Comprehensive management of post-LASIK ectasia: From prevention to treatment.

Post-laser in situ keratomileusis (post-LASIK) ectasia (PLE) is one of the most serious complications after refractive surgery, mainly manifested as progressive thinning and trembling thinning of the cornea, accompanied by increased myopia and astigmatism. The mechanisms behind mainly include genetic risk factors and external environmental factors such as eye rubbing and cornea surgery. In order to achieve the goal of reducing the incidence of ectasia, preoperative screening strategies need to be continuously improved, through the collection and assessment of genetic and environmental risk factors. Although previous preoperative screening methods did not have a uniform standard, the emergence of artificial intelligence (AI) can help us process a large amount of information and make rational use of the data. By using high-fidelity finite element modelling, differences in preoperative and postoperative strain distributions can be observed, which can predict the risk of postoperative ectasia. In this review, we describe the incidence, aetiology, prevention and treatment of PLE for the purpose of comprehensive management. In terms of treatment, corneal collagen cross-linking has been widely used to treat progressive keratoconus and other ectasia disease, either as a preventive measure during surgery or as a therapeutic modality after surgery to prevent progression of corneal dilation. Although the standard Dresden protocol has been identified as the gold standard treatment for corneal dilatation, a series of refinements, investigations and long-term studies have been conducted in recent years. Thus, understanding the factors involved in delaying the onset and slowing progression of cornea ectasia will be key to reducing the incidence worldwide.

A New Predictor of Obstructive Coronary Artery Ectasia in Patients with Non-ST-Elevation Acute Coronary Syndrome: The Atherogenic Index of Plasma / Un nuevo predictor de ectasia obstructiva de la arteria coronaria en pacientes con síndrome coronario agudo sin elevación del segmento ST: el índice aterogénico del plasma

Introduction: Coronary artery ectasia (CAE) is one of the uncommon cardiovascular disorders with a clinical spectrum ranging from asymptomatic cases to myocardial infarction. Atherosclerosis plays a pivotal role in the pathogenesis of CAE. Recently, it has been determined that the atherogenic index of plasma (AIP) is a strong predictive marker for atherosclerosis. The aim of this study was to investigate whether there is a relationship between obstructive CAE and AIP in patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS). Materials and methods: In this retrospective study, hospital electronic patient records were retrospectively examined. A total of 213 NSTE-ACS patients were included in the study. Patients were divided into two groups according to non-obstructive and obstructive CAE. The AIP value was compared between groups and regression analysis evaluated whether it is an indicator to predict the risk of obstructive CAE. Results: The AIP value was found to be numerically and statistically significant in the obstructive CAE group compared to the non-obstructive CAE group. The multivariate logistic regression analysis identified AIP as a predictor of obstructive CAE in NSTE-ACS patients in the receiver operating curve analysis, AIP values above 0.33 had 90% sensitivity and 68% specificity to predict obstructive CAE in NSTE-ACS patients. Conclusions: AIP values were increased in the presence of obstructive CAE in NSTE-ACS patients. Our findings suggest that AIP may be involved in the pathogenesis of obstructive CAE. (AU)

Introducción: La ectasia arterial coronaria (EAC) es uno de los trastornos cardiovasculares poco frecuentes con un espectro clínico que va desde casos asintomáticos hasta infarto de miocardio. La aterosclerosis juega un papel fundamental en la patogenia de la CAE. Recientemente, se ha determinado que el índice aterogénico del plasma (AIP) es un fuerte marcador predictivo de aterosclerosis. El objetivo de este estudio fue investigar si existe una relación entre el CAE obstructivo y la PAI en pacientes con síndrome coronario agudo sin elevación del segmento ST (SCASEST). Materiales y métodos: En este estudio retrospectivo, se examinaron retrospectivamente las historias clínicas electrónicas de los pacientes. Se incluyeron en el estudio un total de 213 pacientes con SCASEST. Los pacientes se dividieron en dos grupos según el CAE obstructivo y no obstructivo. El valor de AIP se comparó entre grupos y el análisis de regresión evaluó si es un indicador para predecir el riesgo de EAC obstructivo. Resultados: Se encontró que el valor AIP era numérica y estadísticamente significativo en el grupo CAE obstructivo en comparación con el grupo CAE no obstructivo. El análisis de regresión logística multivariable identificó a la AIP como predictor de EAC obstructiva en pacientes con SCASEST en el análisis de la curva operativa del receptor, valores de AIP superiores a 0,33 tenían una sensibilidad del 90 % y una especificidad del 68 % para predecir EAC obstructiva en pacientes con SCASEST. Conclusiones: Los valores de AIP se incrementaron en presencia de EAC obstructivo en pacientes con SCASEST. Nuestros hallazgos sugieren que AIP puede estar involucrado en la patogenia de CAE obstructivo. (AU)

