
Fibrilação Atrial , Ponte de Artéria Coronária , Infarto do Miocárdio , Complicações Pós-Operatórias , Humanos , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Masculino , Feminino , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/mortalidade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Fibrilação Atrial/etiologia , Fibrilação Atrial/cirurgia , Fatores Sexuais , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/epidemiologia , Fatores de Risco , Resultado do TratamentoRESUMO
Novel engineered IL-2 agonists strive to increase the therapeutic window of aldesleukin (human IL-2) by increasing selectivity toward effector over regulatory T cells and reducing dose-limiting toxicities. Here we describe ANV419, an IL-2/anti-IL2 antibody fusion protein designed for selective IL-2 receptor ßγ (IL-2 Rßγ) activation by sterically hindering IL-2 from binding to IL-2 Rα. The fusion protein has an IL-2 connected to the light chain complementarity-determining region (CDR) domain of a humanized antibody that binds to IL-2 at the same epitope as IL-2 Rα. Optimization of the selectivity and pharmacological properties led to the selection of ANV419. ANV419 preferentially expands CD8+ T cells and natural killer (NK) cells over Tregs and can be safely administered at doses that elicit strong pharmacodynamic effects and efficacy in mouse tumor models. Its anti-tumor efficacy was enhanced when combined with programmed cell death protein 1 (PD-1) or cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) checkpoint inhibitors. ANV419 also enhances the NK cell killing capacity and increases tumor growth inhibition when used alongside trastuzumab in a Her-2+ xenograft mouse model. In cynomolgus monkeys, the estimated half-life of ANV419 is 24 h, and doses that induced sustained expansion of effector cells were well tolerated without the severe toxicities typically observed with high-dose IL-2. These data support the clinical development of ANV419 in solid tumors and hematological malignancies as monotherapy and in combination with checkpoint inhibitors or agents that induce antibody-dependent cellular cytotoxicity. ANV419 is currently in Phase 1/2 clinical development and may provide cancer patients with a wider therapeutic window than aldesleukin.
Assuntos
Linfócitos T CD8-Positivos , Interleucina-2 , Células Matadoras Naturais , Proteínas Recombinantes de Fusão , Animais , Células Matadoras Naturais/imunologia , Humanos , Interleucina-2/imunologia , Linfócitos T CD8-Positivos/imunologia , Camundongos , Proteínas Recombinantes de Fusão/farmacologia , Proteínas Recombinantes de Fusão/imunologia , Proteínas Recombinantes de Fusão/genética , Imunoterapia/métodos , Macaca fascicularis , Anticorpos Monoclonais Humanizados/imunologia , Anticorpos Monoclonais Humanizados/farmacologia , Neoplasias/imunologia , Neoplasias/terapia , Neoplasias/tratamento farmacológico , Ensaios Antitumorais Modelo de Xenoenxerto , Linhagem Celular Tumoral , FemininoRESUMO
BACKGROUND: The management of hemostasis in patients medicated with apixaban (Eliquis) undergoing emergency cardiac surgery is exceedingly difficult. The body's natural elimination pathways for apixaban prove ineffective in emergency situations, and the impact of hemodialysis is limited. The application of Cytosorb® may attenuate the concentration of apixaban, thereby facilitating the stabilization of these patients. CASE PRESENTATION: An 84-year-old man treated with apixaban, underwent emergency ascending aorta replacement surgery due to an acute type A aortic dissection. To address the challenges induced by apixaban, we integrated Cytosorb® cartridge into the Cardiopulmonary bypass circuit. There was a 63.7% decrease in perioperative apixaban-specific anti-factor Xa activity. The patient's postoperative course was favourable. CONCLUSION: Hemoadsorption with Cytosorb® may offers a safe and feasible approach for reducing apixaban concentration in emergency cardiac surgery, thereby mitigating the risk of hemorrhagic complications.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Masculino , Humanos , Idoso de 80 Anos ou mais , Pirazóis/uso terapêutico , Piridonas/uso terapêutico , Ponte CardiopulmonarRESUMO
Erdheim-Chester disease is a rare histiocytosis that primarily affects the skeletal system, but cardiovascular manifestations occur in 75% of cases and are associated with a poor prognosis. Given the small number of cases, the evolution and management of the disease are uncertain. Therefore, it is important to report and share Erdheim-Chester cases. This report presents the case of a young patient with constrictive pericarditis and mitral valve regurgitation resulting from Erdheim-Chester disease.
