Paradoxical Computed Tomography-Derived Fractional Flow Reserve Changes Due to Vessel Morphology and Constituents.

Computed tomography-derived fractional flow reserve decreases from the proximal to the distal with coronary stenosis. According to the principles of fluid dynamics, paradoxical computed tomography-derived fractional flow reserve changes require an unconventional vessel mor-phology and specific site of the vessels with a high driving force. Therefore, only a few articles have reported a paradoxical increase of computed tomography-derived fractional flow reserve. We present a case report of marked computed tomography-derived fractional flow reserve elevation in the middle left anterior descending artery with a severe coronary stenosis. Computed tomography-derived fractional flow reserve was 0.94 just proximal to the stenotic lesion and decreased to 0.65 at the maximum stenosis area but recovered to 0.80 in the distal segment. We speculated that the vessel morphology could have caused a pressure recovery phenomenon, resulting in paradoxical computed tomography-derived fractional flow reserve changes.

Functional and Safety Outcomes of Carotid Artery Stenting and Mechanical Thrombectomy for Large Vessel Occlusion Ischemic Stroke With Tandem Lesions.

Importance: Approximately 10% to 20% of large vessel occlusion (LVO) strokes involve tandem lesions (TLs), defined as concomitant intracranial LVO and stenosis or occlusion of the cervical internal carotid artery. Mechanical thrombectomy (MT) may benefit patients with TLs; however, optimal management and procedural strategy of the cervical lesion remain unclear. Objective: To evaluate the association of carotid artery stenting (CAS) vs no stenting and medical management with functional and safety outcomes among patients with TL-LVOs. Design, Setting, and Participants: This cross-sectional study included consecutive patients with acute anterior circulation TLs admitted across 17 stroke centers in the US and Spain between January 1, 2015, and December 31, 2020. Data analysis was performed from August 2021 to February 2022. Inclusion criteria were age of 18 years or older, endovascular therapy for intracranial occlusion, and presence of extracranial internal carotid artery stenosis (>50%) demonstrated on pre-MT computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography. Exposures: Patients with TLs were divided into CAS vs nonstenting groups. Main Outcomes and Measures: Primary clinical and safety outcomes were 90-day functional independence measured by a modified Rankin Scale (mRS) score of 0 to 2 and symptomatic intracranial hemorrhage (sICH), respectively. Secondary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction score ≥2b), discharge mRS score, ordinal mRS score, and mortality at 90 days. Results: Of 685 patients, 623 (mean [SD] age, 67 [12.2] years; 406 [65.2%] male) were included in the analysis, of whom 363 (58.4%) were in the CAS group and 260 (41.6%) were in the nonstenting group. The CAS group had a lower proportion of patients with atrial fibrillation (38 [10.6%] vs 49 [19.2%], P = .002), a higher proportion of preprocedural degree of cervical stenosis on digital subtraction angiography (90%-99%: 107 [32.2%] vs 42 [20.5%], P < .001) and atherosclerotic disease (296 [82.0%] vs 194 [74.6%], P = .003), a lower median (IQR) National Institutes of Health Stroke Scale score (15 [10-19] vs 17 [13-21], P < .001), and similar rates of intravenous thrombolysis and stroke time metrics when compared with the nonstenting group. After adjustment for confounders, the odds of favorable functional outcome (adjusted odds ratio [aOR], 1.67; 95% CI, 1.20-2.40; P = .007), favorable shift in mRS scores (aOR, 1.46; 95% CI, 1.02-2.10; P = .04), and successful reperfusion (aOR, 1.70; 95% CI, 1.02-3.60; P = .002) were significantly higher for the CAS group compared with the nonstenting group. Both groups had similar odds of sICH (aOR, 0.90; 95% CI, 0.46-2.40; P = .87) and 90-day mortality (aOR, 0.78; 95% CI, 0.50-1.20; P = .27). No heterogeneity was noted for 90-day functional outcome and sICH in prespecified subgroups. Conclusions and Relevance: In this multicenter, international cross-sectional study, CAS of the cervical lesion during MT was associated with improvement in functional outcomes and reperfusion rates without an increased risk of sICH and mortality in patients with TLs.

