Timed screening colonoscopy: a randomized trial of two colonoscopic withdrawal techniques.

BACKGROUND AND GOALS: Missed adenomas are likely to be located in the proximal colon and failure to detect these lesions might explain the occurrence of a certain percentage of interval carcinomas. Though studies have demonstrated increased detection of significant neoplastic lesions in colonoscopic examinations where the withdrawal time is 6 min or more, there are no recommendations on how much time to spend in each colonic segment. The aim of the trial was to find ways to reduce the number of lesions missed in the proximal segments of the colon assessing the difference in adenoma detection rate (ADR) between two colonoscopic withdrawal timed techniques. STUDY: This was a randomized trial in a university hospital. Population was composed of patients referred for screening colonoscopy. The Main Outcome measurements was ADRs for patients subjected to a timed colonoscopy with specific withdrawal times, with special interest in the proximal colon, and implying a minimum of 2-min withdrawal delay in the cecum and right colon, a 1-min delay time in the transverse colon, and a minimum additional 3-min delay time in the left colon, as compared to a standard timed colonoscopy with free withdrawal delay time of at least 6 min. RESULTS: A total of 1160 patients were included. Eleven were initially excluded due to incomplete colonoscopies. Of the remaining 1149 patients, 573 were randomized to the group with fixed withdrawal times (Group A) and 576 to conventional withdrawal (Group B). Median age was 57 years (SD 6), a total of 634 (55.2%) were male patients and the mean withdrawal time was 7:05 min (SD 1 min). Seven hundred and eighty-one adenomas/serrated lesions were found in 470 patients (1.66 per patient), with 28 advanced lesions and 3 adenocarcinomas. Global ADR was 41% with no significant statistical differences between the two groups (42.1% vs 39.8%, p 0.43), respectively. A multivariate analysis showed clear relation between the finding of adenomas and higher BBPS ratings (Adjusted Odds Ratio [aOR] 0.92, p 0.05), age (aOR 1.03, p 0.01), male sex (aOR 1.51, p 0.001), and time of withdrawal (aOR 1.17, p 0.001), while no association was observed with either withdrawal technique (aOR 0.89, IC 95% 0.70-1.03, p 0.32). There was no statistical significant difference between the two groups concerning the finding of proximal lesions (cOR 0.93, CI 95% 0.71-1.20, p 0.56) (aOR 0.89, CI 95% 0.69-1.17, p 0.41) or serrated polyps (cOR 0.81, CI 95% 0.51-1.27, p 0.35) (aOR 0.81, IC 95% 0.51-1.28, p 0.36). CONCLUSIONS: Fixed withdrawal times did not prove to lead to an increase in the number of detected adenomas. Nevertheless, our study supports previous reports stating that longer withdrawal times are indeed associated with better proximal and distal adenoma detection.

[Aggresive angiomyxoma after renal transplantation]. / Angiomixoma agresivo postrasplante renal.

The condition of immunosuppressed increases the risk of cancer in kidney transplant patients, as compared to the general population. The best survival of inmunosupressed patients in recent years has turned both neoplasms and cardiovascular diseases into the main causes of morbidity and mortality. We present the case of a renal transplanted patient who developed an unusual form of mesenchymal tumor such as the aggressive angiomyxoma, four years after the implant and requiring wide surgical resection.

Infective endocarditis after transcatheter aortic valve implantation: results from a large multicenter registry.