Assuntos
Doença de Erdheim-Chester , Insuficiência da Valva Mitral , Humanos , Valva Aórtica , Doença de Erdheim-Chester/complicações , Insuficiência da Valva Mitral/complicações , PericardiectomiaRESUMO
BACKGROUND: Achieving optimal exposure of the mitral valve during surgical intervention poses a significant challenge. This study aimed to compare perioperative and postoperative outcomes associated with 3 left atriotomy techniques in mitral valve surgery-the conventional direct, transseptal, and superior septal approaches-and assess differences during the surgical procedure and the postoperative period. METHODS: Inclusion criteria were patients undergoing mitral valve surgery from January 2010 to December 2020, categorized into 3 cohorts: group 1 (conventional direct; n = 115), group 2 (transseptal; n = 33), and group 3 (superior septal; n = 59). To bolster sample size, the study included patients undergoing mitral valve surgery independently or in conjunction with other procedures (eg, coronary artery bypass grafting, aortictricuspid surgery, or maze procedure). RESULTS: No substantial variance was observed in the etiology of mitral valve disease across groups, except for a higher incidence of endocarditis in group 3 (P = .01). Group 1 exhibited a higher frequency of elective surgeries and isolated mitral valve procedures (P = .008), along with reduced aortic clamping and cardiopulmonary bypass durations (P = .002). Conversely, group 3 patients represented a greater proportion of emergency procedures (P = .01) and prolonged intensive care unit and hospital stays (P = .001). No significant disparities were detected in terms of permanent pacemaker implantation, postoperative complications, or mortality among the groups. CONCLUSION: Mitral valve operations that employed these 3 atriotomy techniques demonstrated a safe profile. The conventional direct approach notably reduced aortic clamping and cardiopulmonary bypass durations. The superior septal method was primarily employed for acute pathologies, with no significant escalation in postoperative arrhythmias or permanent pacemaker implantation, although these patients had prolonged intensive care unit and hospital stays. These outcomes may be linked to the underlying pathology and nature of the surgical intervention rather than the incision method itself.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Doenças das Valvas Cardíacas , Implante de Prótese de Valva Cardíaca , Humanos , Doenças das Valvas Cardíacas/cirurgia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/métodos , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/cirurgia , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Período Pós-Operatório , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/métodos , Resultado do TratamentoRESUMO
A mass in the right atrium (RA) is an unusual finding that warrants further investigation. We report the case of a 72-year-old male patient who underwent a Bentall operation with a biological composite graft and closure of patent foramen ovale 18 months prior to his presentation with an incidental new RA mass during follow-up echocardiography. Transesophageal echocardiography and thoracic CT angiography confirmed a right atrial mass attached to the Eustachian valve and additionally revealed a non-occlusive pulmonary embolism in the inferior lobar artery of the left lung. Despite 2 months of anticoagulation treatment, the size of the mass did not decrease. Further MRI imaging showed a central mass enhancement which raised concerns about a tumoral lesion. Following a discussion with the local Heart Team, management with surgical treatment was decided. The intraoperative findings revealed a 2.5â cm × 2.1â cm mass arising from the Eustachian valve and a non-diagnosed Chiari network in the RA. Both were resected and sent for a frozen section procedure which excluded a malignancy. The final histopathological analysis described fibrotic tissues compatible with an organized thrombus. The patient was discharged on postoperative day 7 without any complications. Although imaging studies are useful for the initial and differential diagnosis of RA masses, it is not always possible to get the final diagnosis without surgery. In case of a suspicion of a potentially malignant pathology, surgical exploration and resection are necessary.
RESUMO
(1) Background: There is a need for a novel surrogate marker to ease decision making when facing ascending aortic dilatation. In this article, we study the ratio between ascending and descending aorta diameters as a potential one. (2) Methods: Retrospective observational cohort study, including all the patients who underwent surgery for acute type A aorta dissection (aTAAD) between January 2014 and September 2020 at our center. A total of 50 patients were included. Clinical and demographic data were collected. The anatomical measurements were made including orthogonal maximal diameters of the ascending and descending aorta, post-dissection whole circumference length (post-wCL), post-dissection true lumen circumference length (post-tCL), and surface and sphericity indices of the ascending and descending aorta. Pre-dissection ascending aorta diameter (pre-AAD) and pre-dissection descending aorta diameter (pre-DAD) were calculated as well as the ratio between them and compared with reference values. (3) Results: Of the pre-AAD patients, 96% had smaller than the recommended 55 mm. The ratio between the descending and ascending aorta pre-dissection diameters was significantly smaller compared to the reference value (0.657 ± 0.125 versus 0.745 ± 0.016 with a mean difference of -0.088 and a p < 0.001). (4) Conclusions: The 55 mm threshold for aorta maximal diameter is an insufficient criterion when assessing the risk of dissection. The ratio between DAD and AAD is a parameter worthy of analysis as a tool to stratify the risk of dissection.