Congenital nasal pyriform aperture stenosis; our experience of 34 cases.

OBJECTIVES: To study our population of patients with congenital nasal pyriform aperture stenosis (CNPAS) in terms of incidence and socioeconomic status; the effect of pyriform aperture size, gestational age, birth weight, and whether congenital abnormalities are associated with surgical requirement. METHODOLOGY: Retrospective case note review of all patients treated for CNPAS at a single tertiary paediatric referral site was undertaken. Diagnosis was made on the basis of a pyriform aperture of <11 mm on CT scanning; patient demographics were collected to explore risk factors for surgery and surgical outcomes. RESULTS: 34 patients were included in the series, 28 (84%) of whom underwent surgery. 58.8% of subjects had an associated mega central incisor. A smaller pyriform aperture size was seen in neonates requiring surgery (4.87 mm ± 1.24 mm vs 6.55 mm ± 1.41 mm, p = 0.031). There was no difference in gestational age in neonates requiring surgery (p = 0.074). Requirement for surgery was not associated with co-existing congenital anomalies (p = 0.297) or lower birth weight (p = 0.859). Low socioeconomic status was not significantly associated with requiring surgery but a potential link between CNPAS and deprivation was identified (p = 0.0583). CONCLUSION: These results suggest that a pyriform aperture of less than 6 mm requires surgical intervention. Associated birth anomalies add additional management considerations but in this cohort were not associated with increased need for surgery. A potential association between CNPAS and low socioeconomic status was identified.

Robotic ureter reconstruction using the native ureter to treat long-segment ureteral stricture of the transplant kidney utilizing Indocyanine green: The first Korean experience.

PURPOSE: Ureteral strictures are a common complication after kidney transplantation. Open reconstruction is preferred for long-segment ureteral strictures that cannot be resolved endoscopically; however, it is known to have the potential to fail. We report 2 successful cases of robotic reconstruction surgery of a transplant ureter using the native ureter with the aid of intraoperative Indocyanine green (ICG). MATERIALS AND METHODS: Patients were placed in semi-lateral position. Using Da Vinci Xi, the transplant ureter was dissected, and the stricture site was identified. End-to-side anastomosis of the native ureter to the transplant ureter was performed. ICG was utilized to identify the course of the transplant ureter and confirm the vascularity of the native ureter. RESULTS: Case 1: A 55-year-old female underwent renal transplantation at another hospital. She had recurrent febrile urinary tract infections (UTIs) and a ureteral stricture requiring percutaneous nephrostomy (PCN). The PCN and ureteral stent were removed successfully after surgery. The patient had only 1 febrile UTI episode after surgery. Case 2: A 56-year-old female underwent renal transplantation at another hospital. She had acute pyelonephritis 1-month post-transplantation, and a long-segment ureteral stricture was identified. She developed a UTI with anastomosis site leakage in the early postoperative period, which resolved with conservative treatment. The PCN and ureteral stent were removed 6 weeks after surgery. CONCLUSIONS: Robotic surgery for managing long-segment ureteral stricture after kidney transplantation is safe and feasible. The use of ICG during surgery to identify the ureter course and its viability can improve the success.

Analysis of Etiology, Diagnosis, and Treatment Strategy and Efficacy of Pulsatile Tinnitus Caused by Abnormal Vascular Anatomy.

