The Results of Urgent and Emergent Transcatheter Mitral Valve Repair (MitraClip®): A Comparison with Standard Elective Repair.

Background: Mitral regurgitation (MR) is the most common valvular disease worldwide. MR has been managed surgically, with either a mitral valve replacement or repair. Percutaneous transcatheter mitral valve repair (TMVr) with MitraClip® insertion has gained wide popularity and success over medical and surgical therapy for MR. Some patients with acute MR or decompensated heart failure could benefit from urgent TMVr. This meta-analysis aims to compare clinical outcomes of urgent versus elective TMVr. Methods: We performed a study-level meta-analysis to compare the clinical outcomes of urgent versus elective TMVr using the MitraClip system. The primary endpoint outcome was all-cause mortality. Additional outcomes included procedural success, postoperative acute kidney injury (AKI), stroke, and length of in-hospital stay. Results: Overall, 30-day mortality was significantly higher in the urgent group (odds ratio [OR]: 2.74; 95% confidence interval [CI] [2.17, 3.48]; P < 0.00001; I² =0%). However, subgroup analysis of matched cohorts showed no significant difference between both groups (OR: 1.80; 95% CI [0.94, 3.46]; P = 0.08; I² =0%). One-year mortality was similar between both groups (and: 1.67; 95% CI [0.96, 2.90]; P = 0.07; I² =0%). Procedural success was similar between both groups (89.4% vs. 89.8%; P = 0.43). Postoperative AKI was significantly higher in the urgent group (OR: 4.12; 95% CI [2.87, 5.91]; P < 0.00001; I² =0%). Conclusion: Urgent TMVr should be indicated in select populations as it is considered therapeutic with acceptable outcomes therein.

Staged Versus Concomitant TAVI and PCI for the Treatment of Coexisting Aortic Stenosis and Coronary Artery Disease.

Aortic stenosis (AS) is one of the most common valvular pathologies. Severe coronary artery disease (CAD) often coexists with AS. Transcatheter aortic valve implantation (TAVI) and percutaneous coronary intervention (PCI) have been established as alternatives to open surgical interventions. The data on the timing for the treatment of the 2 conditions are scarce and depend on multiple factors. This review compares the clinical outcomes of the concomitant versus staged PCI and TAVI for the treatment of AS and CAD. A systematic, electronic search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines to identify relevant articles that compared outcomes of the staged versus concomitant approaches for the TAVI and PCI. Seven studies were included involving 3745 patients. We found no statistically significant difference in primary outcomes such as 30-day mortality [odds ratio (OR) = 0.78; 95% confidence interval (CI): 0.39-1.57] and secondary outcomes including length of hospital stay (mean difference = -4.74, 95% CI: -10.96 to 1.48), new-onset renal failure (OR = 0.83, 95% CI: 0.22-3.13), cerebrovascular accidents (OR = 1.28, 95% CI: 0.64-2.57), and intraoperative blood loss (OR = 0.83, 95% CI: 0.32-2.12). New pacemaker insertion was statistically significant in favor of the concomitant approach (OR = 0.78, 95% CI: 0.63-0.96). This analysis suggests that while the 2 approaches are largely comparable in terms of most outcomes, patients at risk of requiring a pacemaker postprocedure may benefit from a concomitant approach. In conclusion, concomitant TAVI + PCI approach is nonsuperior to the staged approach for the treatment of CAD and AS. This review calls for robust trials in the field to further strengthen the evidence.

Incidence Rates of Penn Classes and Class-Specific Mortality in Acute Type A Aortic Dissection Patients: An Epidemiologic Systematic Review and Meta-Analysis.

