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Myeloid sarcoma (MS) is a rare extramedullary tumor of immature granulocytic cells and is most often associated with acute myeloid leukemia (AML). Myeloid sarcomas can occur anywhere in the body but are seldom present in the testicles, especially in the pediatric population. The treatment of MS, especially testicular myeloid sarcoma (TMS) is not well defined in the literature and the role of radiation therapy in the treatment of TMS is even less well defined. In this case report, we discuss the treatment for TMS in a pediatric patient, review the literature, and discuss the role of radiation therapy in the treatment.
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Study objective: Assess the utilization of aortic valve replacements (AVR). Design: Retrospective analysis of the Nationwide Readmissions Database (2016-2018). Setting: Nationwide. Participants: Heart failure patients with concomitant aortic stenosis (CHF + AS cohort) or aortic stenosis with aortic regurgitation (CHF + AS+AR cohort). Interventions: Transcatheter aortic valve implantation (TAVI), surgical aortic valve replacement (SAVR), no-AVR. Main outcome measures: Utilization of treatment interventions. Results: In the CHF + AS cohort, TAVI, SAVR and no-AVR were done in 9.3 %, 10.8 % and 79.9 % of patients respectively. Similarly, majority of CHF + AS+AR patients were managed with no-AVR (53.2 %). Of patients managed with no-AVR in the first six months of each year, only 7.9 % of CHF + AS and 11.8 % of CHF + AS+AR patients underwent AVR in the subsequent six months of the year. No-AVR patients had worse short-term outcomes in comparison to AVR recipients. Conclusion: More studies are needed to understand the timing, indications and utilization of AVR in this population.
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Background: Post-procedural hospital length of stay (P-LOS) is an important determinant of cost-related outcomes. In the present study, we aimed to assess the impact of P-LOS on short-term outcomes after transcatheter aortic valve replacement (TAVR) and MitraClip. Methods: We performed a retrospective cohort study, retrieving data from the National Readmissions Database (NRD) for patients who underwent transfemoral TAVR and MitraClip between January 2014 and December 2017. We employed multivariable logistic regression to evaluate the association between P-LOS and 30-day all-cause mortality and readmissions. Results: A total of 65,726 and 7347 patients underwent TAVR and MitraClip, respectively within the study period. After 30 days of discharge, 13.7% and 15.1% of TAVR and MitraClip patients were readmitted for any reason, while 0.5% and 0.9% died within the readmission hospitalization. A longer P-LOS was associated with an increased risk of 30-day all-cause readmission in both TAVR (OR = 1.027, 95% CI [1.023-1.032]) and MitraClip (OR = 1.025, 95%CI [1.012-1.038]) patients. This finding remained true for patients who developed or did not develop complications after both procedures. In terms of 30-day inhospital mortality, a longer P-LOS was associated with a higher risk in TAVR patients (OR = 1.039, 95%CI [1.028-1.049]), but no increased risk in MitraClip patients (OR = 1.014, 95%CI [0.985-1.044]). Other predictors of 30-day readmission after both procedures included heart failure, post-procedural acute kidney injury, and discharge with disability. Conclusion: The current study shows that shorter P-LOS was associated with reduced risk of short-term readmission after both TAVR and MitraClip and reduced short-term mortality after TAVR (mainly in patients who developed post-procedural complications). Shorter P-LOS is a predictor of readmission and sicker patient group. Patients requiring longer LOS should be followed closely to prevent readmission and enhance better outcomes. Future studies evaluating P-LOS impact on long-term and patient-oriented outcomes are needed.
RESUMEN
Background: Coronary obstruction during transcatheter aortic valve replacement (TAVR) is a rare, yet life-threatening, complication. The routine use of left main (LM) protection with or without stent placement in high-risk patients remains controversial. The aim of this study was to evaluate the outcomes of LM protection during TAVR and identify anatomic factors associated with need for stent placement. Methods: We retrospectively reviewed all TAVR cases (native and valve-in-valve) performed in our institution between 2014 and 2019 and identified patients who underwent LM protection with a coronary wire, balloon, and/or stent during the procedure. We compared the pre-TAVR computed tomography aortic root characteristics, procedural data, short-, and long-term outcomes among the patients who eventually received an LM stent and those who did not. Results: Among 1925 TAVR patients, 41 (2.1%) underwent LM protection, and 10 of them (25%) had eventually a stent placed in the LM for threatened obstruction after valve deployment. In the native TAVR group (n = 35), 8 patients underwent LM stenting. A larger TAVR prosthesis, larger annular circumference (83.8 vs 76.1 âmm; P = .038), lower ratio of sinotubular junction diameter to prosthesis size (1.02 vs 1.11; P = .032), and longer left coronary cusp (15.1 vs 13.9 âmm; P = .18) were associated with higher incidence of LM stenting. In the valve-in-valve TAVR group (n = 6), 5 patients had a valve-to-coronary distance of less than 4 âmm, and 2 of them received an LM stent. Both stent and nonstent groups had excellent outcomes with no major adverse cardiovascular events or coronary obstruction at 30 âdays. After a median follow-up of 351 âdays, 4 patients died (9.7%) (1 in the stent and 3 in the nonstent group), without any cases of late coronary obstruction or percutaneous coronary intervention in either group. Conclusions: LM protection with a coronary guidewire, balloon, or stent is a safe and effective method of coronary protection during TAVR in appropriately selected high-risk patients. Annular circumference, prosthesis size, left coronary cusp length, LM ostial height, and ratio of sinotubular junction to prosthesis size are important predictors of stent deployment.