Supporting the Ross procedure: preserving root physiology while mitigating autograft dilatation.

PURPOSE OF REVIEW: The purpose of this article is to describe the optimized approach to nonrepairable aortic valve disease in young adults with a Ross procedure, while preserving the dynamic physiology of the aortic root. RECENT FINDINGS: As the techniques for supporting pulmonary autografts continue to be refined, and the applicability of the Ross procedure continues to expand, an assessment of the various techniques based on aortic root physiology is warranted. Semi-resorbable scaffolds show promise in ovine models for improving the Ross procedure. Recent long-term outcomes for the Dacron inclusion technique in comparison to more physiologic methods of support emphasize the importance of balancing the prevention of early dilatation with the preservation of root haemodynamics. As this review will synthesize, the dynamic physiology of the root may be preserved even in patients at a higher risk of autograft dilatation. SUMMARY: The favourable long-term outcomes of the Ross procedure can be partly attributed to the ability of the autograft to restore dynamism to the neoaortic root. Patient-specific modifications that respect root physiology can tailor the Ross procedure to address each patient's risk factors for early dilatation and late failure. As such, the Ross procedure should be recognized as an increasingly favourable solution for a wide spectrum of nonpreservable aortic valve disease in young adults.

A contemporary approach to a young female patient with Loeys-Dietz syndrome and an uncomplicated type B aortic dissection: a case report.

BACKGROUND: Aortic dissection is a relatively uncommon, but often catastrophic disease that requires early and accurate diagnosis. It often presents in patients with congenital connective tissue disorders. The current aortic surgical techniques are related with serious early and late complications. This case report emphasizes the importance of early diagnosis of aortic root dilatation and the risk of dissection, especially in patients with congenital connective tissue disorders. We present an alternative, contemporary and multidisciplinary approach based on the present state of knowledge. CASE PRESENTATION: We present a rare case of a young female patient with Loeys-Dietz syndrome who was admitted with an uncomplicated aortic dissection (Stanford type B / DeBakey type III) and a dilated aortic root. After a period of close surveillance and extensive vascular imaging, thoracic endovascular aortic repair was deemed to be technically not possible. Medical treatment was optimized and our patient successfully underwent a personalised external aortic root support procedure (PEARS) as a contemporary alternative to existing aortic root surgical techniques. CONCLUSIONS: This case highlights the importance of interdisciplinary approach, close follow-up and multimodality imaging. The decision to intervene in a chronic type B aortic dissection is still challenging and should be made in experienced centers by an interdisciplinary team. However, if an acute complication occurs, thoracic endovascular aortic repair TEVAR is the method of choice. In all cases optimal medical treatment is important. There is increasing evidence that personalized external aortic root support procedure PEARS is effective in stabilizing the aortic root and preventing its dilatation and dissection not only in patients with Marfan syndrome, but also in other cases of aortic root dilation of other etiologies. Moreover, many publications have reported the additional benefit of reduction or even eradication of aortic regurgitation by improving coaptation of the aortic valve leaflets in dilated aortas.

Meta-analysis Examining the Usefulness of Angiotensin Receptor blockers for the Prevention of Aortic Root Dilation in Patients With the Marfan Syndrome.

