Is Surgical Intervention the Optimal Therapy for the Treatment of Aortic Valve Stenosis for Patients With Intermediate Society of Thoracic Surgeons Risk Score?

BACKGROUND: Patients at intermediate risk (IR) according to The Society of Thoracic Surgeons risk score are today frequently oriented toward the transfemoral aortic valve replacement (TAVR) option. Our goal was to evaluate the best treatment strategies for IR patients with severe aortic stenosis. METHODS: Of a consecutive series of 1,144 surgical aortic valve replacements (AVRs) performed in our institution between 2008 and 2014, we reviewed the early and late outcomes of two different groups: a low-risk (LR) group of 470 patients, and an IR group of 620. We eliminated from the analysis 54 high-risk patients who were currently candidates for TAVR. All patients underwent surgical AVR with or without concomitant coronary artery bypass grafting. Social Security database interrogation provided long-term information. RESULTS: The early mortality rate (30 days) between LR and IR patients was similar (1.70% vs 2.74%, p = 0.25) and both lower than predicted mortality rates. However, cumulative 5-year survival was significantly higher in LR patients (86.3%) than in IR patients (75.4%; p = 0.0007 by log-rank test), although excellent in IR group. Comparing IR survivors and nonsurvivors, ages at operation were 69.5 ± 12.7 years for survivors vs 75.4 ± 9.6 years for those experiencing late deaths (p = 0.002). Risk factors for late deaths after multivariate analysis were age, hemodialysis, and chronic lung disease. CONCLUSIONS: Most IR patients today should undergo surgical AVR, but because of survival rates combined with still unavailable late structural deterioration rates in TAVR valves, patients in the IR group with high Society of Thoracic Surgeons scores and known risk factors may be better served with TAVR as data regarding late percutaneous valve function accrue.

High resolution IR diode laser study of collisional energy transfer between highly vibrationally excited monofluorobenzene and CO2: the effect of donor fluorination on strong collision energy transfer.

Collisional energy transfer between vibrational ground state CO2 and highly vibrationally excited monofluorobenzene (MFB) was studied using narrow bandwidth (0.0003 cm(-1)) IR diode laser absorption spectroscopy. Highly vibrationally excited MFB with E' = ∼41,000 cm(-1) was prepared by 248 nm UV excitation followed by rapid radiationless internal conversion to the electronic ground state (S1→S0*). The amount of vibrational energy transferred from hot MFB into rotations and translations of CO2 via collisions was measured by probing the scattered CO2 using the IR diode laser. The absolute state specific energy transfer rate constants and scattering probabilities for single collisions between hot MFB and CO2 were measured and used to determine the energy transfer probability distribution function, P(E,E'), in the large ΔE region. P(E,E') was then fit to a bi-exponential function and extrapolated to the low ΔE region. P(E,E') and the biexponential fit data were used to determine the partitioning between weak and strong collisions as well as investigate molecular properties responsible for large collisional energy transfer events. Fermi's Golden rule was used to model the shape of P(E,E') and identify which donor vibrational motions are primarily responsible for energy transfer. In general, the results suggest that low-frequency MFB vibrational modes are primarily responsible for strong collisions, and govern the shape and magnitude of P(E,E'). Where deviations from this general trend occur, vibrational modes with large negative anharmonicity constants are more efficient energy gateways than modes with similar frequency, while vibrational modes with large positive anharmonicity constants are less efficient at energy transfer than modes of similar frequency.

Evaluating effects of self-reported domestic physical activity on pregnancy and neonatal outcomes in "stay at home" military wives.

OBJECTIVE: To determine if an association exists between daily physical activity, and pregnancy/neonatal outcomes in stay at home military wives. METHODS: This is a prospective observational study of pregnant military wives who do not work outside the home. Participants completed a validated questionnaire of their daily activity from which the average energy expenditure per day (kcal/day) was calculated. Participants were grouped, according to their energy expenditure and assessed for antepartum, intrapartum, and neonatal outcomes. RESULTS: There were 55 women (group 1) who expended ≤ 2,200 kcal/day, 77 expended 2,201 to 3,000 kcal/day, and 58 expended ≥ 3,001 kcal/day. Group 1 had the lowest maternal weight at first visit (p < 0.001) and delivery (p < 0.001) and highest percentage of primigravidas (p = 0.002). After adjusting for key maternal characteristics, women in group 1 were more likely to develop gestational diabetes. Although not significant, the women in group 1 had more intrauterine growth restriction and preterm labor whereas group 3 had a greater risk of antepartum hemorrhage. CONCLUSIONS: Primigravida women of low weight not working are most likely to use the least energy compared to the heaviest women who use the most calories and are more likely to develop gestational diabetes.