BACKGROUND: We aimed to determine the incidence, predictors, clinical characteristics, management, and outcomes of infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS: This multicenter registry included 53 patients (mean age, 79±8 years; men, 57%) who suffered IE after TAVI of 7944 patients after a mean follow-up of 1.1±1.2 years (incidence, 0.67%, 0.50% within the first year after TAVI). Mean time from TAVI was 6 months (interquartile range, 1-14 months). Orotracheal intubation (hazard ratio, 3.87; 95% confidence interval, 1.55-9.64; P=0.004) and the self-expandable CoreValve system (hazard ratio, 3.12; 95% confidence interval, 1.37-7.14; P=0.007) were associated with IE (multivariate analysis including 3067 patients with individual data). The most frequent causal microorganisms were coagulase-negative staphylococci (24%), followed by Staphylococcus aureus (21%) and enterococci (21%). Vegetations were present in 77% of patients (transcatheter valve leaflets, 39%; stent frame, 17%; mitral valve, 21%). At least 1 complication of IE occurred in 87% of patients (heart failure in 68%). However, only 11% of patients underwent valve intervention (valve explantation and valve-in-valve procedure in 4 and 2 patients, respectively). The mortality rate in hospital was 47.2% and increased to 66% at the 1-year follow-up. IE complications such as heart failure (P=0.037) and septic shock (P=0.002) were associated with increased in-hospital mortality. CONCLUSIONS: The incidence of IE at 1 year after TAVI was 0.50%, and the risk increased with the use of orotracheal intubation and a self-expandable valve system. Staphylococci and enterococci were the most common agents. Although most patients presented at least 1 complication of IE, valve intervention was performed in a minority of patients, and nearly half of the patients died during the hospitalization period.

[Acute aortic syndrome]. / Síndrome aórtico agudo.

Acute aortic syndrome embraces a group of heterogenous pathological entities involving the aortic wall with a common clinical profile. The current epidemiology, clinical presentation, diagnosis and treatment strategy are discussed in this review. Besides, the importance of multidisciplinary aortic teams, aortic centers and the implementation of an aortic code are emphasized.

Latest-iteration balloon- and self-expandable transcatheter valves for severe bicuspid aortic stenosis: the TRITON study.

INTRODUCTION AND OBJECTIVES: No comparisons have been published yet regarding the newest iteration of balloon- and self-expandable transcatheter heart valves for the treatment of bicuspid aortic valve (BAV) stenosis. METHODS: Multicenter registry of consecutive patients with severe BAV stenosis treated with balloon-expandable transcatheter heart valves (Myval and SAPIEN 3 Ultra, S3U) or self-expanding Evolut PRO+(EP+). TriMatch analysis was carried out to minimize the impact of baseline differences. The primary endpoint of the study was 30-day device success, and the secondary endpoints were the composite and individual components of early safety at 30 days. RESULTS: A total of 360 patients (age 76.6±7.6 years, 71.9% males) were included: 122 Myval (33.9%), 129 S3U (35.8%), and 109 EP+(30.3%). The mean STS score was 3.6±1.9%. There were no cases of coronary artery occlusion, annulus rupture, aortic dissection, or procedural death. The primary endpoint of device success at 30 days was significantly higher in the Myval group (Myval: 100%; S3U: 87.5%; and EP+: 81.3%), mainly due to higher residual aortic gradients with S3U and greater≥moderate aortic regurgitation (AR) with EP+. No significant differences were found in the unadjusted rate of pacemaker implantation. CONCLUSIONS: In patients with BAV stenosis deemed unsuitable for surgery, Myval, S3U and EP+showed similar safety but balloon-expandable Myval had better gradients than S3U, and both balloon-expandable devices had lower residual AR than EP+, suggesting that, taking into consideration the patient-specific risks, any of these devices can be selected with optimal outcomes.

Structural and Functional Evaluation of Coronary Arteries Treated With ABSORB Bioresorbable Vascular Scaffold at 5-Year Follow-Up.