The Marfan syndrome (MFS) patients are highly predisposed to thoracic aortic aneurysm and/or dissection, with virtually every patient having evidence of aortic disease at some point during their lifetime. We conducted a meta-analysis to investigate the efficacy of angiotensin receptor blockers (ARBs) in slowing down the progression of aortic dilatation in MFS patients. PUBMED, EMBASE, and COCHRANE databases were searched for relevant articles published from inception to February 1, 2020. We included randomized clinical trials evaluating the effect of ARBs on aortic root size in patients with MFS with a follow-up period of at least 2.5 years. Seven studies were included with a total of 1,510 patients. Our analysis demonstrated a significantly smaller change in aortic root and ascending aorta dilation in the ARBs treated group when compared with placebo (mean difference 0.68; 95% confidence interval [CI] -1.31 to -0.04; p = 0.04, I2 = 94%, and mean difference -0.13, 95% CI -0.17 to -0.09; p < 0.00001, I2 = 0%, respectively). ARBs as an add-on therapy to beta-blockers resulted in a significantly smaller change in aortic root dilation when compared with the arm without ARBs (mean difference -2.06, 95% CI -2.54 to -1.58; p < 0.00001, I2 = 91%). However, there was no statistically significant difference in the number of clinical events (aortic complications/surgery) observed in the ARBs arm when compared with placebo (Risk ratio of 1.01, 95% CI 0.74 to 1.38; p = 0.94, I2 = 0%). In conclusion, ARBs therapy is associated with a slower progression of aortic root dilation when compared with placebo and as an addition to beta-blocker therapy.

Diabetes attenuated age-related aortic root dilatation in end-stage renal disease patients receiving peritoneal dialysis.

AIMS/INTRODUCTION: Recently, some data have supported the concept that diabetes is negatively associated with aortic aneurysm. In the present study, we aimed to investigate the relationship between diabetes and cardiac structural and functional characteristics, in particular, aortic root dimensions, in end-stage renal disease (ESRD) patients. METHODS: ESRD patients receiving peritoneal dialysis for >3 months were consecutively enrolled. Clinical features and echocardiographic parameters were analyzed according to the presence of diabetes history. Correlation analyses were carried out for diabetes mellitus and aortic root dilatation. Multiple logistic regression analysis was carried out to identify variables correlated with aortic root dilatation. RESULTS: A total of 218 ESRD patients receiving peritoneal dialysis were enrolled. Patients with diabetes showed lower left ventricular internal measurements in end-diastole, left ventricular internal measurements in end-systole and aortic root diameter (ARD)/body surface area (BSA). Worse cardiac diastolic function was also observed in these patients. In addition, the age-related increase of ARD/BSA and ARD/height was attenuated in patients with diabetes. With the increase of ARD/BSA, lower levels of serum creatinine, phosphorus and serum glucose, as well as higher serum high-density lipoprotein cholesterol and apolipoprotein A-1 were also observed. Increased normalized left ventricular internal measurements were shown in patients with greater ARD/BSA. Multiple regression analysis showed that diabetes (odds ratio 0.353, P = 0.015) was an independent correlate of aortic root dilatation, even after correction for age, sex and other clinical confounders in the enrolled patients. CONCLUSIONS: The present findings shown an inverse association between diabetes and age-related aortic root dilatation in ESRD patients. Diabetes remained to be independently correlated with aortic root dilatation even after adjustment for age, sex and other clinical confounders in ESRD patients.

Losartan Versus Atenolol for Prevention of Aortic Dilation in Patients With Marfan Syndrome.

BACKGROUND: Beta-blockers are the standard treatment in Marfan syndrome (MFS). Recent clinical trials with limited follow-up yielded conflicting results on losartan's effectiveness in MFS. OBJECTIVES: The present study aimed to evaluate the benefit of losartan compared with atenolol for the prevention of aortic dilation and complications in Marfan patients over a longer observation period (>5 years). METHODS: A total of 128 patients included in the previous LOAT (LOsartan vs ATenolol) clinical trial (64 in the atenolol and 64 in the losartan group) were followed up for an open-label extension of the study, with the initial treatment maintained. RESULTS: Mean clinical follow-up was 6.7 ± 1.5 years. A total of 9 events (14.1%) occurred in the losartan group and 12 (18.8%) in the atenolol group. Survival analysis showed no differences in the combined endpoint of need for aortic surgery, aortic dissection, or death (p = 0.462). Aortic root diameter increased with no differences between groups: 0.4 mm/year (95% confidence interval: 0.2 to 0.5) in the losartan and 0.4 mm/year (95% confidence interval: 0.3 to 0.6) in the atenolol group. In the subgroup analyses, no significant differences were observed considering age, baseline aortic root diameter, or type of dominant negative versus haploinsufficient FBN1 mutation. CONCLUSIONS: Long-term outcome of Marfan syndrome patients randomly assigned to losartan or atenolol showed no differences in aortic dilation rate or presence of clinical events between treatment groups. Therefore, losartan might be a useful, low-risk alternative to beta-blockers in the long-term management of these patients.