Acute type A aortic dissection (ATAAD) is a life-threatening emergency that is associated with a high morbidity and mortality rate. One of the complications is end-organ ischemia, a known predictor of mortality. The primary aims of this meta-analysis were to summarize the findings of observational studies investigating the utility of the Penn classification system and to analyze the incidence rates and mortality patterns within each class. The electronic databases PubMed, MEDLINE, and Embase were searched through to April 2023. These were filtered by multiple reviewers to give 10 studies that met the inclusion criteria. The extracted data included patient characteristics, and primary outcomes were the incidence rates of different Penn classes, along with the corresponding mortality for each class. Out of 1,512 studies identified during the initial search, 10 studies, including 4,494 patients, met the inclusion criteria. The pooled incidence of Penn A was highest at 0.55 (95% CI 0.52, 0.58), followed by Penn B at 0.21 (95% CI 0.17, 0.25), and finally Penn C at 0.14 (95% CI 0.11, 0.17). Patients with Penn BC were found to be at the highest risk of death, as their early mortality rates were 0.36 (95% CI 0.31, 0.41). Within those populations, the subtype with the highest individual mortality was Penn C at 0.21 (95% CI 0.15, 0.27), followed by Penn B at 0.19 (95% CI 0.15, 0.23) and Penn A at 0.07 (95% CI 0.05, 0.10). Among patients presenting with ATAAD, class A was most frequently observed, followed by classes B, C, and BC. These findings indicate an incremental increase in mortality rates with the progression of Penn classification.

Computed Tomography Scanning for Sternal Wound Infections: A Systematic Review.

Background: Sternal wound infection (SWI) has always been a significant risk in patients who undergo sternotomies as part of their cardiac surgical procedures. Computed tomography (CT) imaging is often used to diagnose and assess sternal wound infections. Its purpose includes identifying and locating infection and any sternal dehiscence. Methods: A systematic literature review across PubMed, Embase, and Ovid was performed according to PRISMA guidelines to identify relevant articles that discussed the utility of CT scanning for SWI, common features identified, patient outcomes and sensitivity/specificity (Figure 1). Results: 25 papers were included. 100% (n=25) of the papers were published in peer-reviewed journals. CT scans in SWIs can be seen as a beneficial aid in diagnosing as well as determining the components of infection. Commonalities were identified such as fluid collection in the mediastinum, free gas, pleural effusions, and sternal dehiscence which point towards the presence of sternal wound infection. Conclusion: CT scanning is a novel and emerging methodology for imaging in SWI and post-sternotomy complications, hence increased research is required to expand the literature on this area as well as the creation of guidelines and cut-offs or signs for radiology professionals to identify and determine the extent of infection.

Local versus General Anaesthesia for Transcatheter Aortic Valve Implantation (TAVI): A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomised and Propensity-Score Matched Studies.

Transcatheter aortic valve implantation (TAVI) is a common practice for severe aortic stenosis, but the choice between general (GA) and local anesthesia (LA) remains uncertain. We conducted a comprehensive literature review until April 2023, comparing the safety and efficacy of LA versus GA in TAVI procedures. Our findings indicate significant advantages of LA, including lower 30-day mortality rates (RR: 0.69; 95% CI [0.58, 0.82]; p < 0.001), shorter in-hospital stays (mean difference: -0.91 days; 95% CI [-1.63, -0.20]; p = 0.01), reduced bleeding/transfusion incidents (RR: 0.64; 95% CI [0.48, 0.85]; p < 0.01), and fewer respiratory complications (RR: 0.56; 95% CI [0.42, 0.76], p<0.01). Other operative outcomes were comparable. Our findings reinforce prior evidence, presenting a compelling case for LA's safety and efficacy. While patient preferences and clinical nuances must be considered, our study propels the discourse towards a more informed anaesthesia approach for TAVI procedures.

TEM Classification of Aortic Dissection-The Evolving Scoring System: A Literature Review.

