Impact of preoperative fractional flow reserve on arterial bypass graft anastomotic function: the IMPAG trial.

AIMS: Visual estimation is the most commonly used method to evaluate the degree of coronary artery stenosis prior to coronary artery bypass grafting. In interventional cardiology, the use of fractional flow reserve (FFR) to guide revascularization decisions has become routine. We investigated whether the preoperative FFR measurement of coronary lesions is associated with anastomosis function 6 months after surgical revascularization using a multiarterial grafting strategy. METHODS AND RESULTS: In this prospective double-blind study, 67 patients were enrolled from two institutions in Europe and Canada. From these patients, 199 coronary lesions were assessed visually and with FFR at the time of the preoperative angiogram. All patients received coronary revascularization using multiple arterial grafts. A post-operative 6-month angiogram was performed to assess anastomosis functionality using a described angiographic method. The primary outcome was the association between preoperative FFR values and anastomosis function 6 months after surgery. Preoperative FFR was significantly associated with 6-months anastomotic function for all conduits and for all targets (P < 0.001). An FFR value of ≤0.78 was associated with an anastomotic occlusion rate of 3%. CONCLUSION: We found a significant association between the preoperative FFR measurement of the target vessel and the anastomotic functionality at 6 months, with a cut-off of 0.78. Integration of FFR measurement into the preoperative diagnostic workup before multiarterial coronary surgical revascularization leads to improved anastomotic graft function. CLINICAL TRIALS. GOV IDENTIFIER: NCT02527044.

Evaluation of the ideal position of the maxillary incisor relative to upper lip thickness.

INTRODUCTION: The anteroposterior position of the maxillary incisors has been studied since the beginning of cephalometric research. Most reports of ideal position have been based on measurements made on subjects with Class I occlusion without consideration of other facial variables. However, the ideal position is reflected in the soft tissues by the position of the lips. The purpose of this study was to consider the position of the maxillary incisor relative to other factors, including the thickness of the upper lip, and to evaluate its most aesthetic position using profile photographs. METHODS: The subjects in this study were 130 patients with Class I occlusion; their sex, age, thickness of the upper lip, and angular position of the maxillary incisor were recorded. From these 130 patients, 70 profile photographs that met the inclusion criteria were chosen for further evaluation. A survey was conducted among 60 lay people, 60 dentists, and 60 orthodontists. They were asked to classify the sets of photographs, from the most esthetic position of the upper lip to the least esthetic. RESULTS: For patients with thin lips, raters tended to prefer a more protruded position of the incisor than normal or between 8.0 mm and 11.5 mm in front of the Na-B bone and 4 mm in front of the Na-A bone. For patients with thick lips, the position of the incisor did not affect the perception of the profile. CONCLUSIONS: A correct skeletal scheme or Class I occlusion does not necessarily result in ideal facial harmony. Therefore, it will be necessary to consider all the factors that come into play, especially the lips, which are a key element in facial esthetics.

A mutation update on the LDS-associated genes TGFB2/3 and SMAD2/3.

The Loeys-Dietz syndrome (LDS) is a connective tissue disorder affecting the cardiovascular, skeletal, and ocular system. Most typically, LDS patients present with aortic aneurysms and arterial tortuosity, hypertelorism, and bifid/broad uvula or cleft palate. Initially, mutations in transforming growth factor-ß (TGF-ß) receptors (TGFBR1 and TGFBR2) were described to cause LDS, hereby leading to impaired TGF-ß signaling. More recently, TGF-ß ligands, TGFB2 and TGFB3, as well as intracellular downstream effectors of the TGF-ß pathway, SMAD2 and SMAD3, were shown to be involved in LDS. This emphasizes the role of disturbed TGF-ß signaling in LDS pathogenesis. Since most literature so far has focused on TGFBR1/2, we provide a comprehensive review on the known and some novel TGFB2/3 and SMAD2/3 mutations. For TGFB2 and SMAD3, the clinical manifestations, both of the patients previously described in the literature and our newly reported patients, are summarized in detail. This clearly indicates that LDS concerns a disorder with a broad phenotypical spectrum that is still emerging as more patients will be identified. All mutations described here are present in the corresponding Leiden Open Variant Database.

Unusual vanishing interstitial lymphatic "pearls" in a patient presenting with extensive interstitial and mediastinal MDCT features of acute cardiogenic failure related to bradycardia and mitral regurgitation.