External Aortic Root Support to Prevent Aortic Dilatation in Patients With Marfan Syndrome.

BACKGROUND: Personalized external aortic root support (PEARS) was introduced in 2004 for prevention of aortic root dilatation in Marfan patients. The individual's aortic root is replicated by 3-dimensional printing. A polymer mesh sleeve is manufactured, which is implanted with the aim to support and stabilize the aortic wall. OBJECTIVES: The aim of this study was to assess effectiveness of PEARS for prevention of aortic root dilatation in Marfan patients. METHODS: A total of 24 consecutive Marfan patients operated 2004 to 2012 were prospectively monitored with magnetic resonance imaging. Following a pre-defined protocol, baseline and follow-up aorta measurements were made in a blinded random sequence. RESULTS: The mean age of the patients was 33 ± 13.3 years (range: 16 to 58 years), and the mean aortic root diameter was 45 ± 2.8 mm (range: 41 to 52 mm). Follow-up was 6.3 ± 2.6 years. There was no increase in the aortic root and ascending aorta diameters, but there was a tendency toward reduction: annulus diameter 28.9 ± 2.3 mm to 28.5 ± 2.4 mm (change -0.39 mm, 95% confidence interval [CI]: -1.05 to 0.27 mm), sinus of Valsalva diameter 44.9 ± 2.9 mm to 44.5 ± 3.0 mm (change -0.37 mm, 95% CI: -1.23 to 0.51 mm), and ascending aorta diameter 32.4 ± 3.6 mm to 32.3 ± 3.7 mm (change -0.10 mm, 95% CI: -0.92 to 0.74 mm). In the same period, the descending aorta diameter increased from 22.9 ± 2.4 mm to 24.2 ± 3.0 mm (change 1.32 mm, 95% CI: 0.70 to 1.94 mm; p < 0.001) with a tendency toward increase in aortic arch diameter 24.1 ± 2.0 mm to 24.5 ± 2.8 mm (change 0.41 mm, 95% CI: -0.56 to 1.37 mm). CONCLUSIONS: PEARS is effective in stabilizing the aortic root and preventing its dilatation. It is a viable alternative for prevention of aortic root dissection in Marfan patients.

Inducing fibrogenesis and new interfibrillary bonds in post-laser in situ keratomileusis keratectasia.

Flap creation weakens the cornea and is a risk factor for keratectasia after laser in situ keratomileusis (LASIK). We describe a new technique to halt the progression of keratectasia by mechanically reintegrating the flap into the residual stroma. Deep stromal vertical puncturing is performed in the 4.0 to 9.0 mm paracentral corneal zone at a depth of 350 to 420 µm. The puncturing is applied in circumferential rows using a 25-gauge needle or a diamond blade, with denser puncturing at the level of the cone. In 5 eyes with worsening post-LASIK keratectasia, improved uncorrected and corrected visual acuities, corneal flattening, and a hyperopic shift were observed. There was no progression of keratectasia on serial topographies. New collagen fibrogenesis was documented by optical coherence tomography. The technique seems to be promising to halt the progression of post-LASIK keratectasia. More clinical data and longer follow-up are needed for validation.

Bracy procedure with ductal mucosal pancreaticogastrostomy and an internal stent for pancreatic complex deep injury: how to do it.

Pancreatic complex deep injury extending to the main pancreatic duct (MPD), caused by strong external forces such as traffic accidents, is lethal without emergency surgery. However, the best surgical procedure for this serious injury has not been established. The Bracey procedure is a relatively simple reconstructive technique involving pancreaticogastrostomy, but it is often followed by postoperative complications, such as dilatation of the MPD caused by anastomotic stenosis, as well as subsequent serious sequela such as repetitive pancreatitis and new-onset pancreatic diabetes. It is possible that the combination of ductal mucosal pancreaticogastrostomy (DMPG) and an internal stent might prevent anastomotic stenosis of the MPD. We found that the Bracey procedure was a safe and effective reconstructive procedure for five patients who suffered a pancreatic complex deep injury with MPD involvement. In three of these patients, postoperative dilatation of the MPD was prevented by combining the Bracey procedure with DMPG including an internal stent. Our experience suggests that this procedure is one of the best techniques for treating pancreatic complex deep injury extending to the MPD.