RESUMO
COVID19 altered and impacted medical and surgical practice around the world. Standard of care and routine procedures are disrupted. Majors shift in personnel, and ad hoc new team as well as delocalization and working with new infrastructures are further challenges to be dealt with. This review of three very unusual scenarios illustrates pitfalls and dangers harbored in the re-shaped landscape of COVID19 exemplifying the narrow path bridging from the medical and surgical comfort zone to uncharted territory and eventually leading to collateral damage.
Le Covid-19 a profondément modifié et sévèrement impacté les pratiques médicales et chirurgicales à long terme. Les standards de prise en charge et les procédures de routine sont altérés, voire perturbés. Des mutations majeures au niveau du personnel et des équipes de même que la délocalisation ou le travail avec de nouvelles infrastructures sont autant de défis à relever, encore aujourd'hui. Trois scénarios inhabituels illustrent les pièges et les dangers qui se cachent dans le paysage marqué par le Covid-19. Ces exemples démontrent la marge étroite entre la zone de confort médicale et chirurgicale classique et l'appréhension d'une situation inhabituelle qui risque d'entraîner des dommages collatéraux pour les patients.
Assuntos
COVID-19 , Procedimentos Cirúrgicos Cardíacos , HumanosRESUMO
Extrinsic compression is a potential cause of stent failure. We have described the case of a 65-year-old paraplegic patient with acute right leg ischemia. His medical history was relevant for aortobifemoral bypass, followed by kissing covered stent reconstruction of a proximal anastomotic false aneurysm. The computed tomography scan showed collapse of the right iliac covered stent with ipsilateral iliofemoral graft thrombosis and partial collapse of the left iliac covered stent. He underwent emergent right iliac limb open thrombectomy and redo covered stent relining. The cause of compression was found to be daily deep abdominal massages for intestinal evacuation. The endovascular device should be tailored to the patient's particularities.
RESUMO
AIMS OF THE STUDY: Minimally invasive extracorporeal circulation (MiECC) is an established alternative to conventional extracorporeal circulation (CECC) in coronary artery bypass graft surgery (CABG), but data on its use in cardiac reoperations are limited. We aimed to analyse perioperative morbidity and mortality in adult patients undergoing reoperations for isolated CABG using either CECC or MiECC circuits at our centre. METHODS AND RESULTS: In a single centre retrospective observational study of all adult patients undergoing cardiac reoperations for isolated CABG between 2004 and 2016, we identified 310 patients, and excluded those who received concomitant cardiac procedures (n = 205). Of the remaining 105 patients, 47 received isolated redo-CABG using MiECC, and 58 received CECC. Propensity score modelling was performed, and inversed probability treatment analysis was used between the treatment groups. Primary endpoint was 30-day all-cause mortality. Secondary endpoints included major adverse cardiac or cerebrovascular events or need for conversion to CECC. Groups were comparable, apart from a higher incidence of NYHA class III or higher in CECC group (33.5% vs 8.6%, p= 0.004). Shorter times for operation, cardiopulmonary bypass and aortic cross-clamp were observed in the MiECC group. The incidence of postoperative atrial fibrillation was significantly lower with MiECC (22.1%, p = 0.012). No significant difference was observed in all-cause 30-day mortality between the MiECC and CECC groups (6.8% vs. 8.3%, p = 0.81). CONCLUSION: We found no difference in overall mortality between CECC and MiECC in patients undergoing reoperation for isolated CABG. Furthermore, we found no indication of differences in most outcomes between extracorporeal circuit types. In the case of redo-CABG, MiECC could provide an alternative strategy.