OBJECTIVE: To investigate the etiology, clinical characteristics, diagnosis, and treatment strategies and efficacy of pulsatile tinnitus (PT) caused by vascular anatomy abnormality. METHODS: The clinical data of 45 patients with PT in our hospital from 2012 to 2019 were collected and retrospectively analyzed. RESULTS: All 45 patients had vascular anatomical abnormalities. The patients were divided into 10 categories according to the different locations of vascular abnormalities: sigmoid sinus diverticulum (SSD), sigmoid sinus wall dehiscence (SSWD), SSWD with high jugular bulb, pure dilated mastoid emissary vein, aberrant internal carotid artery (ICA) in the middle ear, transverse-sigmoid sinus (TSS) transition stenosis, TSS transition stenosis with SSD, persistent occipital sinus stenosis, petrous segment stenosis of ICA, and dural arteriovenous fistula. All patients complained of PT synchronous with heartbeat rhythm. Endovascular interventional therapy and extravascular open surgery were used according to the location of the vascular lesions. Tinnitus disappeared in 41 patients, was significantly relieved in 3 patients, and was unchanged in 1 patient postoperatively. Except for one patient with transient headache postoperatively, no obvious complications occurred. CONCLUSION: PT caused by vascular anatomy abnormalities can be identified by detailed medical history and physical and imaging examination. PT can be relieved or even completely alleviated after appropriate surgical treatments.

Patient-specific computational simulation of coronary artery bypass grafting.

INTRODUCTION: Coronary artery bypass graft surgery (CABG) is an intervention in patients with extensive obstructive coronary artery disease diagnosed with invasive coronary angiography. Here we present and test a novel application of non-invasive computational assessment of coronary hemodynamics before and after bypass grafting. METHODS AND RESULTS: We tested the computational CABG platform in n = 2 post-CABG patients. The computationally calculated fractional flow reserve showed high agreement with the angiography-based fractional flow reserve. Furthermore, we performed multiscale computational fluid dynamics simulations of pre- and post-CABG under simulated resting and hyperemic conditions in n = 2 patient-specific anatomies 3D reconstructed from coronary computed tomography angiography. We computationally created different degrees of stenosis in the left anterior descending artery, and we showed that increasing severity of native artery stenosis resulted in augmented flow through the graft and improvement of resting and hyperemic flow in the distal part of the grafted native artery. CONCLUSIONS: We presented a comprehensive patient-specific computational platform that can simulate the hemodynamic conditions before and after CABG and faithfully reproduce the hemodynamic effects of bypass grafting on the native coronary artery flow. Further clinical studies are warranted to validate this preliminary data.

ASSESSMENT OF CORONARY COLLATERAL CIRCULATION PREDICTORS AMONG PATIENTS WITH ACUTE CORONARY SYNDROME IN POPULATION GEORGIA.

Coronary collateral circulation (CCC) has been shown to have a prognostic role in acute myocardial infarction (MI). We aimed to identify factors associated with CCC development in patients with acute myocardial ischemia. In the present analysis, 673 consecutive patients aged 27 - 94 years (64.7±11.48) with acute coronary syndrome (ACS), who underwent coronary angiography within the first 24 hours after symptom onset were included. Baseline data, including sex, age, cardiovascular risk factors, medication, antecedent angina, prior coronary revascularization, EF%, blood pressure levels were obtained from patient medical records. The study individuals were divided into two groups: patients with Rentrop grade 0 to 1 were classified as the poor collateral group (456 patients), and the patients with grade 2 to 3 - as the good collateral group (217 patients). Prevalence of good collaterals of 32% was found. Odds of good collateral circulation increases with higher eosinophil count - OR=17.36 (95% CI: 3.25-92.86); history of MI (OR=1.76; 95% CI:1.13-2.75); multivessel disease - OR=9.78 (95% CI: 5.65-16.96); culprit vessel stenosis - OR=3.91 (95% CI: 2.35-6.52); presence of angina pectoris > 5 years - OR=5.55 (95% CI:2.66-11.57) and decreases with high N/L- OR=0.37 (95% CI:0.31-0.45) and male gender - OR=0.44 (95% CI:0.29-0.67). High N/L is a predictor of poor collateral circulation, with 68.4 sensitivity and 72.8% specificity (cutoff: 2.73*109). Relative chance of good collateral circulation increases with the higher number of eosinophils, presence of angina pectoris with duration of more than 5 years, history of past myocardial infarction, culprit vessel stenosis, multivessel disease, and reduces if patient is male and has high N/L ratio. Peripheral blood parameters may serve as an additional simple risk assessment tool in ACS patients.