Surgical strategies protecting against right ventricular dilatation following tetralogy of Fallot repair.

BACKGROUND: Right ventricular (RV) volume overload increases morbidity and mortality after tetralogy of Fallot (TOF) repair. Surgical strategies like pulmonary leaflets sparing and tricuspid valve repair at time of primary repair may decrease RV overload. Our objective is to evaluate early and midterm results of pulmonary leaflets sparing with infundibular preservation and tricuspid valve repair in selected TOF patients with moderate pulmonary annular hypoplasia. METHODS: From 2011 to 2016; 46 patients with TOF and moderate pulmonary annular hypoplasia had surgical repair with sparing of the pulmonary valve leaflets. Concomitant tricuspid valve repair was performed in 33 patients (71.8%). Mean age was 13.1 ± 4.8 months, 68% were males (n = 31) and mean weight was 9.5 ± 2.3 kg. Preoperative McGoon ratio was 1.9 ± 0.4 and pulmonary valve z-score ranges from - 2 to - 3. Preoperative pressure gradient of RVOT was 80.9 ± 7.7 mmHg and 10.9% had minor coronary anomalies (n = 5). RESULTS: All repairs were performed through trans-atrial trans-pulmonary approach. 87% had pulmonary valve commissurotomy (n = 40). Mean cardiopulmonary bypass time was 71 ± 6.3 min and ischemic time 42.4 ± 4.9 min. Hospital mortality occurred in 4.3% (n = 2). Mean RVOT pressure gradient decreased significantly postoperatively (28.8 ± 7.2 mmHg, p-value< .001) and at the last follow up (23.6 ± 1.8 mmHg, p-value< .001). Pulmonary regurgitation progressed by one grade in 2 patients compared to the postoperative grade. 1 patient (2.5%) had late mortality and reintervention was required in 5 patients (12.5%). CONCLUSION: Pulmonary leaflets sparing, and tricuspid valve repair are safe for TOF repair with no added morbidity or mortality. These procedures could contribute to reducing right ventricular volume overload over time after TOF repair.

Biomechanics of Failed Pulmonary Autografts Compared With Normal Pulmonary Roots.

BACKGROUND: Progressive dilatation of pulmonary autografts after the Ross operation may reflect inadequate remodeling of the native pulmonary root to adapt to systemic circulation. Understanding the biomechanics of autograft root dilatation may aid designing strategies to prevent dilatation. We have previously characterized normal human pulmonary root material properties; however, the mechanical properties of failed autografts are unknown. In this study, failed autograft roots explanted during reoperation were acquired, and their material properties were determined. METHODS: Failed pulmonary autograft specimens were obtained from patients undergoing reoperation after the Ross operation. Fresh human native pulmonary roots were obtained from the transplant donor network as controls. Biaxial stretch testing was performed to determine tissue mechanical properties. Tissue stiffness was determined at patient-specific physiologic stresses at pulmonary pressures. RESULTS: Nonlinear stress-strain response was present in both failed autografts and normal pulmonary roots. Explanted pulmonary autografts were less stiff than were their native pulmonary root counterparts at 8 mm Hg (134 ± 42 vs 175 ± 49 kPa, respectively) (p = 0.086) and 25 mm Hg (369 ± 105 vs 919 ± 353 kPa, respectively) (p = 0.006). Autograft wall stiffness at both 8 and 25 mm Hg was not correlated with age at the Ross procedure (p = 0.898 and p = 0.813, respectively) or with time in the systemic circulation (p = 0.609 and p = 0.702, respectively). CONCLUSIONS: Failed pulmonary autografts retained nonlinear response to mechanical loading typical of healthy human arterial tissue. Remodeling increased wall thickness but decreased wall stiffness in failed autografts. Increased compliance may explain progressive autograft root dilatation in autograft failures.

Combined laser in-situ keratomileusis and accelerated corneal cross-linking: an update.