Aortic dissection is an acute presentation that, if unnoticed, poses a significant risk to life. Anatomically, it is defined as a tear in the intimal layer of the aorta, but management differs significantly based on the location of this tear. Traditionally the Stanford and DeBakey classifications have been used to distinguish tear types and thus guide the most favourable management option, be it medical optimisation or surgery. Recently, a new Type-Entry-Malperfusion classification has been proposed to more accurately define and thus risk stratify patients with aortic dissection. This review summarises the Type-Entry-Malperfusion classification and highlights its potential advantages and limitations compared to other classifications. Clinical insights and potential barriers to adopting this classification are also described in this review.

Foreign Body Misdiagnosed as Mucus Plugging After Percutaneous Tracheostomy.

We report a case of a 59-year-old male who presented with a persistent cough for a year after being discharged from critical care following a subarachnoid haemorrhage. As part of his initial critical care management and in order to allow full neurological assessment, the patient required a period of prolonged mechanical ventilation, which necessitated a percutaneous tracheostomy. Following recovery and subsequent discharge, the patient presented on multiple occasions with cough, undergoing serial computed tomography (CT) scans which reported mucus plugging as a possible cause of the cough. As his symptoms continued to worsen, a flexible bronchoscopy was carried out, which identified a foreign body in the trachea. This object was later recognised as a retained part of the guiding catheter, part of the percutaneous tracheostomy tube dilator. After the object was retrieved, the patient reported a complete resolution of symptoms. Percutaneous tracheostomy is a common procedure within critical care units, and early complications such as bleeding or airway obstruction are typically recognised immediately after insertion. This report documents a late complication caused by the retention of a foreign object from insertion, which was misdiagnosed on serial CT scans, leading to persistent cough over a period of months.

A Rare Case of Extraction of Ventriculoperitoneal Shunt From the Left Main Bronchus.

We present the case of a 40-year-old female who underwent several insertions of ventriculoperitoneal (VP) shunts as a part of the treatment for idiopathic intracranial hypertension (IIH). Several years after the insertion of the last VP shunt, the patient started experiencing shortness of breath (SOB) and cough; after further assessment, it was noted on computed tomography (CT) scan that the VP shunt had migrated into the right lower lobe of the lung and perforated the distal left main bronchus. The shunt was successfully retrieved using bronchoscopy under general anesthesia, after which the patient had a complete resolution of symptoms. Shunt migration is one of the rare complications that can happen years after shunt insertion. Therefore, we present this rare case of shunt migration into the thorax cavity to highlight the presentation of this complication and its successful management.

Optimizing Outcomes in Extracorporeal Membrane Oxygenation Postcardiotomy in Pediatric Population.

Extracorporeal membrane oxygenation (ECMO) is a rapidly emerging advanced life support technique used in cardiorespiratory failure refractory to other treatments. There has been an influx in the number of studies relating to ECMO in recent years, as the technique becomes more popular. However, there are still significant gaps in the literature including complications and their impacts and methods to predict their development. This review evaluates the available literature on the complications of ECMO postcardiotomy in the pediatric population. Areas explored include renal, cardiovascular, hematological, infection, neurological, and hepatic complications. Incidence, risk factors and potential predictors, and scoring systems for the development of these complications have been evaluated.

Transcatheter edge-to-edge repair in mitral regurgitation: A comparison of device systems and recommendations for tailored device selection. A systematic review and meta-analysis.