Assuntos
Ponte de Artéria Coronária , Circulação Extracorpórea , Adulto , Ponte de Artéria Coronária/métodos , Circulação Extracorpórea/métodos , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Período Pós-Operatório , Reoperação , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVES: Technical skills are an essential component of cardiac surgery, and the operating room is becoming an even more challenging environment for trainees who want to acquire such skills. Simulation, which partially overcomes this limitation, represents a valid adjunct to surgical education. We describe an original simulator and provide results in terms of trainees' evaluations and ratings. METHODS: We used a humanoid that is a silicone replica of the chest of an adult human that provides a complete anatomical platform for hands-on skin-to-skin practice of surgical techniques in arrested heart coronary artery bypass graft (CABG) surgery cases. Learners were residents in cardiac surgery. The teaching sessions included 2 full three-vessel CABG procedures using both mammary arteries and a hydrogel vein. Five board-certified cardiovascular surgeons scored the surgical activity of all trainees. The trainees were asked to complete an exit questionnaire to evaluate their course. RESULTS: Overall, 16 residents participated in the simulation, including 5 women and 11 men, with a mean age of 30 ± 4 years, all of whom had at least 2 years of cardiac surgery training. All participants completed the 2 CABG operations. Three mammary arteries (4.6%) were seriously damaged during harvesting. In 1 case (3.1%), an aortic tear occurred during aortic cannulation. Each trainee performed overall 6 distal and 2 proximal coronary anastomoses. All participants agreed that the 'humanoid reproduces real-life situations, the feeling is realistic, and they are now more confident in performing coronary anastomosis'. CONCLUSIONS: Trainees involved in this simulation curriculum acquired and refined technical skills that could be applied directly to human patients. In addition, we were able to foster a higher level of teamwork within the operating room team.
Assuntos
Internato e Residência , Cirurgiões , Adulto , Competência Clínica , Ponte de Artéria Coronária/métodos , Educação de Pós-Graduação em Medicina/métodos , Feminino , Humanos , MasculinoRESUMO
We report sterile peri-graft abscess formation following an ascending aortic and hemiarch replacement for acute type A aortic dissection, possibly caused as a reaction to BioGlue®. The patient was successfully treated by drainage, cleaning, removal of BioGlue® remnants, three sessions of negative-pressure wound dressing, and secondary chest closure.
Assuntos
Dissecção Aórtica , Implante de Prótese Vascular , Abscesso/etiologia , Implante de Prótese Vascular/efeitos adversos , Humanos , Proteínas , Resultado do TratamentoRESUMO
Treating patients who have cancer with vaccines that stimulate a targeted immune response is conceptually appealing, but cancer vaccine trials have not been successful in late-stage patients with treatment-refractory tumours1,2. We are testing melanoma FixVac (BNT111)-an intravenously administered liposomal RNA (RNA-LPX) vaccine, which targets four non-mutated, tumour-associated antigens that are prevalent in melanoma-in an ongoing, first-in-human, dose-escalation phase I trial in patients with advanced melanoma (Lipo-MERIT trial, ClinicalTrials.gov identifier NCT02410733). We report here data from an exploratory interim analysis that show that melanoma FixVac, alone or in combination with blockade of the checkpoint inhibitor PD1, mediates durable objective responses in checkpoint-inhibitor (CPI)-experienced patients with unresectable melanoma. Clinical responses are accompanied by the induction of strong CD4+ and CD8+ T cell immunity against the vaccine antigens. The antigen-specific cytotoxic T-cell responses in some responders reach magnitudes typically reported for adoptive T-cell therapy, and are durable. Our findings indicate that RNA-LPX vaccination is a potent immunotherapy in patients with CPI-experienced melanoma, and suggest the general utility of non-mutant shared tumour antigens as targets for cancer vaccination.
Assuntos
Antineoplásicos/uso terapêutico , Vacinas Anticâncer/genética , Vacinas Anticâncer/imunologia , Melanoma/imunologia , Melanoma/terapia , Receptor de Morte Celular Programada 1/antagonistas & inibidores , RNA Neoplásico/genética , Linfócitos T/imunologia , Antígenos de Neoplasias/imunologia , Antineoplásicos/farmacologia , Vacinas Anticâncer/administração & dosagem , Vacinas Anticâncer/efeitos adversos , Terapia Combinada , Humanos , Melanoma/tratamento farmacológico , Melanoma/patologia , Estadiamento de Neoplasias , Linfócitos T/citologia , Linfócitos T Citotóxicos/citologia , Linfócitos T Citotóxicos/imunologia , VacinaçãoRESUMO
Brachiocephalic vein aneurysm is an extremely rare clinical entity, with a limited number of case reports in the literature. We report the case of a 74-year-old woman with a left brachiocephalic vein aneurysm (3 × 3 × 6.5 cm) that was discovered fortuitously by contrast-enhanced chest computed tomography. Surgical intervention was performed simultaneously during tricuspid valve surgery with coronary artery bypass grafting. This paper discusses the details of our case, the surgical treatment of brachiocephalic vein aneurysms, and the different treatment options.