Epicardial ultrasonic ablation of atrial fibrillation during concomitant cardiac surgery is a valid option in patients with ischemic heart disease.

BACKGROUND: Surgical therapy of atrial fibrillation concomitant to coronary bypass grafting using epicardial Ultrasound technology was assessed after a minimum 6-month follow-up. METHODS AND RESULTS: A cohort of 98 consecutive patients with a mean age of 72+/-7.58 years and a primary diagnosis of ischemic heart disease had surgery for structural disease. Coronary artery bypass grafting was isolated (n=51) or associated (n=47) with various combinations of aortic, mitral, tricuspid, and left ventricular restoration surgery. Atrial fibrillation duration ranged from 6 to 360 months (mean 71 months) and was permanent in 47 patients, paroxysmal in 34, and persistent in 17. Left atrial mean diameter was 48+/-6.71 mm. A circumferential ablation was performed off-pump, before the concomitant procedure, and was always associated with an epicardial mitral line lesion using the same technology. At 3-, 6-, and 12-month visits, patients were routinely evaluated by physical examination, ECG, chest X-ray, and 24-hour Holter. There were 1 early death (1%) and 4 extracardiac late deaths. A pacemaker was implanted in 4 patients. Mean follow-up time was 325 days, 2 patients being lost to follow-up. Freedom from atrial fibrillation and flutter at the 6-month visit was 84% for the entire population, 76% in patients with permanent, and 91% in patients with paroxysmal atrial fibrillation. At the 1-year visit, 85% were free from atrial fibrillation or flutter. CONCLUSIONS: Epicardial beating heart ablation using therapeutic ultrasound is safe, reliable, and can easily treat atrial fibrillation in a difficult surgical population of patients with primary ischemic heart disease.

Collisional relaxation of the three vibrationally excited difluorobenzene isomers by collisions with CO2: effect of donor vibrational mode.

Relaxation of highly vibrationally excited 1,2-, 1,3-, and 1,4-difluorobenzne (DFB) by collisions with carbon dioxide has been investigated using diode laser transient absorption spectroscopy. Vibrationally hot DFB (E' approximately 41,000 cm(-1)) was prepared by 248 nm excimer laser excitation followed by rapid radiationless relaxation to the ground electronic state. Collisions between hot DFB isomers and CO2 result in large amounts of rotational and translational energy transfer from the hot donors to the bath. The CO2 nascent rotational population distribution of the high-J (J = 58-80) tail of the 00(0)0 state was probed at short times following the excimer laser pulse to measure rate constants and probabilities for collisions populating these states. The amount of translational energy gained by CO2 during collisions was determined using Doppler spectroscopy to measure the width of the absorption line for each transition. The energy transfer probability distribution function, P(E,E'), for the large DeltaE tail was obtained by resorting the state-indexed energy transfer probabilities as a function of DeltaE. P(E,E') was fit to a biexponential function to determine the average energy transferred in a single DFB/CO2 collision and fit parameters describing the shape of P(E,E'). P(E,E') fit parameters for DFB/CO2 and the previously studied C6F6/CO2 system are compared to various donor molecular properties. A model based on Fermi's Golden Rule indicates that the shape of P(E,E') is primarily determined by the low-frequency out-of-plane donor vibrational modes. A fractional mode population analysis is performed, which suggests that for energy transfer from DFB and C6F6 to CO2 the two key donor vibrational modes from which energy leaks out of the donor into the bath are nu11 and nu16. These "gateway" modes are some of the same modes determined to be the most efficient energy transfer modes by quantum scattering studies of benzene/He collisions.

Ultrasonic cardiac ablation for atrial fibrillation during concomitant cardiac surgery: long-term clinical outcomes.

BACKGROUND: Therapeutic ultrasound as an alternative to the maze procedure was evaluated in this large US experience. Safety and efficacy were assessed at 6-, 12-, and 18-month visits with systematic 24-hour Holter monitoring. METHODS: From February 2005 to February 2007, 220 patients were prospectively enrolled in a single center study, and among them 129 patients with concomitant cardiac surgery and at least 6-month follow-up were reviewed. Primary procedures were mitral surgery in 50% of the cases, coronary bypass in 32%, and aortic surgery in 16%. Atrial fibrillation was permanent in 66 (51.1%), paroxysmal in 43 (33.3%), and persistent in 20 (15.5%) patients. An epicardial and circumferential left atrial encircling line was created on the beating heart. Routinely a mitral isthmus line was also created from the left atrium epicardium using an ultrasonic handheld device. RESULTS: No morbidity or mortality was device-related. There were four (2.33%) early deaths and six late extra-cardiac deaths. Follow-up ranged from 6 to 670 days with a mean follow-up of 358.5 days, median 340 days with two patients lost to follow-up. Freedom from atrial fibrillation or left-sided flutter was 83.2%, 84.4%, and 86.2% at 6, 12, and 18 months, respectively. A pacemaker was implanted in seven patients (5.4%). Male gender and left atrial dimension were significant risk factors for failure. CONCLUSIONS: The study confirms the excellent safety record of the technology, and the efficacy at the level reported in a previous European multicenter study. Efficacy is also maintained at longer (12 and 18 months) follow-up.

Management approach for recurrent spontaneous pneumothorax in consecutive pregnancies based on clinical and radiographic findings.

OBJECTIVE: To describe management and clinical features observed in a patient's seven spontaneous pneumothoraces that developed during two consecutive pregnancies involving both hemithoraces. MATERIALS AND METHODS: A 21 year old former smoker developed three spontaneous left pneumothoraces in the index pregnancy, having already experienced four right pneumothorax events in a prior pregnancy at age 19. RESULTS: Chest tubes were required in several (but not all) hospitalizations during these two pregnancies. Following her fourth right pneumothorax, thoracoscopic excision of right apical lung blebs and mechanical pleurodesis was performed. The series of left pneumothoraces culminated in mini-thoracotomy and thoracoscopically directed mechanical pleurodesis. For both pregnancies unassisted vaginal delivery was performed with no adverse perinatal sequelae. With the exception of multiple pneumothoraces, there were no additional pregnancy complications. CONCLUSION: Spontaneous pneumothorax in pregnancy is believed to be a rare phenomenon, yet the exact incidence is unknown. Here we present the first known case of multiple spontaneous pneumothoraces in two consecutive pregnancies involving both hemithoraces. Clinical management coordinated with obstetrics and surgical teams facilitated a satisfactory outcome for both pregnancies. The diagnosis of pneumothorax should be contemplated in any pregnant patient with dyspnea and chest pain, followed by radiographic confirmation.

Heat shock protein 70 is a potential virulence factor in murine toxoplasma infection via immunomodulation of host NF-kappa B and nitric oxide.

We propose that the 70-kDa heat shock protein (HSP70) protects virulent Toxoplasma gondii from the effects of the host by immunomodulation. This hypothesis was tested using quercetin and antisense oligonucleotides targeting the start codon of the virulent T. gondii HSP70 gene. Oligonucleotides were transiently transfected into two virulent (RH, ENT) and two avirulent (ME49, C) strains of T. gondii, significantly reducing HSP70 expression in treated parasites. Virulent parasites with reduced HSP70 expression displayed reduced proliferation in vivo, as measured by the number of tachyzoites present in spleens of infected mice. They also exhibited an enhanced rate of conversion from tachyzoites to bradyzoites in vitro. Our results implicate HSP70 as a means by which virulent strains of T. gondii evade host proinflammatory responses: when RAW 264.7 cells were exposed to parasites with reduced HSP70 expression, differential expression of inducible NO synthase (iNOS) and cell NO production were observed between infections with normal and HSP70-deficient T. gondii. iNOS message levels were significantly increased when host cells were infected with HSP70 reduced virulent tachyzoites and HSP70-related inhibition of iNOS transcription resulted in altered host NO production by virulent T. gondii infection. Virulent parasites expressing reduced levels of HSP70 initiated significantly more NF-kappa B activation in host splenocytes than infections with untreated parasites. Neither proliferative ability nor conversion from tachyzoites to bradyzoites was affected by lack of HSP70 in avirulent strains of T. gondii. Furthermore, avirulent T. gondii strains induced high levels of host iNOS expression and NO production, regardless of HSP70 expression in these parasites, and inhibition of HSP70 had no significant effects on translocation of NF-kappa B to the nucleus. Therefore, the 70-kDa parasite stress protein may be part of an important survival strategy by which virulent strains down-regulate host parasiticidal mechanisms.