BACKGROUND: Mitral valve transcatheter edge-to-edge repair (M-TEER) is a minimally invasive method for the treatment of mitral regurgitation (MR) in patients with prohibitive surgical risks. The traditionally used device, MitraClip, showed both safety and effectiveness in M-TEER. PASCAL is a newer device that has emerged as another feasible option to be used in this procedure. METHODS: We searched for observational studies that compared PASCAL to MitraClip devices in M-TEER. The electronic databases searched for relevant studies were PubMed/MEDLINE, Scopus, and Embase. The primary outcomes were technical success and the grade of MR at follow-up. Secondary outcomes included all-cause mortality, bleeding, device success and reintervention. RESULTS: Technical success (PASCAL: 96.5% vs MitraClip: 97.6%, p = 0.24) and MR ≤ 2 at 30-day follow-up (PASCAL: 89.4vs MitraClip 89.9%, p = 0.51) were comparable between both groups. Both devices showed similar outcomes including all-cause mortality (RR: 0.68 [0.34, 1.38]; P = 0.28), major bleeding (RR: 1.87 [0.68, 5.10]; P = 0.22) and reintervention (RR: 1.02 [0.33, 3.16]; P = 0.97). Device success was more frequent with PASCAL device (PASCAL: 86% vs MitraClip 68.5%; P = 0.44), however, the results did not reach statistical significance. CONCLUSION: Clinical outcomes of PASCAL were comparable to those of MitraClip with no significant difference in safety and effectiveness. The choice between MitraClip and PASCAL devices should be guided by various factors, including mitral valve anatomy, etiology of regurgitation, and device-specific characteristics.

Aortic Valve Replacement and Repair With or Without Concomitant Ascending Aorta Replacement: Impact on Outcomes: A Systematic Review.

Aortic valve surgery is a common procedure used to treat significant aortic valve stenosis or insufficiency. Some of these patients have coexisting pathology affecting the ascending aorta requiring ascending aorta replacement (AAR). Although the outcomes of these procedures are independently positive, it is proposed that concomitant AAR improves outcomes and minimizes the chances of future ascending aorta replacement. A comprehensive literature search for relevant studies published since 2010 comparing outcomes of aortic valve repair and replacement with or without concomitant ascending aorta replacement was undertaken using electronic databases PubMed, Cochrane Library, Embase Ovid, and SCOPUS. Major exclusion criteria were (1) conference posters, literature reviews, editorials; (2) aortic root surgery, aortic arch surgery, or other surgeries (3) case series with less than 5 participants. A total of 1189 patients from 6 retrospective cohort studies were included in the final review, from which clinical outcomes such as mortality and complications were compared. Mortality rates were similar in both intervention groups. No significant differences were found between the 2 groups in reexploration rates due to bleeding, stroke, postoperative dialysis, and atrial fibrillation. Survival rates varied but had no significant difference between interventions. Both isolated aortic valve surgery and concomitant AAR procedures offer comparable favourable outcomes in terms of mortality, survival rates, and complication risks. However, the evidence is limited by the lack of randomized controlled trials. We recommend that future studies should standardize reporting on postoperative recovery, complications, long-term freedom from reoperations, and long-term changes to aorta dimensions.

Caduceus vs. Rod of Asclepius: A Serpentine Dilemma in Medical Iconography.

This scholarly inquiry delves into the historical significance of two enduring medical symbols: the Rod of Asclepius and the Caduceus. Tracing their origins back to ancient Greek mythology, we uncover their distinct identities and profound meanings as symbols of healing, unity among medical practitioners, and ethical responsibilities. Beyond aesthetics, these emblems serve as powerful educational tools, fostering universal understanding and connecting modern medicine to its historical heritage. Consequently, embracing their true essence can inspire genuine dedication to the noble mission of caring for others.

Long Saphenous Vein Harvesting: Reviewing Various Techniques.

Ischemic heart disease is the leading cause of mortality and morbidity in the Western world. Thus, coronary artery bypass graft is the most common cardiac procedure performed as it remains the gold standard for multiple vessel disease and left main disease. Long saphenous vein is the conduit of choice for coronary artery bypass graft as it is accessible and easy to harvest. Over the previous 4 decades, several techniques have emerged to optimize harvesting and reducing adverse clinical outcomes. The most cited techniques are open vein harvesting, no-touch technique, endoscopic vein harvesting, and standard bridging technique. In this literature review, we aim to summarize current literature for each of the 4 techniques in terms of: (A) graft patency and attrition, (B) myocardial infarction and revascularization, (C) wound infections, (D) postoperative pain, and (E) patient satisfaction.

Analyzing the Evolution of Medical Ethics Education: A Bibliometric Analysis of the Top 100 Cited Articles.