RESUMO
OBJECTIVES: The SwissTAVI Registry includes all consecutive patients undergoing transcatheter aortic valve implantation (TAVI) and valve-in-valve (VinV) procedures for a failed bioprosthesis in Switzerland. We report the real world, all-comers, 30-day and 1-year outcomes of patients undergoing VinV and standard TAVI procedures. METHODS: Prospectively collected data from the 2 groups (VinV and standard TAVI patients) were retrospectively analysed. In an adjusted analysis, in-hospital and 1-year outcomes of VinV patients were compared with those of patients undergoing TAVI for native aortic valve disease in the same registry. A subanalysis of VinV procedures in stenotic or regurgitant bioprosthesis was also performed. RESULTS: Between February 2011 and December 2016, 4599 and 157 consecutive patients underwent TAVI in native aortic valves and VinV procedures in degenerate bioprosthesis, respectively. VinV patients were younger (78 ± 9.1 years vs 82.2 ± 6.3 years; P < 0.001) but at a higher risk for surgery (the logistic EuroSCORE: 28.48 ± 15.3% vs 18.2 ± 13.6%; P < 0.001; the Society of Thoracic Surgery (STS) score: 6.4 ± 5% vs 5.5 ± 4.3%; P = 0.008). Valve predilatation was less frequently performed during VinV procedures (22.9% vs 69.1%; P < 0.001), and the hospital stay was shorter after VinV procedure (8.46 ± 4.2 days vs 9.83 ± 6 days; P = 0.005). VinV patients showed higher predischarge transvalvular mean gradients (14.14 ± 7.9 mmHg vs 8.42 ± 5.0 mmHg; P < 0.001), smaller mean valve surface area (1.54 ± 0.7 cm2 vs 1.83 ± 0.5 cm2; P < 0.001) and a lower risk of moderate/severe paravalvular leak (1.3% vs 5%). Post-procedural kidney injury (1.3% vs 4.8%; P = 0.06) and new pacemakers for conduction abnormalities (3.3% vs 18.5%; P < 0.001) were higher after TAVI. All-cause mortality and cardiovascular mortality at 30 days were similar between the 2 groups (1.9% vs 3.8%; P = 0.242 and 1.9% vs 3.4%; P = 0.321), whereas after 1 year, all-cause mortality was lower for VinV patients (6.8% vs 13%; P = 0.035). The bioprosthetic valve size correlated inversely with postoperative gradients after VinV procedures. CONCLUSIONS: VinV aortic procedures showed favourable 30-day and 1-year clinical outcomes compared with TAVI procedures for the native aortic valve disease. Despite higher transvalvular mean gradients following VinV implants, this appears not to impact the early clinical outcomes.
Assuntos
Valva Aórtica/cirurgia , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Bioprótese/efeitos adversos , Bioprótese/estatística & dados numéricos , Feminino , Próteses Valvulares Cardíacas/efeitos adversos , Próteses Valvulares Cardíacas/estatística & dados numéricos , Humanos , Masculino , Complicações Pós-Operatórias , Desenho de Prótese , Falha de Prótese , Sistema de Registros , Estudos Retrospectivos , Suíça , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/instrumentação , Substituição da Valva Aórtica Transcateter/mortalidade , Substituição da Valva Aórtica Transcateter/estatística & dados numéricos , Resultado do TratamentoRESUMO
External iliac artery endofibrosis is a rare disease described mainly in male endurance athletes. It presents as claudication of the lower limb during near-maximum effort. The patients lack the usual risk factors for atherosclerosis, which makes diagnosis challenging. We present a case of external iliac artery endofibrosis in a female competitive cyclist. The initial surgical management was complicated by early recurrence due to intimal hyperplasia. After secondary drug-eluting balloon angioplasty, the patient was able to resume competition. As such, it is important to maintain a high index of suspicion when evaluating a patient presenting with claudication symptoms in this setting. Primary treatment is surgical, and in cases of early recurrence angioplasty may be indicated. Most patients can return to full activity after healing is complete.