Minimally Invasive Direct Coronary Artery Bypass Versus Percutaneous Coronary Intervention for Isolated Left Anterior Descending Artery Stenosis: An Updated Meta-Analysis.

BACKGROUND: The optimal revascularization strategy for isolated left anterior descending (LAD) coronary artery lesion between minimally invasive direct coronary artery bypass (MIDCAB) and percutaneous coronary intervention (PCI) remains controversial. This updated meta-analysis aims to compare the long- and short-term outcomes of MIDCAB versus PCI for patients with isolated LAD coronary artery lesions. METHODS: The Pubmed, Web of Science, and Cochrane databases were searched for retrieving potential publications from 2002 to 2022. The primary outcome was long-term survival. Secondary outcomes were long-term target vessel revascularization (TVR), long-term major adverse cardiovascular events (MACEs), and short-term outcomes, including postoperative mortality, myocardial infarction (MI), TVR, and MACEs of any cause in-hospital or 30 days after the revascularization. RESULTS: Six randomized controlled trials (RCTs) and eight observational studies were included in this updated meta-analysis. In total, 1757 patients underwent MIDCAB and 15245 patients underwent PCI. No statistically significant difference was found between the two groups in the rates of long-term survival. MIDCAB had a lower long-term MACE rate compared with PCI. Besides, PCI resulted in an augmented risk of TVR. Postoperative mortality, MI, TVR, and MACEs were similar between the two groups. CONCLUSIONS: The updated meta-analysis presents the evidence that MIDCAB has a reduced risk of long-term TVR and MACEs, with no benefit in terms of long-term mortality and short-term results, in comparison with PCI. Large multicenter RCTs, including patients treated with newer techniques, are warranted in the future.

Early detection of myocardial ischemia in resting ECG: analysis by HHT.

BACKGROUND: Exercise electrocardiography (ECG) is a noninvasive test aiming at producing ischemic changes. However, resting ECG cannot be adopted in diagnosing myocardial ischemia till ST-segment depressions. Therefore, this study aimed to detect myocardial energy defects in resting ECG using the Hilbert-Huang transformation (HHT) in patients with angina pectoris. METHODS: Electrocardiographic recordings of positive exercise ECG by performing coronary imaging test (n = 26) and negative exercise ECG (n = 47) were collected. Based on the coronary stenoses severity, patients were divided into three categories: normal, < 50%, and ≥ 50%. During the resting phase of the exercise ECG, all 10-s ECG signals are decomposed by HHT. The RT intensity index, composed of the power spectral density of the P, QRS, and T components, is used to estimate the myocardial energy defect. RESULTS: After analyzing the resting ECG using HHT, the RT intensity index was significantly higher in patients with positive exercise ECG (27.96%) than in those with negative exercise ECG (22.30%) (p < 0.001). In patients with positive exercise ECG, the RT intensity index was gradually increasing with the severity of coronary stenoses: 25.25% (normal, n = 4), 27.14% (stenoses < 50%, n = 14), and 30.75% (stenoses ≥ 50%, n = 8). The RT intensity index of different coronary stenoses was significantly higher in patients with negative exercise ECG, except for the normal coronary imaging test. CONCLUSIONS: Patients with coronary stenoses had a higher RT index at the resting stage of exercise ECG. Resting ECG analyzed using HHT could be a method for the early detection of myocardial ischemia.

Comparison of 270-degree percutaneous transforaminal endoscopic decompression under local anesthesia and minimally invasive transforaminal lumbar interbody fusion in the treatment of geriatric lateral recess stenosis associated with degenerative lumbar spondylolisthesis.