Ethics education plays a pivotal role in healthcare by providing professionals and students with the essential competencies to navigate intricate ethical challenges. This study conducts a comprehensive bibliometric analysis of the most-cited articles on ethics education, investigating parameters such as citation count, document types, geographical origin, journal analysis, publication year, author analysis, and keyword usage. The findings reveal a substantial impact characterized by high citation counts and the influence of a prominent publication focusing on the hidden curriculum and structure of medical education. Moreover, the analysis demonstrates a discernible increase in research output since 2000, signaling a growing recognition of the significance of ethics education in the healthcare domain. Notably, specific journals, particularly those dedicated to medical education and ethics, emerge as major contributors in this field, publishing many articles. Renowned authors have made noteworthy contributions, and emerging themes encompass the ethical implications of virtual reality and artificial intelligence in healthcare education. Additionally, undergraduate medical education garners significant attention, emphasizing the importance of establishing ethical values and professionalism early. Overall, this study highlights the imperative of interdisciplinary collaboration and the necessity for effective ethics education programs to equip healthcare professionals with the requisite skills to navigate complex ethical challenges. The findings inform educators, curriculum developers, and policymakers about enhancing ethics education and ensuring the ethical competence of future healthcare practitioners.

Elective Thoracic Aortic Aneurysm Surgery: A Tertiary Center Experience.

Background A thoracic aortic aneurysm (TAA) is a diseased expansion of the thoracic aorta. There is morbidity associated with a dilated aorta, as well as significant mortality. Open thoracic surgery is the fundamental management for proximal lesions, offering definitive treatment with excellent results. This study aimed to summarize preoperative data and operative outcomes of patients who underwent TAA repair at our institution. Methods Data were retrospectively collected from 234 patients that underwent elective open thoracic surgery at University Hospital Southampton for TAA disease, between 2015 and 2019. Demographics, clinical factors, surgical details, as well as outcome measures, were gathered. Results There were 166 males and 68 females, with an overall mean age of 66 years. The breakdown of operations comprised 105 aortic roots, 171 ascending aorta, 20 aortic arch, and 12 descending aorta cases. The mean follow-up was 370 days. 30-day mortality was 5.13%. Mortality was associated with female gender, aortic root surgery, and prosthetic valves. Mean aortic diameters at the time of surgery for the non-genetic aortopathy and genetic aortopathy groups were respectively 4.93cm and 4.63cm in the aortic root, 5.56cm and 4.88cm in the ascending aorta, 5.08cm and 3.87cm in the aortic arch, and 6.63cm and 5.50cm in the descending aorta. Conclusion Several factors are associated with complications and morbidity, which should be considered when discussing the risks of intervention with patients. There were no neuroprotective strategies that altered post-operative neurological function. Current practice in our unit fits in with current international guidance.

#MedEd: Mapping the Current Landscape of Medical Education Discourse and Stakeholder Participation Across Social Media Platforms.

Background Medical education is a constantly evolving and multifaceted field that requires ongoing discussion and innovation. Social media platforms have emerged as a popular medium for disseminating information and engaging in professional discourse among medical educators. In particular, the hashtag #MedEd has gained widespread recognition amongst individuals and organizations within the medical education community. Our objective is to gain insights into the types of information and discussions surrounding medical education, as well as the individuals or organizations involved in these conversations. Methods Searches were conducted across major social media platforms, including Twitter, Instagram, and Facebook, using the hashtag #MedEd. The top 20 posts posted on these platforms were analyzed through a reflexive thematic analysis approach utilizing the Braun and Clarke method. Furthermore, an examination was conducted on the profiles of those responsible for posting the aforementioned top posts, to ascertain the degree of participation from individuals versus organizations within the broader discourse pertaining to the topic. Results Our analysis revealed three thematic categories associated with the usage of the #MedEd hashtag, including discussions on "continuous learning and medical case presentations," "medical specialties and topics," and "medical education pedagogy." The analysis revealed that social media can serve as a valuable platform for medical education by providing access to a diverse range of learning resources, fostering collaboration and professional networking, and providing innovative teaching methods. Furthermore, profile analysis showed that individuals were more actively involved in the discussion of medical education topics on social media compared to organizations across all three platforms. Conclusion Our study highlights the significant role that social media platforms play in facilitating the exchange of information and ideas within the medical education community. The hashtag #MedEd serves as a means of connecting individuals and organizations across the globe, enabling them to engage in professional discourse and stay informed on the latest developments in the field. Our findings suggest that a better understanding of the thematic categories and stakeholders involved in medical education discussions on social media can aid educators, learners, and organizations in enhancing their engagement with this dynamic field.