Thoracic multidetector computed tomography-MDCT-was simultaneously performed during emergency abdominal CT in a patient presenting with abdominal pain and acute cardiogenic edema related to sick sinus syndrome and mitral prolapse with regurgitation. A constellation of severe but completely reversible interstitial and mediastinal features was found comprising pleural effusions, diffuse alveolar ground glass, thickening of the bronchial walls and septal lines, hazy infiltration of the mediastinal fat, and enlarged lymphatic nodes. Multiple atypical hypodense nodular "pearls" were also found. These oval shape or fusiform pearls were distributed along the thickened septal lines and disappeared completely after treatment. The hypothesis of transient lymphatic ectasia or lakes is proposed for these never previously described abnormalities.

Exclusive percutaneous approach for surgical transaortic transcatheter valve replacement.

Direct transaortic implantation (TAo) has been described as a new alternative approach for transcatheter aortic valve implantation in patients with unsuitable transfemoral access. TAo is usually achieved through an upper ministernotomy or, more recently, through a right thoracotomy in the second intercostal space. We describe here our first experience with a fully thoracoscopic approach that allowed successful deployment of a 23-mm Edwards SAPIEN valve.

Transaortic transcatheter aortic valve implantation with the Edwards SAPIEN valve: feasibility, technical considerations, and clinical advantages.

The randomized Partner study [1] has recently shown superiority of transfemoral transcatheter aortic valve implantation, in patients who are not candidates for surgical aortic valve replacement, when compared with conventional nonsurgical therapies. In patients who are not candidates for the transfemoral approach because of peripheral vascular disease or other contraindications, deployment of the SAPIEN valve (Edwards Lifesciences, Irvine, CA) in an antegrade fashion can be achieved through the apex of the left ventricle. However this valuable technique carries specific risks inherent to the access route. Transaortic implantation, through an upper ministernotomy, offers a new alternative that could avoid complications related to the transapical approach.

Embol-X intraaortic filter and transaortic approach for improved cerebral protection in transcatheter aortic valve implantation.

Techniques for transcatheter aortic valve implantation involve manipulation of the native aortic valve and the aortic arch. As a result, excellent technical outcomes of this technique remain counterbalanced by a level of neurologic complications that remain unacceptably high. We present here a report of a new potential combined approach to reduce periprocedural neurologic events. After a 6-cm J-shaped upper-mini-sternotomy, 26-mm Sapien valve (Edwards Lifesciences, Irvine, CA) was deployed through a transaortic approach. In addition, the Embol-X device (Edwards Lifescience) was directly inserted in the distal ascending aorta was deployed during all the procedure. Postoperative evolution was clinically uneventful. Postoperative magnetic resonance imaging revealed no new ischemic lesions in this first patient.

Reduced mortality in high-risk coronary patients operated off pump with preoperative intraaortic balloon counterpulsation.

BACKGROUND: Preoperative intraaortic balloon pump (IABP) counterpulsation has better outcomes compared with perioperative or postoperative insertion in critical patients, and off-pump surgical procedures have been advocated to reduce mortality in high-risk patients. However, some surgeons are reluctant to perform beating heart operations in specific patient subgroups, including those with unstable angina or patients with low ejection fraction, because of their possible perioperative hemodynamic instability. METHODS: We evaluated combined beating heart procedures and preoperative IABP in selected high-risk patients and compared our results with the predictive European System for Cardiac Operative Risk Evaluation (EuroSCORE) model. Fifty-five high-risk patients with a mean logistic EuroSCORE of 24 were prospectively enrolled and then divided into emergency (group 1, n = 25) and nonemergency (group 2, n = 30) groups. IABP was inserted immediately before operation in group 1 and the day before the procedure in group 2. RESULTS: Compared with the EuroSCORE predictive model, a dramatic decrease in mortality occurred in both groups. Group I predicted mortality was 36.8%, and observed was 20%; and group 2 predicted mortality was 15.2% and observed was 0%. No specific complications from the use of IABP were encountered. During mid-term (2 years) follow-up, no patient died from a cardiac cause or required percutaneous coronary intervention or subsequent reoperation due to incomplete revascularization. CONCLUSIONS: The combined use of preoperative intraaortic counterpulsation and beating heart intervention allows complete revascularization in high-risk patients with a important reduction in operative mortality and excellent mid-term results.