PURPOSE: Various lumbar decompression techniques have been used for the treatment of degenerative lumbar spondylolisthesis (DLS). Few studies have compared the clinical efficacy of percutaneous transforaminal endoscopic decompression (PTED) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of lateral recess stenosis associated with DLS (LRS-DLS) in geriatric patients. The objective of the study was to compare the safety and short-term clinical efficacy of 270-degree PTED under local anesthesia and MIS-TLIF in the treatment of LRS-DLS in Chinese geriatric patients over 60 years old. MATERIALS AND METHODS: From January 2017 to August 2019, the data of 90 consecutive geriatric patients with single-level L4-5 LRS-DLS were retrospectively reviewed, including those in the PTED group (n = 44) and MIS-TLIF group (n = 46). The patients were followed up for at least 1 year. Patient demographics and perioperative outcomes were reviewed before and after surgery. The Oswestry Disability Index (ODI), visual analog scale (VAS) for leg pain, and modified MacNab criteria were used to evaluate the clinical outcomes. X-ray examinations were performed 1 year after surgery to assess the progression of spondylolisthesis in the PTED group and bone fusion in the MIS-TLIF group. RESULTS: The mean patient ages in the PTED and MIS-TLIF groups were 70.3 years and 68.6 years, respectively. Both the PTED and MIS-TLIF groups demonstrated significant improvements in the VAS score for leg pain and ODI score, and no significant differences were found between the groups at any time point (P > 0.05). Although the good-to-excellent rate of the modified MacNab criteria in the PTED group was similar to that in the MIS-TLIF group (90.9% vs. 91.3%, P > 0.05), PTED was advantageous in terms of the operative time, estimated blood loss, incision length, drainage time, drainage volume, length of hospital stay, and complications. CONCLUSIONS: Both PTED and MIS-TLIF led to favorable outcomes in geriatric patients with LRS-DLS. In addition, PTED caused less severe trauma and fewer complications. In terms of perioperative quality-of-life and clinical outcomes, PTED could supplement MIS-TLIF in geriatric patients with LRS-DLS.

Characteristics of Radial Artery Coronary Bypass Graft Failure and Outcomes Following Subsequent Percutaneous Coronary Intervention.

BACKGROUND: When patients with prior coronary artery bypass grafting (CABG) undergo percutaneous coronary intervention (PCI), targeting the native vessel is preferred. Studies informing such recommendations are based predominantly on saphenous vein graft (SVG) PCI. There are few data regarding arterial graft intervention, particularly to a radial artery (RA) graft. OBJECTIVES: The aim of this study was to report the characteristics of arterial graft stenoses and evaluate the feasibility of RA PCI. METHODS: This study included 2,780 consecutive patients with prior CABG undergoing PCI between 2005 and 2018 who were prospectively enrolled in the MIG (Melbourne Interventional Group) registry. Data were stratified by PCI target vessel. RA graft PCI was compared with both native vessel (native PCI) and SVG PCI. Internal mammary graft PCI data were reported. The primary outcome was 3-year mortality. RESULTS: Overall, 1,928 patients (69.4%) underwent native PCI, 716 (25.6%) SVG PCI, 86 (3.1%) RA PCI, and 50 (1.8%) internal mammary graft PCI. Compared with SVG PCI, the RA PCI cohort presented earlier after CABG, less frequently had acute coronary syndrome, and more commonly had ostial or distal anastomosis intervention (P < 0.005 for all). Compared with patients who underwent native PCI, those who underwent RA PCI were more likely to have diabetes and peripheral vascular disease (P < 0.001 for both) and to present with non-ST-segment elevation myocardial infarction (P = 0.010). The RA PCI group had no perforations or in-hospital myocardial infarctions, though no significant difference was found in periprocedural outcomes compared with either native or SVG PCI. No differences were found between RA PCI and either native or SVG PCI in 30-day outcomes or 3-year mortality. CONCLUSIONS: Presenting and lesion characteristics differed between patients undergoing arterial compared with SVG PCI, implying a varied pathogenesis of graft stenosis. RA PCI appears feasible, safe, and where anatomically suitable, may be a viable alternative to native PCI.