Although complete bioresorbable vascular scaffold (BVS) resorption has been demonstrated at 5-year follow-up, whether corresponding vasomotor function restoration occurs remains unknown. The objective was to simultaneously assess the structural healing response along with vasomotor responses at 5-year follow-up of BVS implantation. We studied consecutive patients treated with ABSORB-BVS at 5-year follow-up (n = 31), who were recruited from a multicenter registry and were contacted to undergo a research protocol-driven repeat coronary angiogram involving intracoronary optical coherence tomography (OCT) and invasive coronary endothelial function testing. Epicardial endothelium-dependent vasomotion was defined as any vasodilatation after intracoronary acetylcholine (ACh), whereas endothelium-independent vasomotion was defined as any vasodilatation after intracoronary nitroglycerine (NTG), using quantitative coronary angiography. The mean implantation time point was 60.5 ± 4.6 months. OCT imaging demonstrated complete scaffold resorption in all patients. New coronary lesions (stenosis >50%) were found in 5 patients (16.1%), 3 of them underwent ad hoc percutaneous revascularization (9.7%). Intracoronary ACh (27 patients) and NTG testing (30 patients) was performed. Quantitative coronary angiography analysis demonstrated vasoconstriction after ACh administration and lack of response to NTG in BVS segments (mean lumen diameter = 2.00 ± 0.61 mm at baseline vs 1.74 ± 0.70 mm post-ACh, p <0.001; 2.05 ± 0.54 mm at baseline vs 2.03 ± 0.50 mm post-NTG, p = 0.69). OCT lumen analysis demonstrated similar vasoconstrictive responses to ACh (mean lumen area = 5.31 ± 2.26 mm2 at baseline vs 5.12 ± 2.55 mm2 post-ACh, p = 0.007) but had a vasodilatory response to NTG (5.96 ± 2.35 mm2 at baseline vs 6.17 ± 2.55 mm2 post-NTG, p<0.001). In conclusion, complete ABSORB-BVS resorption was demonstrated at 5-year follow-up. However, this healing response was associated with endothelium-dependent vasomotor dysfunction within the BVS segment.

Beta Blockers as Salvage Treatment in Refractory Septic Shock Complicated With Dynamic Left Ventricular Outflow Tract Obstruction: A Rare Case Presentation.

Hypotension is the main finding in patients admitted to an intensive care unit (ICU) with the diagnosis of septic shock and it is related to worse outcomes. In these patients, several underlying causes of hypotension may co-exist, including vasoplegia, hypovolemia, drug-mediated venodilation, or myocardial dysfunction. Nowadays, echocardiography has been positioned as an essential tool in any ICU set to assess fluid status, ventricular ejection fraction, or any other myocardial complications. The high sympathetic tone in severely ill patients, in addition to high doses of adrenergic drugs often needed, may provoke a hypercontractile cardiac state. In the basis of our experience, we present a case of a patient with refractory septic shock and severe hemodynamic collapse, refractory to vasopressors with concomitant respiratory deterioration due to dynamic left ventricular outflow tract obstruction (LVOTO). Transesophageal echocardiography (TOE) was used to assess hemodynamic status and to guide treatment. A critical response to intravenous ß-blockers was seen, with a dramatic decrease in vasopressor dosage and respiratory support.

Open surgical repair and endovascular treatment in adult coarctation of the aorta.

BACKGROUND: The aim of this study was to compare the results of endovascular therapy (covered stenting) with surgical technique to repair aortic coarctation in adults. METHODS: A prospective study of 11 patients who were treated during the past 10 years was carried out. Of these, five patients underwent endoprosthesis (group A) and six an open surgical repair (group B). Follow-up comprised monitoring of the blood pressure, echocardiography, and computed tomography and magnetic resonance angiographic studies. RESULTS: The mean age of the patients was 46 years (range: 17-67 years) and the mean follow-up was 52.6 months (range: 1-117 months; 32.3 for group A vs. 69.7 for group B; p = 0.01). Two cases in group A were recoarctations after child angioplasty. The rate of postoperative complications was 27.7% (one hemothorax for group A vs. one pneumothorax and one hemothorax for group B); however, mortality did not occur. The success rate of the endovascular technique was 80%. The stay in the intensive care unit was 2.3 days with significant differences (one group A vs. three group B; p = 0.01), whereas length of hospital stay was 11 days (7.8 group A vs. 11.83 group B; p = 0.17). The pressure gradient across the stenosis decreased by 21.9 ± 3.7 mm Hg (24.5 ± 4.3 group A vs. 33 ± 3.2 group B). Six patients (54.5%) showed persistent hypertension (80% group A vs. 33% group B), with a mean residual pressure gradient of 23.4 ± 4.3 mm Hg (22.5 ± 5.4 group A vs. 22 ± 2.1 group B; p = 0.58). CONCLUSIONS: Short- and medium-term results of the endovascular therapy are similar, with shorter stay in the intensive care unit and higher necessity of antihypertensive treatment. Echocardiography and Doppler aortic coarctation gradients slightly higher than 20 mm Hg are usual during follow-up.