PURPOSE OF REVIEW: The purpose is to review the literature of combined laser in-situ keratomileusis (LASIK) and accelerated corneal collagen cross-linking (CXL) in context of its indications-contraindications, kerato-refractive, visual and safety outcomes, particularly with reference to preventing the development of post-LASIK ectasia. RECENT FINDINGS: LASIK + accelerated CXL has been developed with the rationale that the addition of CXL after LASIK may strengthen the LASIK compromised corneal biomechanics and minimize the complications such as post-LASIK ectasia. Different clinical studies have documented the safety and efficacy of LASIK + accelerated CXL for the correction of myopia or hyperopia and in the patients with low predicted residual bed thickness. SUMMARY: Available literature shows that refractive and keratometric outcomes of LASIK + accelerated CXL are comparable or better than LASIK alone. Less regression has been observed after LASIK + accelerated CXL compared with LASIK alone and no case of post-LASIK ectasia development has been reported among 673 eyes with the follow-up ranging from 3 months to 4.5 years. Future studies with large numbers of patients and longer postoperative follow-ups are needed to establish the efficacy of LASIK + accelerated CXL in preventing the development of post-LASIK ectasia.

Flavanone-rich citrus beverages counteract the transient decline in postprandial endothelial function in humans: a randomised, controlled, double-masked, cross-over intervention study.

Specific flavonoid-rich foods/beverages are reported to exert positive effects on vascular function; however, data relating to effects in the postprandial state are limited. The present study investigated the postprandial, time-dependent (0-7 h) impact of citrus flavanone intake on vascular function. An acute, randomised, controlled, double-masked, cross-over intervention study was conducted by including middle-aged healthy men (30-65 years, n 28) to assess the impact of flavanone intake (orange juice: 128·9 mg; flavanone-rich orange juice: 272·1 mg; homogenised whole orange: 452·8 mg; isoenergetic control: 0 mg flavanones) on postprandial (double meal delivering a total of 81 g of fat) endothelial function. Endothelial function was assessed by flow-mediated dilatation (FMD) of the brachial artery at 0, 2, 5 and 7 h. Plasma levels of naringenin/hesperetin metabolites (sulphates and glucuronides) and nitric oxide species were also measured. All flavanone interventions were effective at attenuating transient impairments in FMD induced by the double meal (7 h post intake; P<0·05), but no dose-response effects were observed. The effects on FMD coincided with the peak of naringenin/hesperetin metabolites in circulation (7 h) and sustained levels of plasma nitrite. In summary, citrus flavanones are effective at counteracting the negative impact of a sequential double meal on human vascular function, potentially through the actions of flavanone metabolites on nitric oxide.

[Aortic root dilatation rate in pediatric patients with Marfan syndrome treated with losartan]. / Progressione della dilatazione aortica nel paziente pediatrico con sindrome di Marfan in terapia medica con losartan.

BACKGROUND: Medical therapy with angiotensin II receptor blockers/angiotensin-converting enzyme inhibitors and/or beta-blockers was reported to reduce aortic root dilatation rates in pediatric patients with Marfan syndrome. No data are available in the literature on losartan effects after 3 years of therapy. The aim of our study was to establish whether losartan reduces aortic root dilatation rates in pediatric patients with Marfan syndrome in the mid and long term. METHODS: This is a retrospective analysis of 38 pediatric patients with Marfan syndrome followed at the Marfan Clinic of S. Orsola-Malpighi Hospital of the University of Bologna (Italy). Aortic diameters were measured at sinuses of Valsalva and proximal ascending aorta with transthoracic echocardiography. RESULTS: After a mean follow-up of 4.5 ± 2.5 years (range 2-9 years), aortic root z score at sinuses of Valsalva and proximal ascending aorta remained stable. The average annual rate of change in aortic root z score was -0.1 ± 0.4 and 0 ± 0.3 at sinuses of Valsalva and proximal ascending aorta, respectively. The mean dose of losartan was 0.7 ± 0.3 mg/kg/day. Three patients were non-responders, probably because of late beginning or low dose of therapy. Eight patients underwent cardiac surgery (aortic root surgery in 5 and mitral valve repair in 3), all of them started losartan later in life. CONCLUSIONS: Despite the retrospective design of the study and the small sample size, a beneficial effect of losartan therapy was observed in pediatric patients with Marfan syndrome in the mid and long term. Late beginning or low doses of losartan can turn off the effects of therapy.

