Renal cell carcinoma and tumour thrombus in the inferior vena cava: clinical outcome of 98 consecutive patients and the prognostic value of preoperative parameters.

OBJECTIVES: To evaluate the outcome of patients after nephrectomy and removal of tumour thrombus and to assess the prognostic value of preoperative parameters. PATIENTS AND METHODS: Ninety-eight patients who were surgically treated between 2002 and 2011 were included. Patients' charts were reviewed, and patients with renal cell carcinoma (RCC) and concomitant tumour thrombus in the renal vein (RV) were compared with those with extended inferior vena cava (IVC) thrombus. Wilcoxon rank-sum test, Kaplan-Meier analysis and uni- and multivariate Cox regression analysis were used for statistical evaluation. RESULTS: Follow-up was 36 months (20-122 months), and 5-year disease-specific survival (DSS) and overall survival were 68.4 and 54.1 %, respectively. Patients with extended thrombus (levels 2-4) had higher intraoperative transfusion rates of concentrated red cells (CRC) and fresh-frozen plasma (FFP) compared with patients with thrombus confined to the RV (CRC: 5.8 vs. 1.5, p < 0.0001; FFP: 2.3 vs. 0.4, p = 0.0032). Surgery time (190 vs. 107 min, p < 0.0001), duration of hospitalisation (16 vs. 11 days, p = 0.0269), serum phosphate (3.64 vs. 3.29 mmol/l, p = 0.0369) and CRP levels (6.7 vs. 4.4 mg/dl, p = 0.0194) as well as aPTT were increased (33.7 vs. 29.6 s, p = 0.0059) in extended thrombus disease. In multivariate analysis, the presence of distant metastasis (p = 0.03) and lymphovascular invasion (p = 0.001), high platelet counts (p = 0.001) and high serum potassium levels (p = 0.032) proved to be independent prognostic factors. CONCLUSION: The surgical treatment of RCC with tumour thrombus in the RV or IVC has favourable results. Extended thrombus disease requires multidisciplinary approach. High serum potassium levels and platelet counts are associated with reduced DSS.

Results of a propensity score-matched comparison of the Perimount Magna and Mosaic Ultra aortic valve prostheses.

BACKGROUND AND AIM OF THE STUDY: Hemodynamic function and clinical outcomes were compared between the bovine pericardial Edwards Perimount Magna (EPM) and the porcine Medtronic Mosaic Ultra (MMU) aortic valve prostheses. METHODS: Between January 2003 and June 2007, a total of 227 consecutive patients was prospectively enrolled, and received either the EPM (n = 125) or the MMU (n = 102) aortic valve prosthesis. The primary study end-point was the mean transvalvular gradient after surgery, at discharge and at six months follow up, as measured echocardiographically. The secondary study end-points were 30-day mortality and major adverse cardiac events (MACEs). RESULTS: The intraoperative transvalvular mean pressure gradients were 9.4 +/- 4.6 mmHg in the EPM group compared to 17.7 +/- 6.7 mmHg in the MMU group (p < 0.001), and these remained essentially unchanged at hospital discharge (11.2 +/- 4.2 mmHg versus 19.1 +/- 6 mmHg; p < 0.001) and at six months' follow up (10 +/- 5 mmHg versus 20 +/- 7 mmHg; p < 0.001). A multivariable risk-adjusted analysis of covariance revealed the MMU valve (p < 0.0001) to be strongly associated with elevated postoperative mean transvalvular gradients during the six-month follow up. In addition, renal insufficiency, concomitant valve surgery and reoperation were identified as being significantly associated with in-hospital mortality (OR 3.3, 95% CI 1.3-8.1; OR 3.7, 95% CI 1.4-9.8; OR 3.3, 95% CI 1.1-10.2, respectively) and major adverse cardiac events (OR 2.2, 95% CI 1.0-4.7; OR 3.7, 95% CI 1.7-8.2; OR 2.7, 95% CI 1.1-7.2, respectively). To further control for selection bias, the propensity score was computed based on the major risk factors of 12 patients. An analysis of covariance model, adjusted for the propensity score, also confirmed the MMU prosthesis to be strongly associated with elevated mean transvalvular gradients during the six-month follow up period (p < 0.0001). CONCLUSION: The study results clearly demonstrated a favorable hemodynamic function as shown by lower transvalvular gradients of the bovine pericardial Edwards Perimount Magna compared to the porcine Medtronic Mosaic Ultra aortic valve prosthesis.

Comparison of flow dynamics of Perimount Magna and Magna Ease aortic valve prostheses.

The aim of the present study was to evaluate and compare the in vitro and flow dynamics of the Magna (MB) and the Magna Ease aortic valve bioprosthesis (MEB) within the ascending aorta. A 2D-particle-image-velocimetry (2D-PIV) study was performed to compare the flow dynamics induced by each pericardial Carpentier-Edwards Magna and Magna Ease aortic valve prosthesis in the aortic flow field directly behind the valve. Both prostheses (diameter 23 mm) were placed inside an artificial aorta under pulsatile flow conditions (70 Hz and 70 ml stroke volume). The flow field was evaluated according to velocity, shear strength, and vorticity. Both prostheses showed a jet flow type profile with a maximum velocity of 0.97±0.09 m/s for MB and 0.83±1.8 m/s for MEB. Flow fields of both valves were similar in acceleration, peak flow deceleration and leakage phase. Maximum shear strength was 20,285±11,774 l/s2 for MB and 17,006±8453 l/s2 for MEB. Vorticity was nearly similar for counterclockwise and clockwise rotation in both prostheses, but slightly higher with MB (251±41 l/s and -250±39 l/s vs. 225±48 l/s and -232±48 l/s). The point-of-interest (POI)-analysis revealed a higher velocity for left-sided aortic wall compared to right-sided at MB (0.12±0.09 m/s vs. 0.18±0.10 m/s, p<0.001), but was consistent at MEB (0.09±0.05 m/s vs. 0.08±0.04 m/s, p=0.508), respectively. Velocity, shear strength and vorticity in an in vitro test set-up are lower with MEB compared to MB, thus resulting in improved flow dynamics with a similar flow field, which might have a positive influence on blood rheology and potential valve degeneration.