Full-Endoscopic Interlaminar Approach for Decompression of Lateral Recess Stenosis.

For lateral recess stenosis, extensive decompression with laminectomy is still performed in most centers. However, tissue-sparing surgeries are becoming more common. Full-endoscopic spinal surgeries have the advantages of being less invasive and offering a shorter recovery time. Here, we describe the technique of the full-endoscopic interlaminar approach for the decompression of lateral recess stenosis. The full-endoscopic interlaminar approach for the lateral recess stenosis procedure took approximately 51 min (range of 39-66 min). Blood loss could not be measured due to continuous irrigation. However, no drainage was required. There were no dura mater injuries reported in our institution. Furthermore, there were no injuries to the nerves, no cauda equine syndrome, and no hematoma formation. The patients were mobilized on the same day as surgery and discharged the next day. Therefore, the full-endoscopic technique for lateral recess stenosis decompression is a feasible procedure that lowers the operational time, complications, traumatization, and rehabilitation duration.

Microvascular resistance reserve in the presence of functionally significant epicardial stenosis and changes after revascularization.

In the presence of functionally significant epicardial lesions, microvascular resistance reserve (MRR) calculation needs incorporation of collateral flow. Coronary fractional flow reserve (FFRcor ) requiring coronary wedge pressure (Pw ), which is an essential part of the true MRR calculation, is reportedly estimated by myocardial FFR (FFRmyo ) not requiring Pw measurement. We sought to find an equation to calculate MRR without the need for Pw . Furthermore, we assessed changes in MRR after percutaneous coronary intervention (PCI). An equation to estimate FFRcor was developed from a cohort of 230 patients who underwent physiological measurements and PCI. Corrected MRR was calculated using this equation and compared with true MRR in 115 patients of the different set of the validation cohort. True MRR was calculated using FFRcor . FFRcor and FFRmyo showed a strong linear relationship (r2  = 0.86) and an equation was FFRcor  = 1.36 × FFRmyo - 0.34. This equation provided no significant difference between corrected MRR and true MRR in the validation cohort. Pre-PCI lower coronary flow reserve and higher index of microcirculatory resistance were independent predictors of pre-PCI decreased true MRR. True MRR significantly decreased after PCI. In conclusion, MRR can be accurately corrected using an equation for FFRcor estimation without Pw .

ACG Clinical Guideline: Diagnosis and Management of Biliary Strictures.

A biliary stricture is an abnormal narrowing in the ductal drainage system of the liver that can result in clinically and physiologically relevant obstruction to the flow of bile. The most common and ominous etiology is malignancy, underscoring the importance of a high index of suspicion in the evaluation of this condition. The goals of care in patients with a biliary stricture are confirming or excluding malignancy (diagnosis) and reestablishing flow of bile to the duodenum (drainage); the approach to diagnosis and drainage varies according to anatomic location (extrahepatic vs perihilar). For extrahepatic strictures, endoscopic ultrasound-guided tissue acquisition is highly accurate and has become the diagnostic mainstay. In contrast, the diagnosis of perihilar strictures remains a challenge. Similarly, the drainage of extrahepatic strictures tends to be more straightforward and safer and less controversial than that of perihilar strictures. Recent evidence has provided some clarity in multiple important areas pertaining to biliary strictures, whereas several remaining controversies require additional research. The goal of this guideline is to provide practicing clinicians with the most evidence-based guidance on the approach to patients with extrahepatic and perihilar strictures, focusing on diagnosis and drainage.

Ligamentum flavum analysis in patients with lumbar discus hernia and lumbar spinal stenosis.