Combined surgical treatment in aortic type A dissection.

Acute Stanford type A aortic dissection is a fatal event that, for its high mortality when left untreated, requires urgent surgical intervention. The established treatment includes repair of the ascending aorta and various portions of the aortic arch, leaving the descending aorta untreated. We report the case of a 62-year-old man in whom a combined approach of the ascending aorta with surgical correction and transluminal placement of a stent in the aortic arch was performed.

The Learning Curve and Annual Procedure Volume Standards for Optimum Outcomes of Transcatheter Aortic Valve Replacement: Findings From an International Registry.

OBJECTIVES: The authors aimed to determine the procedural learning curve and minimum annual institutional volumes associated with optimum clinical outcomes for transcatheter aortic valve replacement (TAVR). BACKGROUND: Transcatheter aortic valve replacement (TAVR) is a complex procedure requiring significant training and experience for successful outcome. Despite increasing use of TAVR across institutions, limited information is available for its learning curve characteristics and minimum annual volumes required to optimize clinical outcomes. METHODS: The study collected data for patients at 16 centers participating in the international TAVR registry since initiation of the respective TAVR program. All cases were chronologically ordered into initial (1 to 75), early (76 to 150), intermediate (151 to 225), high (226 to 300), and very high (>300) experience operators for TAVR learning curve characterization. In addition, participating institutions were stratified by annual TAVR case volume into low-volume (<50), moderate-volume (50 to 100), and high-volume (>100) groups for comparative analysis. Procedural and 30-day clinical outcomes were collected and multivariate regression analysis performed for 30-day mortality and the early safety endpoint. RESULTS: A total of 3,403 patients comprised the study population. On multivariate analysis, all-cause mortality was significantly higher for initial (odds ratio [OR]: 3.83; 95% confidence interval [CI]: 1.93 to 7.60), early (OR: 2.41; 95% CI: 1.51 to 5.03), and intermediate (OR: 2.53; 95% CI: 1.19 to 5.40) experience groups compared with the very high experience operators. In addition, the early safety endpoint was significantly worse for all experience groups compared with the very high experience operators. Low annual volume (<50) TAVR institutions had significantly higher all-cause 30-day mortality (OR: 2.70; 95% CI: 1.44 to 5.07) and worse early safety endpoint (OR: 1.60; 95% CI: 1.17 to 2.17) compared with the moderate- and high-volume groups. There was no difference in patient outcomes between intermediate and high annual volume groups. CONCLUSIONS: TAVR procedures display important learning curve characteristics with both greater procedural safety and a lower mortality when performed by experienced operators. In addition, TAVR performed at low annual volume (<50 procedures) institutions is associated with decreased procedural safety and higher patient mortality. These findings have important implications for operator training and patient care at centers performing TAVR.

The diagnostic ability of echocardiography for infective endocarditis and its associated complications.

Echocardiography, transthoracic and transoesophageal, plays a key role in the diagnosis and prognosis assessment of patients with infective endocarditis. It constitutes a major Duke criterion and is pivotal in treatment guiding. Seven echocardiographic findings are major criteria in the diagnosis of infective endocarditis (IE) (vegetation, abscess, pseudoaneurysm, fistulae, new dehiscence of a prosthetic valve, perforation and valve aneurysm). Echocardiography must be performed as soon as endocarditis is suspected. Transoesophageal echocardiography should be done in most cases of left-sided endocarditis to better define the anatomic lesions and to rule out local complications. Transoesophageal echocardiography is not necessary in isolated right-sided native valve IE with good quality transthoracic examination and unequivocal echocardiographic findings. Echocardiography is a very useful tool to assess the prognosis of patients with IE at any time during the course of the disease. Echocardiographic predictors of poor outcome include presence of periannular complications, prosthetic dysfunction, low left ventricular ejection fraction, pulmonary hypertension and very large vegetations.