Emerging sodium-glucose cotransporter-2 inhibitor therapies for managing heart failure in patients with chronic kidney disease.

INTRODUCTION: Although sodium-glucose cotransporter-2 (SGLT2) inhibitors have risen in popularity for managing heart failure (HF) and chronic kidney disease (CKD), little guidance is available for the management of patients with an overlap of HF and CKD. AREAS COVERED: Following a brief review of the cardiorenal effects of SGLT2 inhibitors, this narrative review focused on the published clinical evidence pertaining to the cardiovascular and renal efficacy of SGLT2 inhibitors in patients with HF and CKD, including both randomized controlled trials and real-world observational studies. Real-world considerations of using SGLT2 inhibitors in these patients were also reviewed. EXPERT OPINION: Although no randomized controlled trial has specifically studied the use of SGLT2 inhibitors in patients with HF and CKD, evidence from existing trials is largely sufficient to demonstrate that SGLT2 inhibitors are efficacious in these patients, in whom these agents should be initiated early to maximally slow declines in renal function. Further studies should focus on better guiding the timing of initiating SGLT2 inhibitors, improving these agents' cost-effectiveness, and bettering equity of access to these agents. Further areas of study may include the prognostic implications of SGLT2 inhibitors-induced changes in biomarker levels (e.g. natriuretic peptides), and the potentials of SGLT1 inhibition.

Redo aortic valve replacement versus valve-in-valve trans-catheter aortic valve implantation: a UK propensity-matched analysis.

This study sought to compare the morbidity and mortality of redo aortic valve replacement (redo-AVR) versus valve-in-valve trans-catheter aortic valve implantation (valve-in-valve TAVI) for patients with a failing bioprosthetic valve. A multicenter UK retrospective study of redo-AVR or valve-in-valve TAVI for patients referred for redo aortic valve intervention due to a degenerated aortic bioprosthesis. Propensity score matching was performed for confounding factors. From July 2005 to April 2021, 911 patients underwent redo-AVR and 411 patients underwent valve-in-valve TAVI. There were 125 pairs for analysis after propensity score matching. The mean age was 75.2±8.5 years. In-hospital mortality was 7.2% (n=9) for redo-AVR versus 0 for valve-in-valve TAVI, p=0.002. Surgical patients suffered more post-operative complications, including intra-aortic balloon pump support (p=0.02), early re-operation (p<0.001), arrhythmias (p<0.001), respiratory and neurological complications (p=0.02 and p=0.03) and multi-organ failure (p=0.01). The valve-in-valve TAVI group had a shorter intensive care unit and hospital stay (p<0.001 for both). However, moderate aortic regurgitation at discharge and higher post-procedural gradients were more common after valve-in-valve TAVI (p<0.001 for both). Survival probabilities in patients who were successfully discharged from the hospital were similar after valve-in-valve TAVI and redo-AVR over the 6-year follow-up (log-rank p=0.26). In elderly patients with a degenerated aortic bioprosthesis, valve-in-valve TAVI provides better early outcomes as opposed to redo-AVR, although there was no difference in mid-term survival in patients successfully discharged from the hospital.