The normal ligamentum flavum (LF) is a well-defined elastic structure with specific innervation. Several studies investigated LF in patients with lumbar spinal stenosis (LSS) and used lumbar discus hernia (LDH) patients as control group, only on the presumed thesis that LF in this patients have normal morphology. In patients with LSS thickening of the LF is the main cause of stenosis, which is most often presented with neurogenic claudication, whose pathophysiological mechanism is not completely understood. We conducted observational cohort study of 60 operated patients divided into two groups. The first group of 30 patients underwent micro-discectomy (LSH group), and second group with 30 patients underwent decompression, after which analysis of harvested LF was performed. Patients from the LDH group and LSS group differed significantly in the frequencies of chief complaints, duration of symptoms, physical examination, and specific morphological/radiological parameters. The LF analysis showed that the groups differed significantly in the amount of collagen and elastic fibers, as well as in the histological appearance/architectonics of elastic fibers. Also, groups differ in the presence of LF nerve fibers. Our findings speak in favor of the recently postulated inflammatory theory in the origin of spinal neurogenic claudication's.

Uretero-neocystostomy: a retrospective comparison of open, laparoscopic and robotic techniques.

BACKGROUND: Uretero-neocystostomy (UNC) is the gold-standard for distal-ureter repair. Whether the surgery should be conducted minimally invasive (laparoscopic (LAP), robotic RAL)) or open remains unanswered by the literature. METHODS: Retrospective analysis of surgical outcome of patients treated with UNC for distal ureteral stenosis (January 2012 - October 2021). Patient demographics, estimated blood loss (EBL), surgical technique, operative time, complications and length of hospital stay (LOS) were recorded. During the follow-up period, patient underwent renal ultrasound and kidney function tests. Success was defined as relieve of symptoms or no findings of obstruction needing urine drainage. RESULTS: 60 patients were included (9 RAL, 25 LAP, 26 open). The different cohorts were similar of age, gender, American Society of Anesthesiologists (ASA) score, body-mass index and history of prior treatment of the ureter. No intraoperative complications were detected in all groups. There was no conversion to open surgery in the RAL group, whereas one was found in the LAP arm. Six patients had a recurrent stricture, but with no significant difference between the cohorts. EBL was not different between the groups. LOS was significantly lower in the RAL + LAP group compared to open (7 vs. 13 days, p = 0.005) despite significantly longer operating times (186 vs. 125.5 min, p = 0.005). CONCLUSION: Minimal invasive UNC, especially RAL, is a feasible and safe surgical method and provides similar results in terms of success rates in comparison to open approach. A shorter LOS could be detected. Further prospective studies need to be done.

Independent Clinical and Echocardiographic Predictors of Restenosis After Percutaneous Mitral Balloon Commissurotomy in a Large, Consecutive Cohort Followed for 24 Years.

OBJECTIVE: To enlighten preprocedural risk factors of mitral valve restenosis in a large, single-center cohort of patients submitted to percutaneous mitral balloon commissurotomy (PMBC) for the treatment of mitral stenosis (MS) secondary to rheumatic heart disease. METHODS: This is a database analysis of a single-center, high-volume tertiary institution involving all consecutive PMBC procedures performed in the mitral valve (MV). Restenosis was diagnosed when MV area was <1.5 cm² and/or loss of 50% or more of the immediate procedural result aligned with the return/worsened symptoms of heart failure. The primary endpoint was to determine the preprocedural independent predictors of restenosis after PMBC. RESULTS: Among a total of 1921 PMBC procedures, 1794 consecutive patients without previous intervention were treated between 1987 and 2010. Throughout 24 years of follow-up, MV restenosis was observed in 483 cases (26%). Mean age was 36 years and most (87%) were female. Median follow-up duration was 9.03 years (interquartile range, 0.33-23.38). Restenosis population, however, presented a significantly lower age at the procedure time as well as a higher Wilkins-Block score. At multivariate analysis, independent preprocedure predictors of restenosis were left atrium diameter (hazard risk [HR], 1.03; 95% confidence interval [CI], 1.02-1.05; P<.04), preprocedure maximum gradient (HR, 1.02; 95% CI, 1.00-1.03; P=.04), and higher Wilkins-Block score (>8) (HR, 1.38; 95% CI, 1.14-1.67; P<.01). CONCLUSIONS: At long-term follow-up, MV restenosis was observed in a quarter of the population undergoing PMBC. Preprocedure echocardiographic findings, including left atrial diameter, maximum MV gradient, and Wilkins-Block score were found to be the only independent predictors.