Assuntos
Atletas , Ciclismo , Artéria Ilíaca/patologia , Claudicação Intermitente/etiologia , Doença Arterial Periférica/etiologia , Adulto , Angioplastia com Balão/instrumentação , Stents Farmacológicos , Feminino , Fibrose , Humanos , Artéria Ilíaca/diagnóstico por imagem , Artéria Ilíaca/cirurgia , Claudicação Intermitente/diagnóstico por imagem , Claudicação Intermitente/patologia , Claudicação Intermitente/cirurgia , Angiografia por Ressonância Magnética , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/patologia , Doença Arterial Periférica/cirurgia , Recidiva , Retratamento , Resultado do TratamentoRESUMO
Transcatheter tricuspid valve-in-ring implantation has emerged as a potential alternative to surgery for high-risk patients with symptomatic severe tricuspid regurgitation that recurs after surgical ring repair. The worldwide experience remains limited. We report a case of unsuccessful transfemoral tricuspid valve-in-ring implantation (using an Edwards SAPIEN 3 valve, Edwards Lifesciences, Irvine, CA) and literature review. The rigidity, open shape, and open configuration of the ring may lead to imperfect positioning, resulting in severe paravalvular leak. Particular attention should be paid to sizing and wire position with respect to the ring while implanting the valve.
Après annuloplastie tricuspide chirurgicale, l'implantation d'une valve percutanée dans l'anneau représente une potentielle alternative à la reprise chirurgicale chez les patients à haut risque présentant une régurgitation tricuspide sévère symptomatique. L'expérience d'une telle intervention dans le monde demeure toutefois limitée. Nous rapportons un cas d'échec de l'implantation transfémorale d'une valve SAPIEN 3 (Edwards Lifesciences, Irvine, CA) dans un anneau tricuspide et nous passons en revue la littérature. La rigidité ainsi que la forme et la configuration ouverte de l'anneau peuvent conduire à une mauvaise position de la prothèse valvulaire avec comme résultat une fuite paravalvulaire potentiellement sévère. Il faut porter une attention particulière à la sélection de la taille de la prothèse valvulaire et à la position du fil guide au moment de l'implantation de la valve.
RESUMO
The sensing of microbial genetic material by leukocytes often elicits beneficial pro-inflammatory cytokines, but dysregulated responses can cause severe pathogenesis. Genome-wide association studies have linked the gene encoding phospholipase D3 (PLD3) to Alzheimer's disease and have linked PLD4 to rheumatoid arthritis and systemic sclerosis. PLD3 and PLD4 are endolysosomal proteins whose functions are obscure. Here, PLD4-deficient mice were found to have an inflammatory disease, marked by elevated levels of interferon-γ (IFN-γ) and splenomegaly. These phenotypes were traced to altered responsiveness of PLD4-deficient dendritic cells to ligands of the single-stranded DNA sensor TLR9. Macrophages from PLD3-deficient mice also had exaggerated TLR9 responses. Although PLD4 and PLD3 were presumed to be phospholipases, we found that they are 5' exonucleases, probably identical to spleen phosphodiesterase, that break down TLR9 ligands. Mice deficient in both PLD3 and PLD4 developed lethal liver inflammation in early life, which indicates that both enzymes are needed to regulate inflammatory cytokine responses via the degradation of nucleic acids.
Assuntos
Células Dendríticas/fisiologia , Endossomos/metabolismo , Exonucleases/metabolismo , Hepatite/genética , Macrófagos/fisiologia , Glicoproteínas de Membrana/metabolismo , Fosfolipase D/metabolismo , Doença de Alzheimer/genética , Animais , Artrite Reumatoide/genética , DNA de Cadeia Simples/imunologia , Exonucleases/genética , Estudo de Associação Genômica Ampla , Humanos , Interferon gama/metabolismo , Glicoproteínas de Membrana/genética , Camundongos , Camundongos Endogâmicos C57BL , Camundongos Knockout , Fosfolipase D/genética , Escleroderma Sistêmico/genética , Transdução de Sinais , Receptor Toll-Like 9/metabolismoRESUMO
We report a rare association of a giant aneurysm of the left circumflex coronary artery with multiple peripheral arterial aneurysms and an abdominal aortic aneurysm in a 70-year-old patient. The exclusion of the giant circumflex artery aneurysm was performed successfully by proximal and distal ligation of all branches and bypass surgery using saphenous grafts to vascularize the distal circumflex artery and the marginal branch.