[High-risk pregnancy in a woman with Marfan syndrome, a bicuspid aortic valve, and a dilated aortic sinus]. / Højrisikograviditet hos en kvinde med Marfans syndrom, bikuspid aortaklap og aortaektasi.

A 29-year-old woman with Marfan syndrome, a bicuspid aortic valve, and a dilated aortic sinus (5.2 cm) presented herself in clinic 14 weeks pregnant. She was advised to discontinue the pregnancy due to risk of dissection; however, she decided to continue. She was treated with labetalol (300 mg/day) to reduce blood pressure and was admitted for bed rest from week 30. Her aortic diameter was assessed by echocardiography every 2nd week and remained unchanged. She was treated with betamethason at week 26 and the child was born by a caesarean section in week 35. The post-operative course was uneventful.

Réplica al artículo «Rotura de aneurisma iliaco durante el preacondicionamiento con levosimendán previo a cirugía de revascularización coronaria, ¿fue levosimendán el factor más influyente?» / Reply to article 'Iliac aneurysm rupture during preconditioning with levosimendan for coronary artery graft, it was levosimendan the most influencing factor?'

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Frequency and risk factors for rebleeding events in patients with small bowel angioectasia.

BACKGROUND: Small bowel angioectasia is reported as the most common cause of bleeding in patients with obscure gastrointestinal bleeding. Although the safety and efficacy of endoscopic treatment have been demonstrated, rebleeding rates are relatively high. To establish therapeutic and follow-up guidelines, we investigated the long-term outcomes and clinical predictors of rebleeding in patients with small bowel angioectasia. METHODS: A total of 68 patients were retrospectively included in this study. All the patients had undergone CE examination, and subsequent control of bleeding, where needed, was accomplished by endoscopic argon plasma coagulation. Based on the follow-up data, the rebleeding rate was compared between patients who had/had not undergone endoscopic treatment. Multivariate analysis was performed using Cox proportional hazard regression model to identify the predictors of rebleeding. We defined the OGIB as controlled if there was no further overt bleeding within 6 months and the hemoglobin level had not fallen below 10 g/dl by the time of the final examination. RESULTS: The overall rebleeding rate over a median follow-up duration of 30.5 months (interquartile range 16.5-47.0) was 33.8% (23/68 cases). The cumulative risk of rebleeding tended to be lower in the patients who had undergone endoscopic treatment than in those who had not undergone endoscopic treatment, however, the difference did not reach statistical significance (P = 0.14). In the majority of patients with rebleeding (18/23, 78.3%), the bleeding was controlled by the end of the follow-up period. Multiple regression analysis identified presence of multiple lesions (≥3) (OR 3.82; 95% CI 1.30-11.3, P = 0.02) as the only significant independent predictor of rebleeding. CONCLUSION: In most cases, bleeding can be controlled by repeated endoscopic treatment. Careful follow-up is needed for patients with multiple lesions, presence of which is considered as a significant risk factor for rebleeding.

A modification of the pulmonary autograft procedure to prevent late autograft dilatation.

Although the pulmonary autograft procedure for aortic valve replacement is a commonly utilized option for children, its use is diminishing in adult-aged patients. One commonly cited concern is the tendency for the pulmonary autograft to dilate in the aortic position. This article reviews a technique we have used in 36 patients since October, 2004 that stabilizes the autograft so that it cannot dilate. There have been no operative or late deaths and the autograft has continued to function in 34 patients. Two patients have undergone autograft replacement because of early failure, which we believe was likely related to technical considerations in our early technique (first reported in the 2005 STCVS Pediatric Cardiac Surgery Annual). The technical modifications described in this article have produced a more reliable and reproducible technique and have not resulted in any autograft failures in our experience. One patient with Marfan's syndrome and a bicuspid aortic valve is symptom- and dilation-free 8 years post op, with no autograft or pulmonary homograft insufficiency, normal activity and a stable aortic root by serial echocardiography. Our results suggest that this technique might be applicable for selected adult patients in whom autograft growth is not necessary and for whom the risk of autograft dilatation would provide a reason to avoid a pulmonary autograft procedure.