Takayasu arteritis and large-vessel giant cell arteritis in Italian population. Comprehensive analysis from a single institutional cohort of 184 cases.

OBJECTIVE: To compare clinical and imaging characteristics in patients with Takayasu arteritis (TAK) and large vessel-giant cell arteritis (LV-GCA) in an Italian population. METHODS: We conducted a retrospective monocenter study comparing characteristics and outcomes of a cohort of 59 patients with TAK and a cohort of 127 patients with LV-GCA diagnosed between 1996 and 2016. Most of them (92%) were followed up for at least 24 months at Reggio Emilia Hospital (Italy). We also reviewed the literature discussing the results of the published manuscripts comparing LV-GCA to TAK RESULTS: LV-GCA patients had a higher prevalence of males (p = 0.003), and more frequently presented with cranial symptoms (p = 0.001), fever ≥38 °C (p = 0.007), polymyalgia rheumatica (p = 0.001), and hypertension (p = 0.001), and they had higher ESR levels at diagnosis (p = 0.0001). Differently, TAK patients had longer delay to diagnosis from the beginning of symptoms (p = 0.048), they presented more frequently with loss of pulses of large arteries (p = 0.0001), vascular bruits (p = 0.001), limb claudication (p = 0.003), myocardial infarction/angina (p = 0.03), and hypertension induced by renal artery stenosis (p = 0.001). Regarding treatment, TAK patients received a higher total and at 1 year cumulative prednisone doses (p = 0.0001 and p = 0.001, respectively), they had a longer duration of prednisone therapy (p = 0.008), and received during follow-up more frequently traditional immunosuppressants (p = 0.0001) and biological agents (p = 0.0001). Flares were more frequently observed in TAK patient (p = 0.001), while no differences were observed for long-term remission. New vascular procedures during the follow-up were more frequently performed in TAK patients (p = 0.0001). Regarding imaging at diagnosis, TAK patients had more frequently vascular stenosis/occlusion (p = 0.0001) and a higher number of vessels with structural damage per person (p = 0.0001), while LV-GCA patients had a higher number of inflamed vessels per person (p = 0.0001). Comparing the involved vascular districts at diagnosis for the presence of vessel inflammation and/or arterial damage, patients with LV-GCA had a more frequent involvement of thoracic and abdominal aorta (p = 0.024 and p = 0.007, respectively), and axillary, iliac and femoral arteries (p = 0.018, p = 0.002, and p = 0.0001. respectively), while in TAK patients, brachiocephalic, celiac, mesenteric and renal arteries were more frequently involved (p = 0.011, p = 0.019, p = 0.019, and p = 0.005, respectively). At imaging arterial damage at diagnosis was more frequently observed in TAK patients, specifically at common carotid, brachiocephalic, and subclavian arteries (p = 0.0001, p = 0.006, p = 0.0001, respectively) and descending aorta (p = 0.022). Regarding imaging during the follow-up, TAK patients developed more frequently new vascular stenosis/occlusion (p = 0.0001) and new vascular thickening (p = 0.002), no differences were observed for the development of new dilatation/aneurysm between the two vasculitides. CONCLUSION: Patients with TAK and LV-GCA show a number of similarities and also differences. Indeed, it is unclear whether they are part of the same disease spectrum or they are different conditions. As more information regarding the pathogenesis and etiology becomes known, answers to these questions are like